Estimated health benefits, costs and cost-effectiveness of eliminating industrial trans-fatty acids in Nigeria: cost-effectiveness analysis.

INTRODUCTION: Nigeria is committed to reducing industrial trans-fatty acids (iTFA) from the food supply, but the potential health gains, costs and cost-effectiveness are unknown. METHODS: The effect on ischaemic heart disease (IHD) burden, costs and cost-effectiveness of a mandatory iTFA limit (≤2% of all fats) for foods in Nigeria were estimated using Markov cohort models. Data on demographics, IHD epidemiology and trans-fatty acid intake were derived from the 2019 Global Burden of Disease Study. Avoided IHD events and deaths; health-adjusted life years (HALYs) gained; and healthcare, policy implementation and net costs were estimated over 10 years and the population's lifetime. Incremental cost-effectiveness ratios using net costs and HALYs gained (both discounted at 3%) were used to assess cost-effectiveness. RESULTS: Over the first 10 years, a mandatory iTFA limit (assumed to eliminate iTFA intake) was estimated to prevent 9996 (95% uncertainty interval: 8870 to 11 118) IHD deaths and 66 569 (58 862 to 74 083) IHD events, and to save US$90 million (78 to 102) in healthcare costs. The corresponding lifetime estimates were 259 934 (228 736 to 290 191), 479 308 (95% UI 420 472 to 538 177) and 518 (450 to 587). Policy implementation costs were estimated at US$17 million (11 to 23) over the first 10 years, and US$26 million USD (19 to 33) over the population's lifetime. The intervention was estimated to be cost-saving, and findings were robust across several deterministic sensitivity analyses. CONCLUSION: Our findings support mandating a limit of iTFAs as a cost-saving strategy to reduce the IHD burden in Nigeria.

The 30 Years of Shifting in The Indonesian Cardiovascular Burden-Analysis of The Global Burden of Disease Study.

IMPORTANCE: Cardiovascular disease (CVD) remains the leading cause of mortality and morbidity. Compared with disease burden rates in 1990, significant reductions in Disability-Adjusted Life Years (DALYs) burden rates for CVD have been recorded. However, general DALYs rates have not changed in Indonesia in the past 30 years. Thus, assessing Indonesian CVD burdens will be an essential first step in determining primary disease interventions. OBJECTIVE: To determine the national and province-level burden of CVD from 1990 to 2019 in Indonesia. DESIGN, SETTING, AND PARTICIPANTS: A retrospective observational study was conducted using data from the Global Burden of Disease (GBD) 2019, provided by the Institute of Health Metrics and Evaluation (IHME), to analyze trends in the burden of CVD, including mortality, morbidity, and prevalence characteristics of 12 underlying CVDs. EXPOSURES: Residence in Indonesia. MAIN OUTCOMES AND MEASURES: Mortality, incidence, prevalence, death, and DALYs of CVD. RESULTS: CVD deaths have doubled from 278 million in 1990 to 651 million in 2019. All CVDs recorded increased death rates, except for rheumatic heart disease (RHD) (- 69%) and congenital heart disease (CHD) (- 37%). Based on underlying diseases, stroke and ischemic heart disease (IHD) are still the leading causes of mortality and morbidity in Indonesia, whereas stroke and peripheral artery disease (PAD) are the most prevalent CVDs. Indonesia has the second worst CVD DALYs rates compared to ASEAN countries after Laos. At provincial levels, the highest CVD DALY rates were recorded in Bangka Belitung, South Kalimantan, and Yogyakarta. In terms of DALYs rate changes, they were recorded in West Nusa Tenggara (24%), South Kalimantan (18%), and Central Java (11%). Regarding sex, only RHD, and PAD burdens were dominated by females. CONCLUSIONS: CVD mortality, morbidity, and prevalence rates increased in Indonesia from 1990 to 2019, especially for stroke and ischemic heart disease. The burden is exceptionally high, even when compared to other Southeast Asian countries and the global downward trend. GBD has many limitations. However, these data could provide policymakers with a broad view of CVD conditions in Indonesia.

Estimated health benefits, costs and cost-effectiveness of eliminating dietary industrial trans fatty acids in Kenya: cost-effectiveness analysis.

OBJECTIVES: To model the potential health gains and cost-effectiveness of a mandatory limit of industrial trans fatty acids (iTFA) in Kenyan foods. DESIGN: Multiple cohort proportional multistate life table model, incorporating existing data from the Global Burden of Disease study, pooled analyses of observational studies and peer-reviewed evidence of healthcare and policy implementation costs. SETTING: Kenya. PARTICIPANTS: Adults aged ≥20 years at baseline (n=50 million). INTERVENTION: A mandatory iTFA limit (≤2% of all fats) in the Kenyan food supply compared with a base case scenario of maintaining current trans fat intake. MAIN OUTCOME MEASURES: Averted ischaemic heart disease (IHD) events and deaths, health-adjusted life years; healthcare costs; policy implementation costs; net costs; and incremental cost-effectiveness ratio. RESULTS: Over the first 10 years, the intervention was estimated to prevent ~1900 (95% uncertainty interval (UI): 1714; 2148) IHD deaths and ~17 000 (95% UI: 15 475; 19 551) IHD events, and to save ~US$50 million (95% UI: 44; 56). The corresponding estimates over the lifespan of the model population were ~49 000 (95% UI: 43 775; 55 326) IHD deaths prevented, ~113 000 (95% UI: 100 104; 127 969) IHD events prevented and some ~US$300 million (256; 331) saved. Policy implementation costs were estimated as ~US$9 million over the first 10 years and ~US$20 million over the population lifetime. The intervention was estimated to be cost saving regardless of the time horizon. Findings were robust across multiple sensitivity analyses. CONCLUSIONS: Findings support policy action for a mandatory iTFA limit as a cost-saving strategy to avert IHD events and deaths in Kenya.

The health and economic impact and cost effectiveness of interventions for the prevention and control of overweight and obesity in Kenya: a stakeholder engaged modelling study.

BACKGROUND: The global increase in mean body mass index has resulted in a substantial increase of non-communicable diseases (NCDs), including in many low- and middle-income countries such as Kenya. This paper assesses four interventions for the prevention and control of overweight and obesity in Kenya to determine their potential health and economic impact and cost effectiveness. METHODS: We reviewed the literature to identify evidence of effect, determine the intervention costs, disease costs and total healthcare costs. We used a proportional multistate life table model to quantify the potential impacts on health conditions and healthcare costs, modelling the 2019 Kenya population over their remaining lifetime. Considering a health system perspective, two interventions were assessed for cost-effectiveness. In addition, we used the Human Capital Approach to estimate productivity gains. RESULTS: Over the lifetime of the 2019 population, impacts were estimated at 203,266 health-adjusted life years (HALYs) (95% uncertainty interval [UI] 163,752 - 249,621) for a 20% tax on sugar-sweetened beverages, 151,718 HALYs (95% UI 55,257 - 250,412) for mandatory kilojoule menu labelling, 3.7 million HALYs (95% UI 2,661,365-4,789,915) for a change in consumption levels related to supermarket food purchase patterns and 13.1 million HALYs (95% UI 11,404,317 - 15,152,341) for a change in national consumption back to the 1975 average levels of energy intake. This translates to 4, 3, 73 and 261 HALYs per 1,000 persons. Lifetime healthcare cost savings were approximately United States Dollar (USD) 0.14 billion (USD 3 per capita), USD 0.08 billion (USD 2 per capita), USD 1.9 billion (USD 38 per capita) and USD 6.2 billion (USD 124 per capita), respectively. Lifetime productivity gains were approximately USD 1.8 billion, USD 1.2 billion, USD 28 billion and USD 92 billion. Both the 20% tax on sugar sweetened beverages and the mandatory kilojoule menu labelling were assessed for cost effectiveness and found dominant (health promoting and cost-saving). CONCLUSION: All interventions evaluated yielded substantive health gains and economic benefits and should be considered for implementation in Kenya.

Estimated Impact of Achieving the Australian National Sodium Reduction Targets on Blood Pressure, Chronic Kidney Disease Burden and Healthcare Costs: A Modelling Study.

Excess sodium intake raises blood pressure which increases the risk of chronic kidney disease (CKD). We aimed to estimate the impact of reduced sodium intake on future CKD burden in Australia. A multi-cohort proportional multistate lifetable model was developed to estimate the potential impact on CKD burden and health expenditure if the Australian Suggested Dietary Target (SDT) and the National Preventive Health Strategy 2021-2030 (NPHS) sodium target were achieved. Outcomes were projected to 2030 and over the lifetime of adults alive in 2019. Achieving the SDT and NPHS targets could lower population mean systolic blood pressure by 2.1 mmHg and 1.7 mmHg, respectively. Compared to normal routines, attaining the SDT and NPHS target by 2030 could prevent 59,220 (95% UI, 53,140-65,500) and 49,890 (44,377-55,569) incident CKD events, respectively, while postponing 568 (479-652) and 511 (426-590) CKD deaths, respectively. Over the lifetime, this generated 199,488 health-adjusted life years (HALYs) and AUD 644 million in CKD healthcare savings for the SDT and 170,425 HALYs and AUD 514 million for the NPHS. CKD due to hypertension and CKD due to other/unspecified causes were the principal contributors to the HALY gains. Lowering sodium consumption in Australia could deliver substantial CKD health and economic benefits.

Changes in ideal cardiovascular health among Malawian adults from 2009 to 2017.

Ideal Cardiovascular Health (CVH) is a concept defined by the American Heart Association (AHA) as part of its 2020 Impact Goals. Until now, changes in ideal CVH have been poorly evaluated in Sub-Saharan African populations. We aimed to investigate changes in the prevalence of ideal CVH and its components in a population of Malawian adults. Secondary analysis was done on cross-sectional data from 2009 to 2017, obtained from the Malawi STEPS surveys which included 5730 participants aged 25-64 years. CVH metrics categorized into "ideal (6-7 ideal metrics)", "intermediate (3-5 ideal metrics)" and "poor (0-2 ideal metrics)" were computed using blood pressure, body mass index (BMI), fasting glycaemia, fruit and vegetable intake, physical activity, smoking, and total cholesterol. Sampling weights were used to account for the sampling design, and all estimates were standardised by age and sex using the direct method. The mean participant age across both periods was 40.1 ± 12.4 years. The prevalence of meeting ≥ 6 ideal CVH metrics increased substantially from 9.4% in 2009 to 33.3% in 2017, whereas having ≤ 2 ideal CVH metrics decreased from 7.6% to 0.5% over this time. For the individual metrics, desirable levels of smoking, fruit and vegetable intake, physical activity, blood pressure (BP), total cholesterol and fasting glucose all increased during the study period whilst achievable levels of BMI (< 25 kg/m2) declined. From 2009 to 2017, the mean number of ideal CVH metrics was higher in women compared to men (from 2.1% to 5.1% vs 2.0% to 5.0%). However, poor levels of smoking and fruit and vegetable intake were higher in men compared to women (from 27.9% to 23.6% vs. 7.4%% to 1.9% , and from 33.7% to 42.9% vs 30.8% to 34.6%, respectively). Also, whilst achievable levels of BMI rose in men (from 84.4% to 86.2%) the proportion reduced in women (from 72.1% to 67.5% ). Overall, CVH improved in Malawian adults from 2009 to 2017 and was highest in women. However, the prevalence of poor fruit and vegetable intake, and poor smoking remained high in men whilst optimal levels of BMI was declined in women. To improve this situation, individual and population-based strategies that address body mass, smoking and fruit and vegetable intake are warranted for maximal health gains in stemming the development of cardiovascular events.

Burden of atrial fibrillation among adults with heart failure in sub-Saharan Africa: a systematic review and meta-analysis.

OBJECTIVES: This study aimed to estimate the prevalence of atrial fibrillation (AF) in adults with heart failure (HF) and summarise the all-cause mortality ratio among adult patients with coexisting HF and AF in sub-Saharan Africa (SSA). SETTING: This was a systematic review and meta-analysis of cross-sectional and cohort studies with primary data on the prevalence and incidence of AF among patients with HF and the all-cause mortality ratio among patients with HF and AF in SSA. We combined text words and MeSH terms to search MEDLINE, PubMed and Global Health Library through Ovid SP, African Journals Online and African Index Medicus from database inception to 10 November 2021. Random-effects meta-analysis was used to estimate pooled prevalence. PRIMARY OUTCOME MEASURES: The prevalence and incidence of AF among patients with HF, and the all-cause mortality ratio among patients with HF and AF. RESULTS: Twenty-seven of the 1902 records retrieved from database searches were included in the review, totalling 9987 patients with HF. The pooled prevalence of AF among patients with HF was 15.6% (95% CI 12.0% to 19.6%). At six months, the all-cause mortality was 18.4% (95% CI 13.1% to 23.6%) in a multinational registry and 67.7% (95% CI 51.1% to 74.3%) in one study in Tanzania. The one-year mortality was 48.6% (95% CI 32.5% to 64.7%) in a study in the Democratic Republic of Congo. We did not find any study reporting the incidence of AF in HF. CONCLUSION: AF is common among patients with HF in SSA, and patients with AF and HF have poor survival. There is an urgent need for large-scale population-based prospective data to reliably estimate the prevalence, incidence and risk of mortality of AF among HF patients in SSA to better understand the burden of AF in patients with HF in the region. PROSPERO REGISTRATION NUMBER: CRD42018087564.

High Urban-Rural Inequities of Abdominal Obesity in Malawi: Insights from the 2009 and 2017 Malawi Noncommunicable Disease Risk Factors Surveys.

Geographical disparities in abdominal obesity (AO) exist in low-income countries due to major demographic and structural changes in urban and rural areas. We aimed to investigate differences in the urban-rural prevalence of AO in the Malawi population between 2009 and 2017. We conducted a secondary analysis of data from the Malawi 2009 and 2017 STEPS surveys. AO (primary outcome) and very high waist circumference (secondary outcome) were defined using WHO criteria. Prevalence estimates of AO and very high waist circumference (WC) were standardized by age and sex using the age and sex structure of the adult population in Malawi provided by the 2018 census. A modified Poisson regression analysis adjusted for sociodemographic covariates was performed to compare the outcomes between the two groups (urban versus rural). In total, 4708 adults in 2009 and 3054 adults in 2017 aged 25-64 were included in the study. In 2009, the age-sex standardized prevalence of AO was higher in urban than rural areas (40.9% vs 22.0%; adjusted prevalence ratio [aPR], 1.51; 95% confidence interval [CI], 1.36-1.67; p < 0.001). There was no significant trend for closing this gap in 2017 (urban 37.0% and rural 21.4%; aPR, 1.48; 95% CI, 1.23-1.77; p < 0.001). This urban-rural gap remained and was slightly wider when considering the 'very high WC' threshold in 2009 (17.0% vs. 7.1%; aPR, 1.98; 95%CI, 1.58-2.47; p < 0.001); and in 2017 (21.4% vs. 8.3%; aPR, 2.03; 95%CI, 1.56-2.62; p < 0.001). Significant urban-rural differences exist in the prevalence of AO and very high WC in Malawi, and the gap has not improved over the last eight years. More effective weight management strategies should be promoted to reduce health care disparities in Malawi, particularly in urban areas.

Prevalence and factors associated with potentially inappropriate medication and medication complexity for older adults in the emergency department of a secondary teaching hospital in Indonesia

Background: Older adults experience progressive decline in various organs and changes in pharmacokinetics and pharmacodynamics of the drugs in the body which lead to an increased risk of medication-related problems. Potentially inappropriate medications (PIMs) and medication complexity are key factors contributing to adverse drug events in the emergency department (ED). Objective: To estimate the prevalence and investigate the risk factors of PIMs and medication complexity among older adults admitted to the ED. Methods: A retrospective observational study was conducted among patients aged > 60 years admitted to the ED of Universitas Airlangga Teaching Hospital in January - June 2020. PIMs and medication complexity were measured using the 2019 American Geriatrics Society Beers Criteria® and Medication Regimen Complexity Index (MRCI), respectively. Results: A total of 1005 patients were included and 55.0% (95% confidence interval [CI]: 52 – 58%) of them received at least one PIM. Whereas, the pharmacological therapy prescribed to older adults had a high complexity index (mean MRCI 17.23 + 11.15). Multivariate analysis showed that those with polypharmacy (OR= 6.954; 95% CI: 4.617 – 10.476), diseases of the circulatory system (OR= 2.126; 95% CI: 1.166 – 3.876), endocrine, nutritional, and metabolic diseases (OR= 1.924; 95% CI: 1.087 – 3.405), and diseases of the digestive system (OR= 1.858; 95% CI: 1.214 – 2.842) had an increased risk of receiving PIM prescriptions. Meanwhile, disease of the respiratory system (OR = 7.621; 95% CI: 2.833 – 15.150), endocrine, nutritional and metabolic diseases (OR = 6.601; 95% CI: 2.935 – 14.847), and polypharmacy (OR = 4.373; 95% CI: 3.540 – 5.401) were associated with higher medication complexity. (AU)

Avoidable burden of stomach cancer and potential gains in healthy life years from gradual reductions in salt consumption in Vietnam, 2019-2030: a modelling study.

OBJECTIVE: Excess salt consumption is causally linked with stomach cancer, and salt intake among adults in Vietnam is about twice the recommended levels. The aim of this study was to quantify the future burden of stomach cancer that could be avoided from population-wide salt reduction in Vietnam. DESIGN: A dynamic simulation model was developed to quantify the impacts of achieving the 2018 National Vietnam Health Program (8 g/d by 2025 and 7 g/d by 2030) and the WHO (5 g/d) salt reduction policy targets. Data on salt consumption were obtained from the Vietnam 2015 WHO STEPS survey. Health outcomes were estimated over 6-year (2019-2025), 11-year (2019-2030) and lifetime horizons. We conducted one-way and probabilistic sensitivity analyses. SETTING: Vietnam. PARTICIPANTS: All adults aged ≥ 25 years (61 million people, 48·4 % men) alive in 2019. RESULTS: Achieving the 2025 and 2030 national salt targets could result in 3400 and 7200 fewer incident cases of stomach cancer, respectively, and avert 1900 and 4800 stomach cancer deaths, respectively. Achieving the WHO target by 2030 could prevent 8400 incident cases and 5900 deaths from stomach cancer. Over the lifespan, this translated to 344 660 (8 g/d), 411 060 (7 g/d) and 493 633 (5 g/d) health-adjusted life years gained, respectively. CONCLUSIONS: A sizeable burden of stomach cancer could be avoided, with gains in healthy life years if national and WHO salt targets were attained. Our findings provide impetus for policy makers in Vietnam and Asia to intensify salt reduction strategies to combat stomach cancer and mitigate pressure on the health systems.

The avoidable disease burden associated with overweight and obesity in Kenya: A modelling study.

Background: Globally, there is a rising burden of non-communicable diseases related to high body mass index (BMI). Estimation of the magnitude of the avoidable disease burden related to high BMI in Kenya could inform priority setting in health. Methods: Using a proportional multistate life table model, we estimated the impact of the elimination of exposure to high BMI (>22·5 kg/m2) on health adjusted life years, health adjusted life expectancy, and burden of 27 obesity-related diseases. Participants were the 2019 Kenyan population modelled over their remaining lifetime. Findings: Elimination of high BMI could save approximately 83·5 million health-adjusted life years and increase the health-adjusted life expectancy by 2·3 (95% UI 2·0-2·8) years for females and 1·0 (95% UI 0·8-1·1) years for males. Over the first 25 years, over 7·4 million new cases of BMI-related diseases could be avoided and approximately half a million BMI related deaths postponed. The cumulative number of new cases of type 2 diabetes could reduce by approximately 1·6 million, cardiovascular diseases by over 1·3 million, chronic kidney disease by 850,473 and cancer would reduce by 55,624 estimated cases. In 2044, an estimated 867,664 prevalent cases of musculoskeletal disease would be prevented. Interpretation: The magnitude of avoidable high BMI-related disease burden in Kenya underscores the need to prioritise the control and prevention of overweight and obesity globally, especially in low- and middle-income settings, where obesity rates are rising rapidly. Reducing population BMI is challenging, but sustained and well-enforced system-wide approaches could be a great starting point. Funding: Mary Njeri Wanjau is supported by the Griffith University International Postgraduate Research Scholarship (GUIPRS) and Griffith University Postgraduate Research Scholarship (GUPRS).

Prevalence and factors associated with potentially inappropriate medication and medication complexity for older adults in the emergency department of a secondary teaching hospital in Indonesia.

Background: Older adults experience progressive decline in various organs and changes in pharmacokinetics and pharmacodynamics of the drugs in the body which lead to an increased risk of medication-related problems. Potentially inappropriate medications (PIMs) and medication complexity are key factors contributing to adverse drug events in the emergency department (ED). Objective: To estimate the prevalence and investigate the risk factors of PIMs and medication complexity among older adults admitted to the ED. Methods: A retrospective observational study was conducted among patients aged > 60 years admitted to the ED of Universitas Airlangga Teaching Hospital in January - June 2020. PIMs and medication complexity were measured using the 2019 American Geriatrics Society Beers Criteria® and Medication Regimen Complexity Index (MRCI), respectively. Results: A total of 1005 patients were included and 55.0% (95% confidence interval [CI]: 52 - 58%) of them received at least one PIM. Whereas, the pharmacological therapy prescribed to older adults had a high complexity index (mean MRCI 17.23 + 11.15). Multivariate analysis showed that those with polypharmacy (OR= 6.954; 95% CI: 4.617 - 10.476), diseases of the circulatory system (OR= 2.126; 95% CI: 1.166 - 3.876), endocrine, nutritional, and metabolic diseases (OR= 1.924; 95% CI: 1.087 - 3.405), and diseases of the digestive system (OR= 1.858; 95% CI: 1.214 - 2.842) had an increased risk of receiving PIM prescriptions. Meanwhile, disease of the respiratory system (OR = 7.621; 95% CI: 2.833 - 15.150), endocrine, nutritional and metabolic diseases (OR = 6.601; 95% CI: 2.935 - 14.847), and polypharmacy (OR = 4.373; 95% CI: 3.540 - 5.401) were associated with higher medication complexity. Conclusion: In our study, over one in every two older adults admitted to the ED had PIMs, and a high medication complexity was observed. Endocrine, nutritional and metabolic disease was the leading risk factors for receiving PIMs and high medication complexity.

Stakeholder-engaged research: strategies for the prevention and control of overweight and obesity in Kenya.

BACKGROUND: This study was done as part of a larger study that aims to identify the most impactful and cost-effective strategies for the prevention and control of overweight and obesity in Kenya. Our objective was to involve stakeholders in the identification of the strategies that would be included in our larger study. The results from the stakeholder engagement are analyzed and reported in this paper. DESIGN: This was a qualitative study. A one-day stakeholder workshop that followed a deliberative dialogue process was conducted. PARTICIPANTS: A sample of stakeholders who participate in the national level policymaking process for health in Kenya. OUTCOME MEASURE: Strategies for the prevention and control of overweight and obesity in Kenya. RESULTS: Out of the twenty-three stakeholders who confirmed attendance, fifteen participants attended the one-day workshop. The stakeholders identified a total of 24 strategies for the prevention and control of overweight and obesity in Kenya. From the ranking process carried out the top six strategies identified were: a research-based strategy for the identification of the nutritional value of indigenous foods, implementation of health promotion strategies that focus on the creation of healthy environments, physical activity behavior such as gym attendance, jogging, walking, and running at the individual level, implementation of school curricula on nutrition and health promotion, integration of physical education into the new Competency-Based Education policy, and policies that increase use of public transport. CONCLUSION: The stakeholders identified and ranked strategies for the prevention and control of overweight and obesity in Kenya. This informs future overweight and obesity prevention research and policy in Kenya and similar settings.

Dietary Salt Reduction, Prevalence of Hypertension and Avoidable Burden of Stroke in Vietnam: Modelling the Health and Economic Impacts.

Dietary salt reduction has been recommended as a cost-effective population-wide strategy to prevent cardiovascular disease. The health and economic impact of salt consumption on the future burden of stroke in Vietnam is not known. Objective: To estimate the avoidable incidence of and deaths from stroke, as well as the healthy life years and healthcare costs that could be gained from reducing salt consumption in Vietnam. Methods: This was a macrosimulation health and economic impact assessment study. Data on blood pressure, salt consumption and stroke epidemiology were obtained from the Vietnam 2015 STEPS survey and the Global Burden of Disease study. A proportional multi-cohort multistate lifetable Markov model was used to estimate the impact of achieving the Vietnam national salt targets of 8 g/day by 2025 and 7 g/day by 2030, and to the 5 g/day WHO recommendation by 2030. Probabilistic sensitivity analysis was conducted to quantify the uncertainty in our projections. Results: If the 8 g/day, 7 g/day, and 5 g/day targets were achieved, the prevalence of hypertension could reduce by 1.2% (95% uncertainty interval [UI]: 0.5 to 2.3), 2.0% (95% UI: 0.8 to 3.6), and 3.5% (95% UI: 1.5 to 6.3), respectively. This would translate, respectively, to over 80,000, 180,000, and 257,000 incident strokes and over 18,000, 55,000, and 73,000 stroke deaths averted. By 2025, over 56,554 stroke-related health-adjusted life years (HALYs) could be gained while saving over US$ 42.6 million in stroke healthcare costs. By 2030, about 206,030 HALYs (for 7 g/day target) and 262,170 HALYs (for 5 g/day target) could be gained while saving over US$ 88.1 million and US$ 122.3 million in stroke healthcare costs respectively. Conclusion: Achieving the national salt reduction targets could result in substantial population health and economic benefits. Estimated gains were larger if the WHO salt targets were attained and if changes can be sustained over the longer term. Future work should consider the equity impacts of specific salt reduction programs.

Stakeholder perceptions of current practices and challenges in priority setting for non-communicable disease control in Kenya: a qualitative study.

OBJECTIVE: To explore the stakeholders' perceptions of current practices and challenges in priority setting for non-communicable disease (NCD) control in Kenya. DESIGN: A qualitative study approach conducted within a 1-day stakeholder workshop that followed a deliberative dialogue process. SETTING: Study was conducted within a 1-day stakeholder workshop that was held in October 2019 in Nairobi, Kenya. PARTICIPANTS: Stakeholders who currently participate in the national level policymaking process for health in Kenya. OUTCOME MEASURE: Priority setting process for NCD control in Kenya. RESULTS: Donor funding was identified as a key factor that informed the priority setting process for NCD control. Misalignment between donors' priorities and the country's priorities for NCD control was seen as a hindrance to the process. It was identified that there was minimal utilisation of context-specific evidence from locally conducted research. Additional factors seen to inform the priority setting process included political leadership, government policies and budget allocation for NCDs, stakeholder engagement, media, people's cultural and religious beliefs. CONCLUSION: There is an urgent need for development aid partners to align their priorities to the specific NCD control priority areas that exist in the countries that they extend aid to. Additionally, context-specific scientific evidence on effective local interventions for NCD control is required to inform areas of priority in Kenya and other low-income and middle-income countries. Further research is needed to develop best practice guidelines and tools for the creation of national-level priority setting frameworks that are responsive to the identified factors that inform the priority setting process for NCD control.

Estimation and determinants of direct medical costs of ischaemic heart disease, stroke and hypertensive heart disease: evidence from two major hospitals in Cameroon.

BACKGROUND: Cardiovascular disease (CVD) is the largest contributor to the non-communicable diseases (NCD) burden in Cameroon, but data on its economic burden is lacking. METHODS: A prevalence-based cost-of-illness study was conducted from a healthcare provider perspective and enrolled patients with ischaemic heart disease (IHD), ischaemic stroke, haemorrhagic stroke and hypertensive heart disease (HHD) from two major hospitals between 2013 and 2017. Determinants of cost were explored using multivariate generalized linear models. RESULTS: Overall, data from 850 patients: IHD (n = 92, 10.8%), ischaemic stroke (n = 317, 37.3%), haemorrhagic stroke (n = 193, 22.7%) and HHD (n = 248, 29.2%) were analysed. The total cost for these CVDs was XAF 676,694,000 (~US$ 1,224,918). The average annual direct medical costs of care per patient were XAF 1,395,200 (US$ 2400) for IHD, XAF 932,700 (US$ 1600) for ischaemic stroke, XAF 815,400 (US$ 1400) for haemorrhagic stroke, and XAF 384,300 (US$ 700) for HHD. In the fully adjusted models, apart from history of CVD event (ß = - 0.429; 95% confidence interval - 0.705, - 0.153) that predicted lower costs in patients with IHD, having of diabetes mellitus predicted higher costs in patients with IHD (ß = 0.435; 0.098, 0.772), ischaemic stroke (ß = 0.188; 0.052, 0.324) and HHD (ß = 0.229; 0.080, 0.378). CONCLUSIONS: This study reveals substantial economic burden due to CVD in Cameroon. Diabetes mellitus was a consistent driver of elevated costs across the CVDs. There is urgent need to invest in cost-effective primary prevention strategies in order to reduce the incidence of CVD and consequent economic burden on a health system already laden with the impact of communicable diseases.

Cost-effectiveness analysis of population salt reduction interventions to prevent cardiovascular disease in Cameroon: mathematical modelling study.

BACKGROUND: Reducing dietary sodium (salt) intake has been proposed as a population-wide strategy to reduce blood pressure and cardiovascular disease (CVD). The cost-effectiveness of such strategies has hitherto not been investigated in Cameroon. METHODS: A multicohort multistate life table Markov model was used to evaluate the cost-effectiveness of three population salt reduction strategies: mass media campaign, school-based salt education programme and low-sodium salt substitute. A healthcare system perspective was considered and adults alive in 2016 were simulated over the life course. Outcomes were changes in disease incidence, mortality, health-adjusted life years (HALYs), healthcare costs and incremental cost-effectiveness ratios (ICERs) over the lifetime. Probabilistic sensitivity analysis was used to quantify uncertainty. RESULTS: Over the life span of the cohort of adults alive in Cameroon in 2016, substantial numbers of new CVD events could be prevented, with over 10 000, 79 000 and 84 000 CVD deaths that could be averted from mass media, school education programme and salt substitute interventions, respectively. Population health gains over the lifetime were 46 700 HALYs, 348 800 HALYs and 368 400 HALYs for the mass media, school education programme and salt substitute interventions, respectively. ICERs showed that all interventions were dominant, with probabilities of being cost-saving of 84% for the school education programme, 89% for the mass media campaign and 99% for the low sodium salt substitute. Results were largely robust in sensitivity analysis. CONCLUSION: All the salt reduction strategies evaluated were highly cost-effective with very high probabilities of being cost-saving. Salt reduction in Cameroon has the potential to save many lives and offers good value for money.

Health-related quality of life and its determinants in patients with chronic low back pain at a tertiary hospital in Cameroon: a cross-sectional study.

OBJECTIVE: To evaluate health-related quality of life (HRQoL) and its determinants in chronic low back pain (CLBP) patients in Cameroon. DESIGN: Observational cross-sectional study. SETTING: Tertiary hospital. PARTICIPANTS: There were 150 eligible adults with low back pain of at least 12 weeks who provided informed consent. Of these, 136 with complete questionnaires were analysed. OUTCOMES: HRQoL was measured using the WHO Quality of Life questionnaire (WHOQOL-BREF). Outcome measures included its four domain (physical health, psychological, social relationships and environmental) scores and two independent scores for overall quality of life (OQOL) and general health satisfaction (GH). RESULTS: Participants had a median age of 52 years, and median pain duration of 33 (IQR: 69) months. The median OQOL score was 50 (IQR: 25). After multivariable adjustment, tertiary education (ß=11.43, 95% CI 3.12 to 19.75), age (ß=0.49, 95% CI 0.12 to 0.87) and being a student (ß=23.07, 95% CI 0.28 to 45.86) contributed to better OQOL. Age (ß=0.57, 95% CI 0.10 to 1.04) and physical-type employment (ß=-14.57, 95% CI -25.83 to -3.31) affected GH. Smoking (ß=-20.49, 95% CI -35.49 to -5.48) and radiological anomalies (ß=-7.57, 95% CI -14.64 to -0.49) affected the physical health domain, while disability (ß=-0.67, 95% CI -1.14 to -0.20) and duration of pain (ß=-0.13, 95% CI -0.20 to -0.05) affected the psychological domain. Income (ß=14.94, 95% CI 4.06 to 25.81) affected the social domain, while education (ß=9.96, 95% CI 1.41 to 18.50) and disability (ß=-0.75, 95% CI -1.26 to -0.24) affected the environmental domain. CONCLUSIONS: Our findings suggest that CLBP affects HRQoL and multiple socioeconomic and clinical factors influence its impact on different domains of HRQoL. Multipronged management programmes, especially those that reduce disability, could improve HRQoL in patients with CLBP.

Availability, cost and affordability of essential cardiovascular disease medicines in the south west region of Cameroon: Preliminary findings from the Cameroon science for disease study.

BACKGROUND: More than 80% of premature deaths due to cardiovascular disease (CVD) occur in low- and middle-income countries. However, access to, and affordability of medications remain a challenge in these countries. OBJECTIVE: To assess the availability, cost and affordability of essential cardiovascular medicines in the South West region of Cameroon. METHODS: In an audit of 63 medicine outlets, twenty-six essential medicines were surveyed using the World Health Organisation (WHO) /Health Action International methodology. Availability, costs and the ratio of the median price to the international reference price were evaluated in public, confessional, private facility medicine outlets, and community pharmacies. Affordability was assessed by calculating the number of days' wages it will cost the lowest-paid unskilled government worker to purchase a month worth of chronic treatment. FINDINGS: Availability ranged from 25.3% (public facility outlets) to 49.2% (community pharmacies) for all medicines. This was higher in urban and semi-urban compared to rural outlets. Cost of medicines was highest in community pharmacies and lowest in public facility outlets. Aspirin, digoxin, furosemide, hydrochlorothiazide and nifedipine were affordable (cost a day's wage or less). Medicines for heart failure and dyslipidaemia (beta blockers, angiotensin converting enzyme inhibitors and statins) required 2-5 days and 6-13 days wages respectively for one month of chronic treatment. CONCLUSION: Overall availability of CVD essential medicines was lower than WHO recommendations, and medicines were largely unaffordable. While primary prevention is pivotal, improving availability and affordability of medicines especially for public facilities would provide additional benefit in curbing the CVD burden.

Burden of non-communicable diseases in sub-Saharan Africa, 1990-2017: results from the Global Burden of Disease Study 2017.

BACKGROUND: Although the burden of disease in sub-Saharan Africa continues to be dominated by infectious diseases, countries in this region are undergoing a demographic transition leading to increasing prevalence of non-communicable diseases (NCDs). To inform health system responses to these changing patterns of disease, we aimed to assess changes in the burden of NCDs in sub-Saharan Africa from 1990 to 2017. METHODS: We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to analyse the burden of NCDs in sub-Saharan Africa in terms of disability-adjusted life-years (DALYs)-with crude counts as well as all-age and age-standardised rates per 100 000 population-with 95% uncertainty intervals (UIs). We examined changes in burden between 1990 and 2017, and differences across age, sex, and regions. We also compared the observed NCD burden across countries with the expected values based on a country's Socio-demographic Index. FINDINGS: All-age total DALYs due to NCDs increased by 67·0% between 1990 (90·6 million [95% UI 81·0-101·9]) and 2017 (151·3 million [133·4-171·8]), reflecting an increase in the proportion of total DALYs attributable to NCDs (from 18·6% [95% UI 17·1-20·4] to 29·8% [27·6-32·0] of the total burden). Although most of this increase can be explained by population growth and ageing, the age-standardised DALY rate (per 100 000 population) due to NCDs in 2017 (21 757·7 DALYs [95% UI 19 377·1-24 380·7]) was almost equivalent to that of communicable, maternal, neonatal, and nutritional diseases (26 491·6 DALYs [25 165·2-28 129·8]). Cardiovascular diseases were the second leading cause of NCD burden in 2017, resulting in 22·9 million (21·5-24·3) DALYs (15·1% of the total NCD burden), after the group of disorders categorised as other NCDs (28·8 million [25·1-33·0] DALYs, 19·1%). These categories were followed by neoplasms, mental disorders, and digestive diseases. Although crude DALY rates for all NCDs have decreased slightly across sub-Saharan Africa, age-standardised rates are on the rise in some countries (particularly those in southern sub-Saharan Africa) and for some NCDs (such as diabetes and some cancers, including breast and prostate cancer). INTERPRETATION: NCDs in sub-Saharan Africa are posing an increasing challenge for health systems, which have to date largely focused on tackling infectious diseases and maternal, neonatal, and child deaths. To effectively address these changing needs, countries in sub-Saharan Africa require detailed epidemiological data on NCDs. FUNDING: Bill & Melinda Gates Foundation, National Health and Medical Research Centre (Australia).