The Heart of the World.

Cardiovascular diseases (CVDs) are the leading cause of mortality globally. Of the 20.5 million CVD-related deaths in 2021, approximately 80% occurred in low- and middle-income countries. Using data from the Global Burden of Disease Study, NCD Risk Factor Collaboration, NCD Countdown initiative, WHO Global Health Observatory, and WHO Global Health Expenditure database, we present the burden of CVDs, associated risk factors, their association with national health expenditures, and an index of critical policy implementation. The Central Europe, Eastern Europe, and Central Asia region face the highest levels of CVD mortality globally. Although CVD mortality levels are generally lower in women than men, this is not true in almost 30% of countries in the North Africa and Middle East and Sub-Saharan regions. Raised blood pressure remains the leading global CVD risk factor, contributing to 10.8 million deaths in 2019. The regions with the highest proportion of countries achieving the maximum score for the WHF Policy Index were South Asia, Central Europe, Eastern Europe, and Central Asia, and the High-Income regions. The Sub-Saharan Africa region had the highest proportion of countries scoring two or less. Policymakers must assess their country's risk factor profile to craft effective strategies for CVD prevention and management. Fundamental strategies such as the implementation of National Tobacco Control Programmes, ensuring the availability of CVD medications, and establishing specialised units within health ministries to tackle non-communicable diseases should be embraced in all countries. Adequate healthcare system funding is equally vital, ensuring reasonable access to care for all communities.

Identifying deprived "slum" neighbourhoods in the Greater Accra Metropolitan Area of Ghana using census and remote sensing data.

Background: Identifying urban deprived areas, including slums, can facilitate more targeted planning and development policies in cities to reduce socio-economic and health inequities, but methods to identify them are often ad-hoc, resource intensive, and cannot keep pace with rapidly urbanizing communities. Objectives: We apply a spatial modelling approach to identify census enumeration areas (EAs) in the Greater Accra Metropolitan Area (GAMA) of Ghana with a high probability of being a deprived area using publicly available census and remote sensing data. Methods: We obtained United Nations (UN) supported field mapping data that identified deprived "slum" areas in Accra's urban core, data on housing and population conditions from the most recent census, and remotely sensed data on environmental conditions in the GAMA. We first fitted a Bayesian logistic regression model on the data in Accra's urban core (n=2,414 EAs) that estimated the relationship between housing, population, and environmental predictors and being a deprived area according to the UN's deprived area assessment. Using these relationships, we predicted the probability of being a deprived area for each of the 4,615 urban EAs in GAMA. Results: 899 (19%) of the 4,615 urban EAs in GAMA, with an estimated 745,714 residents (22% of its urban population), had a high predicted probability (≥80%) of being a deprived area. These deprived EAs were dispersed across GAMA and relatively heterogeneous in their housing and environmental conditions, but shared some common features including a higher population density, lower elevation and vegetation abundance, and less access to indoor piped water and sanitation. Conclusion: Our approach using ubiquitously available administrative and satellite data can be used to identify deprived neighbourhoods where interventions are warranted to improve living conditions, and track progress in achieving the Sustainable Development Goals aiming to reduce the population living in unsafe or vulnerable human settlements.

Spatial heterogeneity in drinking water sources in the Greater Accra Metropolitan Area (GAMA), Ghana.

Universal access to safe drinking water is essential to population health and well-being, as recognized in the Sustainable Development Goals (SDG). To develop targeted policies which improve urban access to improved water and ensure equity, there is the need to understand the spatial heterogeneity in drinking water sources and the factors underlying these patterns. Using the Shannon Entropy Index and the Index of Concentration at the Extremes at the enumeration area level, we analyzed census data to examine the spatial heterogeneity in drinking water sources and neighborhood income in the Greater Accra Metropolitan Area (GAMA), the largest urban agglomeration in Ghana. GAMA has been a laboratory for studying urban growth, economic security, and other concomitant socio-environmental and demographic issues in the recent past. The current study adds to this literature by telling a different story about the spatial heterogeneity of GAMA's water landscape at the enumeration area level. The findings of the study reveal considerable geographical heterogeneity and inequality in drinking water sources not evidenced in previous studies. We conclude that heterogeneity is neither good nor bad in GAMA judging by the dominance of both piped water sources and sachet water (machine-sealed 500-ml plastic bag of drinking water). The lessons from this study can be used to inform the planning of appropriate localized solutions targeted at providing piped water sources in neighborhoods lacking these services and to monitor progress in achieving universal access to improved drinking water as recognized in the SDG 6 and improving population health and well-being.

Sachet water in Ghana: A spatiotemporal analysis of the recent upward trend in consumption and its relationship with changing household characteristics, 2010-2017.

The consumption of packaged water in Ghana has grown significantly in recent years. By 2017, "sachet water"-machine-sealed 500ml plastic bags of drinking water-was consumed by 33% of Ghanaian households. Reliance on sachet water has previously been associated with the urban poor, yet recent evidence suggests a customer base which crosses socioeconomic lines. Here, we conduct a repeated cross-sectional analysis of three nationally representative datasets to examine the changing demography of sachet water consumers between 2010 and 2017. Our results show that over the course of the study period sachet water has become a ubiquitous source of drinking water in Ghana, with relatively wealthy households notably increasing their consumption. In 2017, the majority of sachet water drinking households had access to another improved water source. The current rate and form of urbanisation, inadequate water governance, and an emphasis on cost recovery pose significant challenges for the expansion of the piped water supply network, leading us to conclude that sachet water will likely continue to be a prominent source of drinking water in Ghana for the foreseeable future. The main challenge for policymakers is to ensure that the growing sachet water market enhances rather than undermines Ghana's efforts towards achieving universal and equitable access to clean drinking water and sanitation.

Quantifying within-city inequalities in child mortality across neighbourhoods in Accra, Ghana: a Bayesian spatial analysis.

OBJECTIVE: Countries in sub-Saharan Africa suffer the highest rates of child mortality worldwide. Urban areas tend to have lower mortality than rural areas, but these comparisons likely mask large within-city inequalities. We aimed to estimate rates of under-five mortality (U5M) at the neighbourhood level for Ghana's Greater Accra Metropolitan Area (GAMA) and measure the extent of intraurban inequalities. METHODS: We accessed data on >700 000 women aged 25-49 years living in GAMA using the most recent Ghana census (2010). We summarised counts of child births and deaths by five-year age group of women and neighbourhood (n=406) and applied indirect demographic methods to convert the summaries to yearly probabilities of death before age five years. We fitted a Bayesian spatiotemporal model to the neighbourhood U5M probabilities to obtain estimates for the year 2010 and examined their correlations with indicators of neighbourhood living and socioeconomic conditions. RESULTS: U5M varied almost five-fold across neighbourhoods in GAMA in 2010, ranging from 28 (95% credible interval (CrI) 8 to 63) to 138 (95% CrI 111 to 167) deaths per 1000 live births. U5M was highest in neighbourhoods of the central urban core and industrial areas, with an average of 95 deaths per 1000 live births across these neighbourhoods. Peri-urban neighbourhoods performed better, on average, but rates varied more across neighbourhoods compared with neighbourhoods in the central urban areas. U5M was negatively correlated with multiple indicators of improved living and socioeconomic conditions among peri-urban neighbourhoods. Among urban neighbourhoods, correlations with these factors were weaker or, in some cases, reversed, including with median household consumption and women's schooling. CONCLUSION: Reducing child mortality in high-burden urban neighbourhoods in GAMA, where a substantial portion of the urban population resides, should be prioritised as part of continued efforts to meet the Sustainable Development Goal national target of less than 25 deaths per 1000 live births.

Trends and Inequalities in the Incidence of Acute Myocardial Infarction among Beijing Townships, 2007-2018.

Acute myocardial infarction (AMI) poses a serious disease burden in China, but studies on small-area characteristics of AMI incidence are lacking. We therefore examined temporal trends and geographic variations in AMI incidence at the township level in Beijing. In this cross-sectional analysis, 259,830 AMI events during 2007-2018 from the Beijing Cardiovascular Disease Surveillance System were included. We estimated AMI incidence for 307 consistent townships during consecutive 3-year periods with a Bayesian spatial model. From 2007 to 2018, the median AMI incidence in townships increased from 216.3 to 231.6 per 100,000, with a greater relative increase in young and middle-aged males (35-49 years: 54.2%; 50-64 years: 33.2%). The most pronounced increases in the relative inequalities was observed among young residents (2.1 to 2.8 for males and 2.8 to 3.4 for females). Townships with high rates and larger relative increases were primarily located in Beijing's northeastern and southwestern peri-urban areas. However, large increases among young and middle-aged males were observed throughout peri-urban areas. AMI incidence and their changes over time varied substantially at the township level in Beijing, especially among young adults. Targeted mitigation strategies are required for high-risk populations and areas to reduce health disparities across Beijing.

English National Health Service's savings plan may have helped reduce the use of three 'low-value' procedures.

The pressure to contain health expenditures is unprecedented. In England a flattening of the health budget but increasing demand led the National Health Service (NHS) to seek reductions in health expenditures of 17 percent over four years. The spending cuts were to be achieved through improvements in service quality and efficiency, including reducing the use of ineffective, overused, or inappropriate procedures. However, the NHS left it to the local commissioning (or funding) organizations, known as primary care trusts, to determine what steps to take to reduce spending. To assess whether the initiative had an impact, we examined six low-value procedures: spinal surgery for lower back pain, myringotomy to relieve eardrum pressure, inguinal hernia repair, cataract removal, primary hip replacement, and hysterectomy for heavy menstrual bleeding. We found significant reductions in three of the six procedures-cataract removal, hysterectomy, and myringotomy-in the program's first year, compared to prior years' trends. However, changes in the rates of all examined procedures varied widely across commissioning organizations. Our findings highlight some of the challenges of making major budget cuts in health care. Reducing ineffective spending remains a significant opportunity for the US health care system, and the English experience may hold valuable lessons.

Associations between green space and health in English cities: an ecological, cross-sectional study.

Green space has been identified as a modifiable feature of the urban environment and associations with physiological and psychological health have been reported at the local level. This study aims to assess whether these associations between health and green space are transferable to a larger scale, with English cities as the unit of analysis. We used an ecological, cross-sectional study design. We classified satellite-based land cover data to quantify green space coverage for the 50 largest cities in England. We assessed associations between city green space coverage with risk of death from all causes, cardiovascular disease, lung cancer and suicide between 2002 and 2009 using Poisson regression with random effect. After adjustment for age, income deprivation and air pollution, we found that at the city level the risk of death from all causes and a priori selected causes, for men and women, did not significantly differ between the greenest and least green cities. These findings suggest that the local health effects of urban green space observed at the neighbourhood level in some studies do not transfer to the city level. Further work is needed to establish how urban residents interact with local green space, in order to ascertain the most relevant measures of green space.