Socioeconomic inequalities in hypertension in Kenya: a decomposition analysis of 2015 Kenya STEPwise survey on non-communicable diseases risk factors

Socioeconomic inequality in hypertension and its determinants in people over 60 years in Fasa, southern Iran: a Blinder-Oaxaca decomposition

BACKGROUND

Hypertension (HTN) is well-known as a major risk factor for various noncommunicable diseases. Evidence indicates a link between socioeconomic status and the likelihood of developing HTN. A thorough comprehension of the inequalities in HTN is crucial for implementing evidence-based interventions. This study aimed to assess the socioeconomic disparities in HTN among people aged 60 and older in Fasa County, located in southern Iran.

METHODS

A total of 1,632 seniors, aged 60 and above, were included in the analysis, with data obtained from the Fasa Adults Cohort Study (FACS). Initially, we utilized both simple and multiple logistic regression models to investigate the associations between HTN and the determinant variables. The Blinder‒Oaxaca decomposition method was used to decompose the disparity between the impoverished and the wealthy.

RESULTS

The research indicated that elderly individuals with a higher risk of developing HTN were notably linked to factors such as socioeconomic status, education level, a history of coronary artery disease, employment status, smoking habits, body mass index (BMI), waist‒hip ratio (WHR), and physical activity (p < 0.05). The decomposition model revealed a significant gap in HTN rate between rich and poor individuals, with those in the lower income bracket having a 7.59% higher rate of HTN (p = 0.001). Additionally, the leading factors contributing to the greatest disparities in HTN among older adults from different socioeconomic backgrounds include education level (33.07%), employment status (12.78%), BMI (12.25%), physical activity (-15.02%), and WHR (-9.22%).

CONCLUSIONS

The decomposition model illustrated a significant disparity in HTN rates among various socioeconomic groups, with a higher rate observed in the lower-income demographic. The analysis revealed that a substantial part of the explained gap can be attributed to factors including education level, employment status, WHR, BMI, and level of physical activity. Nonetheless, a considerable portion of HTN inequality among older adults remains unexplained by the model, highlighting the necessity for additional research that includes a wider variety of factors and variables to gain a deeper insight into the root causes of these disparities.

Association of socioeconomic inequality in cardiovascular disease risk with economic development across 57 low- and middle-income countries: Cross-sectional analysis of nationally representative individual-level data

BACKGROUND

According to epidemiological transition theory, cardiovascular disease (CVD) risk shifts down the socioeconomic distribution with economic development.

METHODS

We tested this hypothesis using nationally representative data on 88,559 individuals aged 40-80 years from 57 low- and middle-income countries (LMICs). We used measured risk factors to estimate the 10-year probability of a CVD event (CVD risk) and proxied socioeconomic status (SES) by years of education. We used a concentration index to measure socioeconomic inequality in CVD risk and decomposed it into risk factor contributions. We estimated associations CVD risk and inequality in that risk with gross national income (GNI) per capita (pc).

RESULTS

We estimated that a 1% higher GNI pc was associated with higher mean CVD risk of 0.0265 percentage points (pp) (95% CI: 0.0169-0.0361) among females and 0.0150 pp (0.0082-0.0219) among males. All risk factors, except systolic blood pressure (SBP) and smoking among females, were positively associated with GNI pc. In most countries, lower SES was associated with higher CVD risk. Age, SBP, diabetes (females only) and smoking (males particularly) contributed most to this inequality, while inequality in total cholesterol was mostly in the opposite direction. Lower SES individuals tended to have relatively higher CVD risk at higher GNI pc, particularly among females. This was due to differences in the distributions of SBP and, for females, age and diabetes.

CONCLUSIONS

Economic development was associated with higher and more unequal CVD risk, which may warrant shifting targeting of CVD primary prevention to socially disadvantaged groups.

Socio-economic and spatial inequalities in animal sources of iron-rich foods consumption among children 6-23 months old in Ethiopia: A decomposition analysis

Iron deficiency anaemia is the most common type of anaemia in young children which can lead to long-term health consequences such as reduced immunity, impaired cognitive development, and school performance. As children experience rapid growth, they require a greater supply of iron from iron-rich foods to support their development. In addition to the low consumption of iron-rich foods in low- and lower-middle-income countries, there are also regional and socio-economic disparities. This study aimed to assess contributing factors of wealth-related inequality and geographic variations in animal sources of iron-rich food consumption among children aged 6-23 months in Ethiopia. We used data from the Ethiopian Mini Demographic and Health Surveys (EMDHS) 2019, a national survey conducted using stratified sampling techniques. A total of 1,461 children of age 6-23 months were included in the study. Iron-rich animal sources of food consumption were regarded when parents/caregivers reported that a child took at least one of the four food items identified as iron-rich food: 1) eggs, 2) meat (beef, lamb, goat, or chicken), 3) fresh or dried fish or shellfish, and 4) organs meat such as heart or liver. Concentration indices and curves were used to assess wealth-related inequalities. A Wagstaff decomposition analysis was applied to identify the contributing factors for wealth-related inequality of iron-rich animal source foods consumption. We estimated the elasticity of wealth-related inequality for a percentage change in socioeconomic variables. A spatial analysis was then used to map the significant cluster areas of iron-rich animal source food consumption among children in Ethiopia. The proportion of children who were given iron-rich animal-source foods in Ethiopia is 24.2% (95% CI: 22.1%, 26.5%), with figures ranging from 0.3% in Dire Dawa to 37.8% in the Oromia region. Children in poor households disproportionately consume less iron-rich animal-source foods than those in wealthy households, leading to a pro-rich wealth concentration index (C) = 0.25 (95% CI: 0.12, 0.37). The decomposition model explained approximately 70% of the estimated socio-economic inequality. About 21% of the wealth-related inequalities in iron-rich animal source food consumption in children can be explained by having primary or above education status of women. Mother's antenatal care (ANC) visits (14.6%), living in the large central and metropolitan regions (12%), household wealth index (10%), and being in the older age group (12-23 months) (2.4%) also contribute to the wealth-related inequalities. Regions such as Afar, Eastern parts of Amhara, and Somali were geographic clusters with low iron-rich animal source food consumption. There is a low level of iron-rich animal source food consumption among children, and it is disproportionately concentrated in the rich households (pro-rich distribution) in Ethiopia. Maternal educational status, having ANC visits, children being in the older age group (12-23 months), and living in large central and metropolitan regions were significant contributors to these wealth-related inequalities in iron-rich animal source foods consumption. Certain parts of Ethiopia such as, Afar, Eastern parts of Amhara, and Somali should be considered priority areas for nutritional interventions to increase children's iron-rich animal source foods consumption.

Why is there a gap in self-rated health among people with hypertension in Zambia? A decomposition of determinants and rural‒urban differences

BACKGROUND

Hypertension affects over one billion people globally and is one of the leading causes of premature death. Low- and middle-income countries, especially the sub-Saharan Africa region, bear a disproportionately higher share of hypertension globally. Recent evidence shows a steady shift in the burden of hypertension from more affluent and urban populations towards poorer and rural communities. Our study examined inequalities in self-rated health (SRH) among people with hypertension and whether there is a rural‒urban gap in the health of these patients. We then quantified factors driving the health gap. We also examined how much HIV accounts for differences in self-rated health among hypertension patients due to the relationship between HIV, hypertension and health in sub-Saharan Africa.

METHODS

We utilized the Zambia Household Health Expenditure and Utilization Survey for data on SRH and other demographic and socioeconomic controls. District HIV prevalence information was from the Zambia Population-Based HIV Impact Assessment (ZAMPHIA) survey. We applied the Linear Probability Model to assess the association between self-rated health and independent variables as a preliminary step. We then used the Blinder-Oaxaca decomposition to identify self-rated health inequality between urban and rural patients and determine determinants of the health gap between the two groups.

RESULTS

Advanced age, lower education and low district HIV prevalence were significantly associated with poor health rating among hypertension patients. The decomposition analysis indicated that 45.5% of urban patients and 36.9% of rural patients reported good self-rated health, representing a statistically significant health gap of 8.6%. Most of the identified health gap can be attributed to endowment effects, with education (73.6%), district HIV prevalence (30.8%) and household expenditure (4.8%) being the most important determinants that explain the health gap.

CONCLUSIONS

Urban hypertension patients have better SRH than rural patients in Zambia. Education, district HIV prevalence and household expenditure were the most important determinants of the health gap between rural and urban hypertension patients. Policies aimed at promoting educational interventions, improving access to financial resources and strengthening hypertension health services, especially in rural areas, can significantly improve the health of rural patients, and potentially reduce health inequalities between the two regions.

Hypertension care cascades and reducing inequities in cardiovascular disease in low- and middle-income countries

Improving hypertension control in low- and middle-income countries has uncertain implications across socioeconomic groups. In this study, we simulated improvements in the hypertension care cascade and evaluated the distributional benefits across wealth quintiles in 44 low- and middle-income countries using individual-level data from nationally representative, cross-sectional surveys. We raised diagnosis (diagnosis scenario) and treatment (treatment scenario) levels for all wealth quintiles to match the best-performing country quintile and estimated the change in 10-year cardiovascular disease (CVD) risk of individuals initiated on treatment. We observed greater health benefits among bottom wealth quintiles in middle-income countries and in countries with larger baseline disparities in hypertension management. Lower-middle-income countries would see the greatest absolute benefits among the bottom quintiles under the treatment scenario (29.1 CVD cases averted per 1,000 people living with hypertension in the bottom quintile (Q1) versus 17.2 in the top quintile (Q5)), and the proportion of total CVD cases averted would be largest among the lowest quintiles in upper-middle-income countries under both diagnosis (32.0% of averted cases in Q1 versus 11.9% in Q5) and treatment (29.7% of averted cases in Q1 versus 14.0% in Q5) scenarios. Targeted improvements in hypertension diagnosis and treatment could substantially reduce socioeconomic-based inequalities in CVD burden in low- and middle-income countries.

Sociodemographic Factors Associated with Improved Metabolic Syndrome in Slum Dwelling Adults in Kenya: A Randomized Controlled Trial

Background

Sociodemographic factors have been implicated in cardiovascular health with differential morbidity and mortality. It is essential to comprehend how sociodemographic factors contribute to the improvement of Metabolic Syndrome (MetS), the primary cardiovascular diseases indicator.

Objective

Determine the role of sociodemographic factors in improving MetS among adults residing in the Slums of Nairobi, Kenya.

Methods

Adults with MetS participated in this randomized controlled trial study for a period of 12-months. A random assignment was used to place eligible participants in the intervention or control groups. The intervention group received lifestyle intervention that entails not using tobacco products or alcohol, exercising, and adhering to recommended dietary guidelines, while the control group had standard medical care. Clinical, biochemistry, and lifestyle habits were measured before and a year after the intervention. The association between the sociodemographic factors and the improvement in MetS was examined using a multiple logistic regression model with backward conditional.

Results

In the intervention group, lack of improvement in metabolic syndrome was significantly higher among aged (≥50 years) respondents [AOR = 9.097; P < .001]; Protestants [AOR = 7.292; P = .017] and Catholics [AOR = 5.270; P = .050]. Compared to unemployed, formally employed respondents had an 84.6% lower chance of having MetS [AOR = 0.154; P = .005]. Within the control group, lack of improvement in metabolic syndrome was significantly higher among aged (≥50 years) respondents [AOR = 5.013; P = .047]. Compared to respondents who had less than $100, individuals with monthly incomes between $100 and $500 had a roughly 10-fold [AOR = 10.499; P = .024] higher chance of having MetS.

Conclusion

In the current study, the findings show that sociodemographic factors namely: advanced age, unemployment, being Protestants and Catholics as well as higher income were negatively associated with improvement in MetS. The findings indicate that social factors have impact in the management and intervention outcomes of CVDs. Programmers and policy makers should plan interventions for CVD prevention and response with these factors in mind.

Why is there a gap in self-rated health among people with hypertension? A decomposition of determinants and rural-urban differences

Background

Hypertension affects over one billion people globally and is one of the leading causes of premature death. The low- and middle-income countries, especially the sub-Saharan Africa region, bear a disproportionately higher share of hypertension globally. Recent evidence shows a steady shift in the burden of hypertension from the more affluent and urban population towards the poorer and rural communities. Our study examined inequalities in self-rated health among people with hypertension and whether there is a rural-urban gap in the health of these patients. We then quantified factors driving the health gap. We also examined how much HIV accounts for differences in self-rated health among hypertension patients due to the relationship between HIV, hypertension and health in sub-Saharan Africa.

Methods

We utilized the Zambia Household Health Expenditure and Utilization Survey for the data on SRH and other demographic and socioeconomic controls. District HIV prevalence information was from a previous study. The linear probability model provided a preliminary assessment of the association between self-rated health and independent variables. We then used the Blinder-Oaxaca decomposition to identify self-rated health inequality between urban and rural patients and determine determinants of the health gap between the two groups.

Results

Advanced age, lower education and low district HIV prevalence were significantly associated with poor health rating among hypertension patients. The decomposition analysis indicated that 45.5% of urban patients and 36.9% of rural patients reported good self-rated health, representing a statistically significant health gap of 8.6%. Most of the identified health gap can be attributed to endowment effects, with education (62%), district HIV prevalence (26%) and household expenditure (12%) being the most important determinants that explain the health gap.

Conclusions

Urban hypertension patients have better SRH than rural patients in Zambia. Educational interventions, financial protection schemes and strengthening hypertension health services in rural areas can significantly reduce the health gap between the two regions.

Comparing socio-economic inequalities in self-reported and undiagnosed hypertension among adults 45 years and over in India: what explains these inequalities?

BACKGROUND

Hypertension (HTN) is a leading cause of mortality and morbidity in developing countries. For India, the hidden burden of undiagnosed hypertension is a major concern. This study aims to assess and explain socio-economic inequalities among self-reported and undiagnosed hypertensives in India.

METHODS

The study utilized data from the Longitudinal Aging Study in India (LASI), a nationally-representative survey of more than 72,000 older adults. The study used funnel plots, multivariable logistic regression, concentration indices, and decomposition analysis to explain the socio-economic gap in the prevalence of self-reported and undiagnosed hypertension between the richest and the poorest groups.

RESULTS

The prevalence of self-reported and undiagnosed hypertension was 27.4 and 17.8% respectively. Monthly per capita consumption expenditure (MPCE) quintile was positively associated with self-reported hypertension but negatively associated with undiagnosed hypertension. The concentration index for self-reported hypertension was 0.133 (p < 0.001), whereas it was - 0.047 (p < 0.001) for undiagnosed hypertension. Over 50% of the inequalities in self-reported hypertension were explained by the differences in the distribution of the characteristics whereas inequalities remained unexplained for undiagnosed hypertension. Obesity and diabetes were key contributors to pro-rich inequality.

CONCLUSIONS

Results imply that self-reported measures underestimate the true prevalence of hypertension and disproportionately affect the poorer MPCE groups. The prevalence of self-reported HTN was higher in the richest group, whereas socio-economic inequality in undiagnosed hypertension was significantly concentrated in the poorest group. As majority of the inequalities remain unexplained in case of undiagnosed hypertension, broader health systems issues including barriers to access to health care may be contributing to inequalities.

Inequality in prevalence, awareness, treatment, and control of hypertension in Iran: the analysis of national households’ data

Background

Providing an equitable Universal Health Coverage (UHC) is key for progressing towards the sustainable development goals in the health systems. To help policymakers make hypertension services more equitable with existing (limited) resources in Iran, we examined the inequality of the prevalence, awareness, treatment, and control (PATC) of hypertension as the four indicators of hypertension UHC in Iran. 

Methods

This research was a cross-sectional study of inequality of PATC of hypertension using a representative sample of Iranians aged ≥ 25 years from the Iran 2016 STEP wise approach to Surveillance study (STEPS). Outcome variables consisted of PATC of hypertension. Covariates were demographic (age, sex, and marital status) and living standard (area of residence, wealth status, education, and health insurance) indicators. We drew concentration curves (CC) and estimated concentration indices (C). We also conducted normalized Erreygers decomposition analysis for binary outcomes to identify covariates that explain the wealth-related inequality in the outcomes. Analysis was conducted in STATA 14.1.

Results

The normalized concentration index of hypertension prevalence and control was -0.066 (p < .001) and 0.082 (p < .001), respectively. The C of awareness and treatment showed nonsignificant difference between the richest and poorest. Inequality in the hypertension prevalence of females was significantly higher than males (C = -0.103 vs. male C = -0.023, p < .001). Our analyses explained 33% of variation in the C of hypertension prevalence and 99.7% of variation in the C of control. Education, wealth index, and complementary insurance explained most inequality in the prevalence. Area of residence, education, wealth status, and complementary insurance had the largest contribution to C of control by 30%, 28%, 26%, and 21%, respectively.

Conclusions

This study showed a pro-rich inequality in the prevalence and control of hypertension in Iran. We call for expanding the coverage of complementary insurance to reduce inequality of hypertension prevalence and control as compared with other factors it can be manipulated in short run. We furthermore advocate for interventions to reduce the inequality of hypertension control between rural and urban areas.

Socioeconomic Inequalities in the Prevalence of Non-Communicable Diseases among Older Adults in India

Understanding socioeconomic inequalities in non-communicable disease prevalence and preventive care usage can help design effective action plans for health equality programs among India's aging population. Hypertension (HTN) and diabetes mellitus (DM) are frequently used as model non-communicable diseases for research and policy purposes as these two are the most prevalent NCDs in India and are the leading causes of mortality. For this investigation, data on 31,464 older persons (aged 60 years and above) who took part in the Longitudinal Ageing Survey of India (LASI: 2017-2018) were analyzed. The concentration index was used to assess socioeconomic inequality whereas relative inequalities indices were used to compare HTN, DM, and preventive care usage between the different groups of individuals based on socioeconomic status. The study reveals that wealthy older adults in India had a higher frequency of HTN and DM than the poor elderly. Significant differences in the usage of preventive care, such as blood pressure/blood glucose monitoring, were found among people with HTN or DM. Furthermore, economic position, education, type of work, and residential status were identified as important factors for monitoring inequalities in access to preventive care for HTN and DM. Disparities in non-communicable diseases can be both a cause and an effect of inequality across social strata in India.

Awareness, treatment, and practices of lifestyle modifications amongst diagnosed hypertensive patients attending the tertiary care hospital of Karachi: A cross-sectional study

Background

Methods

Results

Conclusion

•

Data regarding the awareness of lifestyle modifications in the general hypertensive population of Pakistan is scarce.

•

Out of 425 hypertensive patients, 70.7% had uncontrolled hypertension. Age and female gender were the only risk factors significantly associated with uncontrolled hypertension.

•

Most of the patients are on treatment and still not controlled, and thus could be considered under treatment. Interventions should be considered and implemented to potentially increase the control rates.

Decomposing socioeconomic inequality in blood pressure and blood glucose testing: evidence from four districts in Kerala, India

BACKGROUND

Non-Communicable Diseases (NCDs) constitute a significant danger to the nation's public health system, both in terms of morbidity and mortality, as well as the financial burden they inflict. Kerala is undergoing an epidemiologic transition, which has significantly impacted the state's morbidity and mortality figures. For decades, the state has been putting in place myriad programs to reduce the burden of NCDs across population groups. Socioeconomic inequalities in NCD testing have been documented in India, although they are understudied in Kerala. The study aimed to estimate and characterize districtwise socioeconomic inequality in Blood Pressure (BP) and Blood Glucose (BG) testing.

METHODS

A cross-sectional household survey was conducted between July-October 2019 in Kasaragod, Alappuzha, Kollam and Thiruvananthapuram districts of Kerala, India. A total of 6383 participants aged 30 years and above were interviewed using multistage random sampling. Descriptive statistics were derived district-wise. We computed ratios, differences, equiplots, and Erreygers concentration indices for each district to measure socioeconomic inequality in BP and BG testing. Erreygers decomposition techniques were used to estimate the relative contribution of covariates to socioeconomic inequality.

RESULTS

There was a significant concentration of BP and BG testing favouring wealthier quintiles in Alappuzha, Kollam, and Thiruvananthapuram districts. The inequality in BP and BG testing was highest in Thiruvananthapuram (0.087 and 0.110), followed by Kollam (0.077 and 0.090), Alappuzha (0.083 and 0.073) and Kasaragod (0.026 and 0.056). Decomposition analysis revealed that wealth quintile and education contributed substantially to socioeconomic inequality in BP and BG testing in all four districts. It was also found that family history of NCDs significantly contributed to observed socioeconomic inequality in BP testing (29, 11, 16, and 27% in Kasaragod, Alappuzha, Kollam, and Thiruvananthapuram, respectively). Similarly, in BG testing, family history of NCDs substantially contributed to observed socioeconomic inequality, explaining 16-17% in Kasaragod, Alappuzha, Kollam, and Thiruvananthapuram respectively of the total inequality.

CONCLUSION

While the magnitude of socioeconomic inequality in NCD risk factor testing did not appear to be very high in four Kerala districts, although levels were statistically significant in three of them. Greater exploration is needed on how education and caste contribute to these inequalities and their relationship to NCD risk factors such as family history. From such analyses, we may be able to identify entry points to mitigate inequalities in testing access, as well as burden.

Socioeconomic-Related Inequalities in COVID-19 Vulnerability in South Africa

Individuals' vulnerability to the risk of COVID-19 infection varies due to their health, socioeconomic, and living circumstances, which also affect the effectiveness of implementing non-pharmacological interventions (NPIs). In this study, we analysed socioeconomic-related inequalities in COVID-19 vulnerability using data from the nationally representative South African General Household Survey 2019. We developed a COVID-19 vulnerability index, which includes health and social risk factors for COVID-19 exposure and susceptibility. The concentration curve and concentration index were used to measure socioeconomic-related inequalities in COVID-19 vulnerability. Recentred influence function regression was then utilised to decompose factors that explain the socioeconomic-related inequalities in COVID-19 vulnerability. The concentration index estimates were all negative and highly significant (p < 0.01), indicating that vulnerability to COVID-19 was more concentrated among the poor. According to the decomposition analysis, higher income and education significantly (p < 0.01) positively impacted lowering socioeconomic-related COVID-19 vulnerability. Living in an urban region, being Black, and old all had significant (p < 0.01) positive impacts on increasing socioeconomic-related COVID-19 vulnerability. Our findings contribute to a better understanding of socially defined COVID-19-vulnerable populations in South Africa and the implications for future pandemic preparedness plans.

Socioeconomic Inequity in the Screening and Treatment of Hypertension in Kenya: Evidence From a National Survey

Background

Non-communicable diseases (NCDs) account for 50% of hospitalisations and 55% of inpatient deaths in Kenya. Hypertension is one of the major NCDs in Kenya. Equitable access and utilisation of screening and treatment interventions are critical for reducing the burden of hypertension. This study assessed horizontal equity (equal treatment for equal need) in the screening and treatment for hypertension. It also decomposed socioeconomic inequalities in care use in Kenya.

Methods

Cross-sectional data from the 2015 NCDs risk factors STEPwise survey, covering 4,500 adults aged 18-69 years were analysed. Socioeconomic inequality was assessed using concentration curves and concentration indices (CI), and inequity by the horizontal inequity (HI) index. A positive (negative) CI or HI value suggests a pro-rich (pro-poor) inequality or inequity. Socioeconomic inequality in screening and treatment for hypertension was decomposed into contributions of need [age, sex, and body mass index (BMI)] and non-need (wealth status, education, exposure to media, employment, and area of residence) factors using a standard decomposition method.

Results

The need for hypertension screening was higher among poorer than wealthier socioeconomic groups (CI = -0.077; p < 0.05). However, wealthier groups needed hypertension treatment more than poorer groups (CI = 0.293; p <0.001). Inequity in the use of hypertension screening (HI = 0.185; p < 0.001) and treatment (HI = 0.095; p < 0.001) were significantly pro-rich. Need factors such as sex and BMI were the largest contributors to inequalities in the use of screening services. By contrast, non-need factors like the area of residence, wealth, and employment status mainly contributed to inequalities in the utilisation of treatment services.

Conclusion

Among other things, the use of hypertension screening and treatment services in Kenya should be according to need to realise the Sustainable Development Goals for NCDs. Specifically, efforts to attain equity in healthcare use for hypertension services should be multi-sectoral and focused on crucial inequity drivers such as regional disparities in care use, poverty and educational attainment. Also, concerted awareness campaigns are needed to increase the uptake of screening services for hypertension.

Stroke Epidemiology, Care, and Outcomes in Kenya: A Scoping Review

Background: Stroke is a leading cause of death and disability in sub-Saharan Africa with increasing incidence. In Kenya, it is a neglected condition with a paucity of evidence despite its need for urgent care and hefty economic burden. Therefore, we reviewed studies on stroke epidemiology, care, and outcomes in Kenya to highlight existing evidence and gaps on stroke in Kenya. Methods: We reviewed all published studies on epidemiology, care, and outcomes of stroke in Kenya between 1 January 1990 to 31 December 2020 from PubMed, Web of Science, EBSCOhost, Scopus, and African journal online. We excluded case reports, reviews, and commentaries. We used the Newcastle-Ottawa scale adapted for cross-sectional studies to assess the quality of included studies. Results: Twelve articles were reviewed after excluding 111 duplicates and 94 articles that did not meet the inclusion criteria. Five studies were of low quality, two of medium quality, and five of high quality. All studies were hospital-based and conducted between 2003 and 2017. Of the included studies, six were prospective and five were single-center. Stroke patients in the studies were predominantly female, in their seventh decade with systemic hypertension. The mortality rate ranged from 5 to 27% in-hospital and 23.4 to 26.7% in 1 month. Conclusions: Our study highlights that stroke is a significant problem in Kenya, but current evidence is of low quality and limited in guiding policy development and improving stroke care. There is thus a need for increased investment in hospital- and community-based stroke care and research.

Decomposition of inequalities in out-of-pocket health expenditure burden in Saudi Arabia

Out-of-pocket (OOP) health expenditure remains a serious welfare problem worldwide. The aim of this study was to investigate and decompose factors that are associated with inequalities in relative OOP health expenditure, estimated as the percentage of income spent on healthcare, in Saudi Arabia. Data from 10,785 respondents were obtained from a national cross-sectional survey conducted in Saudi Arabia as a part of the 2018 Family Health Survey. Inequalities in relative OOP health expenditure were measured using concentration indices and concentration curves. Moreover, the Wagstaff approach was used to decompose the concentration index of relative OOP health expenditure to assess the contribution of each of its determinants. The results revealed that relative OOP health expenditure in Saudi Arabia are concentrated among the poor (concentration index = -0.151, p < 0.01), resulting in a greater burden for the poor. Decomposition of the factors that contribute to this inequality revealed heterogeneity. Specifically, factors that increase the burden amongst the poor included aged above 60 years, and low levels of education, whereas factors that increase the burden amongst the rich included male gender, below the age of 60 years, secondary and higher education, having health insurance coverage, and suffering from chronic illnesses. Importantly, these results demonstrate that poor people might be exposed to hazardous health spending. Therefore, efforts to curbing OOP health expenditure should be framed by taking into account the specific factors that drive the burden towards the poor, such as older age and lack of education, so as to safeguard the overall welfare of the poor.