Availability and affordability of essential medicines for diabetes across high-income, middle-income, and low-income countries: a prospective epidemiological study

BACKGROUND: Data are scarce on the availability and affordability of essential medicines for diabetes. Our aim was to examine the availability and affordability of metformin, sulfonylureas, and insulin across multiple regions of the world and explore the effect of these on medicine use. METHODS: In the Prospective Urban Rural Epidemiology (PURE) study, participants aged 35­70 years (n=156625) were recruited from 110803 households, in 604 communities and 22 countries; availability (presence of any dose of medication in the pharmacy on the day of audit) and medicine cost data were collected from pharmacies with the Environmental Profile of a Community's Health audit tool. Our primary analysis was to describe the availability and affordability of metformin and insulin and also commonly used and prescribed combinations of two medicines for diabetes management (two oral drugs, metformin plus a sulphonylurea [either glibenclamide (also known as glyburide) or gliclazide] and one oral drug plus insulin [metformin plus insulin]). Medicines were defined as affordable if the cost of medicines was less than 20% of capacity-to-pay (the household income minus food expenditure). Our analyses included data collected in pharmacies and data from representative samples of households. Data on availability were ascertained during the pharmacy audit, as were data on cost of medications. These cost data were used to estimate the cost of a month's supply of essential medicines for diabetes. We estimated affordability of medicines using income data from household surveys. FINDINGS: Metformin was available in 113 (100%) of 113 pharmacies from high-income countries, 112 (88·2%) of 127 pharmacies in upper-middle-income countries, 179 (86·1%) of 208 pharmacies in lower-middle-income countries, 44 (64·7%) of 68 pharmacies in low-income countries (excluding India), and 88 (100%) of 88 pharmacies in India. Insulin was available in 106 (93·8%) pharmacies in high-income countries, 51 (40·2%) pharmacies in upper-middle-income countries, 61 (29·3%) pharmacies in lower-middle-income countries, seven (10·3%) pharmacies in lower-income countries, and 67 (76·1%) of 88 pharmacies in India. We estimated 0·7% of households in high-income countries and 26·9% of households in low-income countries could not afford metformin and 2·8% of households in high-income countries and 63·0% of households in low-income countries could not afford insulin. Among the 13 569 (8·6% of PURE participants) that reported a diagnosis of diabetes, 1222 (74·0%) participants reported diabetes medicine use in high-income countries compared with 143 (29·6%) participants in low-income countries. In multilevel models, availability and affordability were significantly associated with use of diabetes medicines.

Availability and affordability of blood pressure-lowering medicines and the effect on blood pressure control in high-income, middle-income, and low-income countries: an analysis of the PURE study data

Hypertension is considered the most important risk factor for cardiovascular diseases, but its control is poor worldwide. We aimed to assess the availability and affordability of blood pressure-lowering medicines, and the association with use of these medicines and blood pressure control in countries at varying levels of economic development. We analysed the availability, costs, and affordability of blood pressure-lowering medicines with data recorded from 626 communities in 20 countries participating in the Prospective Urban Rural Epidemiological (PURE) study. Medicines were considered available if they were present in the local pharmacy when surveyed, and affordable if their combined cost was less than 20% of the households' capacity to pay. We related information about availability and affordability to use of these medicines and blood pressure control with multilevel mixed-effects logistic regression models, and compared results for high-income, upper-middle-income, lower-middle-income, and low-income countries. Data for India are presented separately because it has a large generic pharmaceutical industry and a higher availability of medicines than other countries at the same economic level...

Tobacco control environment: cross-sectional survey of policy implementation, social unacceptability, knowledge of tobacco health harms and relationship to quit ratio in 17 low-income, middle-income and high-income countries

OBJECTIVES: This study examines in a cross-sectional study 'the tobacco control environment' including tobacco policy implementation and its association with quit ratio.SETTING:545 communities from 17 high-income, upper-middle, low-middle and low-income countries (HIC, UMIC, LMIC, LIC) involved in the Environmental Profile of a Community's Health (EPOCH) study from 2009 to 2014. PARTICIPANTS: Community audits and surveys of adults (35-70 years, n=12 953).PRIMARY AND SECONDARY OUTCOME MEASURES: Summary scores of tobacco policy implementation (cost and availability of cigarettes, tobacco advertising, antismoking signage), social unacceptability and knowledge were associated with quit ratios (former vs ever smokers) using multilevel logistic regression models. RESULTS: Average tobacco control policy score was greater in communities from HIC. Overall 56.1% (306/545) of communities had >2 outlets selling cigarettes and in 28.6% (154/539) there was access to cheap cigarettes (80% of participants disapproved youth smoking (95.7% HIC, 57.6% UMIC, 76.3% LMIC and 58.9% LIC). The average knowledge score was >80% in 48.4% of communities (94.6% HIC, 53.6% UMIC, 31.8% LMIC and 35.1% LIC). Summary scores of policy implementation, social unacceptability and knowledge were positively and significantly associated with quit ratio and the associations varied by gender, for example, communities in the highest quintile of the combined scores had 5.0 times the quit ratio in men (Odds ratio (OR) 5·0, 95% CI 3.4 to 7.4) and 4.1 times the quit ratio in women (OR 4.1, 95% CI 2.4 to 7.1)...

Wealth and cardiovascular health: across-sectional study of wealth-related inequalities in the awareness, treatmentand control of hypertension in high-,middle- and low-income countries

Effective policies to control hypertension require an understanding of its distribution in the population and the barriers people face along the pathway from detection through to treatment and control. One key factor is household wealth, which may enable or limit a household’s ability to access health care services and adequately control such a chronic condition. This study aims to describe the scale and patterns of wealth-related inequalities in the awareness, treatment and control of hypertension in 21 countries using baseline data from the Prospective Urbanand Rural Epidemiology study. Methods: A cross-section of 163,397 adults aged 35 to 70 years were recruited from 661 urban and rural communities in selected low-, middle- and high-income countries (complete data for this analysis from 151,619 participants). Using blood pressure measurements, self-reported health and household data, concentration indices adjusted for age, sex and urban-rural location, we estimate the magnitude of wealth-related inequalities in thelevels of hypertension awareness, treatment, and control in each of the 21 country samples. Results: Overall, the magnitude of wealth-related inequalities in hypertension awareness, treatment, and control wasobserved to be higher in poorer than in richer countries. In poorer countries, levels of hypertension awareness and treatment tended to be higher among wealthier households; while a similar pro-rich distribution was observed forhypertension control in countries at all levels of economic development. In some countries, hypertension awarenesswas greater among the poor (Sweden, Argentina, Poland), as was treatment (Sweden, Poland) and control (Sweden)...

Availability, affordability, and consumption of fruits and vegetables in 18 countries across income levels: findings from the Prospective Urban Rural Epidemiology (PURE) study

Several international guidelines recommend the consumption of two servings of fruits and three servingsof vegetables per day, but their intake is thought to be low world wide. We aimed to determine the extent to which suchlow intake is related to availability and aff ordability. Methods We assessed fruit and vegetable consumption using data from country-specific, validated semi-quantitativefood frequency questionnaires in the Prospective Urban Rural Epidemiology (PURE) study, which enrolled participants from communities in 18 countries between Jan 1, 2003, and Dec 31, 2013. We documented house hold income datafrom participants in these communities; we also recorded the diversity and non-sale prices of fruits and vegetables from grocery stores and market places between Jan 1, 2009, and Dec 31, 2013. We determined the cost of fruits andvegetables relative to income per house hold member. Linear random eff ects models, adjusting for the clustering ofhouseholds with in communities, were used to assess mean fruit and vegetable intake by their relative cost...

Availability and affordability of cardiovascular disease medicines and their effect on use in high-income, middle-income, and low-income countries: an analysis of the PURE study data

Background WHO has targeted that medicines to prevent recurrent cardiovascular disease be available in 80% of communities and used by 50% of eligible individuals by 2025. We have previously reported that use of these medicines is very low, but now aim to assess how such low use relates to their lack of availability or poor affordability. Methods We analysed information about availability and costs of cardiovascular disease medicines (aspirin, β blockers, angiotensin-converting enzyme inhibitors, and statins) in pharmacies gathered from 596 communities in 18 countries participating in the Prospective Urban Rural Epidemiology (PURE) study. Medicines were considered available if present at the pharmacy when surveyed, and affordable if their combined cost was less than 20% of household capacity-to-pay. We compared results from high-income, upper middle-income, lower middle-income, and low-income countries. Data from India were presented separately given its large, generic pharmaceutical industry. Findings Communities were recruited between Jan 1, 2003, and Dec 31, 2013. All four cardiovascular disease medicines were available in 61 (95%) of 64 urban and 27 (90%) of 30 rural communities in high-income countries, 53 (80%) of 66 urban and 43 (73%) of 59 rural communities in upper middle-income countries, 69 (62%) of 111 urban and 42 (37%) of 114 rural communities in lower middle-income countries, eight (25%) of 32 urban and one (3%) of 30 rural communities in low-income countries (excluding India), and 34 (89%) of 38 urban and 42 (81%) of 52 rural communities in India...

Nutrition labelling, marketing techniques, nutrition claims andhealth claims on chip and biscuit packages from sixteen countries

Food packages were objectively assessed to explore differences innutrition labelling, selected promotional marketing techniques and health andnutrition claims between countries, in comparison to national regulations.Design: Cross-sectional.Setting: Chip and sweet biscuit packages were collected from sixteen countries atdifferent levels of economic development in the EPOCH (Environmental Profile ofa Community’s Health) study between 2008 and 2010.Subjects: Seven hundred and thirty-seven food packages were systematicallyevaluated for nutrition labelling, selected promotional marketing techniquesrelevant to nutrition and health, and health and nutrition claims. We comparedpack labelling in countries with labelling regulations, with voluntary regulationsand no regulations.Results: Overall 86 % of the packages had nutrition labels, 30 % had health ornutrition claims and 87 % displayed selected marketing techniques. On average,each package displayed two marketing techniques and one health or nutritionclaim. In countries with mandatory nutrition labelling a greater proportion ofpackages displayed nutrition labels, had more of the seven required nutrientspresent, more total nutrients listed and higher readability compared with those withvoluntary or no regulations. Countries with no health or nutrition claim regulationshad fewer claims per package compared with countries with regulations.Conclusions: Nutrition label regulations were associated with increased prevalenceand quality of nutrition labels. Health and nutrition claim regulations wereunexpectedly associated with increased use of claims, suggesting that currentregulations may not have the desired effect of protecting consumers. Of concern,lack of regulation was associated with increased promotional marketing techniquesdirected at children and misleadingly promoting broad concepts of health.

A Novel Method to Evaluate the Community BuiltEnvironment Using Photographs – Environmental Profileof a Community Health (EPOCH) Photo NeighbourhoodEvaluation Tool

Previous research has shown that environments with features that encourage walking are associated withincreased physical activity. Existing methods to assess the built environment using geographical information systems (GIS)data, direct audit or large surveys of the residents face constraints, such as data availability and comparability, when used tostudy communities in countries in diverse parts of the world. The aim of this study was to develop a method to evaluatefeatures of the built environment of communities using a standard set of photos. In this report we describe the method ofphoto collection, photo analysis instrument development and inter-rater reliability of the instrument.Methods/Principal Findings: A minimum of 5 photos were taken per community in 86 communities in 5 countriesaccording to a standard set of instructions from a designated central point of each community by researchers at each site. Astandard pro forma derived from reviewing existing instruments to assess the built environment was developed and used toscore the characteristics of each community. Photo sets from each community were assessed independently by threeobservers in the central research office according to the pro forma and the inter-rater reliability was compared by intra-classcorrelation (ICC). Overall 87% (53 of 60) items had an ICC of $0.70, 7% (4 of 60) had an ICC between 0.60 and 0.70 and 5% (3of 60) items had an ICC #0.50.Conclusions/Significance: Analysis of photos using a standardized protocol as described in this study offers a means toobtain reliable and reproducible information on the built environment in communities in very diverse locations around theworld. The collection of the photographic data required minimal training and the analysis demonstrated high reliability forthe majority of items of interest.

Environmental profile of a community’s health (EPOCH): an ecometric assessment of measures of the community environment based on individual perception

Background: Public health research has turned towards examining upstream, community-level determinants ofcardiovascular disease risk factors. Objective measures of the environment, such as those derived from direct observation,and perception-based measures by residents have both been associated with health behaviours. However, current methodsare generally limited to objective measures, often derived from administrative data, and few instruments have beenevaluated for use in rural areas or in low-income countries. We evaluate the reliability of a quantitative tool designed tocapture perceptions of community tobacco, nutrition, and social environments obtained from interviews with residents incommunities in 5 countries.Methodology/ Principal Findings: Thirteen measures of the community environment were developed from responses toquestionnaire items from 2,360 individuals residing in 84 urban and rural communities in 5 countries (China, India, Brazil,Colombia, and Canada) in the Environmental Profile of a Community’s Health (EPOCH) study. Reliability and other propertiesof the community-level measures were assessed using multilevel models. High reliability (.0.80) was demonstrated for allcommunity-level measures at the mean number of survey respondents per community (n = 28 respondents). Questionnaireitems included in each scale were found to represent a common latent factor at the community level in multilevel factoranalysis models.Conclusions/ Significance: Reliable measures which represent aspects of communities potentially related to cardiovasculardisease (CVD)/risk factors can be obtained using feasible sample sizes. The EPOCH instrument is suitable for use in differentsettings to explore upstream determinants of CVD/risk factors.

Use of secondary prevention drugs for cardiovascular disease in the community in high-income, middle-income, andlow-income countries (the PURE Study): a prospective epidemiological survey

Background Although most cardiovascular disease occurs in low-income and middle-income countries, little is known about the use of effective secondary prevention medications in these communities. We aimed to assess use of proven effective secondary preventive drugs (antiplatelet drugs, â blockers, angiotensin-converting-enzyme [ACE] inhibitors or angiotensin-receptor blockers [ARBs], and statins) in individuals with a history of coronary heart disease or stroke.MethodsIn the Prospective Urban Rural Epidemiological (PURE) study, we recruited individuals aged 35—70 years from rural and urban communities in countries at various stages of economic development. We assessed rates of previous cardiovascular disease (coronary heart disease or stroke) and use of proven effective secondary preventive drugs and blood-pressure-lowering drugs with standardised questionnaires, which were completed by telephone interviews, household visits, or on patient's presentation to clinics. We report estimates of drug use at national, community, and individual levels.FindingsWe enrolled 153 996 adults from 628 urban and rural communities in countries with incomes classified as high (three countries), upper-middle (seven), lower-middle (three), or low (four) between January, 2003, and December, 2009. 5650 participants had a self-reported coronary heart disease event (median 5·0 years previously [IQR 2·0—10·0]) and 2292 had stroke (4·0 years previously [2·0—8·0]). Overall, few individuals with cardiovascular disease took antiplatelet drugs (25·3%), â blockers (17·4%), ACE inhibitors or ARBs (19·5%), or statins (14·6%). Use was highest in high-income countries (antiplatelet drugs 62·0%, â blockers 40·0%, ACE inhibitors or ARBs 49·8%, and statins 66·5%), lowest in low-income countries (8·8%, 9·7%, 5·2%, and 3·3%, respectively), and decreased in line with reduction of country economic status (ptrend<0·0001 for every drug type)...