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MEDiterranean studies of Cardiovascular disease and Hyperglycaemia: Analytical Modelling of Population Socio-economic transitions

Periodic Report Summary 2 - MEDCHAMPS (Mediterranean studies of cardiovascular disease and hyperglycaemia: analytical modelling of population socio-economic transitions)

Non-communicable diseases (NCDs), particularly cardiovascular diseases (CVD) and diabetes are increasing dramatically in many low and middle income countries. The MEDCHAMPS project aimed to be able to make recommendations about the policy initiatives, within and outside the health sector, likely to be the most cost-effective in reducing the burden of CVD and diabetes mortality and morbidity in each country. The analysed countries were Tunisia, Syria, Palestine and Turkey.

MEDCHAMPS used a mixed methods approach to identify potential policy initiatives. Our research project coincided with tumultuous political upheaval in two of the four countries.

Regarding the epidemiological modelling, which consisted in the development of a coronary heart disease (CHD) mortality model, detailed epidemiological risk factor data required to populate quantitative models of CVD mortality and diabetes was collected and interpolated. Key findings were a rise in body mass index (BMI) of 1 to 2 kg/m2 over the previous 15 years, with diabetes prevalence increasing by 40 to 50 % in men and women in all four countries. Regional smoking prevalence was high in men, persisting in Syria but decreasing in Tunisia, Palestine and Turkey. Age adjusted CHD mortality rates rose by 20 % in Tunisia and by 65 % in Syria and fell by 12 % in Palestine and 17 % in Turkey. Adverse risk factors trends explained about 98 % of the observed mortality rise in Tunisia and over 80 % of the increase in Syria. In Palestine risk factor changes explained more than 65 % of the overall mortality fall with treatments accounting for approximately 30 %. In Turkey, risk factor improvements explained about 60 % of the mortality fall with treatments accounting for the remaining 40 %.

Moreover, we developed and validated a new diabetes model, enabling us to project trends for 30 years. The model was tested in each country, as well as in the United States of America, the United Kingdom and Saudi Arabia, and by the end of the reporting period was used to explore the impact of prevention policies.

Three distinct 'levels' of data collection were carried out, including documentary analysis, key informant interviews and clinic fieldwork. There was a formal recognition about the increased burden of NCDs in the partner countries. However, they were placed differentially in terms of planning and managing this emerging situation. While Turkey and Tunisia developed some policies and strategies concerning CVD and diabetes, Syria was lagging well behind. Despite the unique political context, Palestine was making good progress in this respect. However, it was apparent that none of these countries had developed a comprehensive, multi-sectoral NCD policy.

Policy options were short listed based on the epidemiological modelling, situation analyses and the literature. Country specific policies were then selected by each country team and evaluated by key stakeholders based on predefined criteria. Five policies for each country were identified as top priority and action plans were developed. Three policies to reduce population dietary salt intake were chosen for economic evaluation, i.e. a health promotion campaign, labelling of food packaging and mandatory reduction of salt content in processed food. The costs of implementing each of the policies were estimated from comparable policies and expert opinion. In all countries most evaluated policies were cost saving. For example, the combination of all three policies together resulted in estimated cost savings of USD 235 million and 6 455 life years gained in Tunisia.

Although each country came up with specific recommendations the following were common:

1. population-based intersectoral, comprehensive policies to control NCD risk factors by legislative, regulatory and health promotion measures
2. steps to improve staff training, numbers and accessibility, and
3. empowering the public in the clinic treatment context.

There was evidence that lifestyle and preventive interventions were relatively neglected from key strategies, particularly interventions at a population level.

Key work tasks on data entry, model analyses and validation in Palestine, Syria, Tunisia and Turkey were to enter data into parallel country models and then to validate data entry by explicit comparison of model results with observed data or other estimates. Progress towards these outcomes was excellent for the CHD impact model and the diabetes models in each of the four settings, but more limited for the ischaemic stroke model.

The CHD impact model was populated with data from each of the four MEDCHAMPS partner countries. It was also validated against observed data and the agreement was good in all four settings. Two manuscripts for publication were submitted from Palestine and Syria by the end of the reporting period, with advanced drafts also from Turkey and Tunisia. The overall results of the CHD impact model across the four countries were presented in a draft paper which was in the submission process by the end of this period. An abstract detailing the work was submitted to the World Congress of Cardiology in 2011.

The diabetes model was populated with Palestinian, Tunisian and Syrian data. It was also validated against country estimates and other estimates, such as the global burden of disease, and International Diabetes Federation (IDF) diabetes atlas data. The results of the diabetes model were presented in a regional conference in Lebanon in 2011. The outline of a paper presenting diabetes model results was drafted, and was being finalised by the end of the reporting period.

A first version of the ischaemic stroke model was prepared and validated with Dutch data. Iterations with different assumptions needed to be made to get the best version for the model. Validating the model was in process, using data from Tunisia and Palestine. Paper outlines for individual countries were not ready yet. Whilst the development of this component was slower it had not impacted on other tasks since key results were available from the other models, developed by the fourth work package (WP4) and from WP5. The development of this model could continue beyond the timescale of this project, since additional funding was secured to continue working towards this objective.

Furthermore, national situation analyses were performed. After the completion and delivery of WP5 report to the European Union in March 2011, the work in this WP focussed on the dissemination of findings, scientific writing and publications. Two manuscripts were drafted, one of which was presented in the Palestinian Health Alliance writing clinic which was held in Birzeit University in March 2011. The abstract of the same manuscript was published online in the Lancet.

In addition, we shortlisted policy options which appeared most practical, feasible and cost-effective for each of the four Mediterranean partners, based on integrating results from the qualitative situation analyses (WP5) and the quantitative epidemiological modelling (WP4). A mixed methods' framework for integration was developed and shared, and used to identify the policy options most likely to be effective and cost-effective in each of the four partner countries. These were shared with key stakeholders in each country setting and stakeholders were asked to rank the policy options based on a framework developed and validated previously by the World Health Organisation (WHO). Based on these stakeholder ratings, we aimed to develop implementation plans for selected policy options. We also assessed the cost-effectiveness of several policies, singly or in combination, to reduce salt intake at a population level. This was chosen as an exemplar across the four partner countries and was based on WP4 findings. Detailed costing methodologies were developed including tools and data sheets to ensure a consistent methodology for each of the four partner countries. Data collection originated from various sources including expert opinion, field visits, the CHD model results and literature review. A thorough literature review was completed to assess effectiveness measures for the salt reduction policies.

Regarding the obtained results, age adjusted CHD mortality rates rose by 20 % in Tunisia and by 65 % in Syria. The adverse trends in risk factors explained approximately 98 % of the observed mortality rise in Tunisia and more than 80 % of the increase in Syria. These mortality rises occurred in spite of treatments which annually prevented or postponed approximately 450 CHD deaths in Tunisia and 2 150 deaths in Syria. On the other hand, CHD mortality rates fell by 12 % in Palestine and 17 % in Turkey. In Palestine risk factor changes explained more than 65 % of the overall mortality fall with treatments accounting for approximately 30 %. In Turkey risk factor improvements explained approximately 60 % of the overall mortality fall with treatments accounting for the remaining 40 %.

In Turkey, the prevalence estimated by the diabetes model was 7.5 % in 1997, increasing to 16 % in 2010, the available year for validation. Comparisons of the model estimates with the observed prevalence from surveys showed a close fit. The observed prevalence of diabetes mellitus in Turkey in 2010 was 14.9 %, more specifically 13.6 % in men and 16.1 % in women, and the estimated values by the model were 16.1 %, 14.9 % in men and 17.1 % in women. The forecasted prevalence for 2025 was 31 %, or 28 % in men and 35 % in women. If obesity prevalence was reduced in future by 10 % and smoking decreased by 20 % this might achieve a 6 % reduction in diabetes prevalence by 2025. Similar results were obtained for all four countries.

Moreover, the national situation analyses obtained interesting results. There was a formal recognition about the increased burden of NCDs in the partner countries. However, they were placed differentially in terms of planning and managing this emerging situation. While Turkey and Tunisia developed some policies and strategies concerning CVD and diabetes, Syria was lagging well behind. Despite the unique political context, Palestine was making good progress. However, it was also apparent that none of these countries had developed a comprehensive, multi-sectoral, well defined policy to deal with NCDs.

The health management system was found to be highly centralised in all partner countries and there was a lack of coordination between different departments. There was a major lack of information on CVD and diabetes in all four countries, as well as a shortage of skilled and specialist health personnel to manage these NCDs. Although the supply of medicine and equipment did not appear as a key problem, there was evidence of unequal distribution between regions, as well as between urban and rural areas. While the degree varied between countries, our research showed that awareness regarding the risks of NCDs among patients was patchy and incomplete everywhere. At the same time, health facilities and treatment processes were generally experienced by patients as unfriendly, with widespread complaints about the time given by health staff to explain the causes and consequences of their condition and the reasons for the steps stipulated to manage it. Controlling NCDs was a complex challenge and required interventions both within and outside the health sector. Each country had come up with specific recommendations to combat these challenges; however the following were common in all cases:

1. population-based intersectoral, comprehensive policies to control NCD risk factors by legislative, regulatory and health promotion measures
2. steps to improve staff numbers, staff accessibility and staff training, and
3. empowering the public in the clinic treatment context as a necessary means to strengthen patients' self management.

These broad recommendations were broken down into specific interventions as well as into short, medium and long term plans.

Results from the policy option appraisal were not available during this reporting period. However, interim results from the salt cost-effectiveness analyses suggested that all salt reduction policies considered would be cost-effective in each country.

More detailed information on the project activities was accessible at 'http://research.ncl.ac.uk/medchamps/index.html'.