Suboptimal Intake of Fruits and Vegetables in Nine Selected Countries of the World Health Organization European Region.

The objective of this study was to characterize fruit and vegetable consumption in 9 selected countries of the World Health Organization (WHO) European Region. We analyzed data on fruit and vegetable intake and participant sociodemographic characteristics for 30,455 adults in 9 Eastern European and Central Asian countries via standardized STEPS survey methodology. Fruit and vegetable consumption across all countries was suboptimal, with a high percentage of populations not meeting the WHO-recommended intake of at least 5 servings (400 g) per day. Strengthened implementation of evidence-based policies to increase intake of fruit and vegetables is needed to reduce the burden of and disparities in NCDs.

Integrating maternal, newborn, child health and non-communicable disease care in the sustainable development goal era.

Noncommunicable diseases (NCDs) and maternal newborn and child health (MNCH) are two deeply intertwined health areas that have been artificially separated by global health policies, resource allocations and programming. Optimal MNCH care can provide a unique opportunity to screen for, prevent and manage early signs of NCDs developing in both the woman and the neonate. This paper considers how NCDs, NCD modifiable risk factors, and NCD metabolic risk factors impact MNCH. We argue that integrated management is essential, but this faces challenges that manifest across all levels of domestic health systems. Progress toward Sustainable Development targets requires joined-up action.

Addressing Determinants of Immunization Inequities Requires Objective Tools to Devise Local Solutions.

Universal immunization substantially reduces morbidity and mortality from vaccine-preventable diseases. In recent years, routine immunization coverage has varied considerably among countries across the WHO European Region, and among different populations and districts within countries. It has even declined in some countries. Sub-optimal immunization coverage contributes to accumulations of susceptible individuals and can lead to outbreaks of vaccine-preventable diseases. The European Immunization Agenda 2030 (EIA2030) seeks to build better health in the WHO European Region by ensuring equity in immunization and supporting immunization stakeholders in devising local solutions to local challenges. The factors that influence routine immunization uptake are context specific and multifactorial; addressing immunization inequities will require overcoming or removing barriers to vaccination for underserved individuals or populations. Local level immunization stakeholders must first identify the underlying causes of inequities, and based on this information, tailor resources, or service provision to the local context, as per the organization and characteristics of the health care system in their countries. To do this, in addition to using the tools already available to broadly identify immunization inequities at the national and regional levels, they will need new pragmatic guidance and tools to address the identified local challenges. It is time to develop the necessary guidance and tools and support immunization stakeholders at all levels, especially those at the subnational or local health centre levels, to make the vision of EIA2030 a reality.

Exploring educational inequalities in hypertension control, salt knowledge and awareness, and patient advice: insights from the WHO STEPS surveys of adults from nine Eastern European and Central Asian countries.

OBJECTIVE: To inform strategies aimed at improving blood pressure (BP) control and reducing salt intake, we assessed educational inequalities in high blood pressure (HBP) awareness, treatment and control; physician's advice on salt reduction; and salt knowledge, perceptions and consumption behaviours in Eastern Europe and Central Asia. DESIGN: Data were collected in cross-sectional, population-based nationally representative surveys, using a multi-stage clustered sampling design. Five HBP awareness, treatment and control categories were created from measured BP and hypertension medication use. Education and other variables were self-reported. Weighted multinomial mixed-effects regression models, adjusted for confounders, were used to assess differences across education categories. SETTINGS: Nine Eastern European and Central Asian countries (Armenia, Azerbaijan, Belarus, Georgia, Kyrgyzstan, Republic of Moldova, Tajikistan, Turkey and Uzbekistan). PARTICIPANTS: Nationally representative samples of 30 455 adults aged 25-65 years. RESULTS: HBP awareness, treatment and control varied substantially by education. The coverage of physician's advice on salt was less frequent among participants with lower education, and those with untreated HBP or unaware of their HBP. The education gradient was evident in salt knowledge and perceptions of salt intake but not in salt consumption behaviours. Improved salt knowledge and perceptions were more prevalent among participants who received physician's advice on salt reduction. CONCLUSIONS: There is a strong education gradient in HBP awareness, treatment and control as well as salt knowledge and perceived intake. Enhancements in public and patient knowledge and awareness of HBP and its risk factors targeting socio-economically disadvantaged groups are urgently needed to alleviate the growing HBP burden in low- and middle-income countries.

Alcohol Control Policy in Europe: Overview and Exemplary Countries.

Alcohol is a major risk factor for burden of disease. However, there are known effective and cost-effective alcohol control policies that could reduce this burden. Based on reviews, international documents, and contributions to this special issue of International Journal of Environmental Research and Public Health (IJERPH), this article gives an overview of the implementation of such policies in the World Health Organization (WHO) European Region, and of best practices. Overall, there is a great deal of variability in the policies implemented between countries, but two countries, the Russian Federation and Lithuania, have both recently implemented significant increases in alcohol taxation, imposed restrictions on alcohol availability, and imposed bans on the marketing and advertising of alcohol within short time spans. Both countries subsequently saw significant decreases in consumption and all-cause mortality. Adopting the alcohol control policies of these best-practice countries should be considered by other countries. Current challenges for all countries include cross-border shopping, the impact from recent internet-based marketing practices, and international treaties.

Socio-Demographic Determinants of Road Traffic Fatalities in Women of Reproductive Age in the Republic of Georgia: Evidence from the National Reproductive Age Mortality Study (2014).

PURPOSE: Globally and in the European region, the road traffic injuries (RTI) have emerged as a major public health and development problem, killing the most productive adult members of a population, including women. This study aimed to identify the key socio-demographic determinants of premature and avoidable RTI mortality in reproductive-aged women (15-49 years) in Georgia. MATERIALS AND METHODS: The study employed verbal autopsy data from the second national reproductive age mortality survey (RAMOS 2014). Univariate and multivariate logistic regression models were fitted using the Firth method to assess the crude and adjusted effects of each individual level socio-demographic factor on the odds of RTI-attributed death, with corresponding 95% confidence intervals (COR and AOR, 95% CI). RESULTS: Of 843 women aged 15-49 years, 78 (9.3%) were the victims of fatal traffic crashes. After multivariate adjustment, the odds of dying from RTI were significantly higher in women aged 15-29 years (AOR=7.73, 95% CI= 4.20 to 14.20), those being employed (AOR=2.11, 95% CI= 1.22 to 3.64) and the wealthiest (AOR=2.88, 95% CI= 1.44 to 5.77) compared, respectively, to their oldest (40-49 years), unemployed and poorest counterparts. Conversely, there were no statistically significant ethnic, marital, rural/urban, and educational disparities in women's RTI fatalities. Overall, motorized four-wheeler occupants (78.2%), particularly passengers (71.8%), appeared to be the most common victims of fatal road injuries than pedestrians (20.5%). Alarmingly, the vast majority (85.9%) of any type of road users died instantly at the scene of collision, as compared to deaths en route to hospital (1.3%) or in hospital (11.5%). CONCLUSION: Age, employment, and wealth status appeared to be the strong independent predictors of young women's RTI mortality in Georgia. Future comprehensive research would be advantageous for further deciphering the differential impact of social determinants on traffic-induced fatalities, as a vital platform for evidence-based remedial actions on this predictable and preventable safety hazard.

Georgia: Health System Review.

This analysis of the Georgian health system reviews developments in its organization and governance, health financing, health care provision, health reforms and health system performance. Since 2012, political commitment to improving access to health care, to protecting the population from the financial risks of health care costs and to reducing inequalities has led to the introduction of reforms to provide universal health coverage. Considerable progress has been made. Over 90% of the resident population became entitled to a tightly defined package of state-funded benefits in 2013; previously, only 45% of the population had been eligible. The package of services has variable depth of coverage depending on the groups covered, with the lowest income groups enjoying the most comprehensive benefits. To finance the broader coverage, the government increased health spending significantly, although this remains low in international comparisons. Out-of-pocket (OOP) payments have fallen as public spending has increased. Nevertheless, current health expenditure (CHE) is still dominated by OOP payments (57% in 2015), two thirds of which are for outpatient pharmaceuticals. For this reason, in July 2017, the package of benefits was expanded for the most vulnerable households to cover essential medicines for four common chronic conditions. The system has retained extensive infrastructure with strong geographical coverage. Georgia also has a large number of doctors per capita, but an acute shortage of nurses. Incentives in the system for patients and providers favour emergency and inpatient care over primary care. There are also limited financial incentives to improve the quality of care and a lack of disincentives to inhibit poor quality care. Future reform plans focus on ensuring universal access to high-quality medical services, strengthening primary care and public health services, and increasing financial protection.

Georgia: health system review

This analysis of the Georgian health system reviews developments in its organization and governance, health financing, health care provision, health reforms and health system performance. Since 2012, political commitment to improving access to health care, to protecting the population from the financial risks of health care costs and to reducing inequalities has led to the introduction of reforms to provide universal health coverage. Considerable progress has been made. Over 90% of the resident population became entitled to a tightly defined package of state-funded benefits in 2013; previously, only 45% of the population had been eligible. The package of services has variable depth of coverage depending on the groups covered, with the lowest income groups enjoying the most comprehensive benefits. To finance the broader coverage, the government increased health spending significantly, although this remains low in international comparisons. Out-of-pocket (OOP) payments have fallen as public spending has increased. Nevertheless, current health expenditure is still dominated by OOP payments (57% in 2015), two thirds of which are for outpatient pharmaceuticals. For this reason, in July 2017, the package of benefits was expanded for the most vulnerable households to cover essential medicines for four common chronic conditions. The system has retained extensive infrastructure with strong geographical coverage. Georgia also has a large number of doctors per capita, but an acute shortage of nurses. Incentives in the system for patients and providers favour emergency and inpatient care over primary care. There are also limited financial incentives to improve the quality of care and a lack of disincentives to inhibit poor quality care. Future reform plans focus on ensuring universal access to high-quality medical services, strengthening primary care and public health services, and increasing financial protection.