Social and Economic Implications of Noncommunicable diseases in India

A retrospective analysis of hypertension screening at a mass gathering in India: implications for non-communicable disease control strategies

Cardiovascular disease is the leading case of mortality from non-communicable diseases (NCD) in India. The government's National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke seeks to increase capacity building, screening, referral and management of NCDs across India, and includes community-based outreach and screening programmes. The government in India routinely provides basic care at religious mass gatherings. However, in 2015, at the Kumbh Mela in Nashik and Trimbakeshwar, the state government extended its services to include a hypertension screening programme. We examine here the value and implications of such opportunistic screening at mass gatherings. At the Kumbh, 5760 persons voluntarily opted for hypertension screening, and received a single blood pressure measurement. In all, 1783 (33.6%) screened positive, of whom, 1580 were previously unaware of their diagnosis. Of the 303 that had previously known hypertension, 240 (79%) were prescribed medications, and 160 were compliant (that is, 52.8% under treatment). Fifty-five (18%) had normal blood pressure readings (BP under control). The data also demonstrated higher prevalence (39%) of hypertension among tobacco users compared to non-users (28%) (P<0.001). Poor recording of phone numbers (0.01%) precluded any phone-based follow-up. The low rates of hypertension awareness, treatment and control underscore the ongoing challenge of both hypertension screening and management in India.

Overcoming Obstacles To Enable Access To Medicines For Noncommunicable Diseases In Poor Countries

The modern access-to-medicines movement grew largely out of the civil-society reaction to the HIV/AIDS pandemic three decades ago. While the movement was successful with regard to HIV/AIDS medications, the increasingly urgent challenge to address access to medicines for noncommunicable diseases has lagged behind-and, in some cases, has been forgotten. In this article we first ask what causes the access gap with respect to lifesaving essential noncommunicable disease medicines and then what can be done to close the gap. Using the example of the push for access to antiretrovirals for HIV/AIDS patients for comparison, we highlight the problems of inadequate global financing and procurement for noncommunicable disease medications, intellectual property barriers and concerns raised by the pharmaceutical industry, and challenges to building stronger civil-society organizations and a patient and humanitarian response from the bottom up to demand treatment. We provide targeted policy recommendations, specific to the public sector, the private sector, and civil society, with the goal of improving access to noncommunicable disease medications globally.

Noncommunicable Diseases in Ghana: Does the Theory of Social Gradient in Health Hold?

The theory of social gradient in health posits that individuals with lower socioeconomic status (SES) have poorer health outcomes, compared with those in higher socioeconomic brackets. Applied to noncommunicable diseases (NCDs), this theory has largely been corroborated by studies from the West. However, evidence from sub-Saharan Africa are mixed, with those from Ghana conspicuously missing in the literature. Using data from the Study on Global Ageing and Adult Health, and applying random-effects C log-log models, this study examined the relationship between SES and the risks of living with NCDs in Ghana. Results confirmed a negative social gradient, as Ghanaians with higher SES were more likely to live with NCDs compared with those with low SES. The addition of lifestyle factors attenuated the risks of living with NCDs among Ghanaian men and women with higher SES. This study underscores the need for policies targeted at specific socioeconomic and demographic groups, such as the emerging middle and upper class Ghanaians. It is similarly important for interventions to move beyond biomedical solutions that put more emphasis on epidemiological risk factors to strategies that embrace psychosocial factors as important correlates of cardiovascular health.

Addressing the escalating burden of chronic diseases in India: Need for strengthening primary care

The growing epidemic of noncommunicable diseases (NCDs) has impacted the national health systems, policies, and socioeconomic developments, thereby leading to increasing country level disparities. Despite substantial improvements in health indicators made in the past decade, the Indian health-care system continues to contribute disproportionately to the global disease burden, wherein NCDs holds significant prominence. Against this background, the present review analyzes the current NCD landscape from the perspective of India's health system preparedness toward meeting this growing challenge. Implementation and delivery of strategies and interventions are often impeded by existing grass root level challenges. Recognizing the importance of effective primary care, the review highlights the importance of implementing affordable, accessible, and comprehensive interventions, and delivering them at societal, a community and individual level. This simultaneously calls for strengthening of the primary care system through appropriate strategy and policy frameworks. Toward addressing India-specific needs in NCD prevention and management, concerted efforts on development of robust surveillance mechanisms, intersectoral and interdepartmental collaborations, integration of national programs, enhanced role of education and awareness should be made, to ensure effectivity, scale-up, and outreach of services in primary care.

Advocacy for outpatient cardiac rehabilitation globally

BACKGROUND

Cardiovascular diseases (CVD) are the leading cause of death globally. Cardiac rehabilitation (CR) is an evidence-based intervention recommended for patients with CVD, to prevent recurrent events and to improve quality of life. However, despite the proven benefits, only a small percentage of those would benefit from CR actually receive it worldwide. This paper by the International Council of Cardiovascular Prevention and Rehabilitation forwards the groundwork for successful CR advocacy to achieve broader reimbursement, and hence implementation.

METHODS

First, the results of the International Council's survey on national CR reimbursement policies by government and insurance companies are summarized. Second, a multi-faceted approach to CR advocacy is forwarded. Finally, as per the advocacy recommendations, the economic impact of CVD and the corresponding benefits of CR and its cost-effectiveness are summarized. This provides the case for CR reimbursement advocacy.

RESULTS

Thirty-one responses were received, from 25 different countries: 18 (58.1 %) were from high-income countries, 10 (32.4 %) from upper middle-income, and 3 (9.9 %) from lower middle-income countries. When asked who reimburses at least some portion of CR services in their country, 19 (61.3 %) reported the government, 17 (54.8 %) reported patients pay out-of-pocket, 16 (51.6 %) reported insurance companies, 12 (38.7 %) reported that it is shared between the patient and another source, and 7 (22.6 %) reported another source.

CONCLUSIONS

Many patients pay out-of-pocket for CR. CR reimbursement around the world is inconsistent and insufficient. Advocacy campaigns forwarding the CR cause, supported by the relevant literature, enlisting sources of support in a unified manner with an organized plan, are needed, and must be pursued persistently.

Widespread inequalities in smoking & smokeless tobacco consumption across wealth quintiles in States of India: Need for targeted interventions

Background & objectives:

India is a large country with each State having distinct social, cultural and economic characteristics. Tobacco epidemic is not uniform across the country. There are wide variations in tobacco consumption across age, sex, regions and socio-economic classes. This study was conducted to understand the wide inequalities in patterns of smoking and smokeless tobacco consumption across various States of India.

Methods:

Analysis was conducted on Global Adult Tobacco Survey, India (2009-2010) data. Prevalence of both forms of tobacco use and its association with socio-economic determinants was assessed across States and Union Territories of India. Wealth indices were calculated using socio-economic data of the survey. Concentration index of inequality and one way ANOVA assessed economic inequality in tobacco consumption and variation of tobacco consumption across quintiles. Multiple logistic regression was done for tobacco consumption and wealth index adjusting for age, sex, area, education and occupation.

Results:

Overall prevalence of smoking and smokeless tobacco consumption was 13.9 per cent (14.6, 13.3) and 25.8 per cent (26.6, 25.0), respectively. Prevalence of current smoking varied from 1.6 per cent (richest quintile in Odisha) to 42.2 per cent (poorest quintile in Meghalaya). Prevalence of current smokeless tobacco consumption varied from 1.7 per cent (richest quintile in Jammu and Kashmir) to 59.4 per cent (poorest quintile in Mizoram). Decreasing odds of tobacco consumption with increasing wealth was observed in most of the States. Reverse trend of tobacco consumption was observed in Nagaland. Significant difference in odds of smoking and smokeless tobacco consumption with wealth quintiles was observed. Concentration index of inequality was significant for smoking tobacco -0.7 (-0.62 to-0.78) and not significant for smokeless tobacco consumption -0.15 (0.01to-0.33)

Interpretation & conclusions:

The findings of our analysis indicate that tobacco control policy and public health interventions need to consider widespread socio-economic inequities in tobacco consumption across the States in India.

Population Study of Urban, Rural, and Semiurban Regions for the Detection of Endovascular Disease and Prevalence of Risk Factors and Holistic Intervention Study: Rationale, Study Design, and Baseline Characteristics of PURSE-HIS

We designed and implemented the PURSE-HIS (Population Study of Urban, Rural and Semiurban Regions for the Detection of Endovascular Disease and Prevalence of Risk Factors and Holistic Intervention Study) to understand the prevalence and progression of subclinical and overt endovascular disease (EVD) and its risk factors in urban, semiurban, and rural communities in South India. The study is also designed to generate clinical evidence for effective, affordable, and sustainable community-specific intervention strategies to control risks factors for EVD. As of June 2012, 8,080 (urban: 2,221; semiurban: 2,821; rural: 3,038) participants >20 years of age were recruited using 2-stage cluster sampling. Baseline measurements included standard cardiovascular disease risk factors, sociodemographic factors, lifestyle habits, psychosocial factors, and nutritional assessment. Fasting blood samples were assayed for putative biochemical risk factors and urine samples for microalbuminuria. All nondiabetic participants underwent oral glucose tolerance test with blood and urine samples collected every 30 min for 2 h. Additional baseline measurements included flow-mediated brachial artery endothelial vasodilation, assessment of carotid intimal medial wall thickness using ultrasonography, screening for peripheral vascular disease using ankle and brachial blood pressures, hemodynamic screening using a high-fidelity applanation tonometry to measure central blood pressure parameters, and aortic pulse wave velocity. To assess prevalence of coronary artery disease, all participants underwent surface electrocardiography and documentation of ventricular wall motion abnormality and function using echocardiography imaging. To detect subclinical lesions, all eligible participants completed an exercise treadmill test. Prospectively, the study will assess progression of subclinical and overt EVD, including risk factor-outcome relation differences across communities. The study will also evaluate community-specific EVD prevention using traditional Indian system of medicine versus recognized allopathic (mainstream) systems of medicine.

Nutrition transition in South Asia: the emergence of non-communicable chronic diseases

Overview: South Asian countries have experienced a remarkable economic growth during last two decades along with subsequent transformation in social, economic and food systems. Rising disposable income levels continue to drive the nutrition transition characterized by a shift from a traditional high-carbohydrate, low-fat diets towards diets with a lower carbohydrate and higher proportion of saturated fat, sugar and salt. Steered by various transitions in demographic, economic and nutritional terms, South Asian population are experiencing a rapidly changing disease profile. While the healthcare systems have long been striving to disentangle from the vicious cycle of poverty and undernutrition, South Asian countries are now confronted with an emerging epidemic of obesity and a constellation of other non-communicable diseases (NCDs). This dual burden is bringing about a serious health and economic conundrum and is generating enormous pressure on the already overstretched healthcare system of South Asian countries.

Objectives: The Nutrition transition has been a very popular topic in the field of human nutrition during last few decades and many countries and broad geographic regions have been studied. However there is no review on this topic in the context of South Asia  as yet. The main purpose of this review is to highlight the factors accounting for the onset of nutrition transition and its subsequent impact on epidemiological transition in five major South Asian countries including Bangladesh, India, Nepal, Pakistan and Sri Lanka. Special emphasis was given on India and Bangladesh as they together account for 94% of the regional population and about half world’s malnourished population.

Methods: This study is literature based. Main data sources were published research articles obtained through an electronic medical databases search.

Socioeconomic inequality in the prevalence of smoking and smokeless tobacco use in India

BACKGROUND

Tobacco consumption has been identified as the single biggest cause of inequality in morbidity and mortality. Understanding pattern of socioeconomic equalities in tobacco consumption in India will help in designing targeted public health control measures.

MATERIALS AND METHODS

Nationally representative data from the India Global Adult Tobacco Survey (GATS) conducted in 2009-2010 was analyzed. The survey provided information on 69,030 respondents aged 15 years and above. Data were analyzed according to regions for estimating prevalence of current tobacco consumption (both smoking and smokeless) across wealth quintiles. Multiple logistic regression analysis predicted the impact of socioeconomic determinants on both forms of current tobacco consumption adjusting for other socio-demographic variables.

RESULTS

Trends of smoking and smokeless tobacco consumption across wealth quintiles were significant in different regions of India. Higher prevalence of smoking and smokeless tobacco consumption was observed in the medium wealth quintiles. Risk of tobacco consumption among the poorest compared to the richest quintile was 1.6 times higher for smoking and 3.1 times higher for smokeless forms. Declining odds ratios of both forms of tobacco consumption with rising education were visible across regions. Poverty was a strong predictor in north and south Indian region for smoking and in all regions for smokeless tobacco use.

CONCLUSIONS

Poverty and poor education are strong risk factors for both forms of tobacco consumption in India. Public health policies, therefore, need to be targeted towards the poor and uneducated.

Age and sex patterns of premature mortality in India

OBJECTIVES

To estimate premature mortality by age, sex and cause of death in India.

BACKGROUND

Studies on premature mortality in India are limited. Although evidence suggests recent reductions in infant and child mortality, little is known about the age and sex patterns of premature deaths in India.

METHODS

Secondary data from the Sample Registration System and, census of India and report on cause of death. A set of indices are used to estimate the premature mortality were analysed.

PRIMARY AND SECONDARY OUTCOME MEASURES

Standardised years of potential life lost (YPLL), premature years of potential life lost (PYPLL) and working years of potential life lost (WYPLL) for broad age groups and by selected causes of death.

RESULTS

From 1991 to 2011, the age-standardised rate of YPLL (per 1000 population) declined from 310 to 235 for males and from 307 to 206 for females. The estimated YPLL (in millions) declined from 134 to 147 for males and from 123 to 108 for females, the YPLL for adults (aged 15-65) increased by 32% for males and 28% for females, the standardised PYPLL (per 1000 population) declined from 259 to 137 for males and from 258 to 115 for females, the estimated PYPLL increased by 13% for all adult males and by 32% for 30-45-year-old adult males, and the standardised rate of WYPLL declined from 274 to 131 for males and from 295 to 91 for females. These findings suggest a significant improvement in early childhood mortality and increasing mortality trends in 30-45-year-old adult males. The YPLL and WYPLL standardised rates for males and females were highest for cardiovascular disease.

CONCLUSIONS

The increasing share of premature deaths among adults and high levels of premature mortality suggest an improvement in child survival increased attention should be given to prevention and treatment of non-communicable diseases in order to avoid premature deaths in India.

Macroeconomic policies and increasing social-health inequality in Iran

BACKGROUND

Health is a complex phenomenon that can be studied from different approaches. Despite a growing research in the areas of Social Determinants of Health (SDH) and health equity, effects of macroeconomic policies on the social aspect of health are unknown in developing countries. This study aimed to determine the effect of macroeconomic policies on increasing of the social-health inequality in Iran.

METHODS

This study was a mixed method research. The study population consisted of experts dealing with social determinants of health. A purposive, stratified and non-random sampling method was used. Semi-structured interviews were conducted to collect the data along with a multiple attribute decision-making method for the quantitative phase of the research in which the Technique for Order Preference by Similarity to Ideal Solution (TOPSIS) was employed for prioritization. The NVivo and MATLAB softwares were used for data analysis.

RESULTS

Seven main themes for the effect of macroeconomic policies on increasing the social-health inequality were identified. The result of TOPSIS approved that the inflation and economic instability exert the greatest impact on social-health inequality, with an index of 0.710 and the government policy in paying the subsidies with a 0.291 index has the lowest impact on social-health inequality in the country.

DISCUSSION

It is required to invest on the social determinants of health as a priority to reduce health inequality. Also, evaluating the extent to which the future macroeconomic policies impact the health of population is necessary.

Worksite health and wellness programs in India

Worksite health and wellness (WH&W) are gaining popularity in targeting cardiovascular (CV) risk factors among various industries. India is a large country with a larger workforce in the unorganized sector than the organized sector. This imbalance creates numerous challenges and barriers to implementation of WH&W programs in India. Large scale surveys have identified various CV risk factors across various industries. However, there is scarcity of published studies focusing on the effects of WH&W programs in India. This paper will highlight: 1) the current trend of CV risk factors across the industrial community, 2) the existing models of delivery for WH&W in India and their barriers, and 3) a concise evidence based review of various WH&W interventions in India.