Development and implementation of non-communicable disease (NCD) prevention polices in the developing countries is a multidimensional challenge. This article highlights the evolution of a strategic approach in Pakistan. The model is evidence-based and encompasses a concerted and integrated approach to NCDs. It has been modelled to impact a set of indicators through the combination of a range of actions capitalizing on the strengths of a public-private partnership. The paper highlights the merits and limitations of this approach. The experience outlines a number of clear imperatives for fostering an enabling environment for integrated NCD prevention public health models, which involve roles played by a range of stakeholders. It also highlights the value that such partnership arrangements bring in facilitating the mission and mandates of ministries of health, international agencies with global health mandates, and the non-profit private sector. The experience is of relevance to developing countries that have NCD programs running and those that need to develop them. It provides an empirical basis for enhancing the performance of the health system by fostering partnerships within integrated evidence-based models and permits an analysis of health systems models built on shared responsibility for the purpose of providing sustainable health outcomes.
Most developing countries do not comprehensively address chronic diseases as part of their health agendas because of lack of resources, limited capacity within the health system, and the threat that the institution of national-level programs will weaken local health systems and compete with other health issues. An integrated partnership-based approach, however, could obviate some of these obstacles.
In Pakistan, a tripartite public–private partnership was developed among the Ministry of Health, the nongovernmental organization (NGO) Heartfile, and World Health Organization. This was the first time an NGO participated in a national health program; NGOs typically assume a contractual role. The partnership developed a national integrated plan for health promotion and the prevention and control of noncommunicable diseases (NCDs), which as of January 2006 is in the first stage of implementation. This plan, called the National Action Plan on NCD Prevention, Control, and Health Promotion (NAP-NCD), was released on May 12, 2004, and attempts to obviate the challenges associated with addressing chronic diseases in countries with limited resources. By developing an integrated approach to chronic diseases at several levels, capitalizing on the strengths of partnerships, building on existing efforts, and focusing primary health care on chronic disease prevention, the NAP-NCD aims to mitigate the effects of national-level programs on local resources.
The impact of the NAP-NCD on population outcomes can only be assessed over time. However, this article details the plan's process, its perceived merits, and its limitations in addition to discussing challenges with its implementation, highlighting the value of such partnerships in facilitating the missions and mandates of participating agencies, and suggesting options for generalizability.
Noncommunicable diseases (NCDs) are now the leading cause of death in the South-East Asia Region, accounting for 55% of all deaths annually. Besides presenting a serious threat to public health, NCDs hamper socioeconomic development in the region. The situation is likely to worsen in the future. Fortunately, cost-effective and high-impact interventions to prevent and control NCDs are, however, available and at individual level, they cost next to nothing. In order to ensure that these interventions are delivered in an efficient and effective manner and have the desired impact especially in light of the prevailing economic difficulties, an integrated approach is necessary. Different approaches to integration can be used although integrating NCD interventions into the health system based on primary health care remain the best model.
Integration; noncommunicable diseases; primary health care; South-East Asia region; World health organization
Although in developing countries the burden of morbidity and mortality due to infectious diseases has often overshadowed that due to chronic non-communicable diseases (NCDs), there is evidence now of a shift of attention to NCDs.
Decreasing the chronic NCD burden requires a two-pronged approach: implementation of the multisectoral policies aimed at decreasing population-level risks for NCDs, and effective and affordable delivery of primary care interventions for patients with chronic NCDs. The primary care response to common NCDs is often unstructured and inadequate. We therefore propose a programmatic, standardized approach to the delivery of primary care interventions for patients with NCDs, with a focus on hypertension, diabetes mellitus, chronic airflow obstruction, and obesity. The benefits of this approach will extend to patients with related conditions, e.g. those with chronic kidney disease caused by hypertension or diabetes. This framework for a "public health approach" is informed by experience of scaling up interventions for chronic infectious diseases (tuberculosis and HIV). The lessons learned from progress in rolling out these interventions include the importance of gaining political commitment, developing a robust strategy, delivering standardised interventions, and ensuring rigorous monitoring and evaluation of progress towards defined targets.
The goal of the framework is to reduce the burden of morbidity, disability and premature mortality related to NCDs through a primary care strategy which has three elements: 1) identify and address modifiable risk factors, 2) screen for common NCDs and 3) and diagnose, treat and follow-up patients with common NCDs using standard protocols. The proposed framework for NCDs borrows the same elements as those developed for tuberculosis control, comprising a goal, strategy and targets for NCD control, a package of interventions for quality care, key operations for national implementation of these interventions (political commitment, case-finding among people attending primary care services, standardised diagnostic and treatment protocols, regular drug supply, and systematic monitoring and evaluation), and indicators to measure progress towards increasing the impact of primary care interventions on chronic NCDs. The framework needs evaluation, then adaptation in different settings.
A framework for a programmatic "public health approach" has the potential to improve on the current unstructured approach to primary care of people with chronic NCDs. Research to establish the cost, value and feasibility of implementing the framework will pave the way for international support to extend the benefit of this approach to the millions of people worldwide with chronic NCDs.
Major noncommunicable diseases (NCDs) share common behavioral risk factors and deep-rooted social determinants. India needs to address its growing NCD burden through health promoting partnerships, policies, and programs. High-level political commitment, inter-sectoral coordination, and community mobilization are important in developing a successful, national, multi-sectoral program for the prevention and control of NCDs. The World Health Organization's “Action Plan for a Global Strategy for Prevention and Control of NCDs” calls for a comprehensive plan involving a whole-of-Government approach. Inter-sectoral coordination will need to start at the planning stage and continue to the implementation, evaluation of interventions, and enactment of public policies. An efficient multi-sectoral mechanism is also crucial at the stage of monitoring, evaluating enforcement of policies, and analyzing impact of multi-sectoral initiatives on reducing NCD burden in the country. This paper presents a critical appraisal of social determinants influencing NCDs, in the Indian context, and how multi-sectoral action can effectively address such challenges through mainstreaming health promotion into national health and development programs. India, with its wide socio-cultural, economic, and geographical diversities, poses several unique challenges in addressing NCDs. On the other hand, the jurisdiction States have over health, presents multiple opportunities to address health from the local perspective, while working on the national framework around multi-sectoral aspects of NCDs.
Health promotion; mainstreaming; multi-sectoral partnerships; noncommunicable diseases; social determinants of NCDs
Chronic non-communicable diseases (NCDs) are the leading cause of morbidity, mortality, and disability worldwide. More than 80% of chronic disease deaths occur in low-income and middle-income countries. Epidemiological data on the burden of chronic NCD and the risk factors which predict them are lacking in most low-income countries. The INDEPTH Network (http://www.indepth-network.org) which includes the Health and Demographic Surveillance System (HDSS) with many surveillance sites in low-middle income countries provided an opportunity to establish surveillance of the major chronic NCD risk factors in 2005 using a standardised approach.
This paper presents the conceptual framework and research design of the chronic NCD risk factor surveillance within nine rural INDEPTH HDSS settings in Asia.
This multi-site study was designed as a baseline cross-sectional survey with sufficient sample size to measure trends over time. In each of nine HDSS sites in five Asian countries, a sample of 2,000 men and women aged 25–64 years, using the WHO STEPwise approach to Surveillance (http://who.int/chp/steps), was selected using stratified random sampling (in each 10-year interval) from the HDSS sampling frame.
A total of 18,494 men and women from the nine sites were interviewed with an overall response rate of 98%. The major NCDs risk factors included self-reported information on tobacco and alcohol consumption, fruit and vegetable intake, physical activity patterns, and measured body weight, height, waist circumference, and blood pressure. A series of training sessions were conducted for research scientists, supervisors, and surveyors in each site. Data quality was ensured through spot check, re-check, and data validation procedures, including accuracy and completeness of data obtained. Standardised data entry programme, created using the EPIDATA software, was used to ensure uniform database structure across sites. The data merging and analysis were done using STATA Version 10.
This multi-site study confirmed the feasibility of conducting chronic NCD risk factor surveillance in the low and middle-income settings by integrating the chronic NCDs risk factor surveillance into an existing HDSS data collection and management setting. This collaborative work has provided reliable epidemiological data as a basis for developing chronic NCD prevention and control activities.
chronic non-communicable diseases; risk factor surveillance; INDEPTH Network; low-middle income countries; WHO STEPS
The major chronic non-communicable diseases (NCDs) operate through a cluster of common risk factors, whose presence or absence determines not only the occurrence and severity of the disease, but also informs treatment approaches. Primary prevention based on mitigation of these common risk factors through population-based programmes is the most cost-effective approach to contain the emerging epidemic of chronic NCDs.
This study was conducted to explore the extent of risk factors clustering for the major chronic NCDs and its determinants in nine INDEPTH Health and Demographic Surveillance System (HDSS) sites of five Asian countries.
Data originated from a multi-site chronic NCD risk factor prevalence survey conducted in 2005. This cross-sectional survey used a standardised questionnaire developed by the WHO to collect core data on common risk factors such as tobacco use, intake of fruits and vegetables, physical inactivity, blood pressure levels, and body mass index. Respondents included randomly selected sample of adults (25–64 years) living in nine rural HDSS sites in Bangladesh, India, Indonesia, Thailand, and Vietnam.
Findings revealed a substantial proportion (>70%) of these largely rural populations having three or more risk factors for chronic NCDs. Chronic NCD risk factors clustering was associated with increasing age, being male, and higher educational achievements. Differences were noted among the different sites, both between and within country.
Since there is an extensive clustering of risk factors for the chronic NCDs in the populations studied, the interventions also need to be based on a comprehensive approach rather than on a single factor to forestall its cumulative effects which occur over time. This can work best if it is integrated within the primary health care system and the HDSS can be an invaluable epidemiological resource in this endeavor.
chronic NCDs; risk factors surveillance; clustering; INDEPTH; Asia; WHO STEPS
The prevalence of non–communicable diseases (NCDs) – such as cancer, diabetes, cardiovascular disease, and chronic respiratory diseases – is surging globally. Yet despite the availability of cost–effective interventions, NCDs receive less than 3% of annual development assistance for health to low and middle income countries. The top donors in global health – including the Bill and Melinda Gates Foundation, the US Government, and the World Bank – together commit less than 2% of their budgets to the prevention and control of NCDs. Why is there such meagre funding on the table for the prevention and control of NCDs? Why has a global plan of action aimed at halting the spread of NCDs been so difficult to achieve?
This paper aims to tackle these two interrelated questions by analysing NCDs through the lens of Jeremy Shiffman’s 2009 political priority framework. We define global political priority as ‘the degree to which international and national political leaders actively give attention to an issue, and back up that attention with the provision of financial, technical, and human resources that are commensurate with the severity of the issue’. Grounded in social constructionism, this framework critically examines the relationship between agenda setting and ‘objective’ factors in global health, such as the existence of cost–effective interventions and a high mortality burden. From a methodological perspective, this paper fits within the category of discipline configurative case study.
We support Shiffman’s claim that strategic communication – or ideas in the form of issue portrayals – ought to be a core activity of global health policy communities. But issue portrayals must be the products of a robust and inclusive debate. To this end, we also consider it essential to recognise that issue portrayals reach political leaders through a vast array of channels. Raising the political priority of NCDs means engaging with the diverse ways in which actors express concern for the global proliferation of these diseases.
Ultimately, our political interactions amount to struggles for influence, and determining which issues to champion in the midst of these struggles – and which to disregard – is informed by subjectively held notions of the right, the good, and the just. Indeed, the very act of choosing which issues to prioritise in our daily lives forces us to evaluate our values and aspirations as individual agents against the shared values that structure the societies in which we live.
India is undergoing a demographic and epidemiological transition which is influencing its health. Noncommunicable diseases (NCDs) are posing major health and development threats, while we are grappling with communicable diseases and maternal and child health-related issues. The major NCDs include cardiovascular diseases (including stroke), diabetes, cancer, chronic obstructive pulmonary diseases, mental health, and injuries. Tobacco, alcohol, diet, physical inactivity, high blood pressure, and obesity are the major risk factors common to many chronic diseases. Research on NCDs under the ICMR and through other institutions has resulted in the initiation of some national health programs such as National Cancer Control Program and District Mental Health Program. Important epidemiological descriptions have informed us on the causes and distribution of NCDs and their risk factors, including the non-health determinants (poverty, education, employment, etc) and health systems assessments, have shown the inadequacies in tackling NCDs. Several global efforts and publications have provided guidance in shaping the research agenda. The special UN NCD Summit held on 19-20 September 2011 brought the world leaders to deliberate on ways to address NCDs in a concerted manner through partnerships. In this paper the authors review the present status of NCDs and their risk factors in the country and propose a strategic research agenda to provide adequate thrust to accelerate research towards a useful outcome.
India; noncommunicable diseases; research
The accelerating epidemics of noncommunicable diseases (NCDs) in India call for a comprehensive public health response which can effectively combat and control them before they peak and inflict severe damage in terms of unaffordable health, economic, and social costs. To synthesize and present recent evidences regarding the effectiveness of several types of public health interventions to reduce NCD burden. Interventions influencing behavioral risk factors (like unhealthy diet, physical inactivity, tobacco and alcohol consumption) through policy, public education, or a combination of both have been demonstrated to be effective in reducing the NCD risk in populations as well as in individuals. Policy interventions are also effective in reducing the levels of several major biological risk factors linked to NCDs (high blood pressure; overweight and obesity; diabetes and abnormal blood cholesterol). Secondary prevention along the lines of combination pills and ensuring evidenced based clinical care are also critical. Though the evidence for health promotion and primary prevention are weaker, policy interventions and secondary prevention when combined with these are likely to have a greater impact on reducing national NCD burden. A comprehensive and integrated response to NCDs control and prevention needs a “life course approach.” Proven cost-effective interventions need to be integrated in a NCD prevention and control policy framework and implemented through coordinated mechanisms of regulation, environment modification, education, and health care responses.
Evidence base; India; NCD; public health interventions
Non-communicable disease continues to be an important public health problem in India, being responsible for a major proportion of mortality and morbidity. Demographic changes, changes in the lifestyle along with increased rates of urbanization are the major reasons responsible for the tilt towards the non-communicable diseases. In India, there is no regular system for collecting data on non-communicable diseases (NCDs) which can be said to be of adequate coverage or quality. Lack of trained health care workers, primary care providers armed with inadequate knowledge and skills along with ill-defined roles of various health sectors i.e. public, private, and voluntary sectors in providing care have played key hurdles in combating the growing burden of non-communicable diseases. Empowerment of the community through effective health education, use of trained public health personnel along with provision of free health care and social insurance would prove beneficial in effectively controlling the growing prevalence of NCDs.
Non-communicable diseases; Cardiovascular diseases; Burden; India
Mozambique is located on the East Coast of Africa bordering South Africa, Zimbabwe, Zambia, Malawi and Tanzania and is one of the poorest countries in the world. Currently NCDs account for 28% of deaths in Mozambique. Risk factors such as tobacco and alcohol use and poor diet are present in both urban and rural settings. Diseases such as hypertension and diabetes affect large proportions of the population, but people are often unaware of their condition or poorly managed. Data from studies on diabetes highlight the financial burden for NCD management in Mozambique for both the individual and health system. The National Strategic Plan for the prevention and control of NCDs in Mozambique has as its aim to create a positive environment to minimise or eliminate the exposure to risk factors and guarantee access to care. The plan has as its overall objective to reduce exposure to risk factors and morbidity and mortality due to NCDs and has 4 areas of intervention: 1) Prevention and health education with regards to NCDs; 2) Access to quality care, treatment and follow-up; 3) Prevention of disability and premature mortality and 4) Surveillance, research, monitoring and evaluation and advocacy for NCDs. The Ministry of Health developed projects for diabetes and hypertension and used these as key lessons that could then be applied to other NCDs. Mozambique, through political commitment from the Ministry of Health and the dedication of local champions, has been able to garner international support to improve care for people with diabetes and then use this to develop its National Plan for NCDs. Despite this increase in attention resources available do not match the challenge of NCDs in Mozambique. Mozambique’s experience provides a practical example of actions that can be undertaken in a resource poor country to tackle the emerging burden of NCDs.
The scale-up of HIV services in sub-Saharan Africa has catalyzed the development of highly effective chronic care systems. The strategies, systems, and tools developed to support life-long HIV care and treatment are locally owned contextually appropriate resources, many of which could be adapted to support continuity care for noncommunicable chronic diseases (NCD), such as diabetes mellitus (DM). We conducted two proof-of-concept studies to further the understanding of the status of NCD programs and the feasibility and effectiveness of adapting HIV program-related tools and systems for patients with DM. In Swaziland, a rapid assessment illustrated gaps in the approaches used to support DM services at 15 health facilities, despite the existence of chronic care systems at HIV clinics in the same hospitals, health centers, and clinics. In Ethiopia, a pilot study found similar gaps in DM services at baseline and illustrated the potential to rapidly improve the quality of care and treatment for DM by adapting HIV-specific policies, systems, and tools.
In 1997 Hong Kong reunified with China and the development of traditional Chinese medicine (TCM) started with this change in national identity. However, the two latest discussion papers on Hong Kong's healthcare reform have failed to mention the role of TCM in primary healthcare, despite TCM's public popularity and its potential in tackling the chronic non-communicable disease (NCD) challenge in the ageing population. This study aims to describe the interrelationship between age, non-communicable disease (NCD) status, and the choice of TCM and western medicine (WM) services in the Hong Kong population.
This study is a secondary analysis of the Thematic Household Survey (THS) 2005 dataset. The THS is a Hong Kong population representative face to face survey was conducted by the Hong Kong Administrative Region Government of China. A random sample of respondents aged >15 years were invited to report their use of TCM and WM in the past year, together with other health and demographic information. A total of 33,263 persons were interviewed (response rate 79.2%).
Amongst those who received outpatient services in the past year (n = 18,087), 80.23% only visited WM doctors, 3.17% consulted TCM practitioners solely, and 16.60% used both type of services (double consulters). Compared to those who only consulted WM doctor, multinomial logistic regression showed that double consulters were more likely to be older, female, NCD patients, and have higher socioeconomic backgrounds. Further analysis showed that the association between age and double consulting was curvilinear (inverted U shaped) regardless of NCD status. Middle aged (45-60 years) NCD patients, and the NCD free "young old" group (60-75 years) were most likely to double consult. On the other hand, the relationship between age and use of TCM as an alternative to WM was linear regardless of NCD status. The NCD free segment of the population was more inclined to use TCM alone as they become older.
In Hong Kong, most patients have chosen WM provided in the public sector as their sole outpatient service provider for NCD. Amongst TCM service users, middle aged NCD patients are more likely to choose both TCM and WM outpatient services. Meanwhile, older people without NCD are more likely to use TCM as their main form of care, but the size of this population group is small. These utilization patterns show that patients choose both modalities to manage their NCD and TCM should be considered within policies for supporting patients with NCD under the wider primary health and social care system that supports patient choice.
Segmented service delivery with consequent inefficiencies in health systems was one of the main concerns raised during scaling up of disease-specific programs in the last two decades. The organized response to NCD is in infancy in most LMICs with little evidence on how the response is evolving in terms of institutional arrangements and policy development processes.
Drawing on qualitative review of policy and program documents from five LMICs and data from global key-informant surveys conducted in 2004 and 2010, we examine current status of governance of response to NCDs at national level along three dimensions— institutional arrangements for stewardship and program management and implementation; policies/plans; and multisectoral coordination and partnerships.
Several positive trends were noted in the organization and governance of response to NCDs: shift from specific NCD-based programs to integrated NCD programs, increasing inclusion of NCDs in sector-wide health plans, and establishment of high-level multisectoral coordination mechanisms.
Several areas of concern were identified. The evolving NCD-specific institutional structures are being treated as ‘program management and implementation’ entities rather than as lead ‘technical advisory’ bodies, with unclear division of roles and responsibilities between NCD-specific and sector-wide structures. NCD-specific and sector-wide plans are poorly aligned and lack prioritization, costing, and appropriate targets. Finally, the effectiveness of existing multisectoral coordination mechanisms remains questionable.
The ‘technical functions’ and ‘implementation and management functions’ should be clearly separated between NCD-specific units and sector-wide institutional structures to avoid duplicative segmented service delivery systems. Institutional capacity building efforts for NCDs should target both NCD-specific units (for building technical and analytical capacity) and sector-wide organizational units (for building program management and implementation capacity) in MOH.
The sector-wide health plans should reflect NCDs in proportion to their public health importance. NCD specific plans should be developed in close consultation with sector-wide health- and non-health stakeholders. These plans should expand on the directions provided by sector-wide health plans specifying strategically prioritized, fully costed activities, and realistic quantifiable targets for NCD control linked with sector-wide expenditure framework. Multisectoral coordination mechanisms need to be strengthened with optimal decision-making powers and resource commitment and monitoring of their outputs.
Cambodia; Fiji; Malaysia; Mongolia; Philippines; Non-communicable diseases; Governance; Policies
Objective. The objective was to evaluate the capacity of primary care (PC) facilities to implement basic interventions for prevention and management of major noncommunicable diseases (NCDs), including cardiovascular diseases and diabetes. Methods. A cross-sectional survey was done in eight low- and middle-income countries (Benin, Bhutan, Eritrea, Sri Lanka, Sudan, Suriname, Syria, and Vietnam) in 90 PC facilities randomly selected. The survey included questions on the availability of human resources, equipment, infrastructure, medicines, utilization of services, financing, medical information, and referral systems. Results and Conclusions. Major deficits were identified in health financing, access to basic technologies and medicines, medical information systems, and the health workforce. The study has provided the foundation for strengthening PC to address noncommunicable diseases. There are important implications of the findings of this study for all low- and middle-income countries as capacity of PC is fundamental for equitable prevention and control of NCDs.
This article addresses an area that has been largely underserved by the development community, and one in which there is a particularly good opportunity for the private sector to take a lead in making a difference to employees, customers and local communities: chronic, non-communicable diseases (NCDs). It highlights the extent of the epidemic of NCDs in developing countries, sets out the 'business case' for the private sector to act on NCDs, and gives examples of initiatives by business to ensure that the healthy choice really is an easier choice for employees, consumers and local communities. It makes the case that, to be genuinely sustainable, businesses should be addressing health as a core part of what they do and, by working in partnership - as called for by the Millennium Development Goals - they can make a real difference and become part of the solution. Identifying ways in which this can be done should form a key part both of planning for, and action after, the UN High-level Meeting on NCDs, to be held in September 2011.
Noncommunicable diseases (NCDs) are reaching epidemic proportions worldwide and in India. Surveillance of NCD risk factors are therefore needed as they could help in policy planning and implementation of preventive measures. This article will focus on the experiences gained, and challenges faced, in conducting NCD risk factor surveillance studies in India. Two major surveillance studies on NCDs were conducted in India – the World Health Organization (WHO) – Indian Council of Medical Research (ICMR) NCD risk factor surveillance study and the Integrated Disease Surveillance Project (IDSP). The WHO-ICMR study was a six-site pilot study representing six different geographical locations in India with a sample size of 44,537 including rural, peri-urban/slum and urban. Phase 1 of the IDSP was completed and included seven states in India with a sample size of 5000 per state. The NCD risk factor surveillance showed that high prevalence of diabetes, hypertension and obesity in urban areas with slightly lower prevalence rates in semi-urban and rural areas. There are several challenges in obtaining data on NCD risk factors, which include challenges in obtaining anthropometric and blood pressure measures and in assessing tobacco consumption, diet and physical activity. The challenges in field operations include contacting and convincing subjects, creating rapport, tracking subjects, climatic conditions, recall ability and interviewer skills. Success in surveillance studies depends on anticipating and managing these challenges
Improving country-level surveillance and monitoring is a valuable step in prevention and control of NCDs in India.
Challenges; diabetes; IDSP; India; noncommunicable diseases; risk factor surveillance
Due to a paucity of data regarding the availability and efficacy of equipment, health promotion methods and materials currently used by health professionals for the management of patients with non-communicable diseases (NCDs) at primary health care (PHC) facilities in Cape Town, an audit was undertaken.
A multi-centre cross-sectional study was undertaken to interview patients (n = 580) with NCDs at 30 PHC facilities. A questionnaire was used to obtain information on preferences for health promotion methods for lifestyle modification. Individual semi-structured interviews were conducted with selected health professionals (n = 14) and captured using a digital recorder. Data were transferred to the Atlas ti software programme and analysed using a thematic content analysis approach.
Blood pressure measurement (97.6%) was the most common diagnostic test used, followed by weight measurement (88.3%), urine (85.7%) and blood glucose testing (80.9%). Individual lifestyle modification counselling was the preferred health education method of choice for the majority of patients. Of the 64% of patients that selected chronic clubs/support groups as a method of choice, only a third rated this as their first choice. Pamphlets, posters and workshops/group counselling sessions were the least preferred methods with only 9%, 13% and 11% of patients choosing these as their first choice, respectively. In an individual counselling setting 44.7% of patients reported that they would prefer to be counselled by a doctor, followed by a nurse (16.9%), health educator (8.8%) and nutrition advisor (4.8%). Health professionals identified numerous barriers to education and counselling. These can be summarised as a lack of resources, including time, space and equipment; staff-related barriers such as staff shortage and staff turnover; and patient-related barriers such as patient load and patient non-compliance.
The majority of patients attending PHC facilities want to receive lifestyle modification education. There is not however, one specific method that can be regarded as the gold standard. Patients’ preferences regarding health education methods differ, and they are more likely to be susceptible to methods that do not involve much reading. Health education materials such as posters, pamphlets and booklets should be used to supplement information received during counselling or support group sessions.
Patient preferences; Health education materials; Health education methods; Chronic diseases of lifestyle; Lifestyle modification
Over the last decade there has been vast interest in and focus on the implementation of personalized genomic medicine. Although there is general agreement that personalized genomic medicine involves utilizing genome technology to assess individual risk and ensure the delivery of the “right treatment, for the right patient, at the right time,” different categories of stakeholders focus on different aspects of personalized genomic medicine and operationalize it in diverse ways. In order to move toward a clearer, more holistic understanding of the concept, this article begins by identifying and defining three major elements of personalized genomic medicine commonly discussed by stakeholders: molecular medicine, pharmacogenomics, and health information technology. The integration of these three elements has the potential to improve health and reduce health care costs, but it also raises many challenges. This article endeavors to address these challenges by identifying five strategic areas that will require significant investment for the successful integration of personalized genomics into clinical care: (1) health technology assessment; (2) health outcomes research; (3) education (of both health professionals and the public); (4) communication among stakeholders; and (5) the development of best practices and guidelines. While different countries and global regions display marked heterogeneity in funding of health care in the form of public, private, or blended payor systems, previous analyses of personalized genomic medicine and attendant technological innovations have been performed without due attention to this complexity. Hence, this article focuses on personalized genomic medicine in the United States as a model case study wherein a significant portion of health care payors represent private, nongovernment resources. Lessons learned from the present analysis of personalized genomic medicine could usefully inform health care systems in other global regions where payment for personalized genomic medicine will be enabled through private or hybrid public-private funding systems.
Personalized Genomic Medicine; Personalized Medicine; Ethics; Genomics; Policy
Although urban residence is consistently identified as one of the primary correlates of non-communicable disease in low- and middle-income countries, it is not clear why or how urban settings predispose individuals and populations to non-communicable disease (NCD), or how this relationship could be modified to slow the spread of NCD. The urban–rural dichotomy used in most population health research lacks the nuance and specificity necessary to understand the complex relationship between urbanicity and NCD risk. Previous studies have developed and validated quantitative tools to measure urbanicity continuously along several dimensions but all have been isolated to a single country. The purposes of this study were 1) To assess the feasibility and validity of a multi-country urbanicity scale; 2) To report some of the considerations that arise in applying such a scale in different countries; and, 3) To assess how this scale compares with previously validated scales of urbanicity.
Household and community-level data from the Young Lives longitudinal study of childhood poverty in 59 communities in Ethiopia, India and Peru collected in 2006/2007 were used. Household-level data include parents’ occupations and education level, household possessions and access to resources. Community-level data include population size, availability of health facilities and types of roads. Variables were selected for inclusion in the urbanicity scale based on inspection of the data and a review of literature on urbanicity and health. Seven domains were constructed within the scale: Population Size, Economic Activity, Built Environment, Communication, Education, Diversity and Health Services.
The scale ranged from 11 to 61 (mean 35) with significant between country differences in mean urbanicity; Ethiopia (30.7), India (33.2), Peru (39.4). Construct validity was supported by factor analysis and high corrected item-scale correlations suggest good internal consistency. High agreement was observed between this scale and a dichotomized version of the urbanicity scale (Kappa 0.76; Spearman’s rank-correlation coefficient 0.84 (p < 0.0001). Linear regression of socioeconomic indicators on the urbanicity scale supported construct validity in all three countries (p < 0.05).
This study demonstrates and validates a robust multidimensional, multi-country urbanicity scale. It is an important step on the path to creating a tool to assess complex processes like urbanization. This scale provides the means to understand which elements of urbanization have the greatest impact on health.
Non-communicable diseases (NCDs), which include cardiovascular disease, cancer, and diabetes, all of which are associated with the common risk factors of poor diet and insufficient physical activity, caused 63% of all deaths globally in 2008. The increasing discussion of global NCDs, including at the 2011 United Nations General Assembly High-level Meeting on the Prevention and Control of Non-communicable Diseases, and a request for multi-stakeholder engagement, prompted the International Food Information Council Foundation to sponsor the Global Diet and Physical Activity Communications Summit: “Insights to Motivate Healthful, Active Lifestyles” on September 19, 2011, in New York City. The Summit brought together a diverse group of stakeholders, representing 34 nations from governments; communication, health, nutrition, and fitness professions; civil society; nonprofits; academia; and the private sector. The Summit provided expert insights and best practices for the use of science-based, behavior-focused communications to motivate individuals to achieve healthful, active lifestyles, with the goal of reducing the prevalence of NCDs. Presented here are some of the highlights and key findings from the Summit.
behavior; communication; energy balance; messages; non-communicable disease
Approximately 40% of the US population report using complementary and alternative medicine, including Maharishi Vedic Medicine (MVM), a traditional, comprehensive system of natural medicine, for relief from chronic and other disorders. Although many reports suggest health benefits from individual MVM techniques, reports on integrated holistic approaches are rare. This case series, designed to investigate the effectiveness of an integrated, multi-modality MVM program in an ideal clinical setting, describes the outcomes in four patients: one with sarcoidosis; one with Parkinson’s disease; a third with renal hypertension; and a fourth with diabetes/essential hypertension/anxiety disorder. Standard symptom reports and objective markers of disease were evaluated before, during, and after the treatment period. Results suggested substantial improvements as indicated by reductions in major signs, symptoms, and use of conventional medications in the four patients during the 3-week in-residence treatment phase and continuing through the home follow-up program.
complementary and alternative medicine; chronic disease; Maharishi Vedic Medicine; natural medicine
Treatment services constitute one of the five priority actions to face the global crisis due to noncommunicable diseases (NCDs). It is important to formulate standard treatment guidelines (STGs) for an effective management, particularly at the primary and secondary levels of health care. Dissemination and implementation of STGs for NCDs on a country-wide scale involves difficult and complex issues. The management of NCDs and the associated costs are highly variable and huge. Besides the educational strategies for promotion of STGs, the scientific and administrative sanctions and sanctity are important for purposes of reimbursements, insurance, availability of facilities, and legal protection. An effective and functional referral- system needs to be built to ensure availability of appropriate care at all levels of health- services. The patient-friendly “to and fro” referral system will help to distribute the burden, lower the costs, and maintain the sustainability of services.
Chronic respiratory disease; evidence-based guidelines; noncommunicable diseases; primary care; referral system; standard treatment guidelines
The International Network of field sites with continuous Demographic Evaluation of Populations and Their Health (INDEPTH) has 34 Health and Demographic Surveillance System (HDSS) in 17 different low and middle-income countries. Of these, 23 sites are in Africa, 10 sites are in Asia, and one in Oceania. The INDEPTH HDSS sites in Asia identified chronic non-communicable diseases (NCDs) as a neglected area of attention. As a first step, they conducted NCD risk factor surveys within nine sites in five countries. These sites are now looking to broaden the agenda of research on NCDs using the baseline data to inform policy and practice.
A conceptual framework for translating research into action for NCDs at INDEPTH sites was developed. This had five steps – assess the problem, understand the nature of the problem, evaluate different interventions in research mode, implement evidence-based interventions in programme mode, and finally, share knowledge and provide leadership to communities and countries. Ballabgarh HDSS site in India has successfully adopted these steps and is used as a case study to demonstrate how this progress was achieved and what factors were responsible for a successful outcome.
Most of the HDSS sites are in the second step of the process of translating research to action (understand the problem). The conduct of NCD risk factor surveys has enabled an assessment of the burden of NCD risk together with determinants in order to understand the burden at the population level. The experience from Ballabgarh HDSS exemplifies that the following steps – pilot testing the interventions, implementing activities in programme mode, and finally, share knowledge and provide leadership – are also possible in rural settings in low-income countries. The critical success factors identified were involvement of a premier medical institution, pre-existing links to policy makers and programme managers, strong commitment of the HDSS team and adequate human resource capacity.
All INDEPTH HDSS sites now need to strengthen their links to health systems at different levels and enhance their capacity to engage different stakeholders in their respective country settings so as to translate the current knowledge into actions that can benefit the health of the population they serve and beyond.
non-communicable diseases; surveillance; policy; translational research