Double Burden Of Disease Research Articles

The double burden of disease among mining workers in Papua, Indonesia: at the crossroads between Old and New health paradigms.

BackgroundAs the global shift toward non-communicable diseases overlaps with the unfinished agenda of confronting infectious diseases in low- and middle-income countries, epidemiological links across both burdens must be recognized. This study examined the non-communicable disease-infectious disease overlap in the specific comorbidity rates for key diseases in an occupational cohort in Papua, Indonesia.MethodsDiagnosed cases of ischaemic heart disease, stroke, hypertension, diabetes (types 1 and 2), chronic obstructive pulmonary disease, asthma, cancer, HIV and AIDS, tuberculosis, and malaria were extracted from 22,550 patient records (21,513 men, 1037 women) stored in identical electronic health information systems from two clinic sites in Papua, Indonesia. Data were collected as International Classification of Diseases, 10th Revision, entries from records spanning January-December 2013. A novel application of Circos software was used to visualize the interconnectedness between the disease burdens as overlapping prevalence estimates representing comorbidities.ResultsOverall, NCDs represented 38 % of all disease cases, primarily in the form of type 2 diabetes (n = 1440) and hypertension (n = 1398). Malaria cases represented the largest single portion of the disease burden with 5310 recorded cases, followed by type 2 diabetes with 1400 cases. Tuberculosis occurred most frequently alongside malaria (29 %), followed by chronic obstructive pulmonary disease (19 %), asthma (17 %), and stroke (12 %). Hypertension-tuberculosis (4 %), tuberculosis-cancer (4 %), and asthma-tuberculosis (2 %) comorbidities were also observed.ConclusionsThe high prevalence of multimorbidity, preponderance of non-communicable diseases, and extensive interweaving of non-communicable and infectious disease comorbidities highlighted in this cohort of mining workers in Papua, Indonesia reflect the markedly double disease burden increasingly plaguing Indonesia and other similar low- and middle-income countries – a challenge with which their over-stretched, under-resourced health systems are ill-equipped to cope. Integrated, person-centered treatment and control strategies rooted in the primary healthcare sector will be critical to reverse this trend.

Intestinal parasites, growth and physical fitness of schoolchildren in poor neighbourhoods of Port Elizabeth, South Africa: a cross-sectional survey.

BackgroundAs traditional lifestyle and diets change with social and economic development, disadvantaged communities in low- and middle-income countries increasingly face a double burden of communicable and non-communicable diseases. We studied the relationship between physical fitness and infections with soil-transmitted helminths (STHs), intestinal protozoa and Helicobacter pylori among schoolchildren in Port Elizabeth, South Africa.MethodsWe conducted a cross-sectional survey among 1009 children, aged 9 to 12 years, from eight primary schools in socioeconomically disadvantaged neighbourhoods of Port Elizabeth. Physical fitness was determined using field-deployable tests of the Eurofit fitness test battery. Stool samples were analysed with the Kato-Katz thick smear technique to diagnose STHs and with rapid diagnostic tests (RDTs) to detect intestinal protozoa and H. pylori infections. Haemoglobin (Hb) levels were assessed and anthropometric indicators determined.ResultsComplete data were available for 934 children (92 %). In two schools, high STH prevalences were found (Ascaris lumbricoides 60 and 72 %; Trichuris trichiura 65 % each). For boys and girls co-infected with A. lumbricoides and T. trichiura (n = 155) the maximal oxygen uptake (VO2 max) was estimated to be 50.1 and 47.2 ml kg-1 min-1, compared to 51.5 and 47.4 ml kg-1 min-1 for their non-infected peers (n = 278), respectively. On average, children without helminth infections had greater body mass (P = 0.011), height (P = 0.009) and a higher body mass index (P = 0.024) and were less often stunted (P = 0.006), but not significantly less wasted compared to their peers with a single or dual species infection. Among 9-year-old boys, a negative correlation between helminth infections and VO2 max, grip strength and standing broad jump distance was observed (P = 0.038). The overall mean Hb level was 122.2 g l-1. In the two schools with the highest prevalence of STHs the Hb means were 119.7 and 120.5 g l-1, respectively.ConclusionsIntestinal parasite infections appear to have a small but significant negative effect on the physical fitness of infected children, as expressed by their maximal oxygen uptake. We observed a clear impact on anthropometric indicators.Electronic supplementary materialThe online version of this article (doi:10.1186/s13071-016-1761-5) contains supplementary material, which is available to authorized users.

The Effect of HIV and the Modifying Effect of Anti-Retroviral Therapy (ART) on Body Mass Index (BMI) and Blood Pressure Levels in Rural South Africa.

BackgroundHigh BMI and blood pressure are leading chronic disease risk factors in South Africa. Longterm effects of HIV and ART on adiposity and blood pressure are poorly understood, and direct comparisons of risk factor trajectories in HIV- versus HIV+ populations are rare.MethodsIn 2003 and 2010, height, weight, and blood pressure were recorded in a study population (n = 505) in KwaZulu-Natal, South Africa (30% adult HIV prevalence). We modeled change in BMI and BP longitudinally in HIV- individuals (n = 315), seroconverters (n = 32), HIV+ patients not on ART (HIV+ART−; n = 52), HIV+ patients on ART for 0–<2 years as of 2010 (HIV+ART0–<2 yrs; n = 18), patients on ART for 2–5 years (HIV+ART2–5yrs; n = 44), and a subgroup with unknown HIV status (n = 44). Difference-in-differences were assessed in reference to the HIV- population.ResultsBetween 2003 and 2010, BMI increased significantly in the HIV- group, by 0.874 (95% CI 0.339, 1.41; p = 0.001), to 30.4. BMI drop was significantly greater in HIV+ART0-<2yrs than in HIV+ART2–5yrs (p = 0.005). DID in BMI in HIV+ART0-<2yrs versus the reference was -5.21 (95% CI -7.53, -2.90; p = 0.001), and DID in HIV+ART2–5yrs versus reference was -1.35 (95% CI -2.89, 0.189; p = 0.086). DID in SBP in HIV+ART−vs HIV- DID was -7.55 mmHg (95% CI -13.2 to -1.90; p = 0.009).ConclusionShort-term ART (0–<2 years) was associated with larger weight loss than either no ART or long-term ART. Once on ART for 2+ years, individuals ‘caught up’ on weight gain with the HIV- population. Our results showcase the importance of health system readiness to address the burgeoning double burden of disease in South Africa.

Relationship between Physical Activity and Stroke: Review From Different Meta Analytical Studies

Introduction: Developing countries like India are facing a double burden of communicable and non-communicable diseases. Stroke is one of the leading causes of death and disability in India. Objective: To systematically review and report the articles from world on physical activity to reduce the risk of stroke. Methodology: Study was done on May 2016 through various databases using search terms „physical activity‟ AND “Meta-analysis” AND „Stroke‟. 17 Meta analytical articles were identified for this review based on inclusion and exclusion criteria. Results: We selected 17 Meta analysis articles including 137 prospective studies, 541 randomized controlled trials, 22 case control and 108 cohort studies. All articles included in this review were from 2000 to till date. Conclusion: Physical activity is found to have an independent protective effect against cerebrovascular events.

Cardiovascular diseases in mega-countries: the challenges of the nutrition, physical activity and epidemiologic transitions, and the double burden of disease.

Purpose of reviewThere are today 11 mega-countries with more than 100 million inhabitants. Together these countries represent more than 60% of the world's population. All are facing noncommunicable chronic disease (NCD) epidemic where high cholesterol, obesity, diabetes, and cardiovascular diseases are becoming the main public health concerns. Most of these countries are facing the double burden of malnutrition where undernutrition and obesity coexist, increasing the complexity for policy design and implementation. The purpose of this study is to describe diverse sociodemographic characteristics of these countries and the challenges for prevention and control in the context of the nutrition transition.Recent findingsMega-countries are mostly low or middle-income and are facing important epidemiologic, nutrition, and physical activity transitions because of changes in food systems and unhealthy lifestyles. NCDs are responsible of two-thirds of the 57 million global deaths annually. Approximately, 80% of these are in low and middle-income countries. Only developed countries have been able to reduce mortality rates attributable to recognized risk factors for NCDs, in particular high cholesterol and blood pressure.SummaryMega-countries share common characteristics such as complex bureaucracies, internal ethnic, cultural and socioeconomic heterogeneity, and complexities to implement effective health promotion and education policies across population. Priorities for action must be identified and successful lessons and experiences should be carefully analyzed and replicated.

Asymmetry in an uneven place: migrants’ lifestyles, social capital, and self-rated health status in James Town, Accra

This exploratory study examines how migrants’ lifestyles are associated with subjective assessment of their health status in a relatively poor urban neighborhood in Accra. For more than half a century, urban centers have been on the receiving end of internal migrants in Ghana with Accra, Kumasi, and Sekondi-Takoradi receiving the lion’s share. However, a lot of migrants end up in poor neighborhoods due to inability to afford relatively costly rents in the better residential areas in the cities. Migrants who live on the margins of society are adversely impacted by poor environmental conditions that make them susceptible to environmentally-induced diseases such as malaria, cholera, and typhoid. While the poverty, health, and place research in Accra, Ghana, have focused on spatial distribution of inequalities in health, burden of sexual ill health, double burden of diseases, environment, wealth and health relationship, as well as income and health connections, there is paucity of research on association between the daily lifestyles of migrants in poor urban neighborhoods and their health status. Specifically on lifestyle and contextual factors, we examine (1) eating and drinking behavior, (2) perception of environmental factors, (3) attitudes and practices during illnesses, and (4) physical activities. Results from Ordinal Logit Regression models suggest that the key predictors of self-rated health status are: (1) socio-demographic elements like length of stay, job type, and religiosity; and (2) eating and drinking behavior—frequency of buying food from food vendors, and (3) social capital.

Non-communicable diseases in sub-Saharan Africa: understanding the drivers of the epidemic to inform intervention strategies

Sub-Saharan Africa is experiencing a rapidly increasing epidemic of non-communicable diseases (NCDs), while it continues to face longstanding challenges from infectious diseases. This double burden of disease could have a devastating impact on a continent that already has significant resource constraints, emphasizing the urgent need for appropriate interventions in the region. However, it is crucial to have a careful understanding of the local drivers of NCDs. This should not only include study of the traditional lifestyle risk factors, but also an examination of emerging risk factors (such as the influence of insults early in life or interactions with infection), which may be of particular importance in Africa.

Fish, food security and health in Pacific Island countries and territories: a systematic literature review.

BackgroundPacific Island countries and territories (PICTs) face a double burden of disease, with a high prevalence of household food insecurity and childhood micronutrient deficiencies, accompanied by a burgeoning increase in adult obesity, diabetes and heart disease.MethodsA systematic literature review was undertaken to assess whether increased availability of, and access to, fish improves a) household food security and b) individual nutritional status.ResultsA total of 29 studies were reviewed. Fourteen studies identified fish as the primary food source for Pacific Islanders and five studies reported fish/seafood as the primary source of dietary protein. Fish consumption varied by cultural sub-region and Pacific Island countries and territories. Fish consumption and nutritional status was addressed in nine studies, reporting moderate iodine deficiency in Vanuatu where only 30 % of participants consumed mostly fresh fish. Similarly, the degree to which Pacific Islanders depended on fishing for household income and livelihood varied between and within PICTs. For more economically developed countries, household income was derived increasingly from salaried work and dependency on fishing activities has been declining.ConclusionsFishing remains a major contributor to food security in PICTs, through subsistence production and income generation. However, there is a paucity of research aimed at assessing how maintaining and/or improving fish consumption benefits the diets and health of Pacific Islanders as they contend with the ongoing nutrition transition that is characterised by an increasing demand for packaged imported foods, such as canned meats, instant noodles, cereals, rice, and sugar-sweetened beverages, with subsequent decreased consumption of locally-produced plants and animals.

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

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

Causes of death in Vanuatu.

BackgroundThe population of the Pacific Melanesian country of Vanuatu was 234,000 at the 2009 census. Apart from subsistence activities, economic activity includes tourism and agriculture. Current completeness of vital registration is considered too low to be usable for national statistics; mortality and life expectancy (LE) are derived from indirect demographic estimates from censuses/surveys. Some cause of death (CoD) data are available to provide information on major causes of premature death.MethodsDeaths 2001–2007 were coded for cause (ICDv10) for ages 0–59 years from: hospital separations (HS) (n = 636), hospital medical certificates (MC) of death (n = 1,169), and monthly reports from community health facilities (CHF) (n = 1,212). Ill-defined causes were 3 % for hospital deaths and 20 % from CHF. Proportional mortality was calculated by cause (excluding ill-defined) and age group (0–4, 5–14 years), and also by sex for 15–59 years. From total deaths by broad age group and sex from 1999 and 2009 census analyses, community deaths were estimated by deduction of hospital deaths MC. National proportional mortality by cause was estimated by a weighted average of MC and CHF deaths.ResultsNational estimates indicate main causes of deaths <5 years were: perinatal disorders (45 %) and malaria, diarrhea, and pneumonia (27 %). For 15–59 years, main causes of male deaths were: circulatory disease 27 %, neoplasms 13 %, injury 13 %, liver disease 10 %, infection 10 %, diabetes 7 %, and chronic respiratory disease 7 %; and for females: neoplasms 29 %, circulatory disease 15 %, diabetes 10 %, infection 9 %, and maternal deaths 8 %. Infection included tuberculosis, malaria, and viral hepatitis. Liver disease (including hepatitis and cancer) accounted for 18 % of deaths in adult males and 9 % in females. Non-communicable disease (NCD), including circulatory disease, diabetes, neoplasm, and chronic respiratory disease, accounted for 52 % of premature deaths in adult males and 60 % in females. Injuries accounted for 13 % in adult males and 6 % in females. Maternal deaths translate into an annual maternal mortality ratio of 130/100,000 for the period.ConclusionVanuatu manifests a double burden of disease with significant proportional mortality from perinatal disorders and infection/pneumonia <5 years and maternal mortality, coupled with significant proportional mortality in adults (15–59 years) from cardiovascular disease (CVD), neoplasms, and diabetes.

Factors associated with BMI, underweight, overweight, and obesity among adults in a population of rural south India: a cross-sectional study.

BackgroundOverweight, obesity, and related chronic diseases are becoming serious public health concerns in rural areas of India. Compounded with the existing issue of underweight, such concerns expose the double burden of disease and may put stress on rural healthcare. The purpose of this article was to present the prevalence and factors associated with underweight, overweight, and obesity in an area of rural south India.MethodsDuring 2013 and 2014, a random sample of adults aged 20–80 years were selected for participation in a cross-sectional study that collected information on diet (using a food frequency questionnaire), physical activity (using the Global Physical Activity Questionnaire), socioeconomic position (using a wealth index), rurality (using the MSU rurality index), education, and a variety of descriptive factors. BMI was measured using standard techniques. Using a multivariate linear regression analysis and multivariate logistic regression analyses, we examined associations between BMI, overweight, obesity, and underweight, and all potential risk factors included in the survey.ResultsAge and sex-adjusted prevalence of overweight, obesity class I, and obesity class II were 14.9, 16.1, and 3.3 % respectively. Prevalence of underweight was 22.7 %. The following variables were associated with higher BMI and/or increased odds of overweight, obesity class I, and/or obesity class II: Low physical activity, high wealth index, no livestock, low animal fat consumption, high n-6 polyunsaturated fat consumption, television ownership, time spent watching television, low rurality index, and high caste. The following variables were associated with increased odds of underweight: low wealth index, high rurality index, and low intake of n-6 PUFAs.ConclusionUnderweight, overweight, and obesity are prevalent in rural regions of southern India, indicating a village-level dual burden. A variety of variables are associated with these conditions, including physical activity, socioeconomic position, rurality, television use, and diet. To address the both underweight and obesity, policymakers must simultaneously focus on encouraging positive behaviour through education and addressing society-level risk factors that inhibit individuals from achieving optimal health.

Changing exposures in a changing world: models for reducing the burden of disease.

Environmental exposures are changing dramatically in location, intensity, and frequency. Many developing countries are undergoing a transition in which they face the double burden of infectious diseases as well as chronic diseases. Noncommunicable diseases have emerged as the leading cause of death and disability in developing countries. Globally, pollution is insufficiently appreciated and inadequately quantified as a cause of disease. The health burden from both noninfectious diseases and infectious disease, especially parasites, is high among exposed people. Mothers and children are particularly vulnerable to pollution-related diseases in developing countries. Exposures to pollution can cause protracted noncommunicable diseases across their life span. A global initiative to promote human health sciences and technologies would enhance collaborations and communications amongst investigators and public environmental health officials. Existing models that facilitate the transfer of information and research results exist and can provide insight into building such an international network, allowing better prediction of disease risk and provide ways to reduce exposure to environmental contaminants. A global network would bring together scientists from multiple disciplines and countries to work toward a better understanding of the double burden of disease, especially in low and middle income countries, and promote ways to improve public health.

Offline: Indonesia—unravelling the mystery of a nation

Size isn't everything. But population does make some contribution to a nation's presence, even its influence, in the world. China is the most populous country on our planet today, with 1·36 billion people (according to World Bank figures) making an increasingly telling impression on our lives. India is second (1·29 billion people). The USA is third (318·9 million). Which country comes next in this demographic league table? You might guess Brazil (population 206·1 million). Or Pakistan (185·0 million). Or maybe Nigeria (177·5 million). But you would be wrong. It's Indonesia (population, 254 ·5 million). Which is perplexing. Most of the countries mentioned occupy part of our imaginative reconstruction of the world (and of world power). But who knows anything about Indonesia? As one companion in Jakarta said last week, “People I meet always talk about going to Bali, never to Indonesia. It's a pity. There's so much more to my country than Bali.” Indeed. Recent excavations on the island of Sulawesi (Indonesia is composed of 17 000 islands, around 6000 of which are inhabited), have found the earliest evidence so far of hominins—teeth, bone fragments, and tools. This discovery dates Indonesia's ancient civilisation from around 118 000 years ago. Yet it is one of the least known, or discussed, today. Indonesia remains a mystery. This lamentation extends to medical science. The first published Lancet research paper with Indonesia in its title was in 1957—on homozygous haemoglobin-E disease, by Lie-Injo Luan Eng and Oey Hoey Giok at the University of Indonesia. But the footprint of Indonesia in the journal is, overall, weak. If you search for the word “India” in the title of Lancet publications, you will find 2098 entries. The US: 1287. China: 841. Indonesia? 33. On the positive side, the number of articles focusing on Indonesia is increasing: one in the 1950s, 22 after 2000. But the pattern of coverage does not reflect the country's burden of disease. Most papers we have published deal with infectious diseases—typhoid, malaria, and dengue, for example. There is almost nothing on non-communicable disease (only liver cancer and mental health after HbE). But the major causes of mortality and morbidity in the country are stroke, ischaemic heart disease, and TB. On health risks, the most influential are high blood pressure, smoking, obesity, malnutrition, and air pollution. Add to these dangers diabetes, road injuries, cirrhosis, and chronic lung disease, and one can see that, at least from this journal's perspective, we have given a wholly incomplete picture of current health predicaments in the fourth most populated country in the world. But these omissions are not ours alone. Why is the Indonesian voice so badly under-represented in the global conversation about health and medical science? Indonesians recognise the problem, and give several reasons. The country has more of an oral than a written culture. Its research community is less familiar with the dominant scientific language of English. The country has tended to look inwards rather than outwards, diminishing the importance of publishing in international journals. Yet Indonesia can be proud of several excellent research institutions. One is the Eijkman Institute, which is making a rapidly growing contribution to global medical science. A decade ago, its publication output was small. But in 2015, Eijkman could boast 50 publications in respected international journals—from strategies to manage hepatitis C to prospects for malaria elimination. Only last month, Eijkman scientists reported that Zika virus was circulating in Indonesia, alerting government authorities to a new public health danger. Indonesia has much to tell (and teach) the world about its experiences. Its struggle to achieve universal health coverage. The challenge of dealing with a double burden of disease. The gift of astonishing biodiversity. The Indonesian voice in medicine and science is too quiet. It's time that voice was heard. Indonesia's chief attribute, indeed its national motto, is Bhinneka Tunggal Ika—Unity in Diversity. The phrase sums up Indonesia's extraordinary cultural and linguistic variation. But, more importantly, it emphasises the nation's solidarity. There can be few phrases that best illustrate the global challenges that nations face today. The world is diverse, with many disagreements creating troubling prospects for our common future. But Indonesia's message is that unity must always overcome the diversity that threatens to tear us apart. Indonesia's values, its predicaments, and its attempted solutions have enormous global bearing.

Prevalence and factors affecting hypertension among old age population in rural area

Background: India, in the associated epidemiological transition, is facing a double burden of communicable and non-communicable diseases. Old age is not a disease in itself, but the elderly are vulnerable to long term diseases of insidious onset like hypertension. Due to deficit of regular screening and unawareness about complications of long term high blood pressure in old age in rural area the large number of population remain undiagnosed so they might suffer from the long term complications of hypertension. The main objectives of the study were to determine prevalence of hypertension among old age population and to study the factors affecting the hypertension. Methods: It was a cross sectional study conducted in rural area of Vadodara district, Gujarat, India from October 2012 to March 2013. The study participants were old age group population with age more than or equal to 60 completed years. A sample size of 600 was obtained using hypothesis testing method. Using simple random sampling, 6 talukas were selected and from each, 4 villages were chosen. From each village, 25 study participants were included by house to house survey. Results: Prevalence of hypertension was 42.7%, significantly higher in age group more than 80 years (61%) and females (48%). Hypertension was significantly associated with current alcohol and tobacco consumption. Education, living arrangements, marital status and working status were significantly affecting hypertension. Conclusions: Specific screening programmes are needed for early detection and control to avoid further complications. Geriatric health care should be integrated in the general health system up to primary health care level.

Study of clinical profile of stroke patients in rural tertiary health care centre

Background: There are 15 million people worldwide who suffer a stroke each year. According to the World Health Organization, stroke is the second leading cause of death for people above the age of 60 years, and the fifth leading cause in people aged 15 to 59 years old. Each year, nearly six million people worldwide die from stroke. One in six people worldwide will have a stroke in their lifetime. Methods: This cross sectional study was carried out from July 2014 to April 2016 of all new patients admitted with stroke in Indian institute of Medical Sciences and Research Center, Badnapur, Jalna, Maharashtra. India. Results: The cerebrovascular strokes were more common in males (58.53%) than females (41.46%). Most common age group was 61-70 years (34.95%). The Most common clinical feature was Hemiplegia (55.28%). most common risk factor was hypertension (48.78%), tobacco chewing (26.01%), smoking (19.51%), followed by past h/o of cerebrovascular stroke (12.19%), Dyslipidemia (8.94%). Most common type of stroke was ischemic (68.28%) and hemorrhagic (31.69%) was second most common in ischemic strokes most common involved areas were parietal (30.08%), basal ganglia (9.75%), frontal lobe (7.31%). In hemorrhagic stroke most common site was thalamus (10.56%) followed by ventricular (5.69%) and basal ganglia (4.06%). Conclusions: Young patients (age ≤45 years) were 16.26% which is more dangerous in view of productive year lost. Stroke having male predominance with hypertension was the most common risk factor smoking tobacco chewing and dyslipidemia were other risk factors for stroke and most common type of stroke was ischemic. Developing countries like India are facing a double burden of communicable and non-communicable diseases. Stroke is one of the leading causes of death and disability in India.

Multimorbidity: What do we know? What should we do?

Multimorbidity, which is defined as the co-occurrence of two or more chronic conditions, has moved onto the priority agenda for many health policymakers and healthcare providers. Patients with multimorbidity are high utilizers of healthcare resources and are some of the most costly and difficult-to-treat patients in Europe. Preventing and improving the way multimorbidity is managed is now a key priority for many countries, and work is at last underway to develop more sustainable models of care. Unfortunately, this effort is being hampered by a lack of basic knowledge about the aetiology, epidemiology, and risk factors for multimorbidity, and the efficacy and cost-effectiveness of different interventions. The European Commission recognizes the need for reform in this area and has committed to raising awareness of multimorbidity, encouraging innovation, optimizing the use of existing resources, and coordinating the efforts of different stakeholders across the European Union. Many countries have now incorporated multimorbidity into their own healthcare strategies and are working to strengthen their prevention efforts and develop more integrated models of care. Although there is some evidence that integrated care for people with multimorbidity can create efficiency gains and improve health outcomes, the evidence is limited, and may only be applicable to high-income countries with relatively strong and well-resourced health systems. In low- to middle-income countries, which are facing the double burden of infectious and chronic diseases, integration of care will require capacity building, better quality services, and a stronger evidence base.

Awareness, Treatment, and Control of Hypertension in Primary Health Care and Secondary Referral Medical Outpatient Clinic Settings at Enugu, Southeast Nigeria.

Essential hypertension is the most common noncommunicable disease (NCD), affecting more than half the adult population in many countries and being the major NCD contributor to the double burden of disease in developing countries. We undertook a survey of the hypertension awareness, treatment, and control in primary and secondary referral health care clinics in Enugu, Nigeria, and compared these data with those obtained in local community surveys. The prevalence of hypertension in the primary care clinic (9.2%) was lower than in a previously reported community survey (42.2%), while, in the referral clinic, 70.3% of patients attending were hypertensive. Hypertension awareness rates were 91.9%, 29.4%, and 93.2% in these respective health care settings. Treatment and control rates (89.9% and 72.9%) were better in the secondary care clinic than in the primary care centre (87.7% and 46.0%). (Chi-square analysis confirmed statistically significant differences between these rates (p < 0.05).) These data may form a useful index of health care system effectiveness in Nigeria. Possible reasons for the differences observed and effective strategies to address the waxing pandemic of hypertension are discussed.

Toward the sustainability of health interventions implemented in sub-Saharan Africa: a systematic review and conceptual framework.

BackgroundSub-Saharan Africa (SSA) is facing a double burden of disease with a rising prevalence of non-communicable diseases (NCDs) while the burden of communicable diseases (CDs) remains high. Despite these challenges, there remains a significant need to understand how or under what conditions health interventions implemented in sub-Saharan Africa are sustained. The purpose of this study was to conduct a systematic review of empirical literature to explore how health interventions implemented in SSA are sustained.MethodsWe searched MEDLINE, Biological s, CINAHL, Embase, PsycInfo, SCIELO, Web of Science, and Google Scholar for available research investigating the sustainability of health interventions implemented in sub-Saharan Africa. We also used narrative synthesis to examine factors whether positive or negative that may influence the sustainability of health interventions in the region.ResultsThe search identified 1819 citations, and following removal of duplicates and our inclusion/exclusion criteria, only 41 papers were eligible for inclusion in the review. Twenty-six countries were represented in this review, with Kenya and Nigeria having the most representation of available studies examining sustainability. Study dates ranged from 1996 to 2015. Of note, majority of these studies (30 %) were published in 2014. The most common framework utilized was the sustainability framework, which was discussed in four of the studies. Nineteen out of 41 studies (46 %) reported sustainability outcomes focused on communicable diseases, with HIV and AIDS represented in majority of the studies, followed by malaria. Only 21 out of 41 studies had clear definitions of sustainability. Community ownership and mobilization were recognized by many of the reviewed studies as crucial facilitators for intervention sustainability, both early on and after intervention implementation, while social and ecological conditions as well as societal upheavals were barriers that influenced the sustainment of interventions in sub-Saharan Africa.ConclusionThe sustainability of health interventions implemented in sub-Saharan Africa is inevitable given the double burden of diseases, health care worker shortage, weak health systems, and limited resources. We propose a conceptual framework that draws attention to sustainability as a core component of the overall life cycle of interventions implemented in the region.

Engaging the Entire Care Cascade in Western Kenya: A Model to Achieve the Cardiovascular Disease Secondary Prevention Roadmap Goals.

Cardiovascular disease (CVD) is the leading cause of death in the world, with a substantial health and economic burden confronted by low- and middle-income countries. In low-income countries such as Kenya, there exists a double burden of communicable and noncommunicable diseases, and the CVD profile includes many nonatherosclerotic entities. Socio-politico-economic realities present challenges to CVD prevention in Kenya, including poverty, low national spending on health, significant out-of-pocket health expenditures, and limited outpatient health insurance. In addition, the health infrastructure is characterized by insufficient human resources for health, medication stock-outs, and lack of facilities and equipment. Within this socio-politico-economic reality, contextually appropriate programs for CVD prevention need to be developed. We describe our experience from western Kenya, where we have engaged the entire care cascade across all levels of the health system, in order to improve access to high-quality, comprehensive, coordinated, and sustainable care for CVD and CVD risk factors. We report on several initiatives: 1) population-wide screening for hypertension and diabetes; 2) engagement of community resources and governance structures; 3) geographic decentralization of care services; 4) task redistribution to more efficiently use of available human resources for health; 5) ensuring a consistent supply of essential medicines; 6) improving physical infrastructure of rural health facilities; 7) developing an integrated health record; and 8) mobile health (mHealth) initiatives to provide clinical decision support and record-keeping functions. Although several challenges remain, there currently exists a critical window of opportunity to establish systems of care and prevention that can alter the trajectory of CVD in low-resource settings.

Mais Medicos Program: an effective action to reduce health inequities in Brazil.

The Program More Doctors (Programa Mais Médicos) aims to decrease the shortage of physicians and reduce the regional health disparities and involves three main strategies: i) more places and new Medical Courses based on the revised Curriculum Guidelines; ii) investments in the (re)construction of Primary Healthcare Units; iii) provision of Brazilian and foreign medical doctors. Until July 2014, the Program made the provision of 14,462 physicians to 3,785 municipalities with vulnerable areas. Evidence indicates a 53% reduction in the number of municipalities with physicians' shortage; in the North, 91% of the municipalities with physicians' shortage have been provisioned, with almost five physicians per municipality, on average. The professionals' integration in the Family Health Teams has strengthened and expanded the capacity of intervention, particularly in the context of adopting a healthcare model that encompasses different demands of health promotion, prevention, diagnosis and treatment of diseases and disorders, to face the challenge of the double burden of disease. The population is affected by obesity and non-communicable chronic diseases, alongside with infection, parasitic diseases and malnutrition remaining. The people of cities, rural areas and forests want more doctors, health perspectives and more social justice.