Luke Allen

Socioeconomic status and non-communicable disease behavioural risk factors in low-income and lower-middle-income countries: a systematic review

Summary Background Non-communicable diseases are the leading global cause of death and disproportionately afflict those living in low-income and lower-middle-income countries (LLMICs). The association between socioeconomic status and non-communicable disease behavioural risk factors is well established in high-income countries, but it is not clear how behavioural risk factors are distributed within LLMICs. We aimed to systematically review evidence on the association between socioeconomic status and harmful use of alcohol, tobacco use, unhealthy diets, and physical inactivity within LLMICs. Methods We searched 13 electronic databases, including Embase and MEDLINE, grey literature, and reference lists for primary research published between Jan 1, 1990, and June 30, 2015. We included studies from LLMICs presenting data on multiple measures of socioeconomic status and tobacco use, alcohol use, diet, and physical activity. No age or language restrictions were applied. We excluded studies that did not allow comparison between more or less advantaged groups. We used a piloted version of the Cochrane Effective Practice and Organisation of Care Group data collection checklist to extract relevant data at the household and individual level from the included full text studies including study type, methods, outcomes, and results. Due to high heterogeneity, we used a narrative approach for data synthesis. We used descriptive statistics to assess whether the prevalence of each risk factor varied significantly between members of different socioeconomic groups. The study protocol is registered with PROSPERO, number CRD42015026604. Findings After reviewing 4242 records, 75 studies met our inclusion criteria, representing 2 135 314 individuals older than 10 years from 39 LLMICs. Low socioeconomic groups were found to have a significantly higher prevalence of tobacco and alcohol use than did high socioeconomic groups. These groups also consumed less fruit, vegetables, fish, and fibre than those of high socioeconomic status. High socioeconomic groups were found to be less physically active and consume more fats, salt, and processed food than individuals of low socioeconomic status. While the included studies presented clear patterns for tobacco use and physical activity, heterogeneity between dietary outcome measures and a paucity of evidence around harmful alcohol use limit the certainty of these findings. Interpretation Despite significant heterogeneity in exposure and outcome measures, clear evidence shows that the burden of behavioural risk factors is affected by socioeconomic position within LLMICs. Governments seeking to meet Sustainable Development Goal (SDG) 3.4—reducing premature non-communicable disease mortality by a third by 2030—should leverage their development budgets to address the poverty-health nexus in these settings. Our findings also have significance for health workers serving these populations and policy makers tasked with preventing and controlling the rise of non-communicable diseases. Funding WHO.

The commercial determinants of health

WHO Director-General Margaret Chan has noted that “eff orts to prevent non-communicable diseases go against the business interests of powerful economic operators”. Selling processed food and drink, alcohol, and tobacco is big business and demand is booming, especially in low-income and middle-income countries. There has always been critical public health analysis of the power of the corporate sector— especially in the fi eld of tobacco—and attention has turned to other areas in recent years, including work on unhealthy commodities, industrial epidemics, profi t-driven diseases, and corporate practices harmful to health. The focus on lifestyle choices has also been extensively critiqued, especially in relation to marketing to children. These domains of study share signifi cant overlaps, yet researchers are often divided by discipline, approach, and health topic. We believe there is value in conceptually uniting this work under the banner of the commercial determinants of health: a synergistic, multidisciplinary fi eld that addresses the drivers and channels through which corporations propagate the non-communicable diseases pandemic. Previous defi nitions of commercial determinants of health have stressed the fundamental confl ict between imperative shareholder value maximisation and population health—for example, West and Marteau’s “factors that infl uence health which stem from the profi t motive”. This broad defi nition does not capture the inherent complexity of commercial determinants, and the profi t motive also applies to companies that sell healthpromoting products such as fruit and vegetables. Other defi nitions have stressed the centrality of consumption, but there are other channels through which companies infl uence governments, society, and consumers. We defi ne the commercial determinants of health as “strategies and approaches used by the private sector to promote products and choices that are detrimental to health”. This single concept unites a number of others: at the micro level, these include consumer and health behaviour, individualisation, and choice; at the macro level, the global risk society, the global consumer society, and the political economy of globalisation. Three inter-related factors have changed the global business and consumption landscapes while boosting the power of large companies: rising demand, increasing market coverage, and the continued internationalisation of trade and investment (fi gure). Empirical evidence can be found in the escalating number of international trade deals, inexorable market penetration in low-income and middle-income countries, and metrics such as the MSCI Consumer Staples Index (covering tobacco, food, and drinks), which has grown by 200% in low-income and middle-income countries over the last decade. Corporate infl uence is exerted through four channels: marketing, which enhances the desirability and acceptability of unhealthy commodities; lobbying, which can impede policy barriers such as plain packaging and minimum drinking ages; corporate social responsibility strategies, which can defl ect attention and whitewash tarnished reputations; and extensive supply chains, which amplify company infl uence around the globe. These channels boost corporate reach and magnify the health impact of commercial enterprise. The breadth and depth of corporate infl uence is expanded as more people are reached with ever more consumption choices. The absence of publicly available data on corporate practices is a major issue and concerted eff orts to quantify these channels are an important task for the public health community. Select data are available; for instance CocaCola, PepsiCo, and the American Beverage Association spent a total of US

Reframing non-communicable diseases as socially transmitted conditions

114 million on lobbying at the federal level between 2009 and 2015; 45% of people living in countries that have ratifi ed the Framework Convention on Tobacco Control report continued exposure to tobacco marketing; and companies openly speak about using socalled corporate citizenship to buff their public image. Health outcomes are determined by the infl uence of corporate activities on the social environment in which

Quantifying the global distribution of premature mortality from non-communicable diseases

In a Comment (February, 2017), we argued that action on the conditions currently referred to as noncommunicable diseases (NCDs) may be hampered by the inadequacy of their label. We received a remarkable amount of feedback on this suggestion, and in this Comment we synthesise the responses garnered from a Lancet Facebook poll, Correspondence letters, and a related GHD Online discussion. We also propose a new definition based on shared social drivers. The majority of respondents (29 of 47) to the Facebook poll thought that the NCD name should indeed be changed, and almost everyone acknowledged the limitations of the current label. Many NCDs are in fact communicable, and the current anti-definition provides no information about what unites these conditions. This makes it hard for politicians and the general public to grasp the main challenges posed by NCDs: a problem that is exacerbated by the implication that individual (rather than societal) factors are the key determinants. The current misnomer is misleading but not completely useless: it has currency within the global health community and multiple donors, government departments, non-governmental organisations, and academic units use NCD in their own names and programme titles. Then there is the fact that the name itself does not matter at all, as long as the conditions and their drivers are being addressed. Unfortunately our efforts to prevent and control NCDs have been underfunded, misdirected, and underwhelming to date. Most governments focus on individual lifestyle choices, and only a minority of developing countries have implemented WHO “best buys” such as tobacco taxation, salt reduction, and elimination of trans fats. There is a lot to gain by For the GHD Online discussion see https://www.ghdonline.org/ ncd/discussion/lancet-globalhealth-call-to-re-name-ncdsyour-cha/

The Emergence of Personalized Health Technology

Background Non‐communicable diseases (NCDs) have slowly risen to the top of the global health agenda and the reduction of premature NCD mortality was recently enshrined in Target 3.4 of the UN Sustainable Development Goals. The unequal global distribution of NCDs is inadequately captured by the most commonly cited statistics. Methods We analyzed ‘WHO Global Health Estimates’ mortality data to calculate the relative burden of NCDs for each World Bank income group, including the ‘risk of premature NCD death’ based on methods in the WHO Global Status Report. We included all deaths from cardiovascular disease, all cancers, respiratory diseases and diabetes in people aged 30‐69 years. Results Developing countries experience 82% of absolute global premature NCD mortality, but they also contain 82% of the worlds population. Examining relative risk shows that individuals in developing countries face a 1.5 times higher risk of premature NCD death than people living in high‐income countries. Premature NCD death rates are highest in lower middle‐income countries. Conclusions Although numbers of deaths are useful to describe the absolute burden of NCD mortality by country type, the inequitable distribution of premature NCD mortality for individuals is more appropriately conveyed with relative risk.

Are we facing a noncommunicable disease pandemic

Personalized health technology is a noisy new entrant to the health space, yet to make a significant impact on population health but seemingly teeming with potential. Devices including wearable fitness trackers and healthy-living apps are designed to help users quantify and improve their health behaviors. Although the ethical issues surrounding data privacy have received much attention, little is being said about the impact on socioeconomic health inequalities. Populations who stand to benefit the most from these technologies are unable to afford, access, or use them. This paper outlines the negative impact that these technologies will have on inequalities unless their user base can be radically extended to include vulnerable populations. Frugal innovation and public–private partnership are discussed as the major means for reaching this end.

Improving the practice of child death overview panels: a paediatric perspective

Abstract The global boom in premature mortality and morbidity from noncommunicable diseases (NCDs) shares many similarities with pandemics of infectious diseases, yet public health professionals have resisted the adoption of this label. It is increasingly apparent that NCDs are actually communicable conditions, and although the vectors of disease are nontraditional, the pandemic label is apt. Arguing for a change in terminology extends beyond pedantry as the move carries serious implications for the public health community and the general public. Additional resources are unlocked once a disease reaches pandemic proportions and, as a long-neglected and underfunded group of conditions, NCDs desperately require a renewed sense of focus and political attention. This paper provides objections, definitions, and advantages to approaching the leading cause of global death through an alternative lens. A novel framework for managing NCDs is presented with reference to the traditional influenza pandemic response.

Evaluation of research on interventions aligned to WHO ‘Best Buys’ for NCDs in low-income and lower-middle-income countries: a systematic review from 1990 to 2015

Objective In England, every death in childhood is reviewed by a local multidisciplinary Child Death Overview Panel (CDOP) with the intention of understanding causation and implementing interventions to reduce future deaths. This study aimed to establish how well panels work from the perspective of the paediatricians involved and to ascertain whether they deliver good value and identify areas for improvement. Design A questionnaire was sent to every CDOP paediatrician in the country (n=93). Questions focused on the quality of CDOP case discussions as well as examples of effective and significant recommendations. Responses were analysed using simple quantitative and qualitative methods. Results 84/93 (90%) of the paediatricians responded. Among the respondents, 60 (71%) believe that investment in CDOPs is offering good value, 73 (87%) feel that case discussions are rigorous and consistent and over 90% believe that the correct issues are emerging from discussions. However, responders noted many areas for improvement: 40 (48%) suggested devolving the discussion of specialist deaths (eg, neonates) to hospital-based review meetings or holding themed meetings with invited specialists, 11 (13%) suggested filtering out cases where learning is unlikely before full CDOP meetings and 13 (15%) called for national integration and analysis of data. Conclusions In this time of economic austerity it is vital that the CDOPs add value to the invested resources. Although CDOP paediatricians feel that panels are working well, there is scope for improvement through enhancing relationships with commissioning bodies, aggregate review and analysis of CDOP data at a national level and consideration of specialist and/or network review of certain categories of deaths such as cardiac surgery, oncology and neonates.

Financing national non-communicable disease responses

Background Non-communicable diseases (NCDs) are the leading cause of death and disability worldwide, with low-income and middle-income countries experiencing a disproportionately high burden. Since 2010 WHO has promoted 24 highly cost-effective interventions for NCDs, dubbed ‘best buys’. It is unclear whether these interventions have been evaluated in low-income and lower-middle-income countries (LLMICs). Aim To systematically review research on interventions aligned to WHO ‘best buys’ for NCDs in LLMICs. Methods We searched 13 major databases and included papers conducted in the 83 World Bank-defined LLMICs, published between 1 January 1990 and 5 February 2015. Two reviewers independently screened papers and assessed risk of bias. We adopted a narrative approach to data synthesis. The primary outcomes were NCD-related mortality and morbidity, and risk factor prevalence. Results We identified 2672 records, of which 36 were included (608 940 participants). No studies on ‘best buys’ were found in 89% of LLMICs. Nineteen of the 36 studies reported on the effectiveness of tobacco-related ‘best buys’, presenting good evidence for group interventions in reducing tobacco use but weaker evidence for interventions targeting individuals. There were fewer studies on smoking bans, warning labels and mass media campaigns, and no studies on taxes or marketing restrictions. There was supportive evidence that cervical screening and hepatitis B immunisation prevent cancer in LLMICs. A single randomised controlled trial supported polypharmacy for cardiovascular disease. Fourteen of the ‘best buy’ interventions did not have any good evidence for effectiveness in LLMICs. Conclusions We found studies on only 11 of the 24 interventions aligned with the WHO ‘best buys’ from LLMIC settings. Most LLMICs have not conducted research on these interventions in their populations. LLMICs should take action to implement and evaluate ‘best buys’ in their national context, based on national priorities, and starting with interventions with the strongest evidence base.

Poverty and risk factors for non-communicable diseases in developing countries: a systematic review

ABSTRACT Non-communicable diseases (NCDs) (also known as socially transmitted diseases) were conspicuously absent from the Millennium Development Goals and seemed to miss out on the ‘golden years’ of health funding despite causing more death and disability than any other disease group worldwide. The share of ‘development assistance for health’ dedicated to NCDs has remained at 1–2% of the total since 2000. This level of funding is insufficient to attain the nine targets in the World Health Organization (WHO) Global Action Plan on NCDs. In 2015 the Sustainable Development Goals – which include the target of reducing premature NCD mortality by a third – were endorsed by 193 countries. Whilst this commitment is welcome, the same text stresses the primacy of domestic financing, which is currently dominated by out-of-pocket payments in low- and middle-income countries (LMICs). This paper presents the findings of the WHO Global Coordination Mechanism on NCDs financing working group. The group was convened to explore NCD financing options with an emphasis on LMICs. The main sources of available finance include taxation, loans, engagement with the private sector, impact investment and innovative financing mechanisms. There is a role for development assistance to increase in the interim as raising additional revenue from these sources will take time. In the medium term it may be appropriate for international NCD funding to remain low where LMICs successfully assume financial responsibility for preventing and controlling NCDs. Countries will have to manage blends of innovative and traditional funding sources, whilst finding ways to boost tax revenue for NCDs.