Equity implications of tobacco taxation: results from WHO FCTC investment cases.

BACKGROUND: Across time, geographies and country income levels, smoking prevalence is highest among people with lower incomes. Smoking causes further impoverishment of those on the lower end of the income spectrum through expenditure on tobacco and greater risk of ill health. METHODS: This paper summarises the results of investment case equity analyses for 19 countries, presenting the effects of increased taxation on smoking prevalence, health and expenditures. We disaggregate the number of people who smoke, smoking-attributable mortality and cigarette expenditures using smoking prevalence data by income quintile. A uniform 30% increase in price was applied across countries. We estimated the effects of the price increase on smoking prevalence, mortality and cigarette expenditures. RESULTS: In all but one country (Bhutan), a one-time 30% increase in price would reduce smoking prevalence by the largest percent among the poorest 20% of the population. All income groups in all countries would spend more on cigarettes with a 30% increase in price. However, the poorest 20% would pay an average of 12% of the additional money spent. CONCLUSIONS: Our results confirm that health benefits from increases in price through taxation are pro-poor. Even in countries where smoking prevalence is higher among wealthier groups, increasing prices can still be pro-poor due to variable responsiveness to higher prices. The costs associated with higher smoking prevalence among the poor, together with often limited access to healthcare services and displaced spending on basic needs, result in health inequality and perpetuate the cycle of poverty.

Advancing progress on tobacco control in low-income and middle-income countries through economic analysis.

BACKGROUND: More than 80% of the world's 1.3 billion tobacco users live in low-income and middle-income countries (LMICs), where progress to address tobacco and its harms has been slow. The perception that tobacco control detracts from economic priorities has impeded progress. The Secretariat of the WHO Framework Convention on Tobacco Control (FCTC) is leading the FCTC 2030 project, which includes technical assistance to LMICs to analyse the economic costs of tobacco use and the benefits of tobacco control. METHODS: The Secretariat of the WHO FCTC, United Nations Development Programme and WHO supported 21 LMICs between 2017 and 2022 to complete national investment cases to guide country implementation of the WHO FCTC, with analytical support provided by RTI International. These country-level cases combine customised estimates of tobacco's economic impact with qualitative analysis of socio-political factors influencing tobacco control. This paper overviews the approach, observed tobacco control advancements and learnings from 21 countries: Armenia, Cabo Verde, Cambodia, Chad, Colombia, Costa Rica, El Salvador, Eswatini, Georgia, Ghana, Jordan, Laos, Madagascar, Myanmar, Nepal, Samoa, Sierra Leone, Sri Lanka, Suriname, Tunisia and Zambia. RESULTS: Tobacco control advancements in line with investment case findings and recommendations have been observed in 17 of the 21 countries, and many have improved collaboration and policy coherence between health and economic stakeholders. CONCLUSIONS: Tobacco control must be seen as more than a health concern. Tobacco control leads to economic benefits and contributes to sustainable development. National investment cases can support country ownership and leadership to advance tobacco control.

Interpreting results, impacts and implications from WHO FCTC tobacco control investment cases in 21 low-income and middle-income countries.

BACKGROUND: Tobacco control investment cases analyse the health and socioeconomic costs of tobacco use and the benefits that can be achieved from implementing measures outlined in the WHO Framework Convention on Tobacco Control (WHO FCTC). They are intended to provide policy-makers and other stakeholders with country-level evidence that is relevant, useful and responsive to national priorities and policy context. METHODS: This paper synthesises findings from investment cases conducted in Armenia, Cabo Verde, Cambodia, Chad, Colombia, Costa Rica, El Salvador, Eswatini, Georgia, Ghana, Jordan, Laos, Madagascar, Myanmar, Nepal, Samoa, Sierra Leone, Sri Lanka, Suriname, Tunisia and Zambia. We examine annual socioeconomic costs associated with tobacco use, focusing on smoking-related healthcare expenditures, the value of lives lost due to tobacco-related mortality and workplace productivity losses due to smoking. We explore potential benefits associated with WHO FCTC tobacco demand-reduction measures. RESULTS: Tobacco use results in average annual socioeconomic losses of US$95 million, US$610 million and US$1.6 billion among the low-income (n=3), lower-middle-income (n=12) and upper-middle-income countries (n=6) included in this analysis, respectively. These losses are equal to 1.1%, 1.8% and 2.9% of average annual national gross domestic product, respectively. Implementation and enforcement of WHO FCTC tobacco demand-reduction measures would lead to reduced tobacco use, fewer tobacco-related deaths and reduced socioeconomic losses. CONCLUSIONS: WHO FCTC tobacco control measures would provide a positive return on investment in every country analysed.

Evolving methodology of national tobacco control investment cases.

BACKGROUND: This article describes an investment case methodology for tobacco control that was applied in 36 countries between 2017 and 2022. METHODS: The WHO Framework Convention on Tobacco Control (FCTC) investment cases compared two scenarios: a base case that calculated the tobacco-attributable mortality, morbidity and economic costs with status quo tobacco control, and an intervention scenario that described changes in those same outcomes from fully implementing and enforcing a variety of proven, evidence-based tobacco control policies and interventions. Health consequences included the tobacco-attributable share of mortality and morbidity from 38 diseases. The healthcare expenditures and the socioeconomic costs from the prevalence of those conditions were combined to calculate the total losses due to tobacco. The monetised benefits of improvements in health resulting from tobacco control implementation were compared with costs of expanding tobacco control to assess returns on investment in each country. An institutional and context analysis assessed the political and economic dimensions of tobacco control in each context. RESULTS: We applied a rigorous yet flexible methodology in 36 countries over 5 years. The replicable model and framework may be used to inform development of tobacco control cases in countries worldwide. CONCLUSION: Investment cases constitute a tool that development partners and advocates have demanded in even greater numbers. The economic argument for tobacco control provided by this set of country-contextualised analyses can be a strong tool for policy change.

Rare causes of genital fistula in nine African countries: a retrospective review.

BACKGROUND: Most genital fistulas result from prolonged, obstructed labor or surgical complications. Other causes include trauma (from accidents, traditional healers, or sexual violence), radiation, carcinoma, infection, unsafe abortion, and congenital malformation. METHODS: This retrospective records review focuses on rare fistula causes among 6,787 women who developed fistula after 1980 and sought treatment between 1994 and 2017 in Tanzania, Uganda, Kenya, Malawi, Zambia, Rwanda, Ethiopia, Somalia, and South Sudan. We compare fistula etiologies across countries and assess associations between rare causes and type of incontinence (urine, feces, or both). RESULTS: Rare fistula accounted for 1.12% (76/6,787) of all fistulas, including traumatic accidents (19/6,787, 0.28%), traumatic sexual violence (15/6,787, 0.22%), traumatic injuries caused by traditional healers (13/6,787, 0.19%), unsafe abortion (10/6,791, 0.15%), radiation (8/6,787, 0.12%), complications of HIV infection (6/6,787, 0.09%), and congenital abnormality (5/6,787, 0.07%). Trauma caused by traditional healers was a particular problem among Somali women. CONCLUSION: Fistulas attributable to rare causes illuminate a variety of risks confronting women. Fistula repair training materials should distinguish trauma caused by traditional healers as a distinct fistula etiology. Diverse causes of fistula call for multi-pronged strategies to reduce fistula incidence.

Community priorities for obesity prevention among low-income adults in Kuala Lumpur: a discrete choice experiment.

Non-communicable diseases and associated risk factors, such as obesity, are prevalent and increasing in Malaysia. To address this burden and the heightened vulnerability of low-income communities to these risk factors, the Better Health Programme Malaysia conducted a partial-profile discrete choice experiment (DCE) to inform the design of a community-based obesity-prevention programme. The DCE survey was conducted with community members (n = 1453) from three publicly supported low-cost, high-rise flat complexes in urban Kuala Lumpur. In the survey, community members were asked to choose between different sets of potential evidence-based interventions for obesity prevention. Their responses to these choice tasks were analysed to quantify preferences for these different health interventions using a random utility maximization model. Based on these results, we determined participants' relative prioritization of the different options. The most preferred interventions were those that reduced the price of fruit and vegetables; altered cooking practices at restaurants and food vendors to reduce salt, sugar and oil; and offered reward incentives for completing online educational activities. Community members did not prioritize several evidence-based interventions, including changes to product placement or product labelling, suggesting that these effective approaches may be less familiar or simply not preferred by respondents. The DCE enabled the clear articulation of these community priorities for evidence-based interventions that focus on the supply and promotion of affordable healthy foods within the local food environment, as well as community demand for healthier food options.

Non-communicable diseases (NCDs) and the factors that increase NCD risk, such as obesity, are widespread and increasing in Malaysia. Low-income communities are particularly vulnerable to these risk factors. The Better Health Programme (BHP) Malaysia conducted a discrete choice experiment (DCE) to elicit community member preferences for evidence-based health promotion interventions to prevent obesity and NCDs. DCE is a research method used to identify participant preferences between different pre-determined options. The DCE survey was conducted with community members (n = 1453) from three publicly supported low-cost, high-rise flat complexes in urban Kuala Lumpur. In the survey, community members were asked to choose between different potential sets of interventions to alter the environment to prevent obesity. Based on their responses, we determined which interventions were most preferred in each community. The most preferred interventions were those that reduced the price of fruit and vegetables; altered cooking practices at restaurants and food vendors to reduce salt, sugar and oil; and offered rewards for completing online educational activities. The survey enabled the clear articulation of these community priorities for evidence-based interventions. These priorities were used to design the BHP Malaysia intervention programme.

The case for investment in tobacco control: lessons from four countries in the Americas.

Objective: To synthesize learnings from four national tobacco control investment cases conducted in the Americas (Colombia, Costa Rica, El Salvador, Suriname) under the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) 2030 project, to describe results and how national health authorities have used the cases, and to discuss implications for the role of investment cases in advancing tobacco control. Methods: We draw on findings from four national investment cases that included 1) a cost-of-illness analysis calculating the health and economic burden of tobacco use, 2) a return-on-investment analysis of implementing key tobacco control demand reduction measures, and 3) a subsidiary analysis of one tobacco control topic of national interest (e.g., equity implications of cigarette taxation). Co-authors reported how cases have been used to advance tobacco control. Results: In Colombia, Costa Rica, El Salvador, and Suriname, tobacco use causes social and economic losses equivalent to between 1.0 to 1.8 percent of GDP. Across these countries, implementing WHO FCTC demand reduction measures would save an average of 11 400 lives per year over the next 15 years. Benefits of the measures would far outweigh the costs of implementation and enforcement. Governments are using the cases to advance tobacco control, including to improve tobacco control laws and their enforcement, strengthen tobacco taxation, prioritize tobacco control planning, coordinate a multisectoral response, and engage political leaders. Conclusions: National investment cases can help to strengthen tobacco control in countries, including by increasing public and political support for implementation of the WHO FCTC and by informing effective planning, legislation, coordination and financing.

A retrospective review of genital fistula occurrence in nine African countries.

BACKGROUND: Female genital fistulas are abnormal communications that lead to urinary and/or fecal incontinence. This analysis compares the characteristics of women with fistulas to understand how countries differ from one another in the circumstances of genital fistula development. METHODS: This retrospective records review evaluated demographics and circumstances of fistula development for 6,787 women who sought fistula treatment between 1994 and 2017 in Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia, and Ethiopia. RESULTS: Most women developed fistula during childbirth, whether vaginal (3,234/6,787, 47.6%) or by cesarean section (3,262/6,787, 48.1%). Others had fistulas attributable to gynecological surgery (215/6,787, 3.2%) or rare causes (76/6,787, 1.1%). Somalia, South Sudan, and Ethiopia had comparatively high proportions following vaginal birth and birth at home, where access to care was extremely difficult. Fistulas with live births were most common in Kenya, Malawi, Rwanda, Uganda, Tanzania, and Zambia, indicating more easily accessible care. CONCLUSIONS: Characteristics of women who develop genital fistula point to geographic differences in obstetric care. Access to care remains a clear challenge in South Sudan, Somalia, and Ethiopia. Higher proportions of fistula after cesarean birth and gynecological surgery in Kenya, Malawi, Rwanda, Uganda, Tanzania, and Zambia signal potential progress in obstetric fistula prevention while compelling attention to surgical safety and quality of care.

The case for investment in tobacco control: lessons from four countries in the Americas

[ABSTRACT]. Objective. To synthesize learnings from four national tobacco control investment cases conducted in the Ameri- cas (Colombia, Costa Rica, El Salvador, Suriname) under the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) 2030 project, to describe results and how national health authorities have used the cases, and to discuss implications for the role of investment cases in advancing tobacco control. Methods. We draw on findings from four national investment cases that included 1) a cost-of-illness analysis calculating the health and economic burden of tobacco use, 2) a return-on-investment analysis of implement- ing key tobacco control demand reduction measures, and 3) a subsidiary analysis of one tobacco control topic of national interest (e.g., equity implications of cigarette taxation). Co-authors reported how cases have been used to advance tobacco control. Results. In Colombia, Costa Rica, El Salvador, and Suriname, tobacco use causes social and economic losses equivalent to between 1.0 to 1.8 percent of GDP. Across these countries, implementing WHO FCTC demand reduction measures would save an average of 11 400 lives per year over the next 15 years. Benefits of the mea- sures would far outweigh the costs of implementation and enforcement. Governments are using the cases to advance tobacco control, including to improve tobacco control laws and their enforcement, strengthen tobacco taxation, prioritize tobacco control planning, coordinate a multisectoral response, and engage political leaders. Conclusions. National investment cases can help to strengthen tobacco control in countries, including by increasing public and political support for implementation of the WHO FCTC and by informing effective plan- ning, legislation, coordination and financing.

[RESUMEN]. Objetivo. Resumir las enseñanzas de cuatro casos nacionales de inversión en el control del tabaco llevados a cabo en la Región de las Américas (Colombia, Costa Rica, El Salvador y Surinam) en el marco del proyecto 2030 del Convenio Marco de la Organización Mundial de la Salud para el Control del Tabaco (CMCT), describir los resultados y cómo las autoridades nacionales de salud han empleado los casos, y abordar las implica- ciones para la función de los casos de inversión en el avance del control del tabaco. Métodos. Este estudio está basado en los hallazgos de cuatro casos de inversión nacional que incluían 1) un análisis del costo de la enfermedad que estima la carga sanitaria y económica del consumo de tabaco, 2) un análisis del rendimiento de la inversión de la ejecución de medidas clave de reducción de la demanda en el control del tabaco, y 3) un análisis subsidiario de un tema de interés nacional sobre el control del tabaco (por ejemplo, el impacto en la equidad de los impuestos sobre los cigarrillos). Los coautores notificaron cómo se han utilizado los casos para avanzar en el control del tabaco. Resultados. En Colombia, Costa Rica, El Salvador y Surinam, el consumo de tabaco causa pérdidas sociales y económicas equivalentes a entre el 1,0 y el 1,8 por ciento del PIB. En todos estos países, la aplicación de las medidas de reducción de la demanda recogidas en el CMCT de la OMS salvaría una media de 11 400 vidas al año en los próximos 15 años. Los beneficios de estas medidas superarían con creces los costos de ejecución y cumplimiento. Los gobiernos están utilizando los casos para avanzar en el control del tabaco, como para mejorar las leyes de control y su aplicación, reforzar los impuestos sobre el tabaco, priorizar la planificación del control del tabaco, coordinar una respuesta multisectorial e involucrar a los líderes políticos. Conclusiones. Los casos de inversión nacional pueden ayudar a fortalecer el control del tabaco en los países, por ejemplo, al aumentar el apoyo público y político a la aplicación del CMCT de la OMS y al informar sobre una planificación, legislación, coordinación y financiación eficaces.

[RESUMO]. Objetivo. Sintetizar as lições aprendidas com quatro casos de investimento nacional no controle do tabaco nas Américas (Colômbia, Costa Rica, El Salvador e Suriname) no âmbito do projeto Convenção-Quadro para o Controle do Tabaco da Organização Mundial da Saúde (CQCT-OMS) 2030, descrever os resultados e as formas como as autoridades sanitárias nacionais utilizaram os casos e discutir as implicações para o papel dos casos de investimento no avanço do controle do tabaco. Métodos. O presente estudo recorre aos achados de quatro casos de investimento nacional, incluindo: 1) análise de custo da doença, com o cálculo da carga do tabagismo para a saúde e a economia; 2) análise do retorno sobre o investimento na implementação de medidas fundamentais de redução da demanda para controle do tabaco; e 3) análise secundária de um tópico de controle do tabaco de interesse nacional (por exemplo, implicações da tributação de cigarros para a equidade). Os coautores relatam como os casos foram utilizados para promover o controle do tabaco. Resultados. Na Colômbia, na Costa Rica, em El Salvador e no Suriname, o tabagismo provoca perdas soci- ais e econômicas que equivalem a 1,0 a 1,8% do produto interno bruto. Nesses países, a implementação de medidas de redução da demanda da CQCT-OMS pouparia em média 11.400 vidas por ano nos próximos 15 anos. Os benefícios dessas medidas superariam em muito os custos de implementação e fiscalização. Os governos estão usando esses casos para promover o controle do tabaco, inclusive para melhorar as leis de controle do tabaco e sua fiscalização, reforçar a tributação do tabaco, priorizar o planejamento do controle do tabaco, coordenar uma resposta multissetorial e envolver líderes políticos. Conclusões. Casos de investimento nacional podem ajudar a fortalecer o controle do tabaco nos países, aumentando o apoio político e do público para a implementação da CQCT-OMS e contribuindo para um planejamento, legislação, coordenação e financiamento efetivos.

Iatrogenic genito-urinary fistula following cesarean birth in nine sub-Saharan African countries: a retrospective review.

BACKGROUND: Genito-urinary fistulas may occur as complications of obstetric surgery. Location and circumstances can indicate iatrogenic origin as opposed to pressure necrosis following prolonged, obstructed labor. METHODS: This retrospective review focuses on 787 women with iatrogenic genito-urinary fistulas among 2942 women who developed fistulas after cesarean birth between 1994 and 2017. They are a subset of 5469 women who sought obstetric fistula repair between 1994 and 2017 in Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia, and Ethiopia. We compared genito-urinary fistula classifications following vaginal birth to classifications following cesarean birth. We assessed whether and how the proportion of iatrogenic genito-urinary fistula was changing over time among women with fistula, comparing women with iatrogenic fistulas to women with fistulas attributable to pressure necrosis. We used mixed effects logistic regression to model the rise in iatrogenic fistula among births resulting in fistula and specifically among cesarean births resulting in fistula. RESULTS: Over one-quarter of women with fistula following cesarean birth (26.8%, 787/2942) had an injury caused by surgery rather than pressure necrosis due to prolonged, obstructed labor. Controlling for age, parity, and previous abdominal surgery, the odds of iatrogenic origin nearly doubled over time among all births resulting in fistula (aOR 1.94; 95% CI 1.48-2.54) and rose by 37% among cesarean births resulting in fistula (aOR 1.37; 95% CI 1.02-1.83). In Kenya and Rwanda the rise of iatrogenic injury outpaced the increasing frequency of cesarean birth. CONCLUSIONS: Despite the strong association between obstetric fistula and prolonged, obstructed labor, more than a quarter of women with fistula after cesarean birth had injuries due to surgical complications rather than pressure necrosis. Risks of iatrogenic fistula during cesarean birth reinforce the importance of appropriate labor management and cesarean decision-making. Rising numbers of iatrogenic fistulas signal a quality crisis in emergency obstetric care. Unaddressed, the impact of this problem will grow as cesarean births become more common.

Factors associated with marital status of women with genital fistula after childbirth: a retrospective review in nine African countries.

OBJECTIVE: To examine characteristics associated with remaining married with fistula. DESIGN: Retrospective record review and logistic regression. SETTING: Tanzania, Uganda, Kenya, Malawi, Zambia, Rwanda, Ethiopia, Somalia and South Sudan. PARTICIPANTS: Women who developed fistula during childbirth (1975-2017) and sought treatment (1994-2017). OUTCOME MEASURE: Self-reported status of living with original husband at time of presentation for fistula repair. RESULTS: Over half of the women lived with their husbands at the time of fistula treatment (57.2%, 3375/5903). The strongest predictor of remaining married with fistula was either parity at fistula development (adjusted odds ratio [AOR] 1.4-4.4) or living kids at fistula repair (among women who had not given birth between fistula development and repair) (AOR 1.7-4.9). Predicted probability of remaining married declined sharply over the first 2 years of incontinence, levelling out thereafter. Predicted probability of remaining married was lower for women with both urinary and faecal incontinence (AOR 0.68) as compared with women with urinary incontinence alone. Probability of remaining married with fistula declined over time (AOR 1.03-0.57). The woman's education was not a statistically significant predictor, but the odds of remaining married were 26% higher if the husband had any formal schooling. CONCLUSION: Most husbands do not abandon wives with fistula following childbirth. Treatment, counselling, social support and rehabilitation must consider the circumstances of each woman, engaging men as partners where appropriate. Communities and facilities offering fistula repair services should stress the importance of early intervention.

Exploring the impact of COVID-19 movement control orders on eating habits and physical activity in low-resource urban settings in Malaysia.

BACKGROUND: The COVID-19 pandemic led Malaysia to introduce movement control orders (MCOs). While MCOs were intended to slow the spread of COVID-19, the effects of such measures on the noncommunicable disease (NCD) risk factors have not been fully explored. This exploratory study aimed to understand the effect of the MCO on the eating habits and physical activity levels of the urban poor in Malaysia as well as potential health promotion interventions during the COVID-19 pandemic. METHODS: This rapid assessment used a mixed-method approach in three low-cost public flats in Kuala Lumpur targeting the B40, which is the bottom 40% of the economic spectrum. A total of 95 community members participated in a quantitative phone survey, while 21 respondents participated in a qualitative phone survey, including 12 community members and nine community health volunteers (CHVs). RESULTS: The movement restriction imposed during the MCO significantly reduced the frequency and duration of respondents' physical activity. At the same time, respondents reported significantly increased consumption of home-cooked meals. More than half of respondents reduced their consumption of packaged snack foods (53.7%), street desserts (54.7%), fast food (50.5%), soft drinks (50.5%), and 3-in-1 or instant drinks (50.5%) due to limited access during the MCO. B40 communities were receptive to potential interventions to encourage healthier eating and physical activity leveraging digital approaches under the 'new normal'. Reported concerns included internet accessibility and affordability, functionality, and digital literacy. CONCLUSION: The COVID-19 pandemic requires innovation to address diseases and risk factors at the community level. While movement restrictions reduced physical activity, they created opportunities for low-income individuals to have greater control over their diet, enabling them to adopt healthier eating habits. Lifestyle changes experienced by vulnerable populations provide an opportunity for creative and technology-enabled interventions to promote healthy eating and exercise.

Dietary practices, food purchasing, and perceptions about healthy food availability and affordability: a cross-sectional study of low-income Malaysian adults.

BACKGROUND: Malaysia has the highest rate of overweight and obesity among Asian countries. Obesity is increasing particularly among low-income populations. This study aimed to assess dietary practices among low-income adults in urban communities, including gender and ethnic variation, to inform the development of locally tailored, evidence-based interventions for health promotion. METHODS: This cross-sectional study was conducted from August to December 2020. Stratified sampling was employed to recruit 2983 low-income adults from households in the bottom 40% of the economic spectrum (B40) at six public, low-cost housing flats in the Federal Territory of Kuala Lumpur, Malaysia. Face-to-face interviews were conducted using a structured questionnaire to understand dietary practices, perceptions of healthy food availability and affordability, and factors affecting food purchasing decisions. RESULTS: A staggering 89.5% of B40 adults were found to not consume adequate daily amounts of fruits and vegetables. In addition, 68.1% reported consuming sugar-sweetened beverages at least once per week, including commercially packed ready-to-drink beverages, sugar-added self-prepared drinks, and premixed drinks. Intake was statistically significantly higher among men (71.7%), Malays (70.3%), and Indians (69.9%). Bread and other commercially baked goods were the most common processed foods, and 52.9% of respondents consumed it at least once per week. Majorities reported that healthy foods were moderately available and priced. The top three reported factors affecting food purchase choices were price (79.4%), availability (75%), and taste (73%). CONCLUSIONS: Adults in low-cost housing communities have unhealthy dietary patterns with low intake of fruits and vegetables and high intake of ultra-processed foods and calorie-dense local foods, with variations across gender and ethnicity. The study highlighted the need for educating low-income families on diet-disease relationships and possibilities for inexpensive, healthy eating that rely on minimally processed fresh foods. Policymakers engaging the food industry are advised to consider how to increase the affordability and availability of healthy foods in low-income communities in urban areas.

The case for investment in tobacco control: lessons from four countries in the Americas / El caso de la inversión en el control del tabaco: las enseñanzas de cuatro países de la Región de las Américas / Em defesa do investimento no controle do tabaco: lições de quatro países das Américas

ABSTRACT Objective. To synthesize learnings from four national tobacco control investment cases conducted in the Americas (Colombia, Costa Rica, El Salvador, Suriname) under the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) 2030 project, to describe results and how national health authorities have used the cases, and to discuss implications for the role of investment cases in advancing tobacco control. Methods. We draw on findings from four national investment cases that included 1) a cost-of-illness analysis calculating the health and economic burden of tobacco use, 2) a return-on-investment analysis of implementing key tobacco control demand reduction measures, and 3) a subsidiary analysis of one tobacco control topic of national interest (e.g., equity implications of cigarette taxation). Co-authors reported how cases have been used to advance tobacco control. Results. In Colombia, Costa Rica, El Salvador, and Suriname, tobacco use causes social and economic losses equivalent to between 1.0 to 1.8 percent of GDP. Across these countries, implementing WHO FCTC demand reduction measures would save an average of 11 400 lives per year over the next 15 years. Benefits of the measures would far outweigh the costs of implementation and enforcement. Governments are using the cases to advance tobacco control, including to improve tobacco control laws and their enforcement, strengthen tobacco taxation, prioritize tobacco control planning, coordinate a multisectoral response, and engage political leaders. Conclusions. National investment cases can help to strengthen tobacco control in countries, including by increasing public and political support for implementation of the WHO FCTC and by informing effective planning, legislation, coordination and financing.

RESUMEN Objetivo. Resumir las enseñanzas de cuatro casos nacionales de inversión en el control del tabaco llevados a cabo en la Región de las Américas (Colombia, Costa Rica, El Salvador y Surinam) en el marco del proyecto 2030 del Convenio Marco de la Organización Mundial de la Salud para el Control del Tabaco (CMCT), describir los resultados y cómo las autoridades nacionales de salud han empleado los casos, y abordar las implicaciones para la función de los casos de inversión en el avance del control del tabaco. Métodos. Este estudio está basado en los hallazgos de cuatro casos de inversión nacional que incluían 1) un análisis del costo de la enfermedad que estima la carga sanitaria y económica del consumo de tabaco, 2) un análisis del rendimiento de la inversión de la ejecución de medidas clave de reducción de la demanda en el control del tabaco, y 3) un análisis subsidiario de un tema de interés nacional sobre el control del tabaco (por ejemplo, el impacto en la equidad de los impuestos sobre los cigarrillos). Los coautores notificaron cómo se han utilizado los casos para avanzar en el control del tabaco. Resultados. En Colombia, Costa Rica, El Salvador y Surinam, el consumo de tabaco causa pérdidas sociales y económicas equivalentes a entre el 1,0 y el 1,8 por ciento del PIB. En todos estos países, la aplicación de las medidas de reducción de la demanda recogidas en el CMCT de la OMS salvaría una media de 11 400 vidas al año en los próximos 15 años. Los beneficios de estas medidas superarían con creces los costos de ejecución y cumplimiento. Los gobiernos están utilizando los casos para avanzar en el control del tabaco, como para mejorar las leyes de control y su aplicación, reforzar los impuestos sobre el tabaco, priorizar la planificación del control del tabaco, coordinar una respuesta multisectorial e involucrar a los líderes políticos. Conclusiones. Los casos de inversión nacional pueden ayudar a fortalecer el control del tabaco en los países, por ejemplo, al aumentar el apoyo público y político a la aplicación del CMCT de la OMS y al informar sobre una planificación, legislación, coordinación y financiación eficaces.

RESUMO Objetivo. Sintetizar as lições aprendidas com quatro casos de investimento nacional no controle do tabaco nas Américas (Colômbia, Costa Rica, El Salvador e Suriname) no âmbito do projeto Convenção-Quadro para o Controle do Tabaco da Organização Mundial da Saúde (CQCT-OMS) 2030, descrever os resultados e as formas como as autoridades sanitárias nacionais utilizaram os casos e discutir as implicações para o papel dos casos de investimento no avanço do controle do tabaco. Métodos. O presente estudo recorre aos achados de quatro casos de investimento nacional, incluindo: 1) análise de custo da doença, com o cálculo da carga do tabagismo para a saúde e a economia; 2) análise do retorno sobre o investimento na implementação de medidas fundamentais de redução da demanda para controle do tabaco; e 3) análise secundária de um tópico de controle do tabaco de interesse nacional (por exemplo, implicações da tributação de cigarros para a equidade). Os coautores relatam como os casos foram utilizados para promover o controle do tabaco. Resultados. Na Colômbia, na Costa Rica, em El Salvador e no Suriname, o tabagismo provoca perdas sociais e econômicas que equivalem a 1,0 a 1,8% do produto interno bruto. Nesses países, a implementação de medidas de redução da demanda da CQCT-OMS pouparia em média 11.400 vidas por ano nos próximos 15 anos. Os benefícios dessas medidas superariam em muito os custos de implementação e fiscalização. Os governos estão usando esses casos para promover o controle do tabaco, inclusive para melhorar as leis de controle do tabaco e sua fiscalização, reforçar a tributação do tabaco, priorizar o planejamento do controle do tabaco, coordenar uma resposta multissetorial e envolver líderes políticos. Conclusões. Casos de investimento nacional podem ajudar a fortalecer o controle do tabaco nos países, aumentando o apoio político e do público para a implementação da CQCT-OMS e contribuindo para um planejamento, legislação, coordenação e financiamento efetivos.

Patient-reported outcomes for diabetes and hypertension care in low- and middle-income countries: A scoping review.

INTRODUCTION: Patient-reported outcome measures (PROMs) assess patients' perspectives on their health status, providing opportunities to improve the quality of care. While PROMs are increasingly used in high-income settings, limited data are available on PROMs use for diabetes and hypertension in low-and middle-income countries (LMICs). This scoping review aimed to determine how PROMs are employed for diabetes and hypertension care in LMICs. METHODS: We searched PubMed, EMBASE, and ClinicalTrials.gov for English-language studies published between August 2009 and August 2019 that measured at least one PROM related to diabetes or hypertension in LMICs. Full texts of included studies were examined to assess study characteristics, target population, outcome focus, PROMs used, and methods for data collection and reporting. RESULTS: Sixty-eight studies met the inclusion criteria and reported on PROMs for people diagnosed with hypertension and/or diabetes and receiving care in health facilities. Thirty-nine (57%) reported on upper-middle-income countries, 19 (28%) reported on lower-middle-income countries, 4 (6%) reported on low-income countries, and 6 (9%) were multi-country. Most focused on diabetes (60/68, 88%), while 4 studies focused on hypertension and 4 focused on diabetes/hypertension comorbidity. Outcomes of interest varied; most common were glycemic or blood pressure control (38), health literacy and treatment adherence (27), and acute complications (22). Collectively the studies deployed 55 unique tools to measure patient outcomes. Most common were the Morisky Medication Adherence Scale (7) and EuroQoL-5D-3L (7). CONCLUSION: PROMs are deployed in LMICs around the world, with greatest reported use in LMICs with an upper-middle-income classification. Diabetes PROMs were more widely deployed in LMICs than hypertension PROMs, suggesting an opportunity to adapt PROMs for hypertension. Future research focusing on standardization and simplification could improve future comparability and adaptability across LMIC contexts. Incorporation into national health information systems would best establish PROMs as a means to reveal the effectiveness of person-centered diabetes and hypertension care.

Development and evaluation of a digital, community-based intervention to reduce noncommunicable disease risk in a low-resource urban setting in Malaysia: a research protocol.

BACKGROUND: Noncommunicable disease burden is rising in Malaysia, accounting for 72% of all deaths. Urbanization and globalization have contributed to changing patterns of diet and physical activity, creating an obesogenic environment that increases noncommunicable disease risk, especially in low-income populations. Community-based and technological interventions can play an important role in addressing structural determinants that influence noncommunicable disease burden. The Better Health Programme Malaysia aims to co-create and develop a community-based digital intervention for low-income populations to enable community stakeholders to address obesogenic environments and improve people's knowledge, attitudes, and practices related to noncommunicable disease risk. METHODS: This quasi-experimental study will assess community member and community health volunteer knowledge, attitudes, and practices on noncommunicable disease prevention, risk factors, and health-seeking behavior in three geographical areas of Kuala Lumpur, each representing a different ethnicity (Malay, Indian, and Chinese). Assessment will take place before and after a 9-month intervention period, comparing intervention areas with matched control geographies. We plan to engage 2880 community members and 45 community health volunteers across the six geographic areas. A digital health needs assessment will inform modification of digital health tools to support project aims. Intervention co-creation will use a discrete choice experiment to identify community preferences among evidence-based intervention options, building from data collected on community knowledge, attitudes, and practices. Community health volunteers will work with local businesses and other stakeholders to effect change in obesogenic environments and NCD risk. The study has been approved by the Malaysian Ministry of Health Medical Research Ethical Committee. DISCUSSION: The Better Health Programme Malaysia anticipates a bottom-up approach that relies on community health volunteers collaborating with local businesses to implement activities that address obesogenic environments and improve community knowledge, attitudes, and practices related to NCD risk. The planned co-creation process will determine which interventions will be most locally relevant, feasible, and needed. The effort aims to empower community members and community health volunteers to drive change that improves their own health and wellbeing. The learnings can be useful nationally and sub-nationally in Malaysia, as well as across similar settings that are working with community stakeholders to reduce noncommunicable disease risk. TRIAL REGISTRATION: National Medical Research Register, Malaysia; NMRR-20-1004-54787 (IIR); July 7, 2020.

Diagnosis and management of 365 ureteric injuries following obstetric and gynecologic surgery in resource-limited settings.

INTRODUCTION: Ureteric injuries are among the most serious complications of pelvic surgery. The incidence in low-resource settings is not well documented. METHODS: This retrospective review analyzes a cohort of 365 ureteric injuries with ureterovaginal fistulas in 353 women following obstetric and gynecologic operations in 11 countries in Africa and Asia, all low-resource settings. The patients with ureteric injury were stratified into three groups according to the initial surgery: (a) obstetric operations, (b) gynecologic operations, and (c) vesicovaginal fistula (VVF) repairs. RESULTS: The 365 ureteric injuries in this series comprise 246 (67.4%) after obstetric procedures, 65 (17.8%) after gynecologic procedures, and 54 (14.8%) after repair of obstetric fistulas. Demographic characteristics show clear differences between women with iatrogenic injuries and women with obstetric fistulas. The study describes abdominal ureter reimplantation and other treatment procedures. Overall surgical results were good: 92.9% of women were cured (326/351), 5.4% were healed with some residual incontinence (19/351), and six failed (1.7%). CONCLUSIONS: Ureteric injuries after obstetric and gynecologic operations are not uncommon. Unlike in high-resource contexts, in low-resource settings obstetric procedures are most often associated with urogenital fistula. Despite resource limitations, diagnosis and treatment of ureteric injuries is possible, with good success rates. Training must emphasize optimal surgical techniques and different approaches to assisted vaginal delivery.

The perils of straying from protocol: sampling bias and interviewer effects.

Fidelity to research protocol is critical. In a contingent valuation study in an informal urban settlement in Nairobi, Kenya, participants responded differently to the three trained interviewers. Interviewer effects were present during the survey pilot, then magnified at the start of the main survey after a seemingly slight adaptation of the survey sampling protocol allowed interviewers to speak with the "closest neighbor" in the event that no one was home at a selected household. This slight degree of interviewer choice led to inferred sampling bias. Multinomial logistic regression and post-estimation tests revealed that the three interviewers' samples differed significantly from one another according to six demographic characteristics. The two female interviewers were 2.8 and 7.7 times less likely to talk with respondents of low socio-economic status than the male interviewer. Systematic error renders it impossible to determine which of the survey responses might be "correct." This experience demonstrates why researchers must take care to strictly follow sampling protocols, consistently train interviewers, and monitor responses by interview to ensure similarity between interviewers' groups and produce unbiased estimates of the parameters of interest.