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

Background Non-communicable diseases are the leading global cause of death and disproportionately affl ict 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 Eff ective 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 signifi cantly between members of diff erent 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 signifi cantly higher prevalence of tobacco and alcohol use than did high socioeconomic groups. These groups also consumed less fruit, vegetables, fi sh, and fi bre 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 fi ndings. Interpretation Despite signifi cant heterogeneity in exposure and outcome measures, clear evidence shows that the burden of behavioural risk factors is aff ected 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 fi ndings also have signifi cance for health workers serving these populations and policy makers tasked with preventing and controlling the rise of non-communicable diseases

Disease mutations reveal residues critical to the interaction of P4-ATPases with lipid substrates

Abstract Phospholipid flippases (P4-ATPases) translocate specific phospholipids from the exoplasmic to the cytoplasmic leaflet of membranes. While there is good evidence that the overall molecular structure of flippases is similar to that of P-type ATPase ion-pumps, the transport pathway for the “giant” lipid substrate has not been determined. ATP8A2 is a flippase with selectivity toward phosphatidylserine (PS), possessing a net negatively charged head group, whereas ATP8B1 exhibits selectivity toward the electrically neutral phosphatidylcholine (PC). Setting out to elucidate the functional consequences of flippase disease mutations, we have identified residues of ATP8A2 that are critical to the interaction with the lipid substrate during the translocation process. Among the residues pinpointed are I91 and L308, which are positioned near proposed translocation routes through the protein. In addition we pinpoint two juxtaposed oppositely charged residues, E897 and R898, in the exoplasmic loop between transmembrane helices 5 and 6. The glutamate is conserved between PS and PC flippases, whereas the arginine is replaced by a negatively charged aspartate in ATP8B1. Our mutational analysis suggests that the glutamate repels the PS head group, whereas the arginine minimizes this repulsion in ATP8A2, thereby contributing to control the entry of the phospholipid substrate into the translocation pathway

A systematic review of associations between non-communicable diseases and socioeconomic status within low- and lower-middle-income countries.

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of death globally. Eighty-two percent of premature NCD deaths occur within low- and lower middle-income countries (LLMICs). Research to date, largely drawn from high-income countries, suggests that disadvantaged and marginalized groups have a higher NCD burden, but there has been a dearth of research studying this relationship within LLMICs. The purpose of this systematic review is to map the literature on evidence from LLMICs on the socio-economic status (SES) gradient of four particular NCDs: cardiovascular disease, cancer, diabetes, and chronic respiratory diseases. METHODS: We conducted a comprehensive literature search for primary research published between 1 January 1990 and 27 April 2015 using six bibliographic databases and web resources. We included studies that reported SES and morbidity or mortality from cardiovascular disease, cancer, diabetes and chronic respiratory diseases within LLMICs. RESULTS: Fifty-seven studies from 17 LLMICs met our inclusion criteria. Fourteen of the 18 papers that reported significant associations between cancer and SES suggested that low SES groups had the highest cancer risk. Eleven of 15 papers reporting significant relationships between CVD and SES suggested that low SES groups have higher risk. In contrast, seven of 12 papers reporting significant findings related to diabetes found that higher SES groups had higher diabetes risk. We identified just three studies on the relationship between chronic respiratory diseases and SES; none of them reported significant findings. CONCLUSIONS: Only 17 of the 84 LLMICs were represented, highlighting the need for more research on NCDs within these countries. The majority of studies were medium to high quality cross-sectional studies. When we restricted our analyses to high quality studies only, for both cancer and cardiovascular disease more than half of studies found a significantly higher risk for those of lower SES. The opposite was true for diabetes, whilst there was a paucity of high quality research on chronic respiratory disease. Development programmes must consider health alongside other aims and NCD prevention interventions must target all members of the population. SYSTEMATIC REVIEW REGISTRATION NUMBER: Prospero: CRD42015020169

Socioeconomic status and alcohol use in low- and lower-middle income countries: A systematic review.

BACKGROUND: Harmful use of alcohol is a major cause of global morbidity and mortality. The role of alcohol as a driver of the unfolding non-communicable disease crisis has led to high-profile calls for better epidemiological data. Despite causing a disproportionate amount of harm in low-income groups, there is a critical dearth of evidence on the intra-national socioeconomic patterning of alcohol use in low- and lower-middle income countries (LLMICs). This review aims to fill the gap, providing evidence on the association between socioeconomic status (SES) and alcohol use in these low-income settings. METHODS: We conducted a comprehensive literature search for primary research published between January 1, 1990 and June 30, 2015 using 13 electronic databases, including Embase and Medline. We also hand-searched references and reviewed 'gray literature' - studies that have not been published in peer-reviewed journals. We included studies from LLMICs presenting data on multiple measures of socioeconomic status and alcohol use. No age or language restrictions were applied. Due to high heterogeneity, we used a narrative approach for data synthesis. FINDINGS: After reviewing 4242 records and 247 full-text articles, 23 studies met our inclusion criteria, reporting data on 861,295 individuals aged >10 years from 10 countries. Alcohol use was found to be more prevalent in lower socioeconomic groups in the majority of Southeast Asian studies. The association was mixed for African studies, although these tended to have smaller sample sizes and weaker methods. Studies that measured multiple domains of SES found good agreement between different indicators. Definitions of alcohol use and abuse varied widely between studies, as did socioeconomic groupings. CONCLUSIONS: The lack of consistency between studies and the abject lack of data from the majority of LLMICs present a major barrier to policymakers tasked with reducing alcohol-related harm in these settings. Adherence to standardized definitions, the publication of WHO survey data on alcohol and SES, and enhanced surveillance is needed to build an accurate picture of the socioeconomic patterning of alcohol use in developing countries

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

BACKGROUND: The association between poverty and health is highly context-specific; in high-income countries, low socioeconomic status is associated with use of tobacco and alcohol, physical inactivity, and poor diet. We lack good quality epidemiological evidence from developing countries, especially from low and lower middle-income countries (LLMICs). This systematic review sought to fill this gap. METHODS: We conducted a comprehensive literature search for primary research published between Jan 1, 1990, and June 30, 2015, using 13 electronic databases, including Embase and Medline, as well as a grey literature review and hand searching of references. Two reviewers independently screened papers retrieved from 13 databases with a search devised by an experienced medical librarian combining MeSH terms and synonyms for non-communicable diseases, behavioural risk factors, poverty, and the 84 LLMICs defined by the World Bank. We included studies from LLMICs that presented data on multiple measures of socioeconomic status and tobacco use, alcohol use, diet, and physical activity. We performed narrative data synthesis. FINDINGS: After review of 4242 records, 75 studies met our inclusion criteria, representing 2 135 314 individuals aged more than 10 years from 39 LLMICs. Most studies found that, compared with high socioeconomic groups, lower status groups had a high prevalence of tobacco and alcohol use (odds ratios up to 18·8 and 3·5, respectively). Most studies also found that lower socioeconomic groups consumed less fruit, vegetables, fish, and fibre (odds ratios negligible to 12·9, depending on context). Higher socioeconomic groups were up to 4·4 times less physically active and consumed more fats, salt, and processed food; however, these dietary studies tended to be smaller with wide confidence intervals. INTERPRETATION: Despite variation in exposure and outcome measures, there is clear evidence that the burden of behavioural risk factors is affected by socioeconomic position within LLMICs. Governments seeking to meet Sustainable Development Goal 3.4—reducing premature mortality from non-communicable diseases by a third by 2030—should leverage their development budgets to address the poverty–health nexus in these settings. Our findings are also important for health workers serving these populations, and for policymakers tasked with preventing and controlling the rise of non-communicable diseases

Barriers and facilitators to the implementation of a national multisectoral action plan for the prevention and control of noncommunicable diseases in Nepal:perspectives of stakeholders

BACKGROUND: Nepal adopted the Multisectoral Action Plan for the Prevention and Control of Non-Communicable Diseases (MSAP) in 2014. Implementation of the plan has been challenging, with limited participation from non-health sectors. OBJECTIVES: The overall aim of the study was to gain the perspectives of key stakeholders involved in the Nepal MSAP on the barriers and facilitators to its implementation, through the participation of relevant sectors in the plan. METHODS: We held face-to-face semi-structured interviews with 12 stakeholders working in sectors involved in the MSAP. These sectors included the Office of the Prime Minister and Council of Ministries; Ministry of Health and Population (MOHP); Ministry of Education, Science and Technology; Ministry of Forest and Environment; academia; and professional organizations. Thematic analysis of transcripts was used to identify themes on awareness of NCDs, awareness of the MSAP, and barriers and facilitators to participation in the MSAP. RESULTS: Participants recognised NCDs as a growing and major burden in Nepal. However, a number of participants were not familiar with the MSAP, identifying a lack of leadership and poor dissemination. Political and systemic transformation, since the adoption of the MSAP, was seen as a key barrier to implementation. International commitments to develop multisectoral action made by the Government of Nepal were identified as drivers. The recent establishment of a separate section for NCDs and Mental Health within the Department of Health Services of MOHP and the promotion of a Health in All Policies (HiAP) approach in recent national documents, were both considered to support implementation. CONCLUSIONS: The establishment of permanent multisectoral or multistakeholder mechanisms has been challenging despite strong political calls for their development. Moving beyond 2020, multisectoral action plans should engage with stakeholders from federal, provincial and local governments in order to develop costed action plans with specific roles and responsibilities for each sector

Health literacy development is central to the prevention and control of non-communicable diseases

Funding Information: This study was funded in part by National Health and Medical Research Council (Principal Research Fellowship APP1155125). Publisher Copyright: © 2022 Author(s). Published by BMJ.The WHO's report Health literacy development for the prevention and control of non-communicable diseases (NCDs) delivers practical what-to-do how-to-do guidance for health literacy development to build, at scale, contextually-relevant public health actions to reduce inequity and the burden of NCDs on individuals, health systems and economies. The key premise for health literacy development is that people's health awareness and behaviours are linked to lifelong experiences and social practices, which may be multilayered, hidden and beyond their control. Meaningful community engagement, local ownership and locally driven actions are needed to identify health literacy strengths, challenges and preferences to build locally fit-for-purpose and implementable actions. Health literacy development needs to underpin local and national policy, laws and regulations to create enabling environments that reduce community exposures to NCD risk factors. Deficit approaches and siloed health system and policy responses need to be avoided, focusing instead on integrating community-based solutions through co-design, cognisant of people's daily experiences and social practices.publishersversionpublishe

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.

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

Are WHO “best buys” for non-communicable diseases effective in low-income and lower-middle-income countries? A systematic review

The central plank of the global strategy to combat non-communicable diseases (NCDs) is a cluster of highly cost-effective interventions that WHO has dubbed “best buys”. These 24 interventions promoted by WHO include tobacco taxation, salt reduction, cervical screening, and aspirin. Although the greatest burden of NCDs is in low-income and lower-middle income countries, evidence for most of the best buys comes from high-income countries. We did a systematic review to assess evidence for the effectiveness of best buys in low-income and lower-middle-income countries (LLMICs), where the need for effective NCD interventions is greatest