Background
The share of NCDs from total deaths. Both sexes. All age (%) | The share of NCDs from total DALYs. Both sexes. All age (%) | Mortality (% of total deaths), all ages, both sexes, 2016 | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
1990 | 2017 | 1990 | 2017 | Cardiovascular diseases | Cancers | Chronic respiratory diseases | Diabetes | Other NCDs | Communicable, maternal, perinatal, etc. | Injuries | |
World | 57.72 | 73.41 | 43.19 | 62.06 | 31 | 16 | 7 | 3 | 15 | 20 | 9 |
Iran | 50.11 | 82.32 | 45.33 | 76.6 | 43 | 16 | 4 | 4 | 15 | 8 | 10 |
Methods
Familiarization and identifying a framework for documentary content analysis
Objective | Actions and interventions a | |
---|---|---|
1. To raise the priority accorded to the prevention and control of NCDs in global, regional and national agendas and internationally agreed development goals, through strengthened international cooperation and advocacy (1.1 to 1.4) | 4 policy options | |
2. To strengthen national capacity, leadership, governance, multisectoral action, and partnerships to accelerate country response for the prevention and control of NCDs. (2.1 to 2.4) | 4 policy options | |
3. Reducing modifiable risk factors for NCDs and underlying social determinants through creation of health-promoting environments (3.1 to 3.49) | TOBACCO | 3 overarching/enabling actions 9 best-buys and other recommended interventions |
HARMFUL USE OF ALCOHOL | 3 overarching/enabling actions 11 best-buys and other recommended interventions | |
UNHEALTHY DIET | 2 overarching/enabling actions 13 best-buys and other recommended interventions | |
PHYSICAL INACTIVITY | 1 overarching/enabling actions 7 best-buys and other recommended interventions | |
4. Strengthen and orient health systems to address the prevention and control of NCDs and the underlying social determinants through people-centered PHC and UHC (4.1 to 4.38) | OVERARCHING/ENABLING ACTIONS | 8 actions |
CARDIOVASCULAR DISEASE | 10 interventions | |
DIABETES | 7 interventions | |
CANCER | 7 interventions | |
CHRONIC RESPIRATORY | 6 interventions | |
5. To promote and support national capacity for high-quality research and development for the prevention and control of NCDs (5.1 to 5.5) | 5 policy options | |
6. To monitor the trends and determinants of NCDs and evaluate progress in their prevention and control (6.1 to 6.5) | 5 policy options |
Indexing, charting, and interpretation
Quantitative analysis
Experts | Knowledge / Expertise / Experience / Position | Level |
---|---|---|
1 | Global Health & Policy, Health Equity, Public Policy, NCDs | International |
2 | Health Equity, Epidemiology, and Biostatistics, Top Level Leadership and Adviser of The MoHME, | National |
3 | Health Economics, Public Health | National |
4 | Director of NCDs National Research Center, Burden of Diseases | National |
5 | NCDs National Research Center | National |
6 | Director of The Ministry of Health’s Center for NCDs | National |
7 | Social Determinants of Health, Public Health | Provincial |
8 | Health Policy, Health Equity, Health Economics | Provincial |
Criteria | Weight | Data on each intervention | |
---|---|---|---|
1 | Number of people to be potentially affected by intervention | .133 | 3.1 to 3.49 and 4.1 to 4.38 (excluded interventions: 3.1–3.2-3.3-3.13-3.14-3.15-3.27-3.28-3.42- and 4.1 to 4.8) |
2 | Cost-effectiveness of intervention | .293 | |
3 | Attributable burden (Daly per 100,000) | .337 | |
4 | The 200 disease codes that led to the largest hospitalization in the whole country over a year. The chance that the intervention may prevent some of them based on the model of 4 diseases, 4 modifiable shared risk factors | .160 | |
5 | Prevalence differences between income levels | .077 | |
Inconsistency = 0.01 with 0 missing judgments |
Data collection for each intervention in the five selected criteria
Tobacco use | Unhealthy diets | Physical inactivity | Harmful use of alcohol | |
---|---|---|---|---|
Cardio-vascular | √ | √ | √ | √ |
Diabetes | √ | √ | √ | √ |
Cancer | √ | √ | √ | √ |
Chronic respiratory | √ |
Disease group | ICD 10 Code a | Number of inpatient admissions | sum | percentage of total admissions |
---|---|---|---|---|
Cardiovascular diseases | I20.0 I25.1 I10 R07.4 I64 I50.0 I25.9 I21.9 I48 I50.9 I80.2 I51.6 G45.9 Z03.5 I24.9 | 56,238 29,660 26,819 16,363 12,663 11,763 11,437 10,174 7187 6906 4048 3794 3412 3012 2347 | 205,823 | 11.99 |
Cancers | Z51.1 N83.2 N63 D48.7 | 21,301 5645 2242 710 | 29,898 | 1.74 |
Diabetes | J35.3 O24.4 E11.5 E14.5 E10.9 E11.9 | 8531 5139 4013 1994 1933 1190 | 22,800 | 1.32 |
Chronic respiratory diseases | J18.9 J44.9 R06.0 J45.9 J44.1 J21.9 J40 J46 | 44,902 16,173 12,856 12,367 3281 2486 2021 966 | 95,052 | 5.54 |
Results
Objective | Missed interventions | Type of intervention |
---|---|---|
1 | 1.3 Strengthen international cooperation for resource mobilization, capacity-building, health workforce training and exchange of information on lessons learned and best practices | Overarching/enabling policy interventions. |
2 | 2.2 Assess national capacity for prevention and control of NCDs | |
4 | 4.2 Explore viable health financing mechanisms and innovative economic tools supported by evidence | |
4 | 4.7 Develop and implement a palliative care policy, including access to opioids analgesics for pain relief, together with training for health workers | |
3 | 3.38 Limiting portion and package size to reduce energy intake and the risk of overweight/obesity | Other recommended interventions from WHO guidance (cost-effective analysis not available). |
3 | 3.45 Ensure that macro-level urban design incorporates the core elements of residential density, connected street networks that include sidewalks, easy access to a diversity of destinations and access to public transport | |
4 | 4.16 Anticoagulation for medium-and high-risk non-valvular atrial fibrillation and for mitral stenosis with atrial fibrillation | |
4 | 4.31 Oral cancer screening in high-risk groups (for example, tobacco users, betel-nut chewers) linked with timely treatment | |
4 | 4.10 Treatment of new cases of acute myocardial infarction** with either: acetylsalicylic acid, or acetylsalicylic acid and clopidogrel, or thrombolysis, or primary percutaneous coronary interventions (PCI) | Effective interventions with cost-effectiveness analysis >I$ 100 per DALY averted in LMICs. |
4 | 4.12 Primary prevention of rheumatic fever and rheumatic heart diseases by increasing appropriate treatment of streptococcal pharyngitis at the primary care level | |
4 | 4.13 Secondary prevention of rheumatic fever and rheumatic heart disease by developing a register of patients who receive regular prophylactic penicillin | |
4 | 4.26 Vaccination against human papillomavirus (2 doses) of 9–13-year-old girls | ‘Best buys’: Effective interventions with cost-effectiveness analysis = I$ 100 per DALY averted in LMICs. |
Code | Full name of the interventions that prioritized in Fig. 3 |
---|---|
3.41 | Implement mass media campaign on healthy diets, including social marketing to reduce the intake of total fat, saturated fats, sugars, and salt, and promote the intake of fruits and vegetables |
3.8 | Implement effective mass media campaigns that educate the public about the harms of smoking/tobacco use and second-hand smoke |
3.7 | Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public places, and public transport |
3.4 | Increase excise taxes and prices on tobacco products |
3.5 | Implement plain/standardized packaging and/or large graphic health warnings on all tobacco packages |
3.6 | Enact and enforce comprehensive bans on tobacco advertising, promotion, and sponsorship |
3.39 | Implement nutrition education and counseling in different settings (for example, in preschools, schools, workplaces, and hospitals) to increase the intake of fruits and vegetables |
3.38 | Limiting portion and package size to reduce energy intake and the risk of overweight/obesity |
3.9 | Provide cost-covered, effective and population-wide support (including brief advice, national toll-free quitline services) for tobacco cessation to all those who want to quit |
3.29 | Reduce salt intake through the reformulation of food products to contain less salt and the setting of target levels for the amount of salt in foods and meals |
3.30 | Reduce salt intake through the establishment of a supportive environment in public institutions such as hospitals, schools, workplaces, and nursing homes, to enable lower sodium options to be provided |
3.31 | Reduce salt intake through a behavior change communication and mass media campaign |
3.32 | Reduce salt intake through the implementation of front-of-pack labeling |
3.10 | Implement measures to minimize illicit trade in tobacco products |
3.11 | Ban cross-border advertising, including using modern means of communication |
3.12 | Provide cessation for tobacco cessation to all those who want to quit |
3.43 | Implement community-wide public education and awareness campaign for physical activity which includes a mass media campaign combined with other community-based education, motivational and environmental programs aimed at supporting behavioral change of physical activity levels |
3.17 | Enact and enforce bans or comprehensive restrictions on exposure to alcohol advertising (across multiple types of media) |
3.33 | Eliminate industrial trans-fats through the development of legislation to ban their use in the food chain |
3.44 | Provide physical activity counseling and referral as part of routine primary health care services through the use of a brief intervention |
3.16 | Increase excise taxes on alcoholic beverages |
3.18 | Enact and enforce restrictions on the physical availability of retailed alcohol (via reduced hours of sale) |
3.36 | Implement subsidies to increase the intake of fruits and vegetables |
3.19 | Enact and enforce drink-driving laws and blood alcohol concentration limits via sobriety checkpoints |
3.34 | Reduce sugar consumption through effective taxation on sugar-sweetened beverages |
3.40 | Implement nutrition labeling to reduce total energy intake (kcal), sugars, sodium and fats |
3.37 | Replace trans-fats and saturated fats with unsaturated fats through reformulation, labeling, fiscal policies or agricultural policies |
3.45 | Ensure that macro-level urban design incorporates the core elements of residential density, connected street networks that include sidewalks, easy access to a diversity of destinations and access to public transport |
3.47 | Provide convenient and safe access to quality public open space and adequate infrastructure to support walking and cycling |
3.49 | Promotion of physical activity through organized sports groups and clubs, programs and events |
3.20 | Provide brief psychosocial intervention for persons with hazardous and harmful alcohol use |
3.46 | Implement a whole-of-school program that includes quality physical education, availability of adequate facilities and programs to support physical activity for all children |
3.48 | Implement multi-component workplace physical activity programs |
3.23 | Enact and enforce an appropriate minimum age for purchase or consumption of alcoholic beverages and reduce the density of retail outlets |
3.24 | Restrict or ban promotions of alcoholic beverages in connection with sponsorships and activities targeting young people |
3.21 | Carry out regular reviews of prices in relation to the level of inflation and income |
3.22 | Establish minimum prices for alcohol where applicable |
3.26 | Provide consumer information about, and label, alcoholic beverages to indicate, the harm related to alcohol |
3.25 | Provide prevention, treatment, and care for alcohol use disorders and comorbid conditions in health and social services |
3.35 | Promote and support exclusive breastfeeding for the first 6 months of life, including the promotion of breastfeeding |
Code | Full name of the interventions that prioritized in Fig. 4 |
---|---|
4.9 | Drug therapy (including glycaemic control for diabetes mellitus and control of hypertension using a total risk* approach) and counseling to individuals who have had a heart attack or stroke and to persons with high risk (≥ 30%) of a fatal and non-fatal cardiovascular event in the next 10 years |
4.10 | Treatment of new cases of acute myocardial infarction** with either: acetylsalicylic acid, or acetylsalicylic acid and clopidogrel, or thrombolysis, or primary percutaneous coronary interventions (PCI) |
4.11 | Treatment of acute ischemic stroke with intravenous thrombolytic therapy |
4.15 | Cardiac rehabilitation post-myocardial infarction |
4.16 | Anticoagulation for medium-and high-risk non-valvular atrial fibrillation and for mitral stenosis with atrial fibrillation |
4.14 | Treatment of congestive cardiac failure with angiotensin-converting-enzyme inhibitor, beta-blocker, and diuretic |
4.13 | Secondary prevention of rheumatic fever and rheumatic heart disease by developing a register of patients who receive regular prophylactic penicillin |
4.12 | Primary prevention of rheumatic fever and rheumatic heart diseases by increasing appropriate treatment of streptococcal pharyngitis at the primary care level |
4.17 | Low-dose acetylsalicylic acid for ischemic stroke |
4.18 | Care of acute stroke and rehabilitation in stroke units |
4.27 | Prevention of cervical cancer by screening women aged 30–49 years |
4.26 | Vaccination against human papillomavirus (2 doses) of 9–13-year-old girls |
4.28 | Screening with mammography (once every 2 years for women aged 50–69 years) linked with timely diagnosis and treatment of breast cancer |
4.29 | Treatment of colorectal cancer stages I and II with surgery +/− chemotherapy and radiotherapy |
4.34 | Symptom relief for patients with chronic obstructive pulmonary disease with inhaled salbutamol |
4.19 | Preventive foot care for people with diabetes (including educational programs, access to appropriate footwear, multidisciplinary clinics |
4.21 | Effective glycaemic control for people with diabetes, along with standard home glucose monitoring for people treated with insulin to reduce diabetes complications |
4.20 | Diabetic retinopathy screening for all diabetes patients and laser photocoagulation for prevention of blindness |
4.33 | Symptom relief for patients with asthma with inhaled salbutamol |
4.35 | Treatment of asthma using low dose inhaled beclometasone and short-acting beta-agonist |
4.32 | Population-based colorectal cancer screening, including through a faecal occult blood test, as appropriate, at age > 50 years, linked with timely treatment |
4.31 | Oral cancer screening in high-risk groups (for example, tobacco users, betel-nutchewers) linked with timely treatment |
4.30 | Prevention of liver cancer through hepatitis B immunization |
4.25 | Screening of people with diabetes for proteinuria and treatment with angiotensin-converting enzyme inhibitor for the prevention and delay of renal disease |
4.37 | Cost-effective interventions to prevent occupational lung diseases, for example, from exposure to silica, asbestos |
4.38 | Influenza vaccination for patients with chronic obstructive pulmonary disease |
4.23 | Influenza vaccination for patients with diabetes |
4.22 | Lifestyle interventions for preventing type 2 diabetes |
4.24 | Preconception care among women of reproductive age who have diabetes including patient education and intensive glucose management |
4.36 | Access to improved stoves and cleaner fuels to reduce indoor air pollution |
Discussion
- In line with the WHO global action plan, the SCHFS, led by President, approved the National Action plan for prevention and control of NCDs [55].
- The INCDC [11], led by the minister of health, was established within the MoHME. The INCDC is the highest decision- making body in the health system to plan, monitor, and lead the country toward a 30% reduction in NCDs-related mortality by 2030.
- The INCDC prepared a number of national standard frameworks to reduce NCDs’ risk factors through multisectoral collaboration. It also approved the IraPEN 2015–25 strategy, which includes several cost-effective interventions for early detection of three common cancers (colorectal, breast, and cervix), accompanied by active risk score assessment for cardiovascular diseases and their appropriate management [55] within the PHC network.
Study limitations
Policy recommendations
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Restrictions on resources in all countries, especially in the LMICs, require that programs be directed towards priority interventions. MCDA is a useful tool to help national policymakers for prioritizing the interventions. For example, this study found that nutrition-centered interventions had a higher priority compared to other interventions.
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The MCDA can also help local policymakers to tailor appropriate interventions into NCDs’ national programs, based on their contextual characteristics.
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Stakeholders’ conflict of interest might slow down the progress of healthcare interventions. Through including different and even contradicting philosophical views of decision-makers, joint weighing methods used in MCDA can balance and weight criteria for prioritization.
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We encourage insurance organizations to utilize group risk assessment and MCDA models to identify priority interventions for different groups of the population.