Exploring educational inequalities in hypertension control, salt knowledge and awareness, and patient advice: insights from the WHO STEPS surveys of adults from nine Eastern European and Central Asian countries.

OBJECTIVE: To inform strategies aimed at improving blood pressure (BP) control and reducing salt intake, we assessed educational inequalities in high blood pressure (HBP) awareness, treatment and control; physician's advice on salt reduction; and salt knowledge, perceptions and consumption behaviours in Eastern Europe and Central Asia. DESIGN: Data were collected in cross-sectional, population-based nationally representative surveys, using a multi-stage clustered sampling design. Five HBP awareness, treatment and control categories were created from measured BP and hypertension medication use. Education and other variables were self-reported. Weighted multinomial mixed-effects regression models, adjusted for confounders, were used to assess differences across education categories. SETTINGS: Nine Eastern European and Central Asian countries (Armenia, Azerbaijan, Belarus, Georgia, Kyrgyzstan, Republic of Moldova, Tajikistan, Turkey and Uzbekistan). PARTICIPANTS: Nationally representative samples of 30 455 adults aged 25-65 years. RESULTS: HBP awareness, treatment and control varied substantially by education. The coverage of physician's advice on salt was less frequent among participants with lower education, and those with untreated HBP or unaware of their HBP. The education gradient was evident in salt knowledge and perceptions of salt intake but not in salt consumption behaviours. Improved salt knowledge and perceptions were more prevalent among participants who received physician's advice on salt reduction. CONCLUSIONS: There is a strong education gradient in HBP awareness, treatment and control as well as salt knowledge and perceived intake. Enhancements in public and patient knowledge and awareness of HBP and its risk factors targeting socio-economically disadvantaged groups are urgently needed to alleviate the growing HBP burden in low- and middle-income countries.

Suboptimal Intake of Fruits and Vegetables in Nine Selected Countries of the World Health Organization European Region.

The objective of this study was to characterize fruit and vegetable consumption in 9 selected countries of the World Health Organization (WHO) European Region. We analyzed data on fruit and vegetable intake and participant sociodemographic characteristics for 30,455 adults in 9 Eastern European and Central Asian countries via standardized STEPS survey methodology. Fruit and vegetable consumption across all countries was suboptimal, with a high percentage of populations not meeting the WHO-recommended intake of at least 5 servings (400 g) per day. Strengthened implementation of evidence-based policies to increase intake of fruit and vegetables is needed to reduce the burden of and disparities in NCDs.

Evaluation of Blood Pressure Status and Mortality in Turkey: Findings from Chronic Diseases and Risk Factors Cohort Study.

Background and objectives: An important Non-Communicable Disease risk factor, hypertension (HT), is highly prevalent and controlled HT rates are not sufficient which increases the risk of developing premature deaths. The purpose of the study is to evaluate differences in all-cause and cardiovascular-related mortality according to HT status by using national data from Chronic Diseases and Risk Factors Survey in Turkey (2011-2017). Materials and Methods: Cox regression models were used to estimate hazard ratios (HR) for predicting the all-cause and cardiovascular system-related mortalities. Median follow-up period was 6.2 years. Results: Among individuals with HT, 41.8% was untreated, 30.1% received treatment and had controlled blood pressure, and 28.1% were under treatment but had uncontrolled BP levels. The hazard for mortality among treated & uncontrolled hypertensive participants was significantly higher for all-cause (HR = 1.32, 95% CI = 1.06-1.65), cardiovascular (HR = 2.11, 95% CI = 1.46-3.06), heart disease (HR = 2.24, 95% CI = 1.46-3.43), and Coronary Heart Disease mortality (HR = 2.66, 95% CI = 1.56-4.53) compared to normotensive participants. Conclusions: Individuals with HT who were treated but do not have controlled blood pressure in Turkey had a significantly increased risk of Cardiovascular Disease and all-cause mortality. Along with studies investigating the causes of uncontrolled blood pressure despite initiation of treatment, support should be provided to patients in cases of non-adherence to antihypertensive medication or life change recommendations.

Physical inactivity in nine European and Central Asian countries: an analysis of national population-based survey results.

BACKGROUND: Physical inactivity is a major risk factor for non-communicable diseases. However, recent and systematically obtained national-level data to guide policy responses are often lacking, especially in countries in Eastern Europe and Central Asia. This article describes physical inactivity patterns among adults in Armenia, Azerbaijan, Belarus, Georgia, Kyrgyzstan, Republic of Moldova, Tajikistan, Turkey and Uzbekistan. METHODS: Data were collected using the Global Physical Activity Questionnaire drawing nationally representative samples of adults in each country. The national prevalence of physical inactivity was calculated as well as the proportional contribution to total physical activity (PA) during work, transport and leisure-time. An adjusted logistic regression model was applied to analyze the association of age, gender, education, household status and income with physical inactivity. RESULTS: National prevalence of physical inactivity ranged from 10.1% to 43.6%. The highest proportion of PA was registered during work or in the household in most countries, whereas the lowest was during leisure-time in all countries. Physical inactivity was more likely with older age in eight countries, with female gender in three countries, and with living alone in three countries. There was no clear pattern of association with education and income. CONCLUSION: Prevalence of physical inactivity is heterogeneous across the region. PA during leisure-time contributes minimally to total PA in all countries. Policies and programs that increase opportunities for active travel and leisure-time PA, especially for older adults, women and people living alone will be an essential part of strategies to increase overall population PA.

Health-related quality of life and perceived health status of Turkish population.

PURPOSE: This study was conducted to assess the health-related quality of life (HRQOL) and perceived health status of the Turkish population. METHODS: The data came from a nationwide survey, which was conducted by Ministry of Health on prevalence and risk factors for chronic diseases in Turkey, with a representative random sample of 18,477 people aged ≥ 15 years from Turkey. Each family physician invited two individuals selected from their registered population to the Family Health Center, conducted the survey by face to face interviews using an electronic form. HRQOL was determined using EQ-5D-3L scale. RESULTS: In Turkish population, each four women out of 10, two men out of 10 have problems in pain/discomfort and anxiety/depression dimensions of the scale; three women out of 10, one man out of 10 have some or severe problems in mobility. Proportion of people without health problems (health state 11,111) were 64,1% in men, 40,7% in women. The mean VAS score for males was 71.5 ± 0.2 (95% CI 70.9-72.1), 66.4 ± 0.2 (95% CI 65.8-66.9) for females (p < 0.05).The most important determinants of having a problem in any of the five dimensions are age, gender, education, diabetes mellitus, coronary heart disease, stroke, alzheimer, cancer, renal failure. The OR of having some or severe problems in any dimensions was 4.6 (95% CI 38-5.4) for over 65-74 and 7.5 (95% CI 5.8-9.6) for over 75 compared to 15-24 age group. CONCLUSIONS: The perceived health level and HRQOL is worse in women, in older age groups, in people from lower socioeconomical status.

[Evaluation of asthma and COPD awareness in primary care doctors in Turkey]. / Türkiye'de birinci basamak hekimlerinde astim ve KOAH farkindaliginin degerlendirilmesi.

INTRODUCTION: Chronic pulmonary diseases cause significant morbidity and mortality. However awareness about the risk factors, symptoms, diagnosis and traetment of these disorders is low among patients and health care providers. Our aim was to evaluate the awareness of asthma and chronic obstructive pulmonary disease among primary care doctors. This study was performed by the national Global Alliance Against Chronic Respiratory Diseases programme. MATERIALS AND METHODS: Primary care doctors employed by the Ministry of Healthy were included to the study. Turkish Statistical Institute randomly selected 680 doctors. Questionnaires evaluating the awareness of asthma and COPD which were developed by the Turkish Thoracic Society COPD and asthma assemblies were completed online by these doctors. RESULT: 84% of the doctors described asthma as airway obstruction. Dyspnea was reported as the most common symptom of asthma (78.8%) and inspiratory rhonci was reported as the most common physical exam finding (42.3%). Around 50% of doctors thought impairment of pulmonary function tests (PFT) was important for diagnosis and evaluation of severity of asthma while 24.2% thought physical exam was more important. When treatment options were evaluated 87.6% chose inhaled treatment for asthma. COPD was described as bronchiectasis and chronic bronchitis by 9.1%, chronic bronchitis and emphysema by 61.6%, chronic bronchitis and asthma by 22.2% and asthma and emphysema by 7.1%. 1.2% of the doctors did not consider cigarette smoking as a risk factor for COPD. PFT was recommended for diagnosis by 83%. Most correctly differentiated asthma and COPD. Bronchodilators were the first choice for COPD by 72.5%. CONCLUSIONS: Awareness is low for asthma and COPD among primary care doctors. Awareness should be raised among health care professionals for these diseases with high economical burden to improve outcome.

Blood pressure control in Türkiye: A primary healthcare pilot study.

Hypertension is present in almost a third of Türkiye's adult population. The Ministry of Health of the Republic of Türkiye in conjunction with the World Health Organization, rolled out a pilot primary health care model from February 2019 to 2020 to improve hypertension screening, management, and follow-up across the provinces of Erzincan, Çankiri and Usak. The model was conducted in selected family health centers for one year and included multiple interventions - training of multidisciplinary primary care teams, implementation of evidence-based, standardised clinical guidelines related to monitoring and treatment of hypertension, clinical supervision and performance monitoring, and provision of health education to hypertensive individuals. Repeat surveys of population-based random samples of 975 patients were taken before (December 2018) and after (February 2020) model implementation to evaluate its effect on care delivery. There was an almost 6.5-fold increase in the measurement and subsequent recording of blood pressure compared to before model implementation (from 50 to 323). Blood pressure control improved to 58 % of measured individuals compared to 46 % of those measured at initial evaluation. The frequency of measuring risk factors and outcomes related to hypertension at least once a year increased for creatinine from 71 % to 79 %, fasting blood glucose from 70 % to 78 %, and tobacco use from 22 % to 31 %. Prescription of antihypertensive drugs increased from 49 % to 61 %. With improvements in hypertension-related care in all measures and across all regions, this primary healthcare model represents a potential paradigm for nationwide implementation.

A Nationwide Chronic Disease Management Solution via Clinical Decision Support Services: Software Development and Real-Life Implementation Report.

BACKGROUND: The increasing population of older adults has led to a rise in the demand for health care services, with chronic diseases being a major burden. Person-centered integrated care is required to address these challenges; hence, the Turkish Ministry of Health has initiated strategies to implement an integrated health care model for chronic disease management. We aim to present the design, development, nationwide implementation, and initial performance results of the national Disease Management Platform (DMP). OBJECTIVE: This paper's objective is to present the design decisions taken and technical solutions provided to ensure successful nationwide implementation by addressing several challenges, including interoperability with existing IT systems, integration with clinical workflow, enabling transition of care, ease of use by health care professionals, scalability, high performance, and adaptability. METHODS: The DMP is implemented as an integrated care solution that heavily uses clinical decision support services to coordinate effective screening and management of chronic diseases in adherence to evidence-based clinical guidelines and, hence, to increase the quality of health care delivery. The DMP is designed and implemented to be easily integrated with the existing regional and national health IT systems via conformance to international health IT standards, such as Health Level Seven Fast Healthcare Interoperability Resources. A repeatable cocreation strategy has been used to design and develop new disease modules to ensure extensibility while ensuring ease of use and seamless integration into the regular clinical workflow during patient encounters. The DMP is horizontally scalable in case of high load to ensure high performance. RESULTS: As of September 2023, the DMP has been used by 25,568 health professionals to perform 73,715,269 encounters for 16,058,904 unique citizens. It has been used to screen and monitor chronic diseases such as obesity, cardiovascular risk, diabetes, and hypertension, resulting in the diagnosis of 3,545,573 patients with obesity, 534,423 patients with high cardiovascular risk, 490,346 patients with diabetes, and 144,768 patients with hypertension. CONCLUSIONS: It has been demonstrated that the platform can scale horizontally and efficiently provides services to thousands of family medicine practitioners without performance problems. The system seamlessly interoperates with existing health IT solutions and runs as a part of the clinical workflow of physicians at the point of care. By automatically accessing and processing patient data from various sources to provide personalized care plan guidance, it maximizes the effect of evidence-based decision support services by seamless integration with point-of-care electronic health record systems. As the system is built on international code systems and standards, adaptation and deployment to additional regional and national settings become easily possible. The nationwide DMP as an integrated care solution has been operational since January 2020, coordinating effective screening and management of chronic diseases in adherence to evidence-based clinical guidelines.

The reported impact of non-communicable disease investment cases in 13 countries.

Non-communicable diseases (NCDs) are a leading health and development challenge worldwide. Since 2015, WHO and the United Nations Development Programme have provided support to governments to develop national NCD investment cases to describe the socioeconomic dimensions of NCDs. To assess the impact of the investment cases, semistructured interviews and a structured process for gathering written feedback were conducted between July and October 2022 with key informants in 13 countries who had developed a national NCD investment case between 2015 and 2020. Investment cases describe: (1) the social and economic costs of NCDs, including their distribution and projections over time; (2) priority areas for scaled up action; (3) the cost and returns from investing in WHO-recommended measures to prevent and manage NCDs; and (4) the political dimensions of NCD responses. While no country had implemented all the recommendations set out in their investment case reports, actions and policy changes attributable to the investment cases were identified, across (1) governance; (2) financing; and (3) health service access and delivery. The pathways of these changes included: (1) stronger collaboration across government ministries and partners; (2) advocacy for NCD prevention and control; (3) grounding efforts in nationally owned data and evidence; (4) developing mutually embraced 'language' across health and finance; and (5) elevating the priority accorded to NCDs, by framing action as an investment rather than a cost. The assessment also identified barriers to progress on the investment case implementation, including the influence of some private sector entities on sectors other than health, the impact of the COVID-19 pandemic, and changes in senior political and technical government officials. The results suggest that national NCD investment cases can significantly contribute to catalysing the prevention and control of NCDs through strengthening governance, financing, and health service access and delivery.

[The evaluation of asthma and COPD awareness in Turkey (GARD Turkey Project-National Control Program of Chronic Airway Diseases)]. / Türkiye'de astim ve KOAH farkindaliginin degerlendirilmesi (GARD Türkiye Projesi-Kronik Hava Yollari Hastaliklari Ulusal Kontrol Programi).

INTRODUCTION: Although chronic respiratory disorders are important causes of morbidity and mortality, health care workers, patients and caretakers are not well informed about these disorders. Therefore these problems are underdiagnosed and undertreated; also preventive measures are not widely taken. Our aim was to evaluate the knowledge of asthma and chronic obstructive pulmonary disease (COPD) in Turkey. This study was designed and performed as a Global Alliance Against Respiratory Disorders (GARD) project. MATERIALS AND METHODS: People greater than 15 years of age who lived in cities with a population of 200 or greater were eligible for the study. A questionnaire including demographic data and questions regarding asthma and COPD was used for the evalution of the participants. RESULTS: 12.000 people were selected (6000 in rural and 6000 in urban areas); 8527 people were reached. 8342 people who completed the questionnaire were included to the study. There were 4182 (50.1%) female and 4160 (%49.9) male subjects. 49.6% of the subjcets knew that COPD is a lung disease, 51.1% indicated that smoking is the most important risk factor for COPD and 48% identified quitting smoking as the most important preventive measure. Every other person had baseline knowledge on COPD. However only 25.2% knew that there are treatment options for COPD. 80% of subjects said astma can be seen in all age groups. 51.1% knew asthma is a genetic disease and 58% said it is not an infectious disease. However when whether asthma medications caused drug dependency only 27% answered as "No" while 55.2% said "They do not know". CONCLUSION: Awareness of COPD and asthma seem to be infsufficient among Turkish people. Since these disorders are important causes of morbidity and mortality and have high impact on work and economic loss, it is important to increase knowledge among public.

The landscape of preventive cardiology in Turkey: Challenges and successes.

Turkey, like many countries, is facing a growing burden of non-communicable disease (NCD)s and is among the countries with high cardiovascular mortality in Europe. Moreover, Turkey currently has the highest rate of premature cardiovascular disease (CVD) in Europe. During the last decades, Turkey made fundamental reforms in the health system to improve the treatment of risk factors to prevent CVD. The most outstanding success was in the area of tobacco control (13.4% decrease in smoking prevalence) and decreasing the salt consumption of the population (from 18 to 9.9 g/day) leading to a significant decrease in CVD mortality from 45% to 36.8% of all deaths. However, obesity and diabetes are increasing rapidly as a result of urbanization, low physical activity and unhealthy eating and the new generation is starting to take up smoking. The increase in cardiometabolic risk factors and aging of the population are expected to increase the number of CVD deaths. All CVD risk factors except smoking are significantly more prevalent in women. In addition, rare disease is a country specific problem with a significant contribution to the high rates of premature CVD in Turkey. Despite major improvements in management in acute coronary syndromes, sustained achievement in guideline recommended goals is suboptimal. In patients with a previous cardiovascular event smoking rate is 25.5%, 80.9% of these patients are overweight (BMI ≥25 kg/m2), 30% obese (BMI ≥30 kg/m2), and LDL-cholesterol targets of 70 mg/dL are attained in only 18%. Herein, we scrutinize the achievements and challenges of Turkey in establishing a 'National Heart Health Policy' aiming to decrease the burden of CVD and its risk factors.