Social determinants of chronic diseases reporting among slum dwellers in Egypt

The high prevalence of chronic diseases in urban slums poses increasing challenges to future social and economic development for these disadvantaged areas. Assessing the health status of slum residents offers guidance for formulating appropriate policies and interventions to improve slum residents' health outcomes. This research aimed to identify the social determinants of chronic diseases reporting among slum dwellers in Egypt. A cross-sectional survey was conducted from March to December 2021 in three slum areas in Giza governorate, Egypt, including 3,500 individuals. We constructed an asset index and a welfare index to measure the economic status and living conditions of slum residents, respectively. We used these indices, along with demographic and socio-economic factors, as independent variables in the analysis. We modeled factors associated with health status using a two-level mixed logistic model to control the effects of slum areas and the potential correlation between household members. The study contributed significantly to a better understanding of the context in which slum dwellers live and the interlinkages among poor living conditions, low economic status, and health outcomes. The results showed a high rate of self-reported chronic diseases among adults aged 18 and older, reaching more than 22%, while it did not exceed 2.0% among children in the slum areas. Therefore, measuring the determinants of chronic diseases was limited to adults. The sample size was 2530 adults after excluding 970 children. The prevalence of chronic diseases among adults ranged between 16.3% in Zenin and 22.6% in Bein El Sarayat. Our findings indicated that low socio-economic status was significantly associated with reporting chronic diseases. Future policies should be dedicated to improving living conditions and providing necessary healthcare services for these vulnerable areas.

Interaction between depressive symptoms and obesity-related anthropometric measures on multimorbidity among community-dwelling older adults: evidence from India

BACKGROUND

This study aimed to examine the associations between depressive symptoms, body mass index (BMI), waist circumference, waist-hip ratio and multimorbidity among community-dwelling older adults. We also examine the interaction effects between depressive symptoms, BMI, waist circumference and waist-hip ratio on multimorbidity among older adults in India.

METHODS

A cross-sectional study was conducted, and the data were obtained from the Longitudinal Ageing Study in India (LASI) wave-1, with a sample of 31,464 older adults aged 60 years and above (men-15,098 and women-16,366). We used multinomial logistic regression to explore the independent associations between depressive symptoms, obesity-measures, and single and multimorbidity. We also estimated the interaction effects of depressive symptoms and obesity-measures on multimorbidity.

RESULTS

The prevalence of multimorbidity was higher among individuals with depressive symptoms (39.22%) than individuals with no depressive symptoms (29.94%). Adjusted models indicated that older adults with depressive symptoms had higher odds of single and multimorbidity [(AOR = 1.40, 95% CI: 1.17-1.68) and (AOR = 1.85, 95% CI: 1.58-2.16), respectively]. Similarly, in comparison to the normal BMI category, overweight and obese older adults were more likely to report single morbidity [(AOR = 1.62, 95% CI: 1.37-1.92 and (AOR = 2.14, 95% CI: 1.67-2.75), respectively] and multimorbidity [(AOR = 2.00, 95% CI: 1.72-2.33) and (AOR = 3.77, 95% CI: 2.94-4.82), respectively].

CONCLUSION

The findings revealed that the presence of depressive symptoms, overweight or obesity, and high-risk anthropometric measures such as high-risk waist circumference and high-risk waist to hip ratio significantly increased the risk of morbidity among older adults in India. Thus, it is suggested to adopt an integrated public health policy approach to control depressive symptoms and high-risk body composition to strategically prepare against the elevated risk of multimorbidity among ageing populations.

Association of Income Level and Ischemic Heart Disease: Potential Role of Walkability

BACKGROUND

Association of Income Level and Ischemic Heart Disease: Potential Role of Walkability Association of ischemic heart disease (adjusted for traditional risk factors and socioeconomics variables) and income level (A), and walkability z-score (B), and association of walkability z-score and income level (C).

BACKGROUND

Socioeconomic status has been linked to ischemic heart disease (IHD). High-income neighborhoods may expose individuals to a walking-promoting built environment for daily activities (walkability). Data from the association between income and IHD is lacking in middle-income countries. It is also uncertain whether walkability mediates this association.

OBJECTIVES

To investigate whether income is associated with IHD in a middle-income country and whether neighborhood walkability mediates the income-IHD association.

METHODS

This cross-sectional study evaluated 44,589 patients referred for myocardial perfusion imaging (SPECT-MPI). Income and walkability were derived from participants' residential census tract. Walkability quantitative score combined 4 variables: street connectivity, residential density, commercial density, and mixed land use. IHD was defined by abnormal myocardial perfusion during a SPECT-MPI study. We used adjusted mixed effects models to evaluate the association between income level and IHD, and we performed a mediation analysis to measure the percentage of the income-IHD association mediated by walkability. We considered p values below 0.01 as statistically significant.

RESULTS

From 26,415 participants, those living in the lowest-income tertile census tract were more physically inactive (79.1% versus 75.8% versus 72.7%) when compared to higher-income tertile census tracts (p < 0.001). Income was associated with IHD (odds ratio: 0.91 [95% confidence interval: 0.87 to 0.96] for each 1,000.00 international dollars increase in income) for both men and women equally (p for interaction = 0.47). Census tracts with a higher income were associated with better walkability (p < 0.001); however, walkability did not mediate the income-IHD association (percent mediated = -0.3%).

CONCLUSIONS

Income was independently associated with higher prevalence of IHD in a middle-income country irrespective of gender. Although walkability was associated with census tract income, it did not mediate the income-IHD association.

Cardiovascular Disease in China: Socioeconomic Status Variation in Prevalence

Introduction

Cardiovascular disease is the single largest contributor to global mortality and the leading cause of both death and premature death in China. Data on the association between cardiovascular disease and socioeconomic status are sparse, especially for Asian countries. Our study collected data to describe the socioeconomic status variation across cardiovascular disease using a large nationwide cross-sectional study.

Methods

We chose participants using the cluster sampling method, prepared a face-to-face questionnaire interview for the selected community residents, and collected information on health conditions, socioeconomic status, demographics, and comorbidities. All collected data were reported as frequencies and corresponding percentages. Linear regression and simple and multivariable logistic regression were performed to identify the prevalence variation. All statistical analyses were performed using SPSS version 26 software.

Results

Socioeconomic information was available for 394,688 participants (covering most provincial districts). The prevalence of cardiovascular disease was 7.9%. The prevalence was higher in rural areas than that in urban areas (rural, 8.4%; urban, 7.5%). There was a negative relationship between urbanization and cardiovascular disease prevalence. Furthermore, cardiovascular disease prevalence had a negative relationship with average earnings.

Conclusion

This cross-sectional analysis of socioeconomic status variation in the prevalence of cardiovascular disease in China showed a significant negative relationship between regional and individual socioeconomic status and cardiovascular disease. The results imply that governments would benefit communities by focusing on effective and targeted interventions for prevention, screening, and treatment in individuals who may be in the socioeconomic status with a high risk for cardiovascular disease.

Socio-economic distribution of modifiable risk factors for cardiovascular diseases: An analysis of the national longitudinal ageing study in India

The association of socioeconomic status (SES) with modifiable risk factors for cardiovascular diseases (CVDs) is unclear in developing nations. We studied SES variations in major risk factors and their percentage distribution for adults aged 45 years or above in India. Using individual records of 59,672 individuals aged 45 years or above from the Longitudinal Ageing Study in India Wave 1 (cross-sectional study design), 2017-18, we chart age-and-sex-adjusted prevalence of clinical risk factors such as measured high blood pressure, hypertension, overweight, obesity, central adiposity and self-reported high blood glucose; and lifestyle risk factors such as excessive use of alcohol, current use of smoking and smokeless tobacco and physical inactivity across SES variables of education, quintiles of mean per capita expenditure and social caste. Multivariable analysis was used to explore the SES gradient of risk factors. The sample used in the study is predominantly rural (69.9%), illiterate (50.7%), has more females (54.2%), and belongs to other backward classes (45.6%). Prevalence of high blood pressure, overweight, obesity, central adiposity, high blood glucose, and physical inactivity increased; and excessive alcohol consumption and current use of smoking/smokeless tobacco decreased with income, education, and social caste. However, no significant income gradient was noted for lifestyle risk factors except the use of smokeless tobacco. The income gradient was largest for central adiposity (waist-circumference) with a difference of 23.4 percentage points as it increased from 38.7% among the poorest to 62.1% among the richest. The major burden of CVDs risk factors among older adults aged 45+ years falls among high SES.

Prevalence of Obesity and Its Relationship With Hypertension Among School-Going Adolescents Aged 12-16 Years

BACKGROUND

Childhood obesity is a significant health issue that has grown in prominence, particularly in developed countries. Primary hypertension has become the dominant cause, leading to an increased incidence of arterial hypertension. This study examined the associations between sex and obesity with hypertension (HTN). Understanding these associations can provide insights into the risk factors and potential preventive strategies for HTN.

MATERIALS AND METHODS

This cross-sectional observational study was conducted at private schools in Chennai, Tamil Nadu, India, for one year. Data analysis was performed on a cohort of participants who underwent health assessments, including blood pressure measurements, self-reported dietary habits, and socio-economic status information. Statistical analyses assessed the associations between sex, dietary habits, socio-economic status, and HTN.

RESULTS

There were 255 (51.0%) males and 245 (49%) females. Among the female participants, only two individuals (0.8%) had HTN, while among males, 11 individuals (4.3%) had HTN, indicating a significant association between sex and HTN (P=0.014). In terms of dietary habits, the prevalence of HTN was similar among non-vegetarians (2.5%) and vegetarians (3.1%), and the association was not statistically significant (P=0.777). Among the obese individuals in the study population, eight individuals (8.8%) had HTN, while the remaining 83 individuals (91.2%) did not have HTN, with a P-value of <0.0001, which indicates a significant association between HTN and obesity.

CONCLUSION

This study revealed a significant association between sex and HTN, with males exhibiting a higher prevalence of HTN than females. Furthermore, the study showed a significant association between obesity and hypertension, indicating that obese individuals were more likely to have HTN.

Risk factor contributions to socioeconomic inequality in cardiovascular risk in the Philippines: a cross-sectional study of nationally representative survey data

BACKGROUND

Primary prevention of cardiovascular diseases (CVD) increasingly relies on monitoring global CVD risk scores. Lack of evidence on socioeconomic inequality in these scores and the contributions that specific risk factors make to this inequality impedes effective targeting of CVD prevention. We aimed to address this evidence gap by measuring and decomposing socioeconomic inequality in CVD risk in the Philippines.

METHODS

We used data on 8462 individuals aged 40-74 years from the Philippines National Nutrition Survey and the laboratory-based Globorisk equation to predict 10-year risk of a CVD event from sex, age, systolic blood pressure, total cholesterol, high blood glucose, and smoking. We used a household wealth index to proxy socioeconomic status and measured socioeconomic inequality with a concentration index that we decomposed into contributions of the risk factors used to predict CVD risk. We measured socioeconomic inequalities in these risk factors and decomposed them into contributions of more distal risk factors: body mass index, fat share of energy intake, low physical activity, and drinking alcohol. We stratified by sex.

RESULTS

Wealthier individuals, particularly males, had greater exposure to all risk factors, with the exception of smoking, and had higher CVD risks. Total cholesterol and high blood glucose accounted for 58% and 34%, respectively, of the socioeconomic inequality in CVD risk among males. For females, the respective estimates were 63% and 69%. Systolic blood pressure accounted for 26% of the higher CVD risk of wealthier males but did not contribute to inequality among females. If smoking prevalence had not been higher among poorer individuals, then the inequality in CVD risk would have been 35% higher for males and 75% higher for females. Among distal risk factors, body mass index and fat intake contributed most to inequalities in total cholesterol, high blood sugar, and, for males, systolic blood pressure.

CONCLUSIONS

Wealthier Filipinos have higher predicted CVD risks and greater exposure to all risk factors, except smoking. There is need for a nuanced approach to CVD prevention that targets anti-smoking programmes on the poorer population while targeting diet and exercise interventions on the wealthier.

Re-examining the reversal hypothesis: A nationwide population-based study of the association between socioeconomic status, and NCDs and risk factors in China

Background

According to the reversal hypothesis, as a country's economic and social development progresses, the burden of NCDs and risk factors shifts from rich to poor. The aim of this research is to examine the reversal hypothesis in the Chinese setting.

Methods

Using data from the China Health and Retirement Longitudinal Study (CHARLS) in 2015, we explored whether the reversal hypothesis applies at the subnational level. Participants aged 45 years and older in 2015 were included. We examined five risk factors (smoking, heavy drinking, physical inactivity, overweight, and obesity) and three objectively measured NCDs (diabetes, hypertension, dyslipidemia). Binary logistic regressions were performed to examine outcomes across people of differing SES in provincial level, in urban and rural areas, and across generations.

Results

Nationally, SES is positively associated with heavy drinking, obesity, diabetes and dyslipidemia, whereas it is negatively associated with physical inactivity. The association between SES and smoking and hypertension was not statistically significant. Except in the cases of diabetes and dyslipidemia, we found that risk factors of all kinds were more concentrated among richer people in rural than in urban areas. Across provinces with increasing GDP per capita, a downward trend in risk factors among those with high SES compared to those with low SES could be interpreted, while the opposite trend could be interpreted with respect to the metabolic syndrome conditions. Obesity and overweight exhibited slight downward trends (in line with those for risk factors) and upward trends (in line with those for metabolic syndrome conditions), respectively.

Conclusion

We conclude that China is at a relatively early stage of 'reversal', visible with respect to risk factors. If these patterns persist over time, the trend will likely feed through to metabolic disorders which will increasingly become diseases of the poor.

Exploring barriers of quitting smokeless tobacco among coronary artery disease patients of India: A qualitative study

BACKGROUND

Cessation of all forms of tobacco is necessary for controlling mortality associated with coronary artery diseases (CADs). In India, smokeless tobacco (SLT) is the most used form of tobacco. With around 60% of the world's smokeless tobacco users living in India, the task of tobacco cessation has become daunting and complicated for Indian researchers and policy makers.

OBJECTIVE

We conducted the present study to understand CAD patients' perspectives towards their SLT use and to identify barriers of SLT cessation.

METHODS

Using a semi-structured interview method, we obtained data from 12 CAD patients who were currently using some form of SLT.

RESULTS

Thematic analysis suggests that CAD patients were unable to quit SLT addiction due to (a) certain socio-environmental factors that support SLT, (b) prevalence of misconceptions about the link between SLT use and their cardiac condition, (c) perceived lower self-efficacy to quit, (d) fatalistic attitude towards health outcomes and (e) substituting addiction with perceived lesser harmful products.

DISCUSSION

The findings reveal that factors responsible for the continuation of SLT usage are multipronged. Current SLT users' perspectives can facilitate the development of effective intervention and rehabilitation programs aimed at de-addiction of cardiac patients.

Frequent sauna bathing offsets the increased risk of death due to low socioeconomic status: A prospective cohort study of middle-aged and older men

BACKGROUND AND AIM

Low socioeconomic status (SES) and frequent sauna bathing are associated with increased and decreased risk of all-cause mortality, respectively. Whether there is an interplay among SES, sauna bathing and all-cause mortality risk is not known. We aimed to evaluate the separate and joint associations of SES and frequency of sauna bathing (FSB) with all-cause mortality risk in a prospective cohort study.

METHODS

We employed the Kuopio Ischaemic Heart Disease Study cohort comprising of 2575 men aged 42-61 years at study entry. Self-reported SES and sauna bathing habits were assessed at baseline. Socioeconomic status was categorized as low and high (median cutoff) and FSB as low and high (defined as ≤2 and 3-7 sessions/week, respectively).

RESULTS

During a median follow-up of 27.8 years, 1618 deaths occurred. Comparing low vs high SES, the multivariable-adjusted HR (95 % CI) for all-cause mortality was 1.31 (1.18-1.45). Comparing high vs low FSB, the multivariable-adjusted HR (95 % CI) for all-cause mortality was 0.86 (0.76-0.97). Compared with high SES-low FSB, low SES-low FSB was associated with an increased risk of all-cause mortality 1.35 (1.20-1.51), without significant evidence of an association for low SES-high FSB and all-cause mortality risk 1.07 (0.89-1.29). Positive additive and multiplicative interactions were found between SES and FSB.

CONCLUSIONS

There exists an interplay among SES, sauna bathing and all-cause mortality risk in a general Finnish male population. Frequent sauna baths may offset the increased overall mortality risk due to low SES.

Socioeconomic inequalities in prevalence, awareness, treatment and control of hypertension: evidence from the PERSIAN cohort study

BACKGROUND

Elevated blood pressure is associated with cardiovascular disease, stroke and chronic kidney disease. In this study, we examined the socioeconomic inequality and its related factors in prevalence, Awareness, Treatment and Control (ATC) of hypertension (HTN) in Iran.

METHOD

The study used data from the recruitment phase of The Prospective Epidemiological Research Studies in IrAN (PERSIAN). A sample of 162,842 adults aged >  = 35 years was analyzed. HTN was defined according to the Joint National Committee)JNC-7(. socioeconomic inequality was measured using concentration index (Cn) and curve.

RESULTS

The mean age of participants was 49.38(SD =  ± 9.14) years and 44.74% of the them were men. The prevalence of HTN in the total population was 22.3%(95% CI: 20.6%; 24.1%), and 18.8%(95% CI: 16.8%; 20.9%) and 25.2%(95% CI: 24.2%; 27.7%) in men and women, respectively. The percentage of awareness treatment and control among individuals with HTN were 77.5%(95% CI: 73.3%; 81.8%), 82.2%(95% CI: 70.2%; 81.6%) and 75.9%(95% CI: 70.2%; 81.6%), respectively. The Cn for prevalence of HTN was -0.084. Two factors, age (58.46%) and wealth (32.40%), contributed most to the socioeconomic inequality in the prevalence of HTN.

CONCLUSION

The prevalence of HTN was higher among low-SES individuals, who also showed higher levels of awareness. However, treatment and control of HTN were more concentrated among those who had higher levels of SES, indicating that people at a higher risk of adverse event related to HTN (the low SES individuals) are not benefiting from the advantage of treatment and control of HTN. Such a gap between diagnosis (prevalence) and control (treatment and control) of HTN needs to be addressed by public health policymakers.

India's Opportunities and Challenges in Establishing a Twin Registry: An Unexplored Human Resource for the World's Second-Most Populous Nation

Nature and nurture have always been a prerogative of evolutionary biologists. The environment's role in shaping an organism's phenotype has always intrigued us. Since the inception of humankind, twinning has existed with an unsettled parley on the contribution of nature (i.e. genetics) versus nurture (i.e. environment), which can influence the phenotypes. The study of twins measures the genetic contribution and that of the environmental influence for a particular trait, acting as a catalyst, fine-tuning the phenotypic trajectories. This is further evident because a number of human diseases show a spectrum of clinical manifestations with the same underlying molecular aberration. As of now, there is no definite way to conclude just from the genomic data the severity of a disease or even to predict who will get affected. This greatly justifies initiating a twin registry for a country as diverse and populated as India. There is an unmet need to set up a nationwide database to carefully curate the information on twins, serving as a valuable biorepository to study their overall susceptibility to disease. Establishing a twin registry is of paramount importance to harness the wealth of human information related to the biomedical, anthropological, cultural, social and economic significance.

Morbidity status and changes in difficulty in activities of daily living among older adults in India: A panel data analysis

Introduction

The study explored the socioeconomic and demographic factors that determine the onset of difficulty, recovery from difficulty and difficulty remaining in functional activity in later years of life. Additionally, the study examined the effects of several combinations of chronic diseases on the changes in later-life functional difficulty.

Methods

We used data from two rounds of India Human Development Survey (IHDS) conducted during 2004–2005 and 2011–2012. A sample of 13,849 respondents aged 55 years and above with a seven year follow-up was considered for this study. The Katz Index of Independence in activities of daily living (ADL) was used to measure the functional disability as an outcome variable. Multinomial logistic regression has been conducted to fulfil the study objectives.

Results

The overall functional difficulty among older adults was 27.3% and onset of functional difficulty (23.5%) was higher than the recovery from difficulty (2.1%) and remaining with difficulty (1.7%). Onset of functional difficulty in second round was higher among women (27.3%) than men (19.3%). Bivariate and multivariate analyses showed that single and multi-morbidity had a positive significant association with all categories of functional difficulty. Female sex, increasing age and rural place of residence had positive association with onset of difficulty and difficulty remaining in second round. The combinations of morbidities were also found to have positive significant association with functional difficulty i.e., the relative risk (RR) of onset of difficulty in second round is higher among those who had diabetes with high blood pressure (RR-1.7; CI: 1.4–2.0), cataracts with high blood pressure (RR-2.0; CI: 1.5–2.6) and cataracts with asthma (RR-3.1; CI: 2.1–4.6) compared to those with no diabetes and cataract but with high blood pressure or asthma, respectively.

Conclusion

The findings suggest that the risk of onset of functional difficulty is higher among older individuals with single and multiple morbidities compared to their healthy counterparts. It is also found that functional difficulty increased with age and was more prevalent in older women and rural residents, suggesting the need for appropriate policy interventions with special focus on the vulnerable senior adults.

The influence of childhood socioeconomic status on non-communicable disease risk factor clustering and multimorbidity among adults in Botswana: a life course perspective

Childhood socioeconomic circumstances have a great influence on the health of individuals in adult life. We used cross-sectional data from a non-communicable disease (NCD) survey conducted in 2016, and respondents aged ≥15 y were selected from 3 cities/towns, 15 urban villages and 15 rural areas using a multistage probability-sampling technique. The total sample for the study was 1178. Two multinomial logistic regression models were fitted to data to ascertain the association between childhood socioeconomic status (SES) and NCD risk factor clustering and multimorbidity, using SPSS version 27. All comparisons were considered to be statistically significant at a 5% level. The prevalence of multiple NCD risk factors and multimorbidity was 30.1 and 5.3%, respectively. The odds of reporting NCD risk factor clustering were significantly high among individuals who reported low (adjusted OR [AOR]=1.88, 95% CI 1.21 to 2.78) and middle (AOR=1.22, 95% CI 1.02 to 2.05) childhood SES compared with high childhood SES. Conversely, individuals from a low SES background were more likely to report both single (AOR=1.17, 95% CI 1.00 to 2.01) and multiple NCD conditions (AOR=1.78, 95% CI 1.11 to 2.68) compared with those with a high childhood SES background. There is a need to stimulate policy debate and research to take cognisance of childhood socioeconomic circumstances in health policy planning.

Association of socioeconomic status with hypertension prevalence and control in Nanjing: a cross-sectional study

BACKGROUND

The role of socioeconomic status (SES) on hypertension prevalence and hypertension control has gotten much attention but with conflicting results. This paper aimed to quantify the association of SES with both hypertension prevalence and hypertension control rate in Nanjing, China.

METHODS

A community-based cross-sectional study was conducted using multistage random sampling on 60,283 adults aged more than 18 years between March 2017 and June 2018. Hypertension was defined as systolic blood pressure (BP) ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg or self-reported diagnosis of hypertension or respondent's report of taking antihypertensive medications. The controlled hypertension was defined by systolic BP < 140 mmHg and diastolic BP of < 90 mmHg among the subjects that self-reported exhibiting hypertensive and taking antihypertensive medications. The associations between SES with hypertension prevalence and hypertension control were quantified using generalized mixed model regression analysis and reported as odds ratios (ORs) and 95% confidence interval (CI).

RESULTS

There was a high prevalence of subjects with primary educational level (49.6%) or unemployed and retired (49.5%) or lower annual household income level (44.9%) in each SES group, respectively. After adjustments for potential confounding factors, there were higher odds of hypertension among those with primary educational level (OR = 1.56), but lower odds for controlled BP (OR = 0.51). Higher odds of hypertension could be found among unemployed and retired, and higher odds of controlled BP was observed in the mental laborers or students (OR = 1.30), compared with the other categories, respectively. The lower-income group was more likely to be hypertensive (OR = 1.35) and less likely to have controlled hypertension (OR = 0.73).

CONCLUSION

Socioeconomic status played an important role in hypertension prevalence and hypertension control among adults in Nanjing, China. Strategies for hypertension prevention and control should especially focus on people in the vulnerable lower SES groups.

Socioeconomic Determinants of Diet Quality on Overweight and Obesity in Adults Aged 40-59 Years in Inner Mongolia: A Cross-Sectional Study

Objectives: This study investigated the relationship of socioeconomic status (SES), diet quality and overweight and obesity in adults aged 40-59 years in Inner Mongolia. Methods: This cross-sectional study was based on the survey of Chronic Disease and Nutrition Monitoring in Adults in Inner Mongolia in 2015. Diet quality was evaluated by the Alternate Mediterranean Diet score (aMeds). SES was measured by household annual income. Generalized estimating equations and path analysis were performed to determine the association of SES, diet quality and overweight and obesity. Results: Among participants, 63.0% had overweight and obesity. In high SES group, 66.4% had overweight and obesity. Higher SES was associated with a higher risk of overweight and obesity (OR = 1.352, 95%CI: 1.020-1.793). And higher aMeds was associated with a lower risk of overweight and obesity (OR = 0.597, 95%CI: 0.419-0.851). There was a positive correlation between SES and the intake of red and processed meat (r = 0.132, p < 0.05). Higher intake of red and processed meat was associated with lower diet quality (β = -0.34). And lower diet quality was associated with a higher risk of overweight and obesity (β = -0.10). Conclusion: In Inner Mongolia, during the period of economic transition, people aged 40-59 years in high SES had poor diet quality, which was related to a higher risk of overweight and obesity.

Exploring Barriers to Medication Adherence Using COM-B Model of Behaviour Among Patients with Cardiovascular Diseases in Low- and Middle-Income Countries: A Qualitative Study

INTRODUCTION

In 2016, cardiovascular diseases (CVDs) led to 17.9 million deaths worldwide, representing 31% of all global deaths. CVDs are the leading cause of mortality worldwide and significant barriers to achieving the sustainable development goals. Modern medicines have been significant in improving health outcomes. However, non-adherence to medication is one of the reasons behind adverse health-related outcomes among patients suffering from atherosclerotic cardiovascular disease in low- and middle-income countries.

PATIENTS AND METHODS

This qualitative study was conducted at two tertiary care hospitals in India and Ghana. A total of 35 in-depth interviews were conducted with atherosclerosis cardiovascular disease (ASCVD) patients. The data were analysed thematically using the Capability Opportunity and Motivation (COM-B) framework.

FINDINGS

The findings were summarised under three important broad themes of the COM-B framework: capability, opportunity and behaviour. Under capability, comprehension of disease, medication schedule, and unplanned travel affected adherence among patients. Cost of medication, insurance and access were the critical factors under opportunity, which negatively influenced medication adherence. Mood, beliefs about treatment and outcome expectations under motivation led to non-adherence among patients. Apart from these factors, some important health system factors such as health care experience and trust in the facilities and reliance on alternative medication also affected adherence in both countries.

CONCLUSION

This study has highlighted that the health system factors have dominantly influenced adherence to medication in India and Ghana. In India, we found participants to be satisfied with their health care provided at the government hospitals. However, limited time for consultation, lack of well-stocked pharmacy and unclear prescription negatively influenced adherence among participants in India and Ghana. The study emphasises that the health system needs to be strengthened, and the patients' belief system needs to be explored to address the issue of medication adherence in LMICs.

Distribution of under-5 deaths in the neonatal, postneonatal, and childhood periods: a multicountry analysis in 64 low- and middle-income countries

Background

As under-5 mortality rates declined all over the world, the relative distribution of under-5 deaths during different periods of life changed. To provide information for policymakers to plan for multi-layer health strategies targeting child health, it is essential to quantify the distribution of under-5 deaths by age groups.

Methods

Using 245 Demographic and Health Surveys from 64 low- and middle-income countries conducted between 1986 and 2018, we compiled a database of 2,437,718 children under-5 years old with 173,493 deaths. We examined the share of deaths that occurred in the neonatal (< 1 month), postneonatal (1 month to 1 year old), and childhood (1 to 5 years old) periods to the total number of under-5 deaths at both aggregate- and country-level. We estimated the annual change in share of deaths to track the changes over time. We also assessed the association between share of deaths and Gross Domestic Product (GDP) per capita.

Results

Neonatal deaths accounted for 53.1% (95% confidence interval [CI]: 52.7, 53.4) of the total under-5 deaths. The neonatal share of deaths was lower in low-income countries at 44.0% (43.5, 44.5), and higher in lower-middle-income and upper-middle income countries at 57.2% (56.8, 57.6) and 54.7% (53.8, 55.5) respectively. There was substantial heterogeneity in share of deaths across countries; for example, the share of neonatal to total under-5 deaths ranged from 20.9% (14.1, 27.6) in Eswatini to 82.8% (73.0, 92.6) in Dominican Republic. The shares of deaths in all three periods were significantly associated with GDP per capita, but in different directions—as GDP per capita increased by 10%, the neonatal share of deaths would significantly increase by 0.78 percentage points [PPs] (0.43, 1.13), and the postneonatal and childhood shares of deaths would significantly decrease by 0.29 PPs (0.04, 0.54) and 0.49 PPs (0.24, 0.74) respectively.

Conclusions

Along with the countries’ economic development, an increasing proportion of under-5 deaths occurs in the neonatal period, suggesting a need for multi-layer health strategies with potentially heavier investment in newborn health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01449-8.

Socioeconomic position and cardiovascular mortality in 63 million adults from Brazil

BACKGROUND

It has been suggested that cardiovascular disease exhibits a 'social cross-over', from greater risk in higher socioeconomic groups to lower socioeconomic groups, on economic development, but robust evidence is lacking. We used standardised data to compare the social inequalities in cardiovascular mortality across states at varying levels of economic development in Brazil.

METHODS

We used national census and mortality data from 2010. We used age-adjusted multilevel Poisson regression to estimate the association between educational status and cardiovascular mortality by state-level economic development (assessed by quintiles of Human Development Index).

RESULTS

In 2010, there were 185 383 cardiovascular deaths among 62.5 million adults whose data were analysed. The age-adjusted cardiovascular mortality rate ratio for women with <8 years of education (compared with 8+ years) was 3.75 (95% CI 3.29 to 4.28) in the least developed one-fifth of states and 2.84 (95% CI 2.75 to 2.92) in the most developed one-fifth of states (p value for linear trend=0.002). Among men, corresponding rate ratios were 2.53 (95% CI 2.32 to 2.77) and 2.26 (95% CI 2.20 to 2.31), respectively (p value=0.258). Associations were similar across subtypes of cardiovascular disease (ischaemic heart disease and stroke) and robust to the size of geographical unit used for analysis.

CONCLUSIONS

Our results do not support a 'social crossover' in cardiovascular mortality on economic development. Our analyses, based on a large standardised dataset from a country that is currently experiencing economic transition, provide strong evidence that low socioeconomic groups experience the highest risk of cardiovascular disease, irrespective of the stage of national economic development.

Clinical Characteristics, Management Strategies, and In-Hospital Outcomes of Acute Coronary Syndrome in a Low Socioeconomic Status Cohort: An Observational Study From Urban India

Background:

Coronary artery disease is the leading cause of mortality in India. There is scarcity of data on demographic profile and outcomes of acute coronary syndrome (ACS) in low socioeconomic status (SES) population of India.

Objectives:

This study was undertaken to determine the clinical presentation, management strategies, and in-hospital outcomes of ACS in low SES population.

Methods:

We conducted 1-year prospective observational cohort study of ACS patients admitted at Employees State Insurance Corporation unit of our tertiary care cardiac center. Clinical parameters, management strategies, and in-hospital outcomes of 621 patients enrolled during the study period from February 2015 to January 2016 were studied.

Results:

Mean age of patients was 56.06 ± 11.29 years. Majority (62%) of the patients had ST elevation myocardial infarction (STEMI), whereas Non-ST elevation acute coronary syndrome (NSTE-ACS) was seen in 38% of the patients. Median time from symptom onset to hospital admission was 285 min with wide range from 105 to 1765 min. Coronary angiography was performed in 81% of patient population. Single-vessel disease (SVD) was the most common pattern (seen in 43.3%) of coronary artery involvement with left anterior descending coronary artery (LAD) being the most frequently involved vessel (62.8%). Pharmaco-invasive approach was the preferred strategy. Overall percutaneous coronary intervention (PCI) rates were 59.1% (62.1% in STEMI and 54.2% in NSTE-ACS). Overall in-hospital mortality was 3.2%, being significantly higher in STEMI (4.2%) as compared with NSTE-ACS (1.7%).

Conclusions:

With implementation of evidence-based pharmacotherapy and interventions, outcomes comparable with developed countries can be achieved even in low SES populations of developing world.

Socioeconomic determinants of chronic health diseases among older Indian adults: a nationally representative cross-sectional multilevel study

OBJECTIVE

Study uses multilevel modelling to examine the effect of individual, household and contextual characteristics on chronic diseases among older Indian adults.

DESIGN

Nationally representative cross-sectional study.

PARTICIPANTS

Data from the nationally representative, India Human Development Survey conducted in 2011-2012 was used in this study. The survey asked information related to the diagnosed chronic illnesses such as cataract, tuberculosis, hypertension, heart disease and others. The sample size of this study comprised 39 493 individuals who belonged to the age group 50 years and above.

MEASURES

Self-reported diagnosed chronic illness.

METHOD

Considering the hierarchal structure of the data multilevel logistic regression analysis was applied to attain the study objective.

RESULTS

Older adults aged 80 years and older were found with three times more chances (OR: 3.99, 95% CI 2.91 to 5.48) of suffering from a chronic ailment than 50-54 years old. Lifestyle risk factors such as alcohol and tobacco (smoked and smokeless) consumption were noted to be significantly associated with the presence of chronic illness whereas older adults who have never consumed smokeless tobacco stood 20% fewer chances (OR: 0.80, 95% CI 0.68 to 0.94) of having any chronic illness. Contextual level variables such as older adults residing in the rural areas were found with 17% fewer chances (OR: 0.83, 95% CI 0.70 to 0.97) of suffering from a chronic illness.

CONCLUSION

Even after controlling for various characteristics at the individual, household and contextual levels, significant variations in chronic illness remain unexplained at the community and state level, respectively. The findings of this study could effectively be utilised to consider more contextual variables to examine the chronic health status among the growing older population of India.

The interaction between district-level development and individual-level socioeconomic gradients of cardiovascular disease risk factors in India: A cross-sectional study of 2.4 million adults

BACKGROUND

Diabetes, hypertension, and obesity tend to be positively associated with socio-economic status in low- and middle-income countries (LMICs). It has been hypothesized that these positive socio-economic gradients will reverse as LMICs continue to undergo economic development. We use population-based cross-sectional data in India to examine how a district's economic development is associated with socio-economic differences in cardiovascular disease (CVD) risk factor prevalence between individuals.

METHODS

We separately analyzed two nationally representative household survey datasets - the NFHS-4 and the DLHS-4/AHS - that are representative at the district level in India. Diabetes was defined based on a capillary blood glucose measurement, hypertension on blood pressure measurements, obesity on measurements of height and weight, and current smoking on self-report. Five different measures of a district's economic development were used. We analyzed the data using district-level regressions (plotting the coefficient comparing high to low socio-economic status against district-level economic development) and multilevel modeling.

RESULTS

757,655 and 1,618,844 adults participated in the NFHS-4 and DLHS-4/AHS, respectively. Higher education and household wealth were associated with a higher probability of having diabetes, hypertension, and obesity, and a lower probability of being a current smoker. For diabetes, hypertension, and obesity, we found that a higher economic development of a district was associated with a less positive (or even negative) association between the CVD risk factor and education. For smoking, the association with education tended to become less negative as districts had a higher level of economic development. In general, these associations did not show clear trends when household wealth quintile was used as the measure of socio-economic status instead of education.

CONCLUSIONS

While this study provides some evidence for the "reversal hypothesis", large-scale longitudinal studies are needed to determine whether LMICs should expect a likely reversal of current positive socioeconomic gradients in diabetes, hypertension, and obesity as their countries continue to develop economically.

Changes in socio-economic patterns of energy consumption and insufficient energy intake across India from 1993-94 to 2011-12

OBJECTIVE

To assess whether disparities in energy consumption and insufficient energy intake in India have changed over time across socio-economic status (SES).

DESIGN

This cross-sectional, population-based survey study examines the relationship between several SES indicators (i.e. wealth, education, caste, occupation) and energy consumption in India at two time points almost 20 years apart. Household food intake in the last 30 d was assessed in 1993-94 and in 2011-12. Average dietary energy intake per person in the household (e.g. kilocalories) and whether the household consumed less than 80 % of the recommended energy intake (i.e. insufficient energy intake) were calculated. Linear and relative risk regression models were used to estimate the relationship between SES and average energy consumed per day per person and the relative risk of consuming an insufficient amount of energy.

SETTING

Rural and urban areas across India.

PARTICIPANTS

A nationally representative sample of households.

RESULTS

Among rural households, there was a positive association between SES and energy intake across all four SES indicators during both survey years. Similar results were seen for energy insufficiency vis-à-vis recommended energy intake levels. Among urban households, wealth was associated with energy intake and insufficiency at both time points, but there was no educational patterning of energy insufficiency in 2011-12.

CONCLUSIONS

Results suggest little overall change in the SES patterning of energy consumption and percentage of households with insufficient energy intake from 1993-94 to 2011-12 in India. Policies in India need to improve energy intake among low-SES households, particularly in rural areas.

The role of socio-economic inequality in the prevalence of hypertension in adults

Introduction: The large portion of burden of diseases, especially in the developing countries is attributed to hypertension. Identification of the potential risk factors of hypertension is essential for disease management. In this study we investigated the role of socio-economic inequality in the prevalence of hypertension in Ilam Province. Methods: Totally, 690 individuals aged over 15 were enrolled in this cross-sectional study, through systematic random sampling from March 1 to October 30, 2017. Socio-economic status (SES) score was calculated by 7 variables including; age, sex, job, marital status, educational level, and economic status, residency, then, it was divided to five levels. Concentration index was used to estimate the inequality in hypertension. To estimate the percentage contribution in final step elasticity divided to concentration index for each contributor and contributions to inequality is estimated. Results: The concentration index for hypertension was -0.154 95% CI (-0.02, -0.23), therefore hypertension was more prevalent in lower socioeconomic groups. The important socioeconomic contributors in inequality were job (P=0.008), educational level (P=0.005), and SES (P=0.003). According to concentration index decomposition, the main sources of inequality in hypertension were job (15%), educational level (18%), and SES (21%), respectively. Conclusion: Hypertension is more prevalent in lower SES groups and the job, education, and SES are important contributory factors of inequality. One substantial key point to achieve an effectiveness approach to deal with chronic diseases might be building partnership with disadvantaged populations.

Do trends in the prevalence of overweight by socio-economic position differ between India's most and least economically developed states?

Background

India’s economic development and urbanisation in recent decades has varied considerably between states. Attempts to assess how overweight (including obesity) varies by socioeconomic position at the national level may mask considerable sub-national heterogeneity. We examined the socioeconomic patterning of overweight among adults in India’s most and least economically developed states between 1998 and 2016.

Methods

We used state representative data from the National Family Health Surveys from 1998 to 99, 2005–06 and 2015–16. We estimated the prevalence of overweight by socioeconomic position in men (15–54 years) and women (15–49 years) from India’s most and least economically developed states using multilevel logistic regressions.

Results

We observed an increasing trend of overweight prevalence among low socioeconomic position women. Amongst high socioeconomic position women, overweight prevalence either increased to a smaller extent, remained the same or even declined between 1998 and 2016. This was particularly the case in urban areas of the most developed states, where in the main analysis, the prevalence of overweight increased from 19 to 33% among women from the lowest socioeconomic group between 1998 and 2016 compared to no change among women from the highest socioeconomic group. Between 2005 and 2016, the prevalence of overweight increased to similar extents among high and low socioeconomic status men, irrespective of residence.

Conclusions

The converging prevalence of overweight by socioeconomic position in India’s most developed states, particularly amongst urban women, implies that this subpopulation may be the first to exhibit a negative association between socioeconomic position and overweight in India. Programs aiming to reduce the increasing overweight trends may wish to focus on poorer women in India’s most developed states, amongst whom the increasing trend in prevalence has been considerable.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7155-9) contains supplementary material, which is available to authorized users.

Socioeconomic status and risk of cardiovascular disease in 20 low-income, middle-income, and high-income countries: the Prospective Urban Rural Epidemiologic (PURE) study

BACKGROUND

Socioeconomic status is associated with differences in risk factors for cardiovascular disease incidence and outcomes, including mortality. However, it is unclear whether the associations between cardiovascular disease and common measures of socioeconomic status-wealth and education-differ among high-income, middle-income, and low-income countries, and, if so, why these differences exist. We explored the association between education and household wealth and cardiovascular disease and mortality to assess which marker is the stronger predictor of outcomes, and examined whether any differences in cardiovascular disease by socioeconomic status parallel differences in risk factor levels or differences in management.

METHODS

In this large-scale prospective cohort study, we recruited adults aged between 35 years and 70 years from 367 urban and 302 rural communities in 20 countries. We collected data on families and households in two questionnaires, and data on cardiovascular risk factors in a third questionnaire, which was supplemented with physical examination. We assessed socioeconomic status using education and a household wealth index. Education was categorised as no or primary school education only, secondary school education, or higher education, defined as completion of trade school, college, or university. Household wealth, calculated at the household level and with household data, was defined by an index on the basis of ownership of assets and housing characteristics. Primary outcomes were major cardiovascular disease (a composite of cardiovascular deaths, strokes, myocardial infarction, and heart failure), cardiovascular mortality, and all-cause mortality. Information on specific events was obtained from participants or their family.

FINDINGS

Recruitment to the study began on Jan 12, 2001, with most participants enrolled between Jan 6, 2005, and Dec 4, 2014. 160 299 (87·9%) of 182 375 participants with baseline data had available follow-up event data and were eligible for inclusion. After exclusion of 6130 (3·8%) participants without complete baseline or follow-up data, 154 169 individuals remained for analysis, from five low-income, 11 middle-income, and four high-income countries. Participants were followed-up for a mean of 7·5 years. Major cardiovascular events were more common among those with low levels of education in all types of country studied, but much more so in low-income countries. After adjustment for wealth and other factors, the HR (low level of education vs high level of education) was 1·23 (95% CI 0·96-1·58) for high-income countries, 1·59 (1·42-1·78) in middle-income countries, and 2·23 (1·79-2·77) in low-income countries (p_interaction<0·0001). We observed similar results for all-cause mortality, with HRs of 1·50 (1·14-1·98) for high-income countries, 1·80 (1·58-2·06) in middle-income countries, and 2·76 (2·29-3·31) in low-income countries (p_interaction<0·0001). By contrast, we found no or weak associations between wealth and these two outcomes. Differences in outcomes between educational groups were not explained by differences in risk factors, which decreased as the level of education increased in high-income countries, but increased as the level of education increased in low-income countries (p_interaction<0·0001). Medical care (eg, management of hypertension, diabetes, and secondary prevention) seemed to play an important part in adverse cardiovascular disease outcomes because such care is likely to be poorer in people with the lowest levels of education compared to those with higher levels of education in low-income countries; however, we observed less marked differences in care based on level of education in middle-income countries and no or minor differences in high-income countries.

INTERPRETATION

Although people with a lower level of education in low-income and middle-income countries have higher incidence of and mortality from cardiovascular disease, they have better overall risk factor profiles. However, these individuals have markedly poorer health care. Policies to reduce health inequities globally must include strategies to overcome barriers to care, especially for those with lower levels of education.

FUNDING

Full funding sources are listed at the end of the paper (see Acknowledgments).

Socioeconomic Gradients and Distribution of Diabetes, Hypertension, and Obesity in India

IMPORTANCE

Cardiovascular disease and risk factors represent a major and increasing burden of death and disability in India, although socioeconomic aspects have been debated in recent years.

OBJECTIVE

To conduct a comprehensive equity analysis of the socioeconomic gradients and distribution of diabetes, hypertension, and obesity in India using the latest national data set.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of data originating from the fourth Indian National Family Health Survey collected from January 20, 2015, to December 4, 2016. The study population was based on a nationally representative cross-sectional sample of women aged 15 to 49 years and men aged 15 to 54 years in India, with a response rate of 97% and 92% among eligible women and men, respectively. Biomarker sampling of survey respondents captured height, weight, blood pressure, and random blood glucose levels. Markers of socioeconomic status (SES) were household wealth, education, and social caste. Descriptive analyses and logistic regression models that account for multistage survey design and sampling weights were estimated.

MAIN OUTCOMES AND MEASURES

Diabetes, hypertension, and obesity assessed by predetermined thresholds based on biomarker sampling or current medication were the primary outcomes.

RESULTS

The survey covered 757 958 individuals (weighted prevalence of 51.2% female). The overall prevalence of diabetes, hypertension, and obesity in the sample was 2.9%, 14.4% and 9.7%, respectively. Positive socioeconomic gradients were observed by household wealth, education, and social caste, and in a majority of states. The magnitude of the SES gradient was strongest for obesity (adjusted odds ratio for highest SES quintile vs lowest, 8.76; 95% CI, 7.70-9.95), followed by diabetes (adjusted odds ratio, 2.31; 95% CI, 1.88-2.85) and hypertension (adjusted odds ratio, 1.58; 95% CI, 1.45-1.72) (P < .001 for all associations). Analyses of the socioeconomic distribution indicated that between 70% and 90% of the population burden of diabetes, hypertension, and obesity was among the higher SES groups, and this figure was similar across states.

CONCLUSIONS AND RELEVANCE

Cardiovascular risk factors have an uneven distribution in India. Prevention and treatment strategies should reflect the distribution of the risk factor burden.

Early Origins of Later Life Psychological Well-Being? A Novel Application of Causal Mediation Analysis to Life Course Research

Objectives

This study employs a novel approach to mediation analysis to clarify the influence of interrelated indicators of life course socioeconomic status (SES) on later life psychological well-being in India. Contrary to traditional approaches (i.e., use of product and difference-in-coefficients), we recognize the role of confounders in the estimation of total, direct, and indirect effects of parental education on respondents' psychological well-being.

Method

Drawing from the first wave (2007-2010) of the Study on Global Ageing and Adult Health (SAGE) and adopting a counterfactual approach, we estimate both natural direct and indirect effects of parental education through individual educational attainment (secondarily, through household assets as an additional mediator) on respondents' life-satisfaction and quality of life (QOL).

Results

Findings document a statistically not significant positive total effect of parental education on life satisfaction and QOL. While lower for women, significant indirect effects suggest that the positive influence of parental education operates primarily through the individual's education. Notably, we found negative direct effect of parental education on psychological well-being outcomes.

Discussion

Contrary to prior literature, we found no positive direct influence of parental education on later life psychological well-being, but established its influence through socioeconomic positioning over the life course.

Implications of scaling up cardiovascular disease treatment in South Africa: a microsimulation and cost-effectiveness analysis

BACKGROUND

Cardiovascular diseases and their risk factors-particularly hypertension, dyslipidaemia, and diabetes-have become an increasing concern for middle-income countries. Using newly available, nationally representative data, we assessed how cardiovascular risk factors are distributed across subpopulations within South Africa and identified which cardiovascular treatments should be prioritised.

METHODS

We created a demographically representative simulated population for South Africa and used data from 17 743 respondents aged 15 years or older of the 2012 South African National Health and Nutrition Examination Survey (SANHANES) to assign information on cardiovascular risk factors to each member of the simulated population. We created a microsimulation model to estimate the health and economic implications of two globally recognised treatment recommendations: WHO's package of essential non-communicable disease interventions (PEN) and South Africa's Primary Care 101 (SA PC 101) guidelines. The primary outcome was total disability-adjusted life-years (DALYs) averted through treatment of all cardiovascular disease or microvascular type 2 diabetes complications per 1000 population. We compared outcomes at the aspirational level of achieving access to treatment among 70% of the population.

FINDINGS

Based on the SANHANES data, South Africans had a high prevalence of hypertension (24·8%), dyslipidaemia (17·5%), and diabetes (15·3%). Prevalence was disproportionately high and treatment low among male, black, and poor populations. Our simulated population experienced a burden of 40·0 DALYs (95% CI 29·5-52·0) per 1000 population per year from cardiovascular disease or type 2 diabetes complications at current treatment levels, which lowered to 32·9 DALYs (24·4-44·7) under WHO PEN implementation and to 32·5 (24·4-44·8) under SA PC 101 implementation. Under both guidelines, there were increases in blood pressure treatment (4·2 percentage points under WHO PEN vs 12·6 percentage points under SA PC 101), lipid treatment (16·0 vs 14·9), and glucose control medications (1·2 vs 0·6). The incremental cost-effectiveness of implementing SA PC 101 over current treatment would be a saving of US$24 902 (95% CI 14 666-62 579) per DALY averted compared with a saving of $17 587 (1840-42 589) under WHO PEN guidelines.

INTERPRETATION

Cardiovascular risk factors are common and disproportionate among disadvantaged populations in South Africa. Treatment with blood pressure agents and statins might need greater prioritisation than blood glucose therapies, which contrasts with observed treatment levels despite a lower monthly cost of blood pressure or statin treatment than of sulfonylurea or insulin treatment.

FUNDING

Stanford University.

The global burden of multiple chronic conditions: A narrative review

Globally, approximately one in three of all adults suffer from multiple chronic conditions (MCCs). This review provides a comprehensive overview of the resulting epidemiological, economic and patient burden. There is no agreed taxonomy for MCCs, with several terms used interchangeably and no agreed definition, resulting in up to three-fold variation in prevalence rates: from 16% to 58% in UK studies, 26% in US studies and 9.4% in Urban South Asians. Certain conditions cluster together more frequently than expected, with associations of up to three-fold, e.g. depression associated with stroke and with Alzheimer's disease, and communicable conditions such as TB and HIV/AIDS associated with diabetes and CVD, respectively. Clusters are important as they may be highly amenable to large improvements in health and cost outcomes through relatively simple shifts in healthcare delivery. Healthcare expenditures greatly increase, sometimes exponentially, with each additional chronic condition with greater specialist physician access, emergency department presentations and hospital admissions. The patient burden includes a deterioration of quality of life, out of pocket expenses, medication adherence, inability to work, symptom control and a high toll on carers. This high burden from MCCs is further projected to increase. Recommendations for interventions include reaching consensus on the taxonomy of MCC, greater emphasis on MCCs research, primary prevention to achieve compression of morbidity, a shift of health systems and policies towards a multiple-condition framework, changes in healthcare payment mechanisms to facilitate this change and shifts in health and epidemiological databases to include MCCs.

Gendered "Long Arm" of Parental Education? Life Course Influences on Later Life Functional Limitations in India

Objective: We adopt a novel approach to mediation analysis to account for interrelated life course social processes that constitute later life health disparities. We examine gender-specific direct effect of parental education on functional limitations in later life. Method: Based on the first wave (2007-2010; n = 7,150) of the Study on Global Ageing and Adult Health (SAGE), we estimate both (natural) direct and indirect effects of parental education on functional limitations in later life. Results: We observed a significant indirect and positive effect of parental education on functional health. Contrary to prior literature, we documented adverse direct effect of parental education on later life functional health. The direct effect is statistically significant only for father's education, and is greater, though not statistically significantly so, for women than men. Discussion: The intersection of gender status and interrelated social stratification documented by this study highlights the need for gender-sensitive life course research. Such research can enhance our understanding of the ways patriarchal social systems produce heterogeneous effects of interrelated structural factors on later life health for men and women.

Trends in the socioeconomic patterning of overweight/obesity in India: a repeated cross-sectional study using nationally representative data

OBJECTIVES

We aimed to examine trends in prevalence of overweight/obesity among adults in India by socioeconomic position (SEP) between 1998 and 2016.

DESIGN

Repeated cross-sectional study using nationally representative data from India collected in 1998/1999, 2005/2006 and 2015/2016. Multilevel regressions were used to assess trends in prevalence of overweight/obesity by SEP.

SETTING

26, 29 and 36 Indian states or union territories, in 1998/99, 2005/2006 and 2015/2016, respectively.

PARTICIPANTS

628 795 ever-married women aged 15-49 years and 93 618 men aged 15-54 years.

PRIMARY OUTCOME MEASURE

Overweight/obesity defined by body mass index >24.99 kg/m².

RESULTS

Between 1998 and 2016, overweight/obesity prevalence increased among men and women in both urban and rural areas. In all periods, overweight/obesity prevalence was consistently highest among higher SEP individuals. In urban areas, overweight/obesity prevalence increased considerably over the study period among lower SEP adults. For instance, between 1998 and 2016, overweight/obesity prevalence increased from approximately 15%-32% among urban women with no education. Whereas the prevalence among urban men with higher education increased from 26% to 34% between 2005 and 2016, we did not observe any notable changes among high SEP urban women between 1998 and 2016. In rural areas, more similar increases in overweight/obesity prevalence were found among all individuals across the study period, irrespective of SEP. Among rural women with higher education, overweight/obesity increased from 16% to 25% between 1998 and 2016, while the prevalence among rural women with no education increased from 4% to 14%.

CONCLUSIONS

We identified some convergence of overweight/obesity prevalence across SEP in urban areas among both men and women, with fewer signs of convergence across SEP groups in rural areas. Efforts are therefore needed to slow the increasing trend of overweight/obesity among all Indians, as we found evidence suggesting it may no longer be considered a 'diseases of affluence'.

Nutritional Status and Psychological Impairment in Rural Adolescent Girls: Pilot Data From "KOKAN" Region of Western India

Background: Adolescence is a period during which psychological foundations are laid down as well as consolidated. Not much information is available on rural Indian adolescent girls and their psychological health.

Methods: We did a pilot survey of psychological health of 80 adolescent girls residing at KOKAN region of western India. Psychological health was evaluated using Youth Paediatric Symptom Checklist (Y-PSC) consisting of 35 items with maximum score of 70. Girls with a score >30 were classified as psychologically impaired. In addition we also collected random blood sample and measured the micronutrients. Macronutrient intake was estimated by 24 h recall.

Results: The mean age of the girls was 14 years with a standard deviation of 1.5. In all 35/76 (46.1%) could be classified as psychologically impaired. There was a high prevalence of micronutrient deficiencies with varying degrees. More than 65% were deficient in calcium, zinc and folic acid. About 22% were anemic and 36% were vitamin B₁ deficient. More than 75% had a low recommended dietary allowance (RDA) of macronutrients. Those with poor serum calcium concentration had higher psychological score (p < 0.05). Fat and calcium intakes were inversely associated with psychological score (p < 0.05 and p < 0.001 respectively). Odds ratios for psychological impairment were significant for those with low calcium levels [1.47 (95% CI 1.21, 4.31)], and for those with low calcium intake 1.43 (1.08, 3.19) and low iron intake 3.04 (1.02, 9.26).

Conclusion: Our pilot data has shown the urgent need to improve the nutrition of adolescent girls, which could improve their psychological health.

Nature cure treatment in the context of India's epidemiological transition

Scholars have argued that theoretical insights of critical medical anthropology should be applied to the analysis of complementary and alternative medicine in order to develop more critically engaged integrative medicine. In this essay we focus on nature cure in the context of India's contemporary epidemiological transition as an example of why engaged integrative medicine is important for public health, and how the institutionalization of nature cure treatment in India provides a critical framework for the development of programs focused on holistic treatment and prevention. After providing an overview of the epidemiological transition in contemporary India, we develop this argument through an examination of illustrative cases in a clinic that operates within the structure of India's Central Council for Research on Yoga and Naturopathy. Based on a review of recent history and contemporary practice we describe how a system of medicine that makes use exclusively of air, earth, sunlight, water and food has been institutionalized and professionalized in India. Whereas biomedical treatment for chronic non-communicable diseases is focused on the problem of curing individual diseases, nature cure establishes a regimen of personalized public healthcare for the integrated management of symptoms. We argue that nature cure is based on an ecological understanding of health, thus providing treatment that reflects a broad appreciation for the risk factors that characterize India's current crises of public health.

Diabetes and Hypertension in India: A Nationally Representative Study of 1.3 Million Adults

IMPORTANCE

Understanding how diabetes and hypertension prevalence varies within a country as large as India is essential for targeting of prevention, screening, and treatment services. However, to our knowledge there has been no prior nationally representative study of these conditions to guide the design of effective policies.

OBJECTIVE

To determine the prevalence of diabetes and hypertension in India, and its variation by state, rural vs urban location, and individual-level sociodemographic characteristics.

DESIGN, SETTING, AND PARTICIPANTS

This was a cross-sectional, nationally representative, population-based study carried out between 2012 and 2014. A total of 1 320 555 adults 18 years or older with plasma glucose (PG) and blood pressure (BP) measurements were included in the analysis.

EXPOSURES

State, rural vs urban location, age, sex, household wealth quintile, education, and marital status.

MAIN OUTCOMES AND MEASURES

Diabetes (PG level ≥126 mg/dL if the participant had fasted or ≥200 mg/dL if the participant had not fasted) and hypertension (systolic BP≥140 mm Hg or diastolic BP≥90 mm Hg).

RESULTS

Of the 1 320 555 adults, 701 408 (53.1%) were women. The crude prevalence of diabetes and hypertension was 7.5% (95% CI, 7.3%-7.7%) and 25.3% (95% CI, 25.0%-25.6%), respectively. Notably, hypertension was common even among younger age groups (eg, 18-25 years: 12.1%; 95% CI, 11.8%-12.5%). Being in the richest household wealth quintile compared with being in the poorest quintile was associated with only a modestly higher probability of diabetes (rural: 2.81 percentage points; 95% CI, 2.53-3.08 and urban: 3.47 percentage points; 95% CI, 3.03-3.91) and hypertension (rural: 4.15 percentage points; 95% CI, 3.68-4.61 and urban: 3.01 percentage points; 95% CI, 2.38-3.65). The differences in the probability of both conditions by educational category were generally small (≤2 percentage points). Among states, the crude prevalence of diabetes and hypertension varied from 3.2% (95% CI, 2.7%-3.7%) to 19.9% (95% CI, 17.6%-22.3%), and 18.0% (95% CI, 16.6%-19.5%) to 41.6% (95% CI, 37.8%-45.5%), respectively.

CONCLUSIONS AND RELEVANCE

Diabetes and hypertension prevalence is high in middle and old age across all geographical areas and sociodemographic groups in India, and hypertension prevalence among young adults is higher than previously thought. Evidence on the variations in prevalence by state, age group, and rural vs urban location is critical to effectively target diabetes and hypertension prevention, screening, and treatment programs to those most in need.

Distinct clusters of stunted children in India: An observational study

Childhood stunting is often conceptualised as a singular concept (i.e., stunted or not), and such an approach implies similarity in the experiences of children who are stunted. Furthermore, risk factors for stunting are often treated in isolation, and limited research has examined how multiple risk factors interact together. Our aim was to examine whether there are subgroups among stunted children, and if parental characteristics influence the likelihood of these subgroups among children. Children who were stunted were identified from the 2005–2006 Indian National Family Health Survey (n = 12,417). Latent class analysis was used to explore the existence of subgroups among stunted children by their social, demographic, and health characteristics. We examined whether parental characteristics predicted the likelihood of a child belonging to each latent class using a multinomial logit regression model. We found there to be 5 distinct groups of stunted children; “poor, older, and poor health‐related outcomes,” “poor, young, and poorest health‐related outcomes,” “poor with mixed health‐related outcomes,” “wealthy and good health‐related outcomes,” and “typical traits.” Both mother and father's educational attainment, body mass index, and height were important predictors of class membership. Our findings demonstrate evidence that there is heterogeneity of the risk factors and behaviours among children who are stunted. It suggests that stunting is not a singular concept; rather, there are multiple experiences represented by our “types” of stunting. Adopting a multidimensional approach to conceptualising stunting may be important for improving the design and targeting of interventions for managing stunting.

Socioeconomic Status and Cardiovascular Disease: an Update

PURPOSE OF REVIEW

The aim of this paper is to summarize the recent and relevant evidence linking socioeconomic status (SES) to cardiovascular disease (CVD) and cardiovascular risk factors (CVRFs).

RECENT FINDINGS

In high-income countries (HICs), the evidence continues to expand, with meta-analyses of large longitudinal cohort studies consistently confirming the inverse association between SES and several CVD and CVRFs. The evidence remains limited in low-income and middle-income countries (LMICs), where most of the evidence originates from cross-sectional studies of varying quality and external validity; the available evidence indicates that the association between SES and CVD and CVRFs depends on the socioeconomic development context and the stage in the demographic, epidemiological, and nutrition transition of the population. The recent evidence confirms that SES is strongly inversely associated with CVD and CVRFs in HICs. However, there remains a need for more research to better understand the way socioeconomic circumstances become embodied in early life and throughout the life course to affect cardiovascular risk in adult and later life. In LMICs, the evidence remains scarce; thus, there is an urgent need for large longitudinal studies to disaggregate CVD and CVRFs by socioeconomic indicators, particularly as these countries already suffer the greatest burden of CVD.

Socioeconomic patterning of chronic conditions and behavioral risk factors in rural South Asia: a multi-site cross-sectional study

OBJECTIVES

Our aim was to examine relationships between markers of socioeconomic status and chronic disease risks in rural South Asia to understand the etiology of chronic diseases in the region and identify high-risk populations.

METHODS

We examined data from 2271 adults in Chennai, Goa and Matlab sites of the Chronic Disease Risk Factor study in South Asia. We report age-sex adjusted odds ratios for risk factors (tobacco, alcohol, fruit-vegetable use and physical activity) and common chronic conditions (hypertension, diabetes, overweight, depression, impaired lung and vision) by education, occupation and wealth.

RESULTS

Respondents with greater wealth and in non-manual professions were more likely to be overweight [OR = 2.48 (95% CI 1.8,3.38)] and have diabetes [OR = 1.88 (95% CI 1.02,3.5)]. Wealth and education were associated with higher fruit and vegetable [OR = 1.89 (95% CI 1.48,2.4)] consumption but lower physical activity [OR = 0.52 (95% CI 0.39,0.69)]. Non-manual workers reported lower tobacco and alcohol use, while wealthier respondents reported better vision and lung function.

CONCLUSIONS

Ongoing monitoring of inequalities in chronic disease risks is needed for planning and evaluating interventions to address the growing burden of chronic conditions.

Prehypertension and socioeconomic status: A cross-sectional study in Chongqing, China

BACKGROUND

A large amount of research is available on the relationship between socioeconomic status (SES) and hypertension. However, the relationship between SES and prehypertension remains complex and unclear. Prehypertension is defined as a systolic blood pressure (SBP) between 120 and 139 mmHg or diastolic blood pressure (DBP) 80 and 89 mmHg. This paper focuses on the impact of SES on the prevalence of prehypertension and provides suggestions for the prevention and control measures of prehypertension and health resource allocation.

METHOD

Using multistage random sampling, 11,773 subjects were selected. Subjects aged above 15 years old and subjects who had been living in the eight selected districts for more than 6 months were analyzed using a multivariable logistical model.

RESULTS

The prevalence of prehypertension at the present time reaches 55.17%, with it being higher among men than that among women (63.15% vs. 47.19%, p < 0.05). After adjustment for other factors such as age and gender, a logistic regression showed that a higher education level and a history of marital status were significantly associated with prehypertension.

CONCLUSIONS

People of different SES indicate different working and living conditions. They also face different risk factors for prehypertension. Lower education and a history of marital status were associated with a higher risk of prehypertension among residents in Chongqing, China.

An Examination of Stroke Risk and Burden in South Asians

BACKGROUND

South Asians (India, Pakistan, Sri Lanka, Bangladesh, Nepal, and Bhutan) are at a disproportionately higher risk of stroke and heart disease due to their cardiometabolic profile. Despite evidence for a strong association between diabetes and stroke, and growing stroke risk in this ethnic minority-notwithstanding reports of higher stroke mortality irrespective of country of residence-the explanation for the excess risk of stroke remains unknown.

METHODS

We have used extensive literature review, epidemiologic studies, morbidity and mortality records, and expert opinions to examine the burden of stroke among South Asians, and the risk factors identified thus far.

RESULTS

We summarize existing evidence and indicate gaps in current knowledge of stroke epidemiology among South Asian natives and immigrants.

CONCLUSIONS

This research focuses attention on a looming epidemic of stroke mainly due to modifiable risk factors, but also new determinants that might aggravate the effect of vascular risk factors in South Asians causing more disabling strokes and death.

Prevalence and incidence of hypertension: Results from a representative cohort of over 16,000 adults in three cities of South Asia

BACKGROUND

Despite high projected burden, hypertension incidence data are lacking in South Asian population. We measured hypertension prevalence and incidence in the Center for cArdio-metabolic Risk Reduction in South Asia (CARRS) adult cohort.

METHODS

The CARRS Study recruited representative samples of Chennai, Delhi, and Karachi in 2010/11, and socio-demographic and risk factor data were obtained using a standard common protocol. Blood pressure (BP) was measured in the sitting position using electronic sphygmomanometer both at baseline and two year follow-up. Hypertension and control were defined by JNC 7 criteria.

RESULTS

In total, 16,287 participants were recruited (response rate=94.3%) and two year follow-up was completed in 12,504 (follow-up rate=79.2%). Hypertension was present in 30.1% men (95% CI: 28.7-31.5) and 26.8% women (25.7-27.9) at baseline. BP was controlled in 1 in 7 subjects with hypertension. At two years, among non-hypertensive adults, average systolic BP increased 2.6mm Hg (95% CI: 2.1-3.1), diastolic BP 0.7mm Hg (95% CI: 0.4-1.0), and 1 in 6 developed hypertension (82.6 per 1000 person years, 95% CI: 80.8-84.4). Risk for developing hypertension was associated with age, low socio-economic status, current alcohol use, overweight, pre-hypertension, and dysglycemia. Risk of incident hypertension was highest (RR=2.95, 95% CI: 2.53-3.45) in individuals with pre-hypertension compared to normal BP. Collectively, 4 modifiable risk factors (pre-hypertension, overweight, dysglycemia, and alcohol use) accounted for 78% of the population attributable risk of incident hypertension.

CONCLUSION

High prevalence and poor control of hypertension, along with high incidence, in South Asian adult population call for urgent preventive measures.

Cardiovascular Diseases in India: Current Epidemiology and Future Directions

Cardiovascular diseases (CVDs) have now become the leading cause of mortality in India. A quarter of all mortality is attributable to CVD. Ischemic heart disease and stroke are the predominant causes and are responsible for >80% of CVD deaths. The Global Burden of Disease study estimate of age-standardized CVD death rate of 272 per 100 000 population in India is higher than the global average of 235 per 100 000 population. Some aspects of the CVD epidemic in India are particular causes of concern, including its accelerated buildup, the early age of disease onset in the population, and the high case fatality rate. In India, the epidemiological transition from predominantly infectious disease conditions to noncommunicable diseases has occurred over a rather brief period of time. Premature mortality in terms of years of life lost because of CVD in India increased by 59%, from 23.2 million (1990) to 37 million (2010). Despite wide heterogeneity in the prevalence of cardiovascular risk factors across different regions, CVD has emerged as the leading cause of death in all parts of India, including poorer states and rural areas. The progression of the epidemic is characterized by the reversal of socioeconomic gradients; tobacco use and low fruit and vegetable intake have become more prevalent among those from lower socioeconomic backgrounds. In addition, individuals from lower socioeconomic backgrounds frequently do not receive optimal therapy, leading to poorer outcomes. Countering the epidemic requires the development of strategies such as the formulation and effective implementation of evidence-based policy, reinforcement of health systems, and emphasis on prevention, early detection, and treatment with the use of both conventional and innovative techniques. Several ongoing community-based studies are testing these strategies.

Age and Socioeconomic Gradients of Health of Indian Adults: An Assessment of Self-Reported and Biological Measures of Health

This paper describes overall socioeconomic gradients and the age patterns of socioeconomic gradients of health of Indian adults for multiple health indicators encompassing the multiple aspects of health. Cross-sectional data on 11,230 Indians aged 18 years and older from the WHO-SAGE India Wave 1, 2007 were analyzed. Multivariate logit models were estimated to examine effects of socioeconomic status (education and household wealth) and age on four health domains: self-rated health, self-reported functioning, chronic diseases, and biological health measures. Results show that socioeconomic status (SES) was negatively associated with prevalence of each health measure but with considerable heterogeneity across age groups. Results for hypertension and COPD were inconclusive. SES effects are significant while adjusting for background characteristics and health risk factors. The age patterns of SES gradient of health depict divergence with age, however, no conclusive age pattern emerged for biological markers. Overall, results in this paper dispelled the conclusion of negative SES-health association found in some previous Indian studies and reinforced the hypothesis of positive association of SES with health for Indian adults. Higher prevalence of negative health outcomes and SES disparities of health outcomes among older age-groups highlight need for inclusive and focused health care interventions for older adults across socioeconomic spectrum.