Identifying key factors for successful formulation and implementation of healthcare policies on non-communicable diseases: a multinational analysis.

Objectives: Non-communicable diseases (NCDs) are a major public health concern that accounts for 74% of global deaths each year. The increasing burden of NCDs exhausts public health resources and threatens the achievement of the 2030 agenda for sustainable development. The purpose of this study is to thematically analyze the contributory factors in the health policy process and reforms to strengthen the prevention of NCDs across borders, as well as the milestones achieved through the process of policy-making, change, and implementation. Method: This study informs and draws on the findings of contributory factors in the health policy process for preventing NCDs across borders: United States, England, Sweden, Bangladesh, Singapore, South Korea, and Thailand. Ten experts from the seven countries were recruited purposively for a semi-structured interview (e-Interview) on the NCD policy-making process in their countries, either through health ministries or the authors' network. This descriptive qualitative study design is guided by the "Three I's" framework of public policy (institutions, ideas, and interests). In addition to the information obtained from the interviewee, data were also sourced from relevant documents and homepages suggested by the interviewee, as well as health homepages of the countries. Result: The following themes were generated: (1) environmental policies and social determinants, (2) multistakeholder involvement, (3) interministerial collaboration, (4) independent evidence and review institution, (5) integrated health data, and (6) primary care system. There was a shift from individual-targeted policies to environmental policies and social determinants. Notably, national campaigns were developed through non-governmental organizations (NGOs) for the primary prevention of NCDs. Conclusion: The shift from behavioral modification and treatment to social determinants is important. NCDs are broad and require a multisector and multilevel approach. Establishing an organization or hierarchical body to overlook NCDs could result in increased awareness, focus, and surveillance and enhance the policy process.

A life-course approach to tackling noncommunicable diseases in women.

Women's health has been critically underserved by a failure to look beyond women's sexual and reproductive systems to adequately consider their broader health needs. In almost every country in the world, noncommunicable diseases are the leading causes of death for women. Among these, cardiovascular disease (including heart disease and stroke) and cancer are the major causes of mortality. Risks for these conditions exist at each stage of women's lives, but recognition of the unique needs of women for the prevention and management of noncommunicable diseases is relatively recent and still emerging. Once they are diagnosed, treatments for these diseases are often costly and noncurative. Therefore, we call for a strategic, innovative life-course approach to identifying disease triggers and instigating cost-effective measures to minimize exposure in a timely manner. Prohibitive barriers to implementing this holistic approach to women's health exist in both the social arena and the medical arena. Recognizing these impediments and implementing practical approaches to surmounting them is a rational approach to advancing health equity for women, with ultimate benefits for society as a whole.

Strengthening the primary health care for non-communicable disease prevention and control in the post-pandemic period: a perspective from China.

Non-communicable diseases (NCDs) have become the leading cause of deaths in China and many other countries worldwide. To call for actions in strengthening primary health care (PHC) and accelerate NCD prevention and control in the post-pandemic era in China, the 2023 Duke Kunshan Health Forum focused on innovative approaches and lessons learned during the pandemic that can be applied in addressing NCD challenges. In this article we summarize key points discussed by the participants in three areas: PHC as the foundation and ultimate solution for NCD prevention and control, post-pandemic opportunities to accelerate the NCD program with innovative approaches, and an action framework proposed by the Forum collaborators to address remaining challenges and achieve NCD control objectives in China. The core of the suggested action framework is to offer people-centered, lifetime, comprehensive, continued, and quality NCD prevention and control services, which rely on an integrated healthcare system connecting the primary, secondary, and tertiary levels of care. To achive this objective, six interconnected actions are recommended in the framework: prioritizing and integrating NCD in PHC and Universal Health Coverage (UHC) framework, engaging multiple stakeholders, directing resources to PHC for quality NCD services, leveraging advantages of new technology, encouraging the use of PHC and improving services, and strengthening best practice sharing.

Integration of point-of-care screening for type 2 diabetes mellitus and hypertension into the COVID-19 vaccine programme in Johannesburg, South Africa.

BACKGROUND: South Africa grapples with a substantial burden of non-communicable diseases (NCDs), particularly type 2 diabetes (diabetes) and hypertension. However, these conditions are often underdiagnosed and poorly managed, further exacerbated by the strained primary healthcare (PHC) system and the disruptive impact of the COVID-19 pandemic. Integrating NCD screening with large-scale healthcare initiatives, such as COVID-19 vaccination campaigns, offers a potential solution, especially in low- and middle-income countries (LMICs). We investigated the feasibility and effectiveness of this integration. METHODS: A prospective cohort study was conducted at four government health facilities in Johannesburg, South Africa. NCD screening was incorporated into the COVID-19 vaccination campaign. Participants underwent COVID-19 rapid tests, blood glucose checks, blood pressure assessments, and anthropometric measurements. Those with elevated blood glucose or blood pressure values received referrals for diagnostic confirmation at local PHC centers. RESULTS: Among 1,376 participants screened, the overall diabetes prevalence was 4.1%, combining previously diagnosed cases and newly identified elevated blood glucose levels. Similarly, the hypertension prevalence was 19.4%, comprising pre-existing diagnoses and newly detected elevated blood pressure cases. Notably, 46.1% of participants displayed waist circumferences indicative of metabolic syndrome, more prevalent among females. Impressively, 7.8% of all participants screened were potentially newly diagnosed with diabetes or hypertension. Approximately 50% of individuals with elevated blood glucose or blood pressure successfully linked to follow-up care within four weeks. CONCLUSION: Our study underscores the value of utilizing even brief healthcare interactions as opportunities for screening additional health conditions, thereby aiding the identification of previously undiagnosed cases. Integrating NCD screenings into routine healthcare visits holds promise, especially in resource-constrained settings. Nonetheless, concerted efforts to strengthen care linkage are crucial for holistic NCD management and control. These findings provide actionable insights for addressing the NCD challenge and improving healthcare delivery in LMICs.

Medium-to-long term sustainability of a health systems intervention to improve service readiness and quality of non-communicable disease (NCD) patient care and experience at primary care settings in Uganda.

BACKGROUND: With the double burden of rising chronic non-communicable diseases (NCDs) and persistent infectious diseases facing sub-Saharan Africa, integrated health service delivery strategies among resource-poor countries are needed. Our study explored the post-trial sustainability of a health system intervention to improve NCD care, introduced during a cluster randomised trial between 2013 and 2016 in Uganda, focusing on hypertension (HT) and type-2 diabetes mellitus (DM) services. In 2020, 19 of 38 primary care health facilities (HFs) that constituted the trial's original intervention arm until 2016 and 3 of 6 referral HFs that also received the intervention then, were evaluated on i) their facility performance (FPS) through health worker knowledge, and service availability and readiness (SAR), and ii) the quality-of-patient-care-and-experience (QoCE) received. METHODS: Cross-sectional data from the original trial (2016) and our study (2020) were compared. FPS included a clinical knowledge test with 222 health workers: 131 (2016) and 91 (2020) and a five-element SAR assessment of all 22 HFs. QoCE assessment was performed among 420 patients: 88 (2016) and 332 (2020). Using a pair-matched approach, FPS and QoCE summary scores were compared. Linear and random effects Tobit regression models were also analysed. RESULTS: The mean aggregate facility performance (FPS) in 2020 was lower than in 2016: 70.2 (95%CI = 66.0-74.5) vs. 74.8 (95%CI = 71.3-78.3) respectively, with no significant difference (p = 0.18). Mean scores declined in 4 of 5 SAR elements. Overall FPS was negatively affected by rural or urban HF location relative to peri-urban HFs (p < 0.01). FPS was not independently predicted but patient club functionality showed weak association (p = 0.09). QoCE declined slightly to 8.7 (95%CI = 8.4-91) in 2020 vs 9.5 (95%CI = 9.1-9.9) in 2016 (p = 0.02) while the proportion of patients receiving adequate quality care also declined slightly to 88.2% from 98.5% respectively, with no statistical difference (p = 0.20). Only the parent district weakly predicted QoCE (p = 0.05). CONCLUSIONS: Four years after the end of research-related support, overall facility performance had declined as expected because of the interrupted supplies and a decline in regular supervision. However, both service availability and readiness and quality of HT/DM care were surprisingly well preserved. Sustainability of an NCD intervention in similar settings may remain achievable despite the funding instability following a trial's end but organisational measures to prepare for the post-trial phase should be taken early on in the intervention process.

Do Food and Nutrition Policies in Ethiopia Support the Prevention of Non-Communicable Diseases through Population-Level Salt Reduction Measures? A Policy Content Analysis.

INTRODUCTION: Despite the importance of salt reduction to health outcomes, relevant policy adoption in Ethiopia has been slow, and dietary consumption of sodium remains relatively high. AIM: This analysis aims to understand the content and context of existing food-related policy, strategy, and guideline documents to identify gaps and potential opportunities for salt reduction in Ethiopia in the wider context of global evidence-informed best practice nutrition policy. METHODS: Policy documents relevant to food and noncommunicable diseases (NCDs), published between 2010 and December 2021, were identified through searches of government websites supplemented with experts' advice. Documentary analysis was conducted drawing on the 'policy cube' which incorporates three dimensions: (i) comprehensiveness of policy measures, which for this study included the extent to which the policy addressed the food-related WHO "Best Buys" for the prevention of NCDs; (ii) policy salience and implementation potential; and (iii) equity (including gender) and human rights orientation. RESULTS: Thirty-two policy documents were retrieved from government ministries, of which 18 were deemed eligible for inclusion. A quarter of these documents address diet-related "Best Buys" through the promotion of healthy nutrition and decreasing consumption of excess sodium, sugar, saturated fat, and trans-fats. The remainder focuses on maternal and child health and micronutrient deficiencies. All documents lack detail relating to budget, monitoring and evaluation, equity, and rights. CONCLUSIONS: This review demonstrates that the Government of Ethiopia has established policy frameworks highlighting its intention to address NCDs, but that there is an opportunity to strengthen these frameworks to improve the implementation of salt reduction programs. This includes a more holistic approach, enhanced clarification of implementation responsibilities, stipulation of budgetary allocations, and promoting a greater focus on inequities in exposure to nutrition interventions across population groups. While the analysis has identified gaps in the policy frameworks, further qualitative research is needed to understand why these gaps exist and to identify ways to fill these gaps.

The state of health in Pakistan and its provinces and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019.

BACKGROUND: Understanding health trends and estimating the burden of disease at the national and subnational levels helps policy makers track progress and identify disparities in overall health performance. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides comprehensive estimates for Pakistan. Comparison of health indicators since 1990 provides valuable insights about Pakistan's ability to strengthen its health-care system, reduce inequalities, improve female and child health outcomes, achieve universal health coverage, and meet the UN Sustainable Development Goals. We present estimates of the burden of disease, injuries, and risk factors for Pakistan provinces and territories from 1990 to 2019 based on GBD 2019 to improve health and health outcomes in the country. METHODS: We used methods and data inputs from GBD 2019 to estimate socio-demographic index, total fertility rate, cause-specific deaths, years of life lost, years lived with disability, disability-adjusted life-years, healthy life expectancy, and risk factors for 286 causes of death and 369 causes of non-fatal health loss in Pakistan and its four provinces and three territories from 1990 to 2019. To generate estimates for Pakistan at the national and subnational levels, we used 68 location-years of data to estimate Pakistan-specific demographic indicators, 316 location-years of data for Pakistan-specific causes of death, 579 location-years of data for Pakistan-specific non-fatal outcomes, 296 location-years of data for Pakistan-specific risk factors, and 3089 location-years of data for Pakistan-specific covariates. FINDINGS: Life expectancy for both sexes in Pakistan increased nationally from 61·1 (95% uncertainty interval [UI] 60·0-62·1) years in 1990 to 65·9 (63·8-67·8) years in 2019; however, these gains were not uniform across the provinces and federal territories. Pakistan saw a narrowing of the difference in healthy life expectancy between the sexes from 1990 to 2019, as health gains for women occurred at faster rates than for men. For women, life expectancy increased by 8·2% (95% UI 6·3-13·8) between 1990 and 2019, whereas the male life expectancy increased by 7·6% (3·5-11·8). Neonatal disorders, followed by ischaemic heart disease, stroke, diarrhoeal diseases, and lower respiratory infections were the leading causes of all-age premature mortality in 2019. Child and maternal malnutrition, air pollution, high systolic blood pressure, dietary risks, and tobacco consumption were the leading all-age risk factors for death and disability-adjusted life-years at the national level in 2019. Five non-communicable diseases-ischaemic heart disease, stroke, congenital defects, cirrhosis, and chronic kidney disease-were among the ten leading causes of years of life lost in Pakistan. Burden varied by socio-demographic index. Notably, Balochistan and Khyber Pakhtunkhwa had the lowest observed gains in life expectancy. Dietary iron deficiency was the leading cause of years lived with disability for both men and women in 1990 and 2019. Low birthweight and short gestation and particulate matter pollution were the leading contributors to overall disease burden in both 1990 and 2019 despite moderate improvements, with a 23·5% (95% UI 3·8-39·2) and 27·6% (14·3-38·6) reduction in age-standardised attributable DALY rates during the study period. INTERPRETATION: Our study shows that progress has been made on reducing Pakistan's disease burden since 1990, but geographical, age, and sex disparities persist. Equitable investment in the health system, as well as the prioritisation of high-impact policy interventions and programmes, are needed to save lives and improve health outcomes. Pakistan is facing several domestic and foreign challenges-the Taliban's return to power in Afghanistan, political turmoil, catastrophic flooding, the COVID-19 pandemic-that will shape the trajectory of the country's health and development. Pakistan must address the burden of infectious disease and curb rising rates of non-communicable diseases. Prioritising these three areas will enhance Pakistan's ability to achieve universal health coverage, meet its Sustainable Development Goals, and improve the overall health outcomes. FUNDING: Bill & Melinda Gates Foundation. TRANSLATION: For the Urdu translation of the abstract see Supplementary Materials section.

Is iron status associated with markers of non-communicable disease in adolescent Indian children?

BACKGROUND: High body iron status has been associated with non-communicable diseases (NCD) like diabetes (high fasting blood glucose, FBG), hypertension (HTN) or dyslipidaemia (high total cholesterol, TC) in adults, but this has not been examined in adolescent children. This is relevant to iron supplementation and food iron fortification programs that are directed at Indian children. METHODS: The association of NCD with Serum Ferritin (SF) was examined using logistic additive models, adjusted for confounders such as age, body mass index, C-Reactive Protein, haemoglobin and sex, in adolescent (10-19 years old) participants of the Indian Comprehensive National Nutrition Survey. The interaction of these associations with wealth and co-existing prediabetes was also examined. A scenario analysis was also done to understand the impact of iron fortification of cereals on the prevalence NCD among adolescents. RESULTS: The odds ratio (OR) of high FBG, HTN and TC were 1.05 (95% CI: 1.01-1.08), 1.02 (95% CI: 1.001-1.03) and 1.04 (95% CI: 1.01-1.06) respectively for every 10 µg/L increase in SF. The odds for high TC increased with co-existing prediabetes. The scenario analysis showed that providing 10 mg of iron/day by fortification could increase the prevalence of high FBG by 2-14% across states of India. Similar increments in HTN and TC can also be expected. CONCLUSIONS: High SF is significantly associated with NCD in adolescents, dependent on wealth and co-existing prediabetes. This should be considered when enhancing iron intake in anaemia prevention programs, and the NCD relationship with body iron stores should be studied.

A new era of HIV care for age-associated multimorbidity.

PURPOSE OF REVIEW: The management of people with HIV has shifted focus from acute AIDS-defining illness towards improving detection of chronic disease and reducing impact of multimorbidity. In this review, we explore this shifting paradigm of HIV care and the evidence for alternative models proposed to provide integrated holistic services for people with HIV (PWH) with multimorbidity. RECENT FINDINGS: Despite 25 years of the antiretroviral treatment (ART) era an increased incidence of noncommunicable disease (NCD) and multimorbidity in PWH persists. As the world moves closer to universal ART coverage this phenomenon is now reported in low- and middle-income settings. Multimorbidity affects PWH disproportionately compared to the general population and results in reduced health related quality of life (HRQoL), greater hospitalization and higher mortality. There is evidence that NCD care provision and outcomes may be inferior for PWH than their HIV negative counterparts. Various models of integrated multimorbidity care have developed and are grouped into four categories; HIV specialist clinics incorporating NCD care, primary care services incorporating HIV care, community NCD clinics offering integrated HIV care, and multidisciplinary care integrated with HIV in secondary care. Evidence is limited as to the best way to provide multimorbidity care for PWH. SUMMARY: A new era of HIV care for an ageing population with multimorbidity brings challenges for health providers who need to develop holistic patient focused services which span a range of coexisting conditions.

Integrated care teams in primary care improve clinical outcomes and care processes in patients with non-communicable diseases.

Introduction: Primary care physicians face the increasing burden of managing multimorbidities in an ageing population. Implementing an integrated care team (ICT) with defined roles and accountability to share consultation tasks is an emerging care model to address this issue. This study compared outcomes with ICT versus usual care for patients with multimorbidities in primary care. Methods: Data was retrospectively extracted from the electronic medical records (EMRs) of consecutive adult Asian patients empanelled to ICT and those in UC at a typical primary care clinic (polyclinic) in eastern Singapore in 2018. The study population had hypertension, and/or hyperlipidaemia and/or type 2 diabetes mellitus (T2DM). Clinical outcomes included the proportion of patients (ICT vs. UC) who attained their treatment goals after 12 months. Process outcomes included the proportion of patients who completed annual diabetic eye and foot screenings, where applicable. Results: Data from 3,302 EMRs (ICT = 1,723, UC = 1,579) from January 2016 to September 2017 was analysed. The ICT cohort was more likely to achieve treatment goals for systolic blood pressure (SBP) (adjusted odds ratio [AOR] = 1.52, 95% confidence interval [CI] = 1.38-1.68), low-density lipoprotein cholesterol (AOR = 1.72, 95% CI = 1.49-1.99), and glycated haemoglobin (AOR = 1.28, 95% CI = 1.09-1.51). The ICT group had higher uptake of diabetic retinal screening (89.1% vs. 83.0%, P < 0.001) and foot screening (85.2% vs. 77.9%, P < 0.001). Conclusion: The ICT model yielded better clinical and process outcomes than UC, with more patients attaining treatment goals.

Scaling up prenatal nutrition could reduce the global burden of noncommunicable diseases in the next generation: a modeling analysis.

BACKGROUND: Nutritional conditions during pregnancy may influence the epigenetic development of an individual and consequently their later-life risk of noncommunicable disease (NCD). Improving nutrition for pregnant females may therefore serve the dual purpose of directly improving pregnancy outcomes and preventing NCDs in the next generation. OBJECTIVES: We estimated the impact of prenatal supplementation with iron and folic acid (IFA), multiple micronutrients (MMS), or calcium at 50%, 75%, or 90% coverage on future NCDs by age and sex in 2015. METHODS: We used secondary data sources from 132 countries to quantify the cases of diabetes and hypertension and the deaths from selected NCDs that could be averted or delayed by scaling up prenatal micronutrient supplementation. RESULTS: Globally, >51,000 NCD deaths, 6 million cases of hypertension, and 3 million cases of diabetes could be prevented per offspring birth cohort if mothers were prenatally supplemented with MMS at 90% coverage. For IFA these numbers would be roughly half. Calcium supplementation at 90% could delay 51,000 deaths per birth cohort. Our model suggests that substantial numbers of NCD deaths and cases of hypertension and diabetes could be prevented in future generations by scaling up micronutrient supplementation for mothers during pregnancy. CONCLUSIONS: Highlighting the additional benefits of proven nutrition interventions is critical in ensuring adequate and sustained investments, and programmatic integration. As the double burden of disease continues to grow, population-wide efforts to scale up micronutrient supplementation to pregnant females could help prevent both undernutrition and chronic disease.

Prevalence of self-reported diabetes risk factors and integration of diabetes screening and referral at two urban HIV care and treatment clinics in Zambia.

People living with HIV (PLWH) on antiretroviral therapy (ART) are living longer and are at risk of HIV co-morbidities including non-communicable diseases (NCDs), particularly in low-resource settings. However, the evidence base for effectively integrating HIV and NCD care is limited. The Chronic Health Care (CHC) checklist, designed to screen for multiple NCDs including a 6-item diabetes self-report screener, was implemented at two PEPFAR-supported HIV clinics in Kabwe and Kitwe, Zambia. Study objectives were to describe the HIV care and treatment population and their self-reported diabetes-related symptoms, and to evaluate provider-initiated screening and referral post-training on the CHC checklist. This cross-sectional study enrolled 435 adults receiving combination ART services. Clinic exit interviews revealed 46% self-reported at least one potential symptom, and 6% self-reported three or more symptoms to the study team, indicating risk for diabetes and need for further diagnostic testing. In comparison, only 8% of all participants reported being appropriately screened for diabetes by their health provider, with less than 1% referred for further testing. This missed opportunity for screening and referral indicates that HIV-NCD integration efforts need more fully resourced and multi-pronged approaches in order to ensure that PLWH who are already accessing ART receive the comprehensive, holistic care they need.

Prevention and control of non-communicable diseases in antenatal, intrapartum, and postnatal care: a systematic scoping review of clinical practice guidelines since 2011.

BACKGROUND: Non-communicable diseases (NCDs) are a leading cause of maternal mortality and morbidity worldwide. The World Health Organization is developing new recommendations focusing on the management of NCDs for pregnant, intrapartum, and postnatal women. Thus, to support the development of new guidelines and recommendations, we aimed to determine the availability, focus, and scope of recommendations of current guidelines for the management of NCDs during pregnancy, intrapartum, and postnatal period. METHODS: PubMed, Global Index Medicus, TRIP, and Guideline International Network databases were searched on 31 May 2021, to identify any NCD-related guidelines published between 2011 and 2021 with no language or country restrictions. Websites of 165 professional organizations were also searched. Characteristics of included guidelines were analyzed, and recommendations were extracted from guidelines of five high-priority NCD conditions (diabetes, chronic hypertension, respiratory conditions, hemoglobinopathies and sickle cell disease, and mental and substance use disorders). RESULTS: From 6026 citations and 165 websites, 405 guidelines were included of which 132 (33%) were pregnancy-specific and 285 (88%) were developed in high-income countries. Among pregnancy-specific guidelines, the most common conditions for which recommendations were provided were gestational diabetes, circulatory diseases, thyroid disorders, and hypertensive disorders of pregnancy. For the five high-priority conditions, 47 guidelines were identified which provided 1834 recommendations, largely focused on antenatal care interventions (62%) such as early detection, screening tools, pharmacological treatment, and lifestyle education. Postnatal recommendations largely covered postnatal clinical assessments, lifestyle education, and breastfeeding. Health system recommendations largely covered multidisciplinary care teams and strengthening referral pathways. CONCLUSIONS: This study provides a robust assessment of currently available guidelines and mapping of recommendations on NCD management within maternal health services, which will inform the scope of the World Health Organization's future guideline development activities. This study identified a need to develop guidelines that consider NCDs holistically, with an integrated approach to antenatal, intrapartum, and postnatal care, and that are relevant for resource-limited contexts. Any such guidelines should consider what interventions are most essential to improving outcomes for women with NCDs and their newborns, and how variations in quality of NCD-related care can be addressed.

The acceptability of integrated healthcare services for HIV and non-communicable diseases: experiences from patients and healthcare workers in Tanzania.

BACKGROUND: In sub-Saharan Africa, the prevalence of non-communicable diseases (NCDs) has risen sharply amidst a high burden of communicable diseases. An integrated approach to HIV and NCD care offers the potential of strengthening disease control programmes. We used qualitative methods to explore patients' and care-providers' experiences and perspectives on the acceptability of integrated care for HIV-infection, diabetes mellitus (DM), and hypertension (HT) in Tanzania. METHODS: A qualitative study was conducted in selected health facilities in Dar es Salaam and Coastal regions, which had started to provide integrated care and management for HIV, DM, and HT using a single research clinic for patients with one or more of these conditions. In-depth interviews were held with patients and healthcare providers at three time points: At enrolment (prior to the patient receiving integrated care, at the mid-line and at the study end). A minimum of 16 patients and 12 healthcare providers were sampled for each time point. Observation was also carried out in the respective clinics during pre- and mid-line phases. The Theoretical Framework of Acceptability (TFA) underpinned the structure and interpretation of the combined qualitative and observational data sets. RESULTS: Patients and healthcare providers revealed a positive attitude towards the integrated care delivery model at the mid-line and at study end-time points. High acceptability was related to increased exposure to service integration in terms of satisfaction with the clinic setup, seating arrangements and the provision of medical care services. Satisfaction also centred on the patients' freedom to move from one service point to another, and to discuss the services and their own health status amongst themselves. Adherence to medication and scheduling of clinic appointments appeared central to the patient-provider relationship as an aspect in the provision of quality services. Multi-condition health education, patient time and cost-saving, and detection of undiagnosed disease conditions emerged as benefits. On the other hand, a few challenges included long waiting times and limited privacy in lower and periphery health facilities due to infrastructural limitations. CONCLUSION: The study reveals a continued high level of acceptability of the integrated care model among study participants in Tanzania. This calls for evaluation in a larger and a comparative study. Nevertheless, much more concerted efforts are necessary to address structural challenges and maximise privacy and confidentiality.

[Role of calcium in health and reducing the risk of non-communicable diseases].

Calcium as an essential mineral is involved in many processes in the body, being the main one in the mineral matrix of bones and teeth. It is necessary for conducting nerve impulses, blood coagulation, muscle contraction, regulation of the transport of various ions through the cell membrane, glycogenolysis and gluconeogenesis, and the activity of many enzymes. In Russia, insufficient calcium intake is noted. The purpose of the work was to assess the role of calcium of various origins in meeting the needs and health of the population. Material and methods. Literature search was carried out using the PubMed, Google Scholar, ResearchGate, RSCI, CyberLeninka systems, mainly for the last 10 years, with the exception of research of fundamental importance, using the keywords "calcium", "milk", "bioavailability". Results. Dairy consumption is associated with an overall reduction in the risk of noncommunicable diseases, including cardiovascular disease, type 2 diabetes mellitus, and some types of cancer. Calcium in natural milk and dairy products, as well as calcium of milk origin, has a higher bioavailability and absorption than from other sources of synthetic or natural mineral origin. The recommendation to reduce dairy consumption may be counterproductive to health and therefore may increase health care costs. Conclusion. Milk and dairy products are the optimal source of calcium. The high bioavailability of calcium of milk origin justifies the expediency of its preferred use in dietary nutrition, both as part of therapeutic diets in hospitals and nutrition in social service institutions, and in outpatient practice. Additional studies, including randomized controlled trials, may be needed to explore in more detail the optimal consumption of milk and dairy products, as well as the use of calcium-containing pharmaceutical products and dietary supplements.

Timing of Complementary Feeding, Growth, and Risk of Non-Communicable Diseases: Systematic Review and Meta-Analysis.

No consensus currently exists on the appropriate age for the introduction of complementary feeding (CF). In this paper, a systematic review is conducted that investigates the effects of starting CF in breastfed and formula-fed infants at 4, 4-6, or 6 months of age (i) on growth at 12 months of age, (ii) on the development of overweight/obesity at 3-6 years of age, (iii) on iron status, and (iv) on the risk of developing (later in life) type 2 diabetes mellitus (DM2) and hypertension. An extensive literature search identified seven studies that evaluated the effects of the introduction of CF at the ages in question. No statistically significant differences related to the age at which CF is started were observed in breastfed or formula-fed infants in terms of the following: iron status, weight, length, and body mass index Z-scores (zBMI) at 12 months, and development of overweight/obesity at 3 years. No studies were found specifically focused on the age range for CF introduction and risk of DM2 and hypertension. Introducing CF before 6 months in healthy term-born infants living in developed countries is essentially useless, as human milk (HM) and formulas are nutritionally adequate up to 6 months of age.

Estimation of national stress index using socioeconomic antecedents - a case of MIMIC model.

Developed economies are at the forefront of facing the brunt of non-communicable diseases (NCD). The majority of the health expenditures are routed in managing obesity and mental disorder-related patients, and there is a fall in the productivity of the distressed and NCD prone labour. Several indicators of stress are used in literature to assess its implications. However, empirically no database has maintained the longitudinal data of national stress level. This study focused on constructing the socioeconomic antecedent of non-communicable stress which is leading to several NCDs. For this Multiple Indicator and Multiple Causes (MIMIC) model is utilized for 151 countries between 2008 and 2018. The results show that macroeconomic conditions, trade, and environmental quality follow fundamentals in explaining stress. While, national stress index is a significant source of smoking and mental disorder prevalence.

Cost of Traditional Herbal Medicines for Noncommunicable Diseases in Rural and Urban Communities in South Africa.

OBJECTIVES: This study assessed traditional herbal medicine (THM) and conventional medicine (CM) utilization among participants with noncommunicable disease in South Africa. METHODS: A cross-sectional study of the Prospective Urban and Rural Epidemiological study collected data through face-to-face interviews using structured questionnaires in 2014. Descriptive, bivariate, and multivariate logistic regression were used to determine the effect of sociodemographic and economic factors on THM and CM use. All statistical analyses were conducted using the statistical computing and graphics language "R." RESULTS: Of the total 417 randomly selected participants in this study, 85% were females, 95% with no health insurance, and 81% with monthly incomes of <2000 rand (R) ($137 equivalent) per month. Moreover, 73% spend 5% of their income on THM, and 10% say they are willing to pay >R500 per year on THM to feel better. Age was significantly associated with different spending patterns after controlling for other demographic factors, given that older adults were 82% (odds ratio 0.18; 95% confidence interval 0.02-0.93) less likely to pay >R100 for THM whereas younger adults were 59% (odds ratio 0.41; 95% confidence interval 0.17-0.97) less likely to pay for CM. CONCLUSIONS: The cost of using THM and CM largely differed by age. The economic insight into this study reveals individuals more willing to pay for THM to payors, which can ultimately clue payors into areas for medication optimization from potential drug-drug interactions and adverse events and, therefore, reduce healthcare costs.

Incorporating neglected non-communicable diseases into the national health program-A review.

Poor nations are already facing the heat of double burden of communicable and non-communicable diseases (NCDs), often known as chronic illnesses, which are characterized by a protracted course and are multifactorial in causation. In addition to this, neglected non-communicable diseases (NNCD) in the form of gout, sickle cell disease, accidents and many more are likely to be one of the biggest public health challenges soon. Nearly three-quarters (31.4 million) of all NCD-related fatalities occur in developing nations. In terms of morbidity and mortality, the "BIG FOUR" NCDs-diabetes, cancer, chronic respiratory diseases, and cardiovascular diseases-are widely acknowledged as the main contributors to global health loss. However, other NCDs account for 55% of the global burden of NCDs and are frequently neglected in terms of premature death, increased Disability Adjusted Life Years (DALY), and decreased Quality-Adjusted Life Year (QALY). We have briefly discussed the disease burden of a few significant, yet neglected NCDs in this paper.