Assessment of the results of a three-year program for National Standardization and Quality Improvement of Medical Laboratories on Drug of Abuse Testing by the Ministry of Health in Turkey.

The aim of this study is to assess the results of inspections in the last three years of drug abuse testing in medical laboratories according to the latest regulations in Turkey. The on-site inspections of medical laboratories for drugs abuse testing performed in Alcohol and Drug Addiction Treatment Centers during 2014-2016 are described, and laboratory processes and performance evaluated. The performance of 35 laboratories in 2014, 62 laboratories in 2015, and 94 laboratories in 2016 were scored as the sum of the scores for all answers on the inspection form. An inspected laboratory was considered to have an unconformity if the total score was less than 2/3 of maximum score. The total scores of inspections and the number of laboratories with between years were compared using one-way analysis of variance and slope Chi-square for trend test, respectively. Total scores increased statistically significantly from 35.9 ± 16.2 in 2014, to 43.5 ± 16.3 in 2015 and 49.1 ± 1.3 in 2016 (p < 0.001). The laboratories with unconformities decreased statistically significantly from 57% in 2014 to 37% in 2015 and 22% in 2016 (p < 0.001). The published legislation and the inspections contributed to national standardization and improved quality of service in medical laboratories for drug abuse testing.

Determinants of Breast and Cervical Cancer Screening Uptake Among Women in Turkey.

The aim of the study was to assess the influence of sociodemographic characteristics on breast and cervical cancer screening among women 30 years and older in Turkey. We used data from the National Chronic Diseases and Risk Factors Survey conducted by the Ministry of Health in 2011. Multivariate logistic regression analysis was used to assess the association of sociodemographic factors, lifestyle variables, and cancer screening. Overall, 22.0% of women ever had a Pap smear test for cervical cancer screening and 19.0% ever had a mammography for breast cancer screening(n = 6846). Individuals with a university degree, social security, doing moderate physical activity, and consuming 5 portions of fruit or vegetable/day were more likely to receive Pap smear test and mammography. Residing in the eastern region and living in rural area was associated with lower likelihood of receiving both types of screening.

Explaining inequalities in Health Care Utilization among Turkish adults: Findings from Health Survey 2008.

BACKGROUND: Turkish health system showed major improvements in health outcomes since initiation of the Health Transition Programme (HTP) in 2003, however little is known regarding income-related inequalities in health care use. The aim of this study was to assess horizontal inequities in health care use in Turkey. METHODS: We used the data from Turkish Health Survey 2008 with 14,655 respondents. We calculated concentration index (C) and horizontal inequity index (HI) to measure the socioeconomic inequalities in utilization of general practitioner (GP) care, specialist care, inpatient care, dental care and emergency care. Contributions of each factor to the observed inequality in health care utilization were assessed through decomposition method. RESULTS: There was a significant pro-rich inequality in specialist care and oral health care utilization among individuals as indicated by positive values of HI (=0.1149) and HI (=0.1137), respectively. However, the poor were more likely to utilize emergency care (HI=-0.0461) and inpatient care (HI=-0.0731). GP care was also slightly pro-poor distributed (HI=-0.0042). CONCLUSION: Pro-poor income-related inequalities in health care use were largely explained by greater health care need among low income groups, while non-need factors were the main determinants for pro-rich utilization (education, residence area). Inequalities in dental and specialist care linked to low income, low education level and rural areas should be given priority by decision makers to reduce the negative impact of utilization on health. Our results provide some evidence of inequity in 2008, after the introduction of HTP and provide a baseline against which the effects of the new reforms can be assessed.

Estimating diabetes prevalence in Turkey in 2025 with and without possible interventions to reduce obesity and smoking prevalence, using a modelling approach.

OBJECTIVES: The purpose of this study is to estimate the prevalence and the number of people with type 2 diabetes (T2DM) in 2025 in Turkey and to evaluate the impact of possible policy options on T2DM prevalence. METHODS: We developed a model to predict future prevalence of T2DM using trend data for adults aged 25-74 in Turkey from 1997 to 2025. The model integrates population, obesity and smoking trends to estimate the future T2DM prevalence using a Markov approach. RESULTS: T2DM prevalence was 7.5% (95% CI: 6.0-9.0%) in 1997 increasing to 16.2% (95% CI: 15.5-21.1%) in 2010. The forecasted prevalence for 2025 was 31.5% (28.6% in men and 35.1% in women). If obesity prevalence declines by 10% and smoking decreases by 20% in 10 years from 2010, a 10% relative reduction in diabetes prevalence (1,655,213 individuals) could be achieved by 2025. CONCLUSIONS: Diabetes burden is now a significant public health challenge, and our model predicts that its burden will increase significantly over the next two decades. Tackling obesity and other diabetes risk factors needs urgent action.

Health policy analysis for prevention and control of cardiovascular diseases and diabetes mellitus in Turkey.

OBJECTIVES: Current capacity of the Turkish health system is reviewed to evaluate and develop appropriate policies for cardiovascular diseases (CVD), diabetes mellitus (DM) and related risk factors. METHODS: This paper qualitatively evaluates existing policies; interviews with key informants (KIs); and rapid appraisal fieldwork in clinical settings about CVD-DM through the framework of Walt and Gilson (Health Policy Plan 9:353-370, 1994). RESULTS: Document review shows that prevention and control of CVD-DM were strongly addressed in Turkey, yet no document mentioned country-wide early detection or screening programs. KIs indicated over-fragmented management of CVD-DM by the Ministry of Health (MoH). Coordination among the MoH, organizational structure at provincial level and civil society organizations are poor where mutual trust is a significant problem according to KIs. Clinical setting findings point to a complete lack of a referral structure and a lack of follow-up, compounding the absence of functioning health information systems for patient records. CONCLUSIONS: Primary care services for CVD-DM require urgent attention, focusing particularly on the training of staff in public facilities, the integration of patient data, referrals and follow-up across all levels of the health system.

Determinants of inpatient costs of angina pectoris, myocardial infarction, and heart failure in a university hospital setting in Turkey.

OBJECTIVE: This study aimed to determine the correlates of in-hospital costs for angina pectoris (AP), myocardial infarction (MI), and heart failure (HF) in a university hospital setting. METHODS: This is a retrospective cost-of-illness study using data from the records of patients who were admitted with AP, MI, or HF to Dokuz Eylül University Hospital during 2008. Direct medical costs were calculated from the Social Security Institute perspective using a bottom-up approach. Socio-demographic and clinical information was abstracted from patient files. Costs were presented in Turkish lira (TL). A generalized linear model was used in the multivariate analysis. RESULTS: We included 337 in-patients in total in the study. AP was present in 26.4% (n=89), MI was present in 55.8% (n=188), and HF was present in 17.8% (n=60) of patients. MI was the most costly disease (2760 TL), followed by HF (2350 TL) and AP (1881 TL). The largest proportion of the total cost was formed by medical interventions (27.5%), followed by surgery (22.2%). Presence of DM, smoking, diagnosis of MI, HF, need for intensive care, and resulting in death were strong predictors of treatment costs. CONCLUSION: Both preadmission characteristics of patients (diabetes mellitus, smoking, use of anti-aggregant before admission) and in-patient characteristics (diagnosis, coronary artery bypass grafting, intensive care need, death) predicted the hospital cost of cardiovascular diseases (CVDs) independently. Our results may be used as input for health-economic models and economic evaluations to support the decision-making of reimbursement and the cost-effectiveness of public health interventions in healthcare.

Priority setting for the prevention and control of cardiovascular diseases: multi-criteria decision analysis in four eastern Mediterranean countries.

OBJECTIVES: To explore the feasibility of using a simple multi-criteria decision analysis method with policy makers/key stakeholders to prioritize cardiovascular disease (CVD) policies in four Mediterranean countries: Palestine, Syria, Tunisia and Turkey. METHODS: A simple multi-criteria decision analysis (MCDA) method was piloted. A mixed methods study was used to identify a preliminary list of policy options in each country. These policies were rated by different policymakers/stakeholders against pre-identified criteria to generate a priority score for each policy and then rank the policies. RESULTS: Twenty-five different policies were rated in the four countries to create a country-specific list of CVD prevention and control policies. The response rate was 100% in each country. The top policies were mostly population level interventions and health systems' level policies. CONCLUSIONS: Successful collaboration between policy makers/stakeholders and researchers was established in this small pilot study. MCDA appeared to be feasible and effective. Future applications should aim to engage a larger, representative sample of policy makers, especially from outside the health sector. Weighting the selected criteria might also be assessed.

Research capacity and training needs for non-communicable diseases in the public health arena in Turkey.

BACKGROUND: The aim of this study is to define the research capacity and training needs for professionals working on non-communicable diseases (NCDs) in the public health arena in Turkey. METHODS: This study was part of a comparative cross-national research capacity-building project taking place across Turkey and the Mediterranean Middle East (RESCAP-Med, funded by the EU). Identification of research capacity and training needs took place in three stages. The first stage involved mapping health institutions engaged in NCD research, based on a comprehensive literature review. The second stage entailed in-depth interviews with key informants (KIs) with an overview of research capacity in public health and the training needs of their staff. The third stage required interviewing junior researchers, identified by KIs in stage two, to evaluate their perceptions of their own training needs. The approach we have taken was based upon a method devised by Hennessy&Hicks. In total, 55 junior researchers identified by 10 KIs were invited to participate, of whom 46 researchers agreed to take part (84%). The specific disciplines in public health identified in advance by RESCAP-MED for training were: advanced epidemiology, health economics, environmental health, medical sociology-anthropology, and health policy. RESULTS: The initial literature review showed considerable research on NCDs, but concentrated in a few areas of NCD research. The main problems listed by KIs were inadequate opportunities for specialization due to heavy teaching workloads, the lack of incentives to pursue research, a lack of financial resources even when interest existed, and insufficient institutional mechanisms for dialogue between policy makers and researchers over national research priorities. Among junior researchers, there was widespread competence in basic epidemiological skills, but an awareness of gaps in knowledge of more advanced epidemiological skills, and the opportunities to acquire these skills were lacking. Self-assessed competencies in each of the four other disciplines considered revealed greater training needs, especially regarding familiarity with the qualitative research skills for medical anthropology/sociology. CONCLUSIONS: In Turkey there are considerable strengths to build upon. But a combination of institutional disincentives for research, and the lack of opportunities for the rising generation of researchers to acquire advanced training skills.

A cost effectiveness analysis of salt reduction policies to reduce coronary heart disease in four Eastern Mediterranean countries.

BACKGROUND: Coronary Heart Disease (CHD) is rising in middle income countries. Population based strategies to reduce specific CHD risk factors have an important role to play in reducing overall CHD mortality. Reducing dietary salt consumption is a potentially cost-effective way to reduce CHD events. This paper presents an economic evaluation of population based salt reduction policies in Tunisia, Syria, Palestine and Turkey. METHODS AND FINDINGS: Three policies to reduce dietary salt intake were evaluated: a health promotion campaign, labelling of food packaging and mandatory reformulation of salt content in processed food. These were evaluated separately and in combination. Estimates of the effectiveness of salt reduction on blood pressure were based on a literature review. The reduction in mortality was estimated using the IMPACT CHD model specific to that country. Cumulative population health effects were quantified as life years gained (LYG) over a 10 year time frame. The costs of each policy were estimated using evidence from comparable policies and expert opinion including public sector costs and costs to the food industry. Health care costs associated with CHDs were estimated using standardized unit costs. The total cost of implementing each policy was compared against the current baseline (no policy). All costs were calculated using 2010 PPP exchange rates. In all four countries most policies were cost saving compared with the baseline. The combination of all three policies (reducing salt consumption by 30%) resulted in estimated cost savings of $235,000,000 and 6455 LYG in Tunisia; $39,000,000 and 31674 LYG in Syria; $6,000,000 and 2682 LYG in Palestine and $1,3000,000,000 and 378439 LYG in Turkey. CONCLUSION: Decreasing dietary salt intake will reduce coronary heart disease deaths in the four countries. A comprehensive strategy of health education and food industry actions to label and reduce salt content would save both money and lives.

Socioeconomic Inequalities in Non-Communicable Diseases and Self Assessed Health in Turkey.

BACKGROUND: Inequities in health need to be monitored and necessary actions should be taken to reduce them. This study aimed to determine the socioeconomic distribution of self-reported chronic diseases and self-assessed health (SAH) in Turkey and try to evaluate the determinants of such inequalities in terms of their contributions. METHODS: Cross-sectional data from the Turkish Health Survey conducted during year 2008, covering 14,655 adults aged 15 or older were analyzed for the first time to assess socioeconomic inequalities in chronic disease and suboptimal SAH prevalence by calculating concentration index (CI), which ranges from -1 to +1 (concentration of disease among lower and higher socioeconomic groups) and the relative index of inequality (RII), reflecting the prevalence ratio between the two extremes of wealth. RESULTS: Several diseases and sub-optimal SAH were more concentrated among those with lower incomes. The concentration indices of chronic obstructive pulmonary disease (COPD), arthritis, chronic bronchitis, migraine and poor SAH were -0.180 (95% CI = -0.241,-0.111), -0.126 (95% CI = -0.148,-0.105),-0.118 (95%CI = -0.149,-0.079), -0.248(95%CI = (-0.278,-0.219) respectively. Of all chronic diseases, COPD demonstrated the highest relative inequality with a RII value of 2.51 (95%CI: 1.57-4.01). Income was the major contributor to inequality in occurrence of COPD (88.2%), migraine (80.4%) and arthritis (77.7%). CONCLUSION: The findings indicate that majority of chronic diseases were more concentrated among less wealthy individuals in Turkey. Wealth and education had the largest contributions to observed inequalities. These inequalities need to be explicitly addressed and vulnerable subgroups should be targeted to reduce these socioeconomic disparities.

Mediterranean studies of cardiovascular disease and hyperglycemia: analytical modeling of population socio-economic transitions (MedCHAMPS)--rationale and methods.

OBJECTIVES: In response to the escalating epidemic of cardiovascular disease (CVD) in the Mediterranean Region (MR), an international collaboration aiming at understanding the burden of CVD and evaluating cost-effective strategies to combat it was recently established. This paper describes the rationale and methods of the project MedCHAMPS to disseminate this successful experience. METHODS: The framework of MedCHAMPS is exceptional in combining multiple disciplines (e.g. epidemiology, anthropology, economics), countries [Turkey, Syria, occupied Palestinian territory (oPt), Tunisia, UK, Ireland], research methods (situational and policy analysis, quantitative and qualitative studies, statistical modeling), and involving local stakeholders at all levels to assess trends of CVD/diabetes in the society and attributes of the local health care systems to provide optimal policy recommendations to reduce the burden of CVD/diabetes. RESULTS AND CONCLUSIONS: MedCHAMPS provides policy makers in the MR and beyond needed guidance about the burden of CVD, and best cost-effective ways to combat it. Our approach of building developed-developing countries collaboration also provides a roadmap for other researchers seeking to build research base into CVD epidemiology and prevention in developing countries.

Decomposing socioeconomic inequalities in self assessed health in Turkey.

INTRODUCTION: This study aimed to measure socioeconomic inequalities in Self Assessed Health (SAH) and evaluate the determinants of such inequalities in terms of their contributions amongst the Turkish population. METHODS: We used data from the Turkish part of World Health Survey 2003 with 10,287 respondents over 18 years old. Concentration index (CI) of SAH was calculated as a measure of socioeconomic inequalities in health, and contributions of each determinant to inequality were evaluated using a decomposition method. RESULTS: In total 952 participants (9.3%) rated their health status as either bad or very bad. The CI for SAH was -0.15, suggesting that suboptimal SAH was reported more by those categorised as poor. The multiple logistic regression results indicated that having secondary, primary or less than primary school education, not being married and being in the lowest wealth quintile, significantly increased the risk of having poor SAH. The largest contributions to inequality were attributed to education level (70.7%), household economic status (9.7%) and geographical area lived in (8.4%). CONCLUSION: The findings indicate that socioeconomic inequalities measured by SAH are apparent amongst the Turkish population. Education and household wealth were the greatest contributing factors to SAH inequality. These inequalities need to be explicitly addressed and vulnerable subgroups should be targeted to reduce the socioeconomic disparities.

Normative data and discriminative properties of short form 36 (SF-36) in Turkish urban population.

BACKGROUND: SF-36 has been both translated into different languages and adapted to different cultures to obtain comparable data on health status internationally. However there have been only a limited number of studies focused on the discriminative ability of SF-36 regarding social and disease status in developing countries. The aim of this study was to obtain population norms of the short form 36 (SF-36) health survey and the association of SF-36 domains with demographic and socioeconomic variables in an urban population in Turkey. METHODS: A cross-sectional study. Face to face interviews were carried out with a sample of households. The sample was systematically selected from two urban Health Districts in Izmir, Turkey. The study group consisted of 1,279 people selected from a study population of 46,290 people aged 18 and over. RESULTS: Internal consistencies of the scales were high, with the exception of mental health and vitality. Physical health scales were associated with both age and gender. On the other hand, mental health scales were less strongly associated with age and gender. Women reported poorer health compared to men in general. Social risk factors (employment status, lower education and economic strain) were associated with worse health profiles. The SF-36 was found to be capable of discriminating disease status. CONCLUSION: Our findings, cautiously generalisable to urban population, suggest that the SF-36 can be a valuable tool for studies on health outcomes in Turkish population. SF-36 may also be a promising measure for research on health inequalities in Turkey and other developing countries.

Coronary heart disease policy models: a systematic review.

BACKGROUND: The prevention and treatment of coronary heart disease (CHD) is complex. A variety of models have therefore been developed to try and explain past trends and predict future possibilities. The aim of this systematic review was to evaluate the strengths and limitations of existing CHD policy models. METHODS: A search strategy was developed, piloted and run in MEDLINE and EMBASE electronic databases, supplemented by manually searching reference lists of relevant articles and reviews. Two reviewers independently checked the papers for inclusion and appraisal. All CHD modelling studies were included which addressed a defined population and reported on one or more key outcomes (deaths prevented, life years gained, mortality, incidence, prevalence, disability or cost of treatment). RESULTS: In total, 75 articles describing 42 models were included; 12 (29%) of the 42 models were micro-simulation, 8 (19%) cell-based, and 8 (19%) life table analyses, while 14 (33%) used other modelling methods. Outcomes most commonly reported were cost-effectiveness (36%), numbers of deaths prevented (33%), life-years gained (23%) or CHD incidence (23%). Among the 42 models, 29 (69%) included one or more risk factors for primary prevention, while 8 (19%) just considered CHD treatments. Only 5 (12%) were comprehensive, considering both risk factors and treatments. The six best-developed models are summarised in this paper, all are considered in detail in the appendices. CONCLUSION: Existing CHD policy models vary widely in their depth, breadth, quality, utility and versatility. Few models have been calibrated against observed data, replicated in different settings or adequately validated. Before being accepted as a policy aid, any CHD model should provide an explicit statement of its aims, assumptions, outputs, strengths and limitations.