Addressing critical barriers to control of non-communicable disease (NCD) in low, middle and high income countries

The burden of disease in middle and low income countries is changing, with growing numbers of chronic diseases requiring long term treatment. Yet, the available evidence, mainly on acute conditions, shows that there are large inequalities in access to care. The goal of this project is to understand the role of health systems in shaping gender, geographical, and socio-economic inequalities in access to continuing effective care for chronic diseases in low-, middle- and high income countries, by combining two unique large data sets (the Prospective Urban and Rural Epidemiology (PURE) individual cohorts and Environmental Profile of a Community's Health (EPOCH) community profiles). These contain individual-level data from a cohort of over 170,000 individuals age 35-70 in over 600 communities in 21 countries at all levels of development (Canada, Sweden, Saudi Arabia, United Arab Emirates, Argentina, Brazil, Chile, Poland, Turkey, Malaysia, South Africa, China, Colombia, Iran, Palestine, Philippines, Bangladesh, India, Pakistan, Tanzania, Zimbabwe), including their socio-economic characteristics, clinical parameters (e.g. blood pressure, ECG, bloods, urine), treatment, health care utilisation, and outcomes, and so far followed up for 3 years, as well as profiles of the communities in which they live, including health facilities and availability and price of medicines. We will identify those with or at risk of cardiovascular disease and assess their probabilities of being diagnosed, treated, and controlled, according to their gender, socio-economic status, and urban/rural residence in each country. We will seek plausible explanations for observed differences, drawing on the literature on access to care and adherence and treatment (including two systematic reviews we have recently completed), as well as research on the roles of gender, rurality, and socio-economic inequalities. In particular we will look at characteristics of the health systems, such as co-payments, price and availability of drugs, and wider characteristics of societies, such as gender empowerment. The project has strong links to policy through global and national professional organisations, thereby increasing the potential for the findings to inform global debates and will be translated into action within countries. It explicitly addresses two of the three of the ESRC's strategic priorities (and their components): how to understand behaviour and risks at multiple levels and a variety of contexts (especially on public and preventative health) and a vibrant and fair society (including internationally and by exploiting data from ongoing longitudinal studies).

Potential beneficiaries of the research include populations in the study countries affected or at risk of CVD. These populations may benefit from improved understanding among health professionals, policy makers and researchers on barriers to CVD prevention and treatment activities. However, this is clearly dependent on the project team engaging with policy agencies to inform and convince them of the key messages arising from the project findings and encouraging policy agencies to implement effective policies and services to reduce barriers to CVD date.
For such benefit to occur, the key agencies that will need to be engaged with include: government ministries (particularly Ministry of Health) and departments at the central and local level; the WHO; key multilateral and bilateral agencies such as the European Commission, the World Bank, USAID, CIDA and DFID; and civil society organisations providing health support. Individuals at these agencies will benefit from the research by increasing their knowledge and understanding on the issue of access to CVD prevention and treatment activities; and being able to utilise empirical findings to help develop appropriate evidence-based policies and services.
In order to ensure that these agencies have the opportunity to benefit from the research we will utilise our professional networks such as the World Heart Federation and its national members, and the European Observatory on Health Systems and Policies and its partners, including WHO, the European Commission, and World Bank, in order to raise understanding of the subject, the research, and the key policy messages. This will be achieved through a variety of activities such as presentations at key meetings, workshops, and conferences. We also plan to hold a workshop on the study findings, with participants invited from disciplines of sociology, economics, political science, and public health and epidemiology. We will also utilise traditional and new media opportunities to increase coverage of the key messages arising from the research to engage as wide an audience as possible, including the general public. These activities can utilise the Communications Departments at LSHTM and the others project partners.
Our work will also benefit academics by improving conceptual, methodological and empirical understanding on CVD prevention and treatment activities in LMICs. Publications of academic papers, presentations at conferences, and the project workshop will help ensure that other academics have the opportunity to benefit from the research. We will utilise the networks of universities involved in the PURE project to maximise benefits among academic partners and strengthen information sharing between them (please see the Academic Beneficiaries Section for further details).
These impact-related activities will take place as part of a broader strategy to develop a clear plan of activities, clear messages and activities targeted for specific audiences, and evaluating the pathways to impact through the use of a range of indicators These indicators include: the number of key meetings, workshops, and conferences in which the research findings have been presented or discussed; the successful completion of the LSHTM workshop and any associated outputs and spin offs; the number of academic publications and associated statistics; and types of media coverage.