Quasi-experimental evaluation of a nationwide diabetes prevention programme.

Diabetes is a leading cause of morbidity, mortality and cost of illness1,2. Health behaviours, particularly those related to nutrition and physical activity, play a key role in the development of type 2 diabetes mellitus3. Whereas behaviour change programmes (also known as lifestyle interventions or similar) have been found efficacious in controlled clinical trials4,5, there remains controversy about whether targeting health behaviours at the individual level is an effective preventive strategy for type 2 diabetes mellitus6 and doubt among clinicians that lifestyle advice and counselling provided in the routine health system can achieve improvements in health7-9. Here we show that being referred to the largest behaviour change programme for prediabetes globally (the English Diabetes Prevention Programme) is effective in improving key cardiovascular risk factors, including glycated haemoglobin (HbA1c), excess body weight and serum lipid levels. We do so by using a regression discontinuity design10, which uses the eligibility threshold in HbA1c for referral to the behaviour change programme, in electronic health data from about one-fifth of all primary care practices in England. We confirm our main finding, the improvement of HbA1c, using two other quasi-experimental approaches: difference-in-differences analysis exploiting the phased roll-out of the programme and instrumental variable estimation exploiting regional variation in programme coverage. This analysis provides causal, rather than associational, evidence that lifestyle advice and counselling implemented at scale in a national health system can achieve important health improvements.

Lifetime Prevalence of Cervical Cancer Screening in 55 Low- and Middle-Income Countries.

Importance: The World Health Organization is developing a global strategy to eliminate cervical cancer, with goals for screening prevalence among women aged 30 through 49 years. However, evidence on prevalence levels of cervical cancer screening in low- and middle-income countries (LMICs) is sparse. Objective: To determine lifetime cervical cancer screening prevalence in LMICs and its variation across and within world regions and countries. Design, Setting, and Participants: Analysis of cross-sectional nationally representative household surveys carried out in 55 LMICs from 2005 through 2018. The median response rate across surveys was 93.8% (range, 64.0%-99.3%). The population-based sample consisted of 1 136 289 women aged 15 years or older, of whom 6885 (0.6%) had missing information for the survey question on cervical cancer screening. Exposures: World region, country; countries' economic, social, and health system characteristics; and individuals' sociodemographic characteristics. Main Outcomes and Measures: Self-report of having ever had a screening test for cervical cancer. Results: Of the 1 129 404 women included in the analysis, 542 475 were aged 30 through 49 years. A country-level median of 43.6% (interquartile range [IQR], 13.9%-77.3%; range, 0.3%-97.4%) of women aged 30 through 49 years self-reported to have ever been screened, with countries in Latin America and the Caribbean having the highest prevalence (country-level median, 84.6%; IQR, 65.7%-91.1%; range, 11.7%-97.4%) and those in sub-Saharan Africa the lowest prevalence (country-level median, 16.9%; IQR, 3.7%-31.0%; range, 0.9%-50.8%). There was large variation in the self-reported lifetime prevalence of cervical cancer screening among countries within regions and among countries with similar levels of per capita gross domestic product and total health expenditure. Within countries, women who lived in rural areas, had low educational attainment, or had low household wealth were generally least likely to self-report ever having been screened. Conclusions and Relevance: In this cross-sectional study of data collected in 55 low- and middle-income countries from 2005 through 2018, there was wide variation between countries in the self-reported lifetime prevalence of cervical cancer screening. However, the median prevalence was only 44%, supporting the need to increase the rate of screening.

Here to stay? Policy changes in alcohol home delivery and "to-go" sales during and after COVID-19 in the United States.

During the early phase of the COVID-19 pandemic, legislative changes that expanded alcohol home delivery and options for "to-go" alcohol sales were introduced across the United States to provide economic relief to establishments and retailers. Using data from the Alcohol Policy Information System, we examined whether these changes have persisted beyond the peak phase of the COVID-19 emergency and explored the implications for public health. Illustration of state-level policy data reveals that the liberalisation of alcohol delivery and "to-go" alcohol sales has continued throughout a 2-year period (2020 and 2021), with indications that many of these changes have or will become permanent after the pandemic. This raises concerns about inadequate regulation, particularly in preventing underage access to alcohol, and ensuing changes in drinking practices. In this commentary, we highlight the need for rigorous empirical evaluation of the public health impact of this changing policy landscape and underscore the potential risks associated with increased alcohol availability, including a corresponding increase in alcohol-attributable mortality and other alcohol-related harm, such as domestic violence. Policy makers should carefully consider public health consequences, whose costs may surpass short-term economic interests in the long term.

Stakeholder-Informed Solutions To Address Barriers for Alcohol Screening and Brief Intervention in Thai Hypertension Care.

Premature deaths from NCDs disproportionately affect people in low- and middle-income countries. Since alcohol use is one of the most common causes of reversible hypertension, interventions targeting alcohol use may be a feasible and effective low-cost approach to synergistically reduce the prevalence of harmful drinking and high blood pressure. This study sought to identify key factors in successfully implementing alcohol use screening and brief intervention in hypertension care in Thailand. For this purpose, we surveyed participants (NRound 1 = 91, NRound 2 = 27) from three different groups of Thai stakeholders (policy- and decisionmakers, primary healthcare practitioners, and patients diagnosed with hypertension) in a two-round stakeholder elicitation. In round 1, we identified limited resources, lack of clear guidelines for lifestyle intervention, stigmatization, and inconsistent monitoring of patients' alcohol use as important barriers. In round 2, we sought to elicit solutions for the barriers identified in round 1. While stakeholders emphasized the need for adaptability to existing realities in Thai primary healthcare such as a high workload and limited digitization, they favorably evaluated a digital alcohol assessment tool with integrated, tailored advice for brief intervention as a potential scalable solution. Findings suggest that as one possible route to reduce the NCD burden caused by hypertension in Thailand, primary healthcare services may be enhanced by digital tools that support resource-effective, intuitive, and seamless delivery of alcohol screening and brief intervention.

Who benefits from alcohol screening and brief intervention? A mini-review on socioeconomic inequalities with a focus on evidence from the United States.

Alcohol-attributable mortality contributes to growing health inequalities. Addressing hazardous alcohol use and alcohol use disorders through alcohol screening and brief intervention is therefore a promising public health strategy to improve health equity. In this narrative mini-review, we discuss the extent to which socioeconomic differences exist in the alcohol screening and brief intervention cascade, highlighting the example of the United States. We have searched PubMed to identify and summarize relevant literature addressing socioeconomic inequalities in (a) accessing and affording healthcare, (b) receiving alcohol screenings, and/or (c) receiving brief interventions, focusing predominantly on literature from the Unites States. We found evidence for income-related inequalities in access to healthcare in the United States, partly due to inadequate health insurance coverage for individuals with low socioeconomic status. Alcohol screening coverage appears to be generally very low, as is the probability of receiving a brief intervention when indicated. However, research suggests that the latter is more likely to be provided to individuals with low socioeconomic status than those with high socioeconomic status. Individuals with low socioeconomic status also tend to benefit more from brief interventions, showing greater reductions in their alcohol use. Once access to and affordability of healthcare is ensured and high coverage of alcohol screening is achieved for all, alcohol screening and brief interventions have the potential to enhance health equity by reducing alcohol consumption and alcohol-related health harms.

Achieving behavior change at scale: Causal evidence from a national lifestyle intervention program for pre-diabetes in the UK.

There remains widespread doubt among clinicians that mere lifestyle advice and counseling provided in routine care can achieve improvements in health. We aimed to determine the health effects of the largest behavior change program for pre-diabetes globally (the English Diabetes Prevention Programme) when implemented at scale in routine care. We exploited the threshold in glycated hemoglobin (HbA1c) used to decide on program eligibility by applying a regression discontinuity design, one of the most credible quasi-experimental strategies for causal inference, to electronic health data from approximately one-fifth of all primary care practices in England. Program referral led to significant improvements in patients' HbA1c and body mass index. This analysis provides causal, rather than associational, evidence that lifestyle advice and counseling implemented in a national health system can achieve important health improvements.

The Relationship Between Alcohol Consumption, BMI, and Type 2 Diabetes: A Systematic Review and Dose-Response Meta-analysis.

BACKGROUND: Moderate alcohol use may be associated with lower risk of type 2 diabetes mellitus (T2DM). Previous reviews have reached mixed conclusions. PURPOSE: To quantify the dose-response relationship between alcohol consumption and T2DM, accounting for differential effects by sex and BMI. DATA SOURCES: Medline, Embase, Web of Science, and one secondary data source. STUDY SELECTION: Cohort studies on the relationship between alcohol use and T2DM. DATA EXTRACTION: Fifty-five studies, and one secondary data source, were included with a combined sample size of 1,363,355 men and 1,290,628 women, with 89,983 and 57,974 individuals, respectively, diagnosed with T2DM. DATA SYNTHESIS: Multivariate dose-response meta-analytic random-effect models were used. For women, a J-shaped relationship was found with a maximum risk reduction of 31% (relative risk [RR] 0.69, 95% CI 0.64-0.74) at an intake of 16 g of pure alcohol per day compared with lifetime abstainers. The protective association ceased above 49 g per day (RR 0.82, 95% CI 0.68-0.99). For men, no statistically significant relationship was identified. When results were stratified by BMI, the protective association was only found in overweight and obese women. LIMITATIONS: Our analysis relied on aggregate data. We included some articles that determined exposure and cases via self-report, and the studies did not account for temporal variations in alcohol use. CONCLUSIONS: The observed reduced risk seems to be specific to women in general and women with a BMI ≥25 kg/m2. Our findings allow for a more precise prediction of the sex-specific relationship between T2DM and alcohol use, as our results differ from those of previous studies.

Reducing alcohol use through alcohol control policies in the general population and population subgroups: a systematic review and meta-analysis.

We estimate the effects of alcohol taxation, minimum unit pricing (MUP), and restricted temporal availability on overall alcohol consumption and review their differential impact across sociodemographic groups. Web of Science, Medline, PsycInfo, Embase, and EconLit were searched on 08/12/2022 and 09/26/2022 for studies on newly introduced or changed alcohol policies published between 2000 and 2022 (Prospero registration: CRD42022339791). We combined data using random-effects meta-analyses. Risk of bias was assessed using the Newcastle-Ottawa Scale. Of 1887 reports, 36 were eligible. Doubling alcohol taxes or introducing MUP (Int$ 0.90/10 g of pure alcohol) reduced consumption by 10% (for taxation: 95% prediction intervals [PI]: -18.5%, -1.2%; for MUP: 95% PI: -28.2%, 5.8%), restricting alcohol sales by one day a week reduced consumption by 3.6% (95% PI: -7.2%, -0.1%). Substantial between-study heterogeneity contributes to high levels of uncertainty and must be considered in interpretation. Pricing policies resulted in greater consumption changes among low-income alcohol users, while results were inconclusive for other socioeconomic indicators, gender, and racial and ethnic groups. Research is needed on the differential impact of alcohol policies, particularly for groups bearing a disproportionate alcohol-attributable health burden. Funding: Research reported in this publication was supported by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health under Award Number R01AA028009.

Personality Change Through Arts Education: A Review and Call for Further Research.

Education involving active engagement in the arts, herein called arts education, is often believed to foster the development of desirable personality traits and skills in children and adolescents. Yet the impact of arts education on personality development has rarely been systematically investigated. In the current article, we reviewed the literature on personality change through arts education. We identified 36 suitable experimental and quasi-experimental studies. Evidence from these studies tentatively suggests that arts-education programs can foster personality traits such as extraversion and conscientiousness but not self-esteem. In addition, the effects of arts education appeared to be stronger in early and middle childhood than in preadolescence and early adolescence. However, the evidence for the effectiveness of arts education was very limited among the few included true experiments. Furthermore, the reviewed studies were heterogenous and subject to content-related, methodological, and statistical limitations. Thus, the current evidence base is inconclusive as to the effects of arts education on personality development. By identifying potential effects of arts education and limitations of past research, our review serves as a call for more research and guidepost for future studies on arts education and personality change.

Use of lifestyle interventions in primary care for individuals with newly diagnosed hypertension, hyperlipidaemia or obesity: a retrospective cohort study.

OBJECTIVE: Lifestyle interventions can be efficacious in reducing cardiovascular disease risk factors and are recommended as first-line interventions in England. However, recent information on the use of these interventions in primary care is lacking. We investigated for how many patients with newly diagnosed hypertension, hyperlipidaemia or obesity, lifestyle interventions were recorded in their primary care electronic health record. DESIGN: A retrospective cohort study. SETTING: English primary care, using UK Clinical Practice Research Datalink. PARTICIPANTS: A total of 770,711 patients who were aged 18 years or older and received a new diagnosis of hypertension, hyperlipidaemia or obesity between 2010 and 2019. MAIN OUTCOME MEASURES: Record of lifestyle intervention and/or medication in 12 months before to 12 months after initial diagnosis (2-year timeframe). RESULTS: Analyses show varying results across conditions: While 55.6% (95% CI 54.9-56.4) of individuals with an initial diagnosis of hypertension were recorded as having lifestyle support (lifestyle intervention or signposting) within the 2-year timeframe, this number was reduced to 45.2% (95% CI 43.8-46.6) for hyperlipidaemia and 52.6% (95% CI 51.1-54.1) for obesity. For substantial proportions of individuals neither lifestyle support nor medication (hypertension: 12.2%, 95% CI 11.9-12.5; hyperlipidaemia: 32.2%, 95% CI 31.2-33.3; obesity: 43.9%, 95% CI 42.3-45.4) were recorded. Sensitivity analyses confirm that limited proportions of patients had lifestyle support recorded in their electronic health record before they were first prescribed medication (diagnosed and undiagnosed), ranging from 12.1% for hypertension to 19.7% for hyperlipidaemia, and 19.5% for obesity (23.4% if restricted to Orlistat). CONCLUSIONS: Limited evidence of lifestyle support for individuals with cardiovascular risk factors (hypertension, hyperlipidaemia, obesity) recommended by national guidelines in England may stem from poor recording in electronic health records but may also represent missed opportunities. Given the link between progression to cardiovascular disease and modifiable lifestyle factors, early support for patients to manage their conditions through non-pharmaceutical interventions by establishing lifestyle modification as first-line treatment is crucial.

Addressing alcohol use among blood pressure patients in Thai primary care: Lessons from a survey-based stakeholder consultation.

Alcohol use is a major risk factor for noncommunicable diseases in Thailand, and one of its pathways is high blood pressure. Given that brief intervention can effectively reduce hazardous alcohol consumption, this study aimed to investigate how hypertensive patients with concomitant alcohol use are identified and treated in Thai primary care settings and what this may mean for screening and lifestyle intervention strategies. In a cross-sectional, mixed-method design, we surveyed 91 participants from three different groups of Thai stakeholders: policy- and decisionmakers; healthcare practitioners; and patients diagnosed with hypertension. Data was collected between December 2020 and May 2021. Responses were analyzed descriptively and using open coding tools to identify current practices, barriers, facilitators, and implications for interventions. All stakeholder groups regarded alcohol use as an important driver of hypertension. While lifestyle interventions among hypertensive patients were perceived as beneficial, current lifestyle support was limited. Barriers included limited resources in primary healthcare facilities, lack of continuous monitoring or follow-up, missing tools or procedures for risk assessment and lifestyle intervention, and stigmatization of alcohol use. Our results suggest that although screening for lifestyle risk factors (including alcohol use) and lifestyle interventions are not yet sufficiently established, a wide range of stakeholders still recognize the potential of interventions targeted at hazardous alcohol use among hypertensive patients. Future interventions may establish standardized assessment tools, be tailored to high-risk groups, and include electronic or remote elements.

Use of statins for the prevention of cardiovascular disease in 41 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data.

BACKGROUND: In the prevention of cardiovascular disease, a WHO target is that at least 50% of eligible people use statins. Robust evidence is needed to monitor progress towards this target in low-income and middle-income countries (LMICs), where most cardiovascular disease deaths occur. The objectives of this study were to benchmark statin use in LMICs and to investigate country-level and individual-level characteristics associated with statin use. METHODS: We did a cross-sectional analysis of pooled, individual-level data from nationally representative health surveys done in 41 LMICs between 2013 and 2019. Our sample consisted of non-pregnant adults aged 40-69 years. We prioritised WHO Stepwise Approach to Surveillance (STEPS) surveys because these are WHO's recommended method for population monitoring of non-communicable disease targets. For countries in which no STEPS survey was available, a systematic search was done to identify other surveys. We included surveys that were done in an LMIC as classified by the World Bank in the survey year; were done in 2013 or later; were nationally representative; had individual-level data available; and asked questions on statin use and previous history of cardiovascular disease. Primary outcomes were the proportion of eligible individuals self-reporting use of statins for the primary and secondary prevention of cardiovascular disease. Eligibility for statin therapy for primary prevention was defined among individuals with a history of diagnosed diabetes or a 10-year cardiovascular disease risk of at least 20%. Eligibility for statin therapy for secondary prevention was defined among individuals with a history of self-reported cardiovascular disease. At the country level, we estimated statin use by per-capita health spending, per-capita income, burden of cardiovascular diseases, and commitment to non-communicable disease policy. At the individual level, we used modified Poisson regression models to assess statin use alongside individual-level characteristics of age, sex, education, and rural versus urban residence. Countries were weighted in proportion to their population size in pooled analyses. FINDINGS: The final pooled sample included 116 449 non-pregnant individuals. 9229 individuals reported a previous history of cardiovascular disease (7·9% [95% CI 7·4-8·3] of the population-weighted sample). Among those without a previous history of cardiovascular disease, 8453 were eligible for a statin for primary prevention of cardiovascular disease (9·7% [95% CI 9·3-10·1] of the population-weighted sample). For primary prevention of cardiovascular disease, statin use was 8·0% (95% CI 6·9-9·3) and for secondary prevention statin use was 21·9% (20·0-24·0). The WHO target that at least 50% of eligible individuals receive statin therapy to prevent cardiovascular disease was achieved by no region or income group. Statin use was less common in countries with lower health spending. At the individual level, there was generally higher statin use among women (primary prevention only, risk ratio [RR] 1·83 [95% CI 1·22-2·76), and individuals who were older (primary prevention, 60-69 years, RR 1·86 [1·04-3·33]; secondary prevention, 50-59 years RR 1·71 [1·35-2·18]; and 60-69 years RR 2·09 [1·65-2·65]), more educated (primary prevention, RR 1·61 [1·09-2·37]; secondary prevention, RR 1·28 [0·97-1·69]), and lived in urban areas (secondary prevention only, RR 0·82 [0·66-1·00]). INTERPRETATION: In a diverse sample of LMICs, statins are used by about one in ten eligible people for the primary prevention of cardiovascular diseases and one in five eligible people for secondary prevention. There is an urgent need to scale up statin use in LMICs to achieve WHO targets. Policies and programmes that facilitate implementation of statins into primary health systems in these settings should be investigated for the future. FUNDING: National Clinician Scholars Program at the University of Michigan Institute for Healthcare Policy and Innovation, and National Institute of Diabetes and Digestive and Kidney Diseases. TRANSLATION: For the Spanish translation of the abstract see Supplementary Materials section.

Patterns of tobacco use in low and middle income countries by tobacco product and sociodemographic characteristics: nationally representative survey data from 82 countries.

OBJECTIVES: To determine the prevalence and frequency of using any tobacco product and each of a detailed set of tobacco products, how tobacco use and frequency of use vary across countries, world regions, and World Bank country income groups, and the socioeconomic and demographic gradients of tobacco use and frequency of use within countries. DESIGN: Secondary analysis of nationally representative, cross-sectional, household survey data from 82 low and middle income countries collected between 1 January 2015 and 31 December 2020. SETTING: Population based survey data. PARTICIPANTS: 1 231 068 individuals aged 15 years and older. MAIN OUTCOME MEASURES: Self-reported current smoking, current daily smoking, current smokeless tobacco use, current daily smokeless tobacco use, pack years, and current use and use frequencies of each tobacco product. Products were any type of cigarette, manufactured cigarette, hand rolled cigarette, water pipe, cigar, oral snuff, nasal snuff, chewing tobacco, and betel nut (with and without tobacco). RESULTS: The smoking prevalence in the study sample was 16.5% (95% confidence interval 16.1% to 16.9%) and ranged from 1.1% (0.9% to 1.3%) in Ghana to 50.6% (45.2% to 56.1%) in Kiribati. The user prevalence of smokeless tobacco was 7.7% (7.5% to 8.0%) and prevalence was highest in Papua New Guinea (daily user prevalence of 65.4% (63.3% to 67.5%)). Although variation was wide between countries and by tobacco product, for many low and middle income countries, the highest prevalence and cigarette smoking frequency was reported in men, those with lower education, less household wealth, living in rural areas, and higher age. CONCLUSIONS: Both smoked and smokeless tobacco use and frequency of use vary widely across tobacco products in low and middle income countries. This study can inform the design and targeting of efforts to reduce tobacco use in low and middle income countries and serve as a benchmark for monitoring progress towards national and international goals.

The Association of Socioeconomic Status With Hypertension in 76 Low- and Middle-Income Countries.

BACKGROUND: Effective equity-focused health policy for hypertension in low- and middle-income countries (LMICs) requires an understanding of the condition's current socioeconomic gradients and how these are likely to change in the future as countries develop economically. OBJECTIVES: This cross-sectional study aimed to determine how hypertension prevalence in LMICs varies by individuals' education and household wealth, and how these socioeconomic gradients in hypertension prevalence are associated with a country's gross domestic product (GDP) per capita. METHODS: We pooled nationally representative household survey data from 76 LMICs. We disaggregated hypertension prevalence by education and household wealth quintile, and used regression analyses to adjust for age and sex. RESULTS: We included 1,211,386 participants in the analysis. Pooling across all countries, hypertension prevalence tended to be similar between education groups and household wealth quintiles. The only world region with a clear positive association of hypertension with education or household wealth quintile was Southeast Asia. Countries with a lower GDP per capita had, on average, a more positive association of hypertension with education and household wealth quintile than countries with a higher GDP per capita, especially in rural areas and among men. CONCLUSIONS: Differences in hypertension prevalence between socioeconomic groups were generally small, with even the least educated and least wealthy groups having a substantial hypertension prevalence. Our cross-sectional interaction analyses of GDP per capita with the socioeconomic gradients of hypertension suggest that hypertension may increasingly affect adults in the lowest socioeconomic groups as LMICs develop economically.

Targeting Hypertension Screening in Low- and Middle-Income Countries: A Cross-Sectional Analysis of 1.2 Million Adults in 56 Countries.

Background As screening programs in low- and middle-income countries (LMICs) often do not have the resources to screen the entire population, there is frequently a need to target such efforts to easily identifiable priority groups. This study aimed to determine (1) how hypertension prevalence in LMICs varies by age, sex, body mass index, and smoking status, and (2) the ability of different combinations of these variables to accurately predict hypertension. Methods and Results We analyzed individual-level, nationally representative data from 1 170 629 participants in 56 LMICs, of whom 220 636 (18.8%) had hypertension. Hypertension was defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or reporting to be taking blood pressure-lowering medication. The shape of the positive association of hypertension with age and body mass index varied across world regions. We used logistic regression and random forest models to compute the area under the receiver operating characteristic curve in each country for different combinations of age, body mass index, sex, and smoking status. The area under the receiver operating characteristic curve for the model with all 4 predictors ranged from 0.64 to 0.85 between countries, with a country-level mean of 0.76 across LMICs globally. The mean absolute increase in the area under the receiver operating characteristic curve from the model including only age to the model including all 4 predictors was 0.05. Conclusions Adding body mass index, sex, and smoking status to age led to only a minor increase in the ability to distinguish between adults with and without hypertension compared with using age alone. Hypertension screening programs in LMICs could use age as the primary variable to target their efforts.