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Prenissl J, De Neve JW, Sudharsanan N, Manne-Goehler J, Mohan V, Awasthi A, Prabhakaran D, Roy A, Tandon N, Davies JI, Atun R, Bärnighausen T, Jaacks LM, Vollmer S, Geldsetzer P. Patterns of multimorbidity in India: A nationally representative cross-sectional study of individuals aged 15 to 49 years. PLOS Glob Public Health 2022; 2:e0000587. [PMID: 36962723 PMCID: PMC10021201 DOI: 10.1371/journal.pgph.0000587] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 07/16/2022] [Indexed: 11/18/2022]
Abstract
There is a dearth of evidence on the epidemiology of multimorbidity in low- and middle-income countries. This study aimed to determine the prevalence of multimorbidity in India and its variation among states and population groups. We analyzed data from a nationally representative household survey conducted in 2015-2016 among individuals aged 15 to 49 years. Multimorbidity was defined as having two or more conditions out of five common chronic morbidities in India: anemia, asthma, diabetes, hypertension, and obesity. We disaggregated multimorbidity prevalence by condition, state, rural versus urban areas, district-level wealth, and individual-level sociodemographic characteristics. 712,822 individuals were included in the analysis. The prevalence of multimorbidity was 7·2% (95% CI, 7·1% - 7·4%), and was higher in urban (9·7% [95% CI, 9·4% - 10·1%]) than in rural (5·8% [95% CI, 5·7% - 6·0%]) areas. The three most prevalent morbidity combinations were hypertension with obesity (2·9% [95% CI, 2·8% - 3·1%]), hypertension with anemia (2·2% [95% CI, 2·1%- 2·3%]), and obesity with anemia (1·2% [95% CI, 1·1%- 1·2%]). The age-standardized multimorbidity prevalence varied from 3·4% (95% CI: 3·0% - 3·8%) in Chhattisgarh to 16·9% (95% CI: 13·2% - 21·5%) in Puducherry. Being a woman, being married, not currently smoking, greater household wealth, and living in urban areas were all associated with a higher risk of multimorbidity. Multimorbidity is common among young and middle-aged adults in India. This study can inform screening guidelines for chronic conditions and the targeting of relevant policies and interventions to those most in need.
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Affiliation(s)
- Jonas Prenissl
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
- Medical Faculty Heidelberg, Heidelberg University, Heidelberg, Germany
| | - Jan-Walter De Neve
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Nikkil Sudharsanan
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
- Technical University of Munich, Munich, Germany
| | - Jennifer Manne-Goehler
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States of America
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation, ICMR Centre for Advanced Research on Diabetes, Chennai, Tamil Nadu, India
- Dr. Mohan's Diabetes Specialities Centre,Chennai, Tamil Nadu, India
| | - Ashish Awasthi
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurugram, Haryana, India
| | - Dorairaj Prabhakaran
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurugram, Haryana, India
- London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom
| | - Ambuj Roy
- Department of Cardiology, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Nikhil Tandon
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Justine I Davies
- Institute of Applied Health Research, Birmingham University, Birmingham, United Kingdom
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rifat Atun
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- Harvard Medical School, Harvard University, Boston, MA, United States of America
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
| | - Lindsay M Jaacks
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurugram, Haryana, India
- The Global Academy of Agriculture and Food Security, The University of Edinburgh, Midlothian, United Kingdom
| | - Sebastian Vollmer
- Department of Economics & Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
| | - Pascal Geldsetzer
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, CA, United States of America
- Chan Zuckerberg Biohub, San Francisco, CA, United States of America
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Prenissl J, Jaacks LM, Mohan V, Manne-Goehler J, Davies JI, Awasthi A, Bischops AC, Atun R, Bärnighausen T, Vollmer S, Geldsetzer P. Variation in health system performance for managing diabetes among states in India: a cross-sectional study of individuals aged 15 to 49 years. BMC Med 2019; 17:92. [PMID: 31084606 PMCID: PMC6515628 DOI: 10.1186/s12916-019-1325-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 04/15/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Understanding where adults with diabetes in India are lost in the diabetes care cascade is essential for the design of targeted health interventions and to monitor progress in health system performance for managing diabetes over time. This study aimed to determine (i) the proportion of adults with diabetes in India who have reached each step of the care cascade and (ii) the variation of these cascade indicators among states and socio-demographic groups. METHODS We used data from a population-based household survey carried out in 2015 and 2016 among women and men aged 15-49 years in all states of India. Diabetes was defined as a random blood glucose (RBG) ≥ 200 mg/dL or reporting to have diabetes. The care cascade-constructed among those with diabetes-consisted of the proportion who (i) reported having diabetes ("aware"), (ii) had sought treatment ("treated"), and (iii) had sought treatment and had a RBG < 200 mg/dL ("controlled"). The care cascade was disaggregated by state, rural-urban location, age, sex, household wealth quintile, education, and marital status. RESULTS This analysis included 729,829 participants. Among those with diabetes (19,453 participants), 52.5% (95% CI, 50.6-54.4%) were "aware", 40.5% (95% CI, 38.6-42.3%) "treated", and 24.8% (95% CI, 23.1-26.4%) "controlled". Living in a rural area, male sex, less household wealth, and lower education were associated with worse care cascade indicators. Adults with untreated diabetes constituted the highest percentage of the adult population (irrespective of diabetes status) aged 15 to 49 years in Goa (4.2%; 95% CI, 3.2-5.2%) and Tamil Nadu (3.8%; 95% CI, 3.4-4.1%). The highest absolute number of adults with untreated diabetes lived in Tamil Nadu (1,670,035; 95% CI, 1,519,130-1,812,278) and Uttar Pradesh (1,506,638; 95% CI, 1,419,466-1,589,832). CONCLUSIONS There are large losses to diabetes care at each step of the care cascade in India, with the greatest loss occurring at the awareness stage. While health system performance for managing diabetes varies greatly among India's states, improvements are particularly needed for rural areas, those with less household wealth and education, and men. Although such improvements will likely have the greatest benefits for population health in Goa and Tamil Nadu, large states with a low diabetes prevalence but a high absolute number of adults with untreated diabetes, such as Uttar Pradesh, should not be neglected.
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Affiliation(s)
- Jonas Prenissl
- Heidelberg Institute of Global Health, Heidelberg University, Im Neuenheimer Feld 130/3, 69120, Heidelberg, Germany. .,Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| | - Lindsay M Jaacks
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Public Health Foundation of India, New Delhi, Delhi NCR, India
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation & Dr. Mohan's Diabetes Specialities Centre, Chennai, Tamil Nadu, India
| | - Jennifer Manne-Goehler
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Justine I Davies
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Education Campus, University of Witwatersrand, Johannesburg, Gauteng, South Africa.,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Ashish Awasthi
- Indian Institute of Public Health, Gandhinagar, Gujarat, India
| | - Anne Christine Bischops
- Heidelberg Institute of Global Health, Heidelberg University, Im Neuenheimer Feld 130/3, 69120, Heidelberg, Germany
| | - Rifat Atun
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Harvard Medical School, Harvard University, Boston, MA, USA
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Im Neuenheimer Feld 130/3, 69120, Heidelberg, Germany.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
| | - Sebastian Vollmer
- Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
| | - Pascal Geldsetzer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Prenissl J, Manne-Goehler J, Jaacks LM, Prabhakaran D, Awasthi A, Bischops AC, Atun R, Bärnighausen T, Davies JI, Vollmer S, Geldsetzer P. Hypertension screening, awareness, treatment, and control in India: A nationally representative cross-sectional study among individuals aged 15 to 49 years. PLoS Med 2019; 16:e1002801. [PMID: 31050680 PMCID: PMC6499417 DOI: 10.1371/journal.pmed.1002801] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 04/10/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Evidence on where in the hypertension care process individuals are lost to care, and how this varies among states and population groups in a country as large as India, is essential for the design of targeted interventions and to monitor progress. Yet, to our knowledge, there has not yet been a nationally representative analysis of the proportion of adults who reach each step of the hypertension care process in India. This study aimed to determine (i) the proportion of adults with hypertension who have been screened, are aware of their diagnosis, take antihypertensive treatment, and have achieved control and (ii) the variation of these care indicators among states and sociodemographic groups. METHODS AND FINDINGS We used data from a nationally representative household survey carried out from 20 January 2015 to 4 December 2016 among individuals aged 15-49 years in all states and union territories (hereafter "states") of the country. The stages of the care process-computed among those with hypertension at the time of the survey-were (i) having ever had one's blood pressure (BP) measured before the survey ("screened"), (ii) having been diagnosed ("aware"), (iii) currently taking BP-lowering medication ("treated"), and (iv) reporting being treated and not having a raised BP ("controlled"). We disaggregated these stages by state, rural-urban residence, sex, age group, body mass index, tobacco consumption, household wealth quintile, education, and marital status. In total, 731,864 participants were included in the analysis. Hypertension prevalence was 18.1% (95% CI 17.8%-18.4%). Among those with hypertension, 76.1% (95% CI 75.3%-76.8%) had ever received a BP measurement, 44.7% (95% CI 43.6%-45.8%) were aware of their diagnosis, 13.3% (95% CI 12.9%-13.8%) were treated, and 7.9% (95% CI 7.6%-8.3%) had achieved control. Male sex, rural location, lower household wealth, and not being married were associated with greater losses at each step of the care process. Between states, control among individuals with hypertension varied from 2.4% (95% CI 1.7%-3.3%) in Nagaland to 21.0% (95% CI 9.8%-39.6%) in Daman and Diu. At 38.0% (95% CI 36.3%-39.0%), 28.8% (95% CI 28.5%-29.2%), 28.4% (95% CI 27.7%-29.0%), and 28.4% (95% CI 27.8%-29.0%), respectively, Puducherry, Tamil Nadu, Sikkim, and Haryana had the highest proportion of all adults (irrespective of hypertension status) in the sampled age range who had hypertension but did not achieve control. The main limitation of this study is that its results cannot be generalized to adults aged 50 years and older-the population group in which hypertension is most common. CONCLUSIONS Hypertension prevalence in India is high, but the proportion of adults with hypertension who are aware of their diagnosis, are treated, and achieve control is low. Even after adjusting for states' economic development, there is large variation among states in health system performance in the management of hypertension. Improvements in access to hypertension diagnosis and treatment are especially important among men, in rural areas, and in populations with lower household wealth.
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Affiliation(s)
- Jonas Prenissl
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Jennifer Manne-Goehler
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Lindsay M. Jaacks
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Public Health Foundation of India, New Delhi, National Capital Region, India
| | | | - Ashish Awasthi
- Public Health Foundation of India, New Delhi, National Capital Region, India
| | | | - Rifat Atun
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Africa Health Research Institute, Somkhele, KwaZulu-Natal, South Africa
| | - Justine I. Davies
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Sebastian Vollmer
- Department of Economics, University of Göttingen, Göttingen, Germany
- Centre for Modern Indian Studies, University of Göttingen, Göttingen, Germany
| | - Pascal Geldsetzer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- * E-mail:
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