Data gaps towards health development goals, 47 low- and middle-income countries.

OBJECTIVE: To assess the availability and gaps in data for measuring progress towards health-related sustainable development goals and other targets in selected low- and middle-income countries. METHODS: We used 14 international population surveys to evaluate the health data systems in the 47 least developed countries over the years 2015-2020. We reviewed the survey instruments to determine whether they contained tools that could be used to measure 46 health-related indicators defined by the World Health Organization. We recorded the number of countries with data available on the indicators from these surveys. FINDINGS: Twenty-seven indicators were measurable by the surveys we identified. The two health emergency indicators were not measurable by current surveys. The percentage of countries that used surveys to collect data over 2015-2020 were lowest for tuberculosis (2/47; 4.3%), hepatitis B (3/47; 6.4%), human immunodeficiency virus (11/47; 23.4%), child development status and child abuse (both 13/47; 27.7%), compared with safe drinking water (37/47; 78.7%) and births attended by skilled health personnel (36/47; 76.6%). Nineteen countries collected data on 21 or more indicators over 2015-2020 while nine collected data on no indicators; over 2018-2020 these numbers reduced to six and 20, respectively. CONCLUSION: Examining selected international surveys provided a quick summary of health data available in the 47 least developed countries. We found major gaps in health data due to long survey cycles and lack of appropriate survey instruments. Novel indicators and survey instruments would be needed to track the fast-changing situation of health emergencies.

Data Sources for Understanding the Social Determinants of Health: Examples from Two Middle-Income Countries: the 3-D Commission.

The expansion in the scope, scale, and sources of data on the wider social determinants of health (SDH) in the last decades could bridge gaps in information available for decision-making. However, challenges remain in making data widely available, accessible, and useful towards improving population health. While traditional, government-supported data sources and comparable data are most often used to characterize social determinants, there are still capacity and management constraints on data availability and use. Conversely, privately held data may not be shared. This study reviews and discusses the nature, sources, and uses of data on SDH, with illustrations from two middle-income countries: Kenya and the Philippines. The review highlights opportunities presented by new data sources, including the use of big data technologies, to capture data on social determinants that can be useful to inform population health. We conducted a search between October 2010 and September 2020 for grey and scientific publications on social determinants using a search strategy in PubMed and a manual snowball search. We assessed data sources and the data environment in both Kenya and the Philippines. We found limited evidence of the use of new sources of data to study the wider SDH, as most of the studies available used traditional sources. There was also no evidence of qualitative big data being used. Kenya has more publications using new data sources, except on the labor determinant, than the Philippines. The Philippines has a more consistent distribution of the use of new data sources across the HEALTHY determinants than Kenya, where there is greater variation of the number of publications across determinants. The results suggest that both countries use limited SDH data from new data sources. This limited use could be due to a number of factors including the absence of standardized indicators of SDH, inadequate trust and acceptability of data collection methods, and limited infrastructure to pool, analyze, and translate data.

Use of Data to Understand the Social Determinants of Depression in Two Middle-Income Countries: the 3-D Commission.

Depression accounts for a large share of the global disease burden, with an estimated 264 million people globally suffering from depression. Despite being one of the most common kinds of mental health (MH) disorders, much about depression remains unknown. There are limited data about depression, in terms of its occurrence, distribution, and wider social determinants. This work examined the use of novel data sources for assessing the scope and social determinants of depression, with a view to informing the reduction of the global burden of depression.This study focused on new and traditional sources of data on depression and its social determinants in two middle-income countries (LMICs), namely, Brazil and India. We identified data sources using a combination of a targeted PubMed search, Google search, expert consultations, and snowball sampling of the relevant literature published between October 2010 and September 2020. Our search focused on data sources on the following HEALTHY subset of determinants: healthcare (H), education (E), access to healthy choices (A), labor/employment (L), transportation (T), housing (H), and income (Y).Despite the emergence of a variety of data sources, their use in the study of depression and its HEALTHY determinants in India and Brazil are still limited. Survey-based data are still the most widely used source. In instances where new data sources are used, the most commonly used data sources include social media (twitter data in particular), geographic information systems/global positioning systems (GIS/GPS), mobile phone, and satellite imagery. Often, the new data sources are used in conjunction with traditional sources of data. In Brazil, the limited use of new data sources to study depression and its HEALTHY determinants may be linked to (a) the government's outsized role in coordinating healthcare delivery and controlling the data system, thus limiting innovation that may be expected from the private sector; (b) the government routinely collecting data on depression and other MH disorders (and therefore, does not see the need for other data sources); and (c) insufficient prioritization of MH as a whole. In India, the limited use of new data sources to study depression and its HEALTHY determinants could be a function of (a) the lack of appropriate regulation and incentives to encourage data sharing by and within the private sector, (b) absence of purposeful data collection at subnational levels, and (c) inadequate prioritization of MH. There is a continuing gap in the collection and analysis of data on depression, possibly reflecting the limited priority accorded to mental health as a whole. The relatively limited use of data to inform our understanding of the HEALTHY determinants of depression suggests a substantial need for support of independent research using new data sources. Finally, there is a need to revisit the universal health coverage (UHC) frameworks, as these frameworks currently do not include depression and other mental health-related indicators so as to enable tracking of progress (or lack thereof) on such indicators.

A call to strengthen data in response to COVID-19 and beyond.

The COVID-19 (coronavirus disease 2019) pandemic has underscored the critical need for all countries to strengthen their health data and information systems and ensure the routes the data travel, from submission to use, are unobstructed. Timely, credible, reliable, and actionable data are key to ensuring that political decisions are data driven and facilitate understanding, monitoring, and forecasting. To ensure that critical decisions related to the wider health and socioeconomic effects of this pandemic are data driven, each country needs to develop or enhance a national data governance plan that includes a clear coordination mechanism, well-defined and documented data processes (manual or electronic), the exchange of data, and a data culture to empower users. In addition, countries should now more than ever invest and enhance their data and health information systems to ensure that all decisions are data driven and that they are prepared for what is next.

Access to Cardiovascular Disease and Hypertension Medicines in Developing Countries: An Analysis of Essential Medicine Lists, Price, Availability, and Affordability.

Background Access to medicines is important for long-term care of cardiovascular diseases and hypertension. This study provides a cross-country assessment of availability, prices, and affordability of cardiovascular disease and hypertension medicines to identify areas for improvement in access to medication treatment. Methods and Results We used the World Health Organization online repository of national essential medicines lists (EMLs) for 53 countries to transcribe the information on the inclusion of 12 cardiovascular disease/hypertension medications within each country's essential medicines list. Data on availability, price, and affordability were obtained from 84 surveys in 59 countries that used the World Health Organization's Health Action International survey methodology. We summarized and compared the indicators across lowest-price generic and originator brand medicines in the public and private sectors and by country income groups. The average availability of the select medications was 54% in low- and lower-middle-income countries and 60% in high- and upper-middle-income countries, and was higher for generic (61%) than brand medicines (41%). The average patient median price ratio was 80.3 for brand and 16.7 for generic medicines and was higher for patients in low- and lower-middle-income countries compared with high- and upper-middle-income countries across all medicine categories. The costs of 1 month's antihypertensive medications were, on average, 6.0 days' wage for brand medicine and 1.8 days' wage for generics. Affordability was lower in low- and lower-middle-income countries than high- and upper-middle-income countries for both brand and generic medications. Conclusions The availability and accessibility of pharmaceuticals is an ongoing challenge for health systems. Low availability and high costs are major barriers to the use of and adherence to essential cardiovascular disease and antihypertensive medications worldwide, particularly in low- and lower-middle-income countries.

Global Surveillance of trans-Fatty Acids.

Trans-fatty acid (TFA) intake can increase the risk of coronary heart disease (CHD) morbidity and mortality and all-cause mortality. Industrially produced TFAs and ruminant TFAs are the major sources in foods. TFA intake and TFA-attributed CHD mortality vary widely worldwide. Excessive TFA intake is a health threat in high-income countries; however, it is also a threat in low- and middle-income countries (LMICs). Data on TFA intake are scarce in many LMICs and an urgent need exists to monitor TFAs globally. We reviewed global TFA intake and TFA-attributed CHD mortality and current progress toward policy or regulation on elimination of industrially produced TFAs in foods worldwide. Human biological tissues can be used as biomarkers of TFAs because they reflect actual intake from various foods. Measuring blood TFA levels is a direct and reliable method to quantify TFA intake.

Assessing the relationship between out-of-pocket spending on blood pressure and diabetes medication and household catastrophic health expenditure: evidence from Pakistan.

BACKGROUND: Treatment of non-communicable diseases (NCDs) in low-and-middle-income countries (LMICs) is costly and could expose households to financial hardship and vulnerability. This paper examines the association between medication costs of two major NCDs - hypertension (blood pressure) and diabetes, and household-level incidences of catastrophic health expenditure (CHE) in a South Asian LMIC, Pakistan. METHODS: The study analyzes self-reported blood pressure and diabetes (BPD) medication expenditure from the latest version (2015-16) of the Household Integrated Economic Survey (HIES) of Pakistan, a nationally representative survey of 24,238 households. The incidence of CHE is defined as households' out-of-pocket (OOP) medical expenditure exceeding 10% of the total household expenditure. Using a linear probability model, we estimate the adjusted differences in CHE incidence between households that are spending and 'not' spending on BPD medication. We also analyze several hypothetical scenarios of BPD medication cost coverage, and compare the estimated CHE incidences of respective scenarios with the status quo. RESULTS: We find that the average monthly medical expenditure, and average medical expenditure share are significantly higher for households spending on BPD medication, compared to households 'not' spending. The incidence of CHE is found 6.7 percentage point higher for the households consuming BPD medication, after controlling for relevant socioeconomic attributes. If 25, 50, and 100% of the BPD medication OOP cost is covered, then the CHE incidence would reduce respectively by 5.9, 12.7, and 21.4% compared to the status quo. CONCLUSION: Medication cost for managing two major NCDs and household catastrophic health expenditure have strong associations. The findings inform policies toward ensuring access to necessary healthcare services, and protecting households from NCD treatment related financial hardship.

Youth access to cigarettes in six sub-Saharan African countries.

OBJECTIVE: Tobacco smoking is initiated and established mostly during adolescence. The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) Article 16 outlines the obligation of parties to prohibit the sale of tobacco products to minors. This study examined where and how student smokers obtain cigarettes. METHODS: We examined Global Youth Tobacco Survey (GYTS) data from 2009 to 2011 on cigarette access among students aged 13-15 in six sub-Saharan African countries. RESULTS: In all countries analyzed, over 20% of student smokers obtained their cigarettes in a store or shop (52.6% in South Africa, 37.7% in Republic of Congo, 28.2% in Swaziland, 27.4% in Cote d'Ivoire, 26.9% in Ghana, and 22.6% in Uganda). In Cote d'Ivoire and South Africa, 68.9% and 68.7% of student cigarette smokers, respectively, were not refused the sale of cigarettes because of age. The percentage of students who were offered free cigarettes by a tobacco company representative ranged from 4.7% in Cote d'Ivoire to 12.1% in South Africa. CONCLUSIONS: The method of obtaining cigarettes and access to cigarettes among students varies among sub-Saharan African countries. Adopting and enforcing interventions that prevent youth from accessing tobacco products could be an effective strategy for reducing smoking initiation among youth in sub-Saharan African countries.

Prevalence of tobacco use among adults in Egypt, 2009.

INTRODUCTION: We assessed the differences in overall use of tobacco and in the use of various tobacco products, by sex and by frequency of use across various demographic groups. METHODS: We used data from the Global Adult Tobacco Survey (GATS), conducted in 2009 in Egypt. The data consist of answers to GATS by 20,924 respondents from a nationally representative, multistage probability sample of adults aged 15 years or older from all regions of Egypt. Current tobacco use was defined as current smoking or use of smokeless tobacco products, either daily or occasionally. We analyzed the differences in current cigarette, shisha, and smokeless tobacco use by sex and frequency of use (daily or occasional); and by demographic characteristics that included age, region, education level and employment status. RESULTS: Overall, 19.7% of the Egyptian population currently use some form of tobacco. Men (38.1% [95% confidence interval (CI) 36.8-39.4]) are much more likely than women (0.6% [95% CI 0.4-0.9]) to use tobacco. Almost 96% of men who use tobacco, do so daily. Men are more likely to use manufactured cigarettes (31.8% [95% CI 30.6-33.1]) than shisha (6.2% [95% CI 5.6-6.9]) or smokeless tobacco (4.1% [95% CI 3.4-4.8]). Few women use tobacco (cigarettes (0.2%), shisha (0.3%) and smokeless tobacco (0.3%)); however, all women who currently smoke shisha, do so daily. Lower educational status, being between ages 25-64 and being employed predicted a higher use of tobacco. CONCLUSION: Egypt has implemented several initiatives to reduce tobacco use. The World Health Organization (WHO) MPOWER technical package, which aims to reverse the tobacco epidemic, is implemented at various levels throughout the country. Our findings show that there is significant variation in the prevalence of tobacco use and types of tobacco used by adult men and women in Egypt. GATS data can be used to better understand comparative patterns of tobacco use by adults, which in turn can be used to develop interventions.

Exposure to secondhand smoke among adults - Philippines, 2009.

INTRODUCTION: We assessed the differences in exposure to secondhand smoke (SHS) among adults at home, in indoor workplaces, and in various public places in the Philippines across various socio-demographic groups. METHODS: Data from the Global Adult Tobacco Survey conducted in 2009 in the Philippines were used. The data consist of survey answers from 9705 respondents from a nationally representative, multistage probability sample of adults aged 15 years or older. We considered that respondents were exposed to SHS if during the previous 30 days they reported that they lived in a home, worked in a building, or visited a public place where people smoked. The public places included in our analysis were indoor workplaces, public transportation vehicles, restaurants, government buildings or offices, and healthcare facilities. The differences in various socioeconomic and demographic groups' exposure to SHS in these places were also examined. RESULTS: Of respondents who reported working indoors, 36.8% were exposed to SHS. Men (43.3% [95% CI 39.7-46.9]) were more likely than women (28.8% [95% CI 25.4-32.4]) to be exposed to SHS (p < 0.001). Of those working in sites where smoking was not allowed, 13.9% were exposed to SHS, whereas 66.5% were exposed where smoking is allowed in some enclosed areas, and 90.7% were exposed where smoking is allowed everywhere. During the 30 days preceding the survey, more than 50% of those who took public transportation were exposed to SHS; exposure for those who visited public buildings was 33.6% in restaurants, 25.5% in government buildings or offices, and 7.6% in healthcare facilities. CONCLUSION: Despite a national law passed and several local government ordinances that have promulgated smoke-free workplaces, schools, government offices, and healthcare facilities, our findings show that a large proportion of adults were exposed to SHS at work and in public places, which offers opportunities to strengthen and improve enforcement of the smoke-free initiatives and ordinances in the Philippines.

Methodology of the Global Adult Tobacco Survey - 2008-2010.

In 2008, the Centers for Disease Control and Prevention (CDC) and the World Health Organization developed the Global Adult Tobacco Survey (GATS), an instrument to monitor global tobacco use and measure indicators of tobacco control. GATS, a nationally representative household survey of persons aged 15 years or older, was conducted for the first time during 2008-2010 in 14 low- and middle-income countries. In each country, GATS used a standard core questionnaire, sample design, and procedures for data collection and management and, as needed, added country-specific questions that were reviewed and approved by international experts. The core questionnaire included questions about various characteristics of the respondents, their tobacco use (smoking and smokeless), and a wide range of tobacco-related topics (cessation; secondhand smoke; economics; media; and knowledge, attitudes, and perceptions). In each country, a multistage cluster sample design was used, with households selected proportionate to the size of the population. Households were chosen randomly within a primary or secondary sampling unit, and one respondent was selected at random from each household to participate in the survey. Interviewers administered the survey in the country's local language(s) using handheld electronic data collection devices. Interviews were conducted privately, and same-sex interviewers were used in countries where mixed-sex interviews would be culturally inappropriate. All 14 countries completed the survey during 2008-2010. In each country, the ministry of health was the lead coordinating agency for GATS, and the survey was implemented by national statistical organizations or surveillance institutes. This article describes the background and rationale for GATS and includes a comprehensive description of the survey methods and protocol.

Waterpipe Tobacco Smoking in Turkey: Policy Implications and Trends from the Global Adult Tobacco Survey (GATS).

Waterpipe tobacco smoking (WTS) is an emerging tobacco product globally, especially among adolescents and young adults who may perceive WTS as a safe alternative to smoking cigarettes. Monitoring the use of WTS in Turkey in relation to the tobacco control policy context is important to ensure that WTS does not become a major public health issue in Turkey. The Global Adult Tobacco Survey (GATS) was conducted in Turkey in 2008 and was repeated in 2012. GATS provided prevalence estimates on current WTS and change over time. Other indicators of WTS were also obtained, such as age of initiation and location of use. Among persons aged 15 and older in Turkey, the current prevalence of WTS decreased from 2.3% in 2008 to 0.8% in 2012, representing a 65% relative decline. Among males, WTS decreased from 4.0% to 1.1% (72% relative decline). While the overall smoking prevalence decreased among females, there was no change in the rate of WTS (0.7% in 2008 vs. 0.5% in 2012), though the WTS prevalence rate was already low in 2008. Comprehensive tobacco control efforts have been successful in reducing the overall smoking prevalence in Turkey, which includes the reduction of cigarette smoking and WTS. However, it is important to continue monitoring the use of waterpipes in Turkey and targeting tobacco control efforts to certain groups that may be vulnerable to future WTS marketing (e.g., youth, women).

The Process of Cessation Among Current Tobacco Smokers: A Cross-Sectional Data Analysis From 21 Countries, Global Adult Tobacco Survey, 2009-2013.

We analyzed data from the Global Adult Tobacco Survey (GATS) from 21 countries to categorize smokers by stages of cessation and highlight interventions that could be tailored to each stage. GATS is a nationally representative household survey that measures tobacco use and other key indicators by using a standardized protocol. The distribution of smokers into precontemplation, contemplation, and preparation stages varied by country. Using the stages of change model, each country can design and implement effective interventions suitable to its cultural, social, and economic situations to help smokers advance successfully through the stages of cessation.

Cigarette prices and smoking prevalence after a tobacco tax increase--Turkey, 2008 and 2012.

Raising the price of tobacco products has been shown to reduce tobacco consumption in the United States and other high-income countries, and evidence of this impact has been growing for low- and middle-income countries as well. Turkey is a middle-income country surveyed by the Global Adult Tobacco Survey (GATS) twice in a 4-year period, in 2008 and 2012. During this time, the country introduced a policy raising its Special Consumption Tax on Tobacco and implemented a comprehensive tobacco control program banning smoking in public places, banning advertising, and introducing graphic health warnings. The higher tobacco tax took effect in early 2010, allowing sufficient time for subsequent changes in prices and smoking to be observed by the time of the 2012 GATS. This report uses data from GATS Turkey to examine how cigarette prices changed after the 2010 tax increase, describe the temporally associated changes in smoking prevalence, and learn whether this smoking prevalence changed more in some demographic groups than others. From 2008 to 2012, the average price paid for cigarettes increased by 42.1%, cigarettes became less affordable, and smoking prevalence decreased by 14.6%. The largest reduction in smoking was observed among persons with lower socioeconomic status (SES), highlighting the potential role of tax policy in reducing health disparities across socioeconomic groups.

CDC Grand Rounds: global tobacco control.

During the 20th century, use of tobacco products contributed to the deaths of 100 million persons worldwide. In 2011, approximately 6 million additional deaths were linked to tobacco use, the world's leading underlying cause of death, responsible for more deaths each year than human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), tuberculosis, and malaria combined. One third to one half of lifetime users die from tobacco products, and smokers die an average of 14 years earlier than nonsmokers. Manufactured cigarettes account for 96% of all tobacco sales worldwide. From 1880 to 2009, annual global consumption of cigarettes increased from an estimated 10 billion cigarettes to approximately 5.9 trillion cigarettes, with five countries accounting for 58% of the total consumption: China (38%), Russia (7%), the United States (5%), Indonesia (4%), and Japan (4%). Among the estimated 1 billion smokers worldwide, men outnumber women by four to one. In 14 countries, at least 50% of men smoke, whereas in more than half of these same countries, fewer than 10% of women smoke. If current trends persist, an estimated 500 million persons alive today will die from use of tobacco products. By 2030, tobacco use will result in the deaths of approximately 8 million persons worldwide each year. Yet, every death from tobacco products is preventable.

A cross-country study of cigarette prices and affordability: evidence from the Global Adult Tobacco Survey.

OBJECTIVE: To describe the characteristics of two primary determinants of cigarette consumption: cigarette affordability and the range of prices paid for cigarettes (and bidis, where applicable) in a set of 15 countries. From this cross-country comparison, identify places where opportunities may exist for reducing consumption through tax adjustments. DATA: Self-response data from 45,838 smokers from 15 countries, obtained from the Global Adult Tobacco Survey (GATS) 2008-2011. DESIGN: Using self-response data on individual cigarette expenditure and consumption, we construct a measure of the average cigarette price smokers pay for manufactured cigarettes (and bidis, where applicable) in 15 countries. We use these prices to evaluate cigarette affordability and the range of prices available in each country. These survey-derived measures of cigarette price and affordability are uniquely suited for cross-country comparison because they represent each country's distinctive mix of individual consumption characteristics such as brand choice, intensity of consumption, and purchasing behavior. RESULTS: In this sample of countries, cigarettes are most affordable in Russia, which has the most room for tobacco tax increase. Affordability is also relatively high in Brazil and China for cigarettes, and in India and Bangladesh for bidis. Although the affordability of cigarettes in India is relatively low, the range of cigarette prices paid is relatively high, providing additional evidence to support the call for simplifying the existing tax structure and reducing the width of price options. China has both high affordability and wide price ranges, suggesting multiple opportunities for reducing consumption through tax adjustments.