The rise of chronic non-communicable diseases in southeast Asia: time for action

Barriers and facilitators of primary care management of type II diabetes mellitus in the West African sub-region: A scoping review

The prevalence of diabetes is rising rapidly across West Africa, posing a significant public health challenge. Effective diabetes management through accessible and quality primary healthcare is crucial, yet multiple barriers persist. This review aimed to synthesise the available evidence on factors influencing access, utilisation, and quality of diabetes primary care in West Africa. Following Arksey and O'Malley's framework and PRISMA-ScR guidelines, we searched four electronic databases (PubMed, Scopus, Google Scholar, CAIRN Info) and grey literature sources. Eligibility criteria included: peer-reviewed studies published between 2000-2023 in English or French; primary research focusing on adult type II diabetes care in West African countries; and studies reporting on factors affecting access, utilisation, or quality of primary healthcare. Data were extracted using a standardised form and analysed through framework synthesis integrating the WHO Primary Health Care Framework, Social Determinants of Health model, and Innovative Care for Chronic Conditions model. Twelve studies were included from Nigeria (n=7), Ghana (n=4), and Senegal (n=1). Key barriers to access, utilisation, and quality were identified as health system deficiencies, including inadequate infrastructure, workforce shortages, supply gaps, fragmented coordination of care, absence of standardised guidelines, high costs of care, and inefficient leadership/governance for chronic disease management. Broader determinants of health, such as poverty, gender, cultural beliefs, reliance on traditional medicine, and health policy gaps, significantly influenced access to and utilisation of care. Individual-level barriers like psychological distress and delays in care-seeking were also significant. Family/social support systems emerged as potential facilitators of accessing and utilising PHC services. Our review identified that to improve diabetes care, West Africa needs context-specific models that align indigenous healing practices with PHC, strengthen health systems, and address sociocultural determinants. Future research should focus on developing and evaluating culturally resonant interventions that can navigate both biomedical and sociocultural factors shaping diabetes management in resource-constrained settings.

Knowledge, Attitude, and Practice Regarding High Salt Intake and Association With Hypertension Among Rural Women in Chandpur District of Bangladesh

Background and Aims

The human body requires a relatively little quantity of sodium to transmit nerve impulses, contract and relax muscles, and maintain appropriate water and mineral balance and which is typically added from diets. The study aimed to assess the level of knowledge, attitude, and practice regarding high salt intake and their association with hypertension among rural women of a selected community in Chandpur.

Methods

A cross-sectional study was adopted to collect data from 250 households of Chandpur district. The study was conducted during May 2022 to July 2022. The semi-structured pretested WHO-modified step-wise approach to the non-communicable disease risk factor surveillance (STEPS). Instrument version 3.1 module was used to administer the knowledge, attitude and practice questionnaire to assess the knowledge, attitude and practice of the participants. Binary logistic regression was performed to examine the factor related with knowledge, attitude, and practices.

Results

The result gives evidence that participant who added always salt to their meals were three times more likely to be hypotensive (AOR: 2.99; CI: 1.40, 6.42). Besides, participants who avoid eating outside are significantly less likely (AOR: 0.19; C.I: 0.05 to 0.70) to be hypertensive.

Conclusion

Findings showed that daily salt consumption and "avoid eating out" were significantly associated with hypertension status. These findings imply that further educational intervention is needed to increase understanding of healthy dietary salt intake among rural women.

Frequency of Lower Lung Field Tuberculosis in Diabetes Mellitus Patients Attending Tertiary Care Hospital in Bangladesh: A Cross-Sectional Study

Background and Aims

People who have diabetes mellitus (DM) are thought to be more susceptible to pulmonary tuberculosis (PTB). Several published comparative investigations have reported that chest x-ray images from PTB with DM are considered atypical due to their frequent involvement of the lower lung field (LLF). This study aimed to investigate the frequency of lower lung field tuberculosis (LLF-TB) in DM and the risk factor of DM for the development of TB.

Methods

This study was a cross-sectional study. PTB was diagnosed by positive sputum acid-fast bacilli (AFB),/Culture,/Gene Xpert MTB/RIF, and DM, which was proven by taking oral hypoglycemic drugs or receiving insulin at the time of hospital admission. Extrapulmonary tuberculosis and seropositive human immunodeficiency virus (HIV) were excluded from this study. A chest x-ray posterior-anterior (P/A) view was done to assess the frequency and patterns of lung involvement. Logistic regression analysis was performed to evaluate the risk factor of DM for the development of TB.

Results

A total of 117 PTB-DM participants were studied in this study. The mean age and frequency of isolated LLF-TB were 53.17 ± 14.38 years and 20.5%, respectively. The prevalence of LLF-TB and other radiological patterns were statistically significantly correlated with smear positivity (83.3% vs. 20.4%), erythrocyte sedimentation rate (ESR) > 50 mm (95.8% vs. 16.1%), and HbA1c > 7 (79.2% vs. 16.1%). Regression analysis showed that the odds ratio (OR) was 6.81 and 3.93 for DM and age (> 40 years) for the development of LLF-TB (p < 0.05).

Conclusion

The frequency of LLF-TB among PTB DM patients was around 1/5th. The development of LLF-TB was substantially associated with DM and age greater than 40 years.

Food consumption and dyslipidemia in middle-aged adults in Indonesia: A cross-sectional national study

Background: Most people with abnormal lipid profiles are found in middle-aged adults in Indonesia. Unhealthy food consumption was positively associated with dyslipidemia. In contrast, healthy food consumption, including fruits and vegetables, was inversely associated with dyslipidemia. Aim: The aim of the study was to explore the association between food consumption with dyslipidemia among middle-aged adults in Indonesia. Methods: This is a cross-sectional study using secondary data from the national representative survey of Indonesian Basic Health Research (IBHR) conducted by the National Institute of Health Research Development (NIHRD), Ministry of Health, Indonesia, in 2018. The study recruited 10,608 participants aged from 45 to 59 years old. An unadjusted or adjusted odds ratio (OR) and 95% confidence intervals (CIs), and a multivariate logistic regression model were performed to evaluate the associations of food consumption with dyslipidemia. Results: Frequent consumption of barbecue and soft drink was significantly correlated with dyslipidemia (OR = 1.149, CI: 1.055-1.251 and OR = 1.202, CI: 1.041-1.388). Frequent consumption of soft drink, and inadequate intakes of fruits and vegetables were significantly correlated with dyslipidemia (OR = 1.254, CI: 1.012-1.553, OR = 1.178, CI: 1.013-1.388, OR = 1.219, CI: 1.011-1.471, respectively) in men. While, frequent consumption of barbecue was significantly correlated with dyslipidemia (OR = 1.203, CI: 1.068-1.355) in women. Conclusion: Frequent consumption of barbecue and soft drink increased the risk of developing dyslipidemia among middle-aged adults in Indonesia.

Psychometric testing of the Thai version of Caregiver Contribution to Self-Care of Chronic Illness Inventory version 2

AIM

To assess the psychometric properties of the Thai version of Caregiver Contribution to Self-Care of Chronic Illness Inventory version 2 (CC-SC-CII-v2) among primary caregivers of individuals with any single or multiple chronic illnesses.

BACKGROUND

The instrument encompasses three scales that evaluate Caregiver Contribution to Self-Care (CC-SC) Maintenance, Monitoring and Management.

METHODS

The English version CC-SC-CII-v2 was translated and adapted for Thai context, and a cross-sectional multicenter study involved 430 caregivers from 16 primary care centres in Thailand. Structural validity, internal consistency reliability and test-retest reliability were examined.

RESULTS

The original two-factor CC-SC Maintenance scale required a re-specified model for good fit, while the CC-SC Monitoring and CC-SC Management scales fit well. The simultaneous model of three scales demonstrated satisfactory fit. The CC-SC Maintenance and CC-SC Management scales both had a composite reliability index of 0.85, with omega coefficients of 0.86 and 0.83, respectively. CC-SC Monitoring had an alpha coefficient of 0.89. The intraclass correlation coefficients ranging from 0.84 to 0.91, indicating good test-retest reliability.

CONCLUSION

The Thai CC-SC-CII-v2 is a valid and reliable instrument that can provide clinicians and investigators with an evaluation of the contributions of caregivers to the self-care of patients with chronic illnesses.

Shifting Trend of Protein Consumption in Southeast Asia: Toward Health, Innovation, and Sustainability

Complementing discourse following a February 2023 event on dietary protein needs in Southeast Asia (SEA), this symposium report summarizes the region's protein intake, while simultaneously examining the impact of dietary shift toward complementary and alternative proteins and their health implications. It highlights the importance of protein quality in dietary evaluations, optimal intake, and sustainability, advocating for environmentally conscious protein production and innovation in future foods. Discussion points, expert opinions, national nutrition data, and relevant literature, addressing protein intake and quality, their impact on human health, and various technologies for future foods production, have been included. Despite increased protein supply in SEA, protein requirements, particularly during crucial life stages, are often unmet owing to insufficient focus on protein quality. Factoring in amino acids content and bioaccessibility are crucial for assessing nutritional requirement and sustainability evaluations, rather than solely relying on protein quantity alone. Different food sources of protein also have different key conutrients for health relevance such as vitamin B-12 and ω-3 fatty acids. Innovations in food structure, processing, and technology are key to developing nutritious, sustainable, and appealing future foods, including from complementary and alternative protein sources, while considering safety aspects, especially allergenicity. Addressing protein needs in SEA requires a dual focus on protein quantity and quality, underlining the role of public health policies and guidelines that consider key nutritional differences of animal-source and plant-based proteins. To address regional demands, future food innovations should aim at creating unique yet needful food categories or supplementing current existing sources, rather than mimicking current products.

The spectrum of health conditions in community-based cross-sectional surveys in Southeast Asia 2010-21: a scoping review

BACKGROUND

Southeast Asia is undergoing an epidemiological transition with non-communicable illnesses becoming increasingly important, yet infectious diseases (tuberculosis, HIV, hepatitis B, malaria) remain widely prevalent in some populations, while emerging and zoonotic diseases threaten. There are also limited population-level estimates of many important heath conditions. This restricts evidence-based decision-making for disease control and prevention priorities. Cross-sectional surveys can be efficient epidemiological tools to measure the prevalence of a wide range of diseases, but no systematic assessment of their coverage of different health conditions has been produced for the region.

METHODS

We conducted a systematic search in Medline, Embase, Global Health, CINAHL, Scopus, Web of Science Core Collection, and Global Index Medicus, and additionally Google Scholar. Our inclusion criteria were cross-sectional surveys conducted with community-based recruitment, in Bangladesh, Cambodia, Laos, Myanmar, and Thailand, published between January 1, 2010 and January 27, 2021, and reporting the prevalence of any health condition.

RESULTS

542 publications from 337 surveys were included. Non-communicable conditions (n = 205) were reported by more surveys than infectious conditions (n = 124). Disability (n = 49), self-report history of any disease or symptoms (n = 35), and self-perceived health status (n = 34), which reflect a holistic picture of health, were studied by many fewer surveys. In addition, 45 surveys studied symptomatic conditions which overlap between non-communicable and infectious conditions. The most surveyed conditions were undernutrition, obesity, hypertension, diabetes, intestinal parasites, malaria, anemia, diarrhea, fever, and acute respiratory infections. These conditions overlap with the most important causes of death and disability in the Global Burden of Disease study. However, other high-burden conditions (e.g. hearing loss, headache disorder, low back pain, chronic liver and kidney diseases, and cancers) were rarely studied.

CONCLUSION

There were relatively few recent surveys from which to estimate representative prevalences and trends of health conditions beyond those known to be high burden. Expanding the spectrum of health conditions in cross-sectional surveys could improve understanding of evolving disease patterns in the region.

Defining the hidden burden of disease in rural communities in Bangladesh, Cambodia and Thailand: a cross-sectional household health survey protocol

INTRODUCTION

In low-income and middle-income countries in Southeast Asia, the burden of diseases among rural population remains poorly understood, posing a challenge for effective healthcare prioritisation and resource allocation. Addressing this knowledge gap, the South and Southeast Asia Community-based Trials Network (SEACTN) will undertake a survey that aims to determine the prevalence of a wide range of non-communicable and communicable diseases, as one of the key initiatives of its first project-the Rural Febrile Illness project (RFI). This survey, alongside other RFI studies that explore fever aetiology, leading causes of mortality, and establishing village and health facility maps and profiles, will provide an updated epidemiological background of the rural areas where the network is operational.

METHODS AND ANALYSIS

During 2022-2023, a cross-sectional household survey will be conducted across three SEACTN sites in Bangladesh, Cambodia and Thailand. Using a two-stage cluster-sampling approach, we will employ a probability-proportional-to-size sample method for village, and a simple random sample for household, selection, enrolling all members from the selected households. Approximately 1500 participants will be enrolled per country. Participants will undergo questionnaire interview, physical examination and haemoglobin point-of-care testing. Blood samples will be collected and sent to central laboratories to test for chronic and acute infections, and biomarkers associated with cardiovascular disease, and diabetes. Prevalences will be presented as an overall estimate by country, and stratified and compared across sites and participants' sociodemographic characteristics. Associations between disease status, risk factors and other characteristics will be explored.

ETHICS AND DISSEMINATION

This study protocol has been approved by the Oxford Tropical Research Ethics Committee, National Research Ethics Committee of Bangladesh Medical Research Council, the Cambodian National Ethics Committee for Health Research, the Chiang Rai Provincial Public Health Research Ethical Committee. The results will be disseminated via the local health authorities and partners, peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

NCT05389540.

Trends and disparities in non-communicable diseases in the Western Pacific region

The WHO Western Pacific region bears disproportionate deaths from non-communicable diseases (NCDs), with increased overall NCD proportional mortality over the past two decades. The disease burden of mental health increased, resulting from rapid ageing, enhanced stress, and the COVID-19 pandemic, but it was largely neglected. The highly diverse cultures, religions, political systems, socioeconomic contexts, lifestyles, and environmental factors probably have led to massive disparities across countries in NCD mortality, risk factors, and NCD management. Geographically, East Asia had the lowest NCD mortality whilst Pacific islands had the highest. Economic booms, ageing, nutrition transition, social stress, prevalent tobacco use, and fast-increasing obesity and hyperglycaemia are important drivers of NCDs. Men tended to have more adverse behavioural and metabolic risk factors. Rural residents are catching up with their urban counterparts in metabolic risk factors and conditions. Sustainable strategies tailored to NCD patterns are needed to fight the NCD epidemic and related disparities.

Accessibility and utilization of healthcare services among diabetic patients: Is diabetes a poor man's ailment?

Diabetes is a non-communicable ailment that has adverse effects on the individual's overall well-being and productivity in society. The main objective of this study was to examine the empirical literature concerning the association between diabetes and poverty and the accessibility and utilization of medical care services among diabetic patients. The diabetes literature was explored using a literature review approach. This review revealed that diabetes is an ailment that affects all individuals irrespective of socioeconomic status; however, its pre-valence is high in low-income countries. Hence, despite the higher prevalence of diabetes in developing countries compared with developed countries, diabetes is not a poor man's ailment because it affects individuals of all incomes. While the number of diabetic patients that access and utilize diabetes medical care services has increased over the years, some personal and institutional factors still limit patients' access to the use of diabetes care. Also, there is a lacuna in the diabetes literature concerning the extent of utilization of available healthcare services by diabetic patients.

Exploring views and experiences of the general public's adoption of digital technologies for healthy lifestyle in Singapore: a qualitative study

Objective

Little is known about the general adult population's adoption of digital technology to support healthy lifestyle, especially when they are expected to take greater personal responsibility for managing their health and well-being today. The current qualitative study intended to gain an in-depth understanding of determinants of digital technology adoption for healthy lifestyle among community-dwelling adults in Singapore.

Design

A qualitative study design, with thematic framework analysis was applied to develop themes from the data.

Setting

Semi-structured individual interviews were conducted with participants either face-to-face or online through a videoconferencing platform.

Participants

14 women and 16 men from the general population who were between the ages of 22 and 71 years.

Results

Three major themes were developed: (1) digitally disempowered (2) safety and perceived risks and harm; (3) cultural values and drives. Adoption of technology among the general population is needs-driven, and contingent on individual, technological and other cross-cultural contextual factors.

Conclusion

Our findings highlight there is no one solution which fits all individuals, emphasizing the challenges of catering to diverse groups to reduce barriers to adoption of digital technologies for healthy lifestyle. Digital guidance and training, as well as social influences, can motivate technological adoption in the population. However, technical problems as well as data security and privacy concerns should first be adequately addressed. This study provides rich cross-cultural insights and informs policy-making due to its alignment with government public health initiatives to promote healthy lifestyle.

Health systems efficiency in China and ASEAN, 2015-2020: a DEA-Tobit and SFA analysis application

OBJECTIVE

To evaluate the health systems efficiency in China and Association of Southeast Asian Nations (ASEAN) countries from 2015 to 2020.

DESIGN

Health efficiency analysis using data envelopment analysis (DEA) and stochastic frontier approach analysis.

SETTING

Health systems in China and ASEAN countries.

METHODS

DEA-Malmquist model and SFA model were used to analyse the health system efficiency among China and ASEAN countries, and the Tobit regression model was employed to analyse the factors affecting the efficiency of health system among these countries.

RESULTS

In 2020, the average technical efficiency, pure technical efficiency and scale efficiency of China and 10 ASEAN countries' health systems were 0.700, 1 and 0.701, respectively. The average total factor productivity (TFP) index of the health systems in 11 countries from 2015 to 2020 was 0.962, with a decrease of 1.4%, among which the average technical efficiency index was 1.016, and the average technical progress efficiency index was 0.947. In the past 6 years, the TFP index of the health system in Malaysia was higher than 1, while the TFP index of other countries was lower than 1. The cost efficiency among China and ASEAN countries was relatively high and stable. The per capita gross domestic product (current US$) and the urban population have significant effects on the efficiency of health systems.

CONCLUSIONS

Health systems inefficiency is existing in China and the majority ASEAN countries. However, the lower/middle-income countries outperformed high-income countries. Technical efficiency is the key to improve the TFP of health systems. It is suggested that China and ASEAN countries should enhance scale efficiency, accelerate technological progress and strengthen regional health cooperation according to their respective situations.

Improving the technical efficiency of public health centers in Cambodia: a two-stage data envelopment analysis

BACKGROUND

Cambodia is undergoing a series of reforms with the objective of reaching universal health coverage. Information on the causes of inefficiencies in health facilities could pave the way for a better utilization of limited resources available to ensure the best possible health care for the population.

OBJECTIVES

The purpose of this study is to evaluate the technical efficiency of health centers and the determinants for inefficiencies.

METHODS

This cross-sectional study used secondary data from a costing study on 43 health centers in six Cambodian provinces (2016-2017). Firstly, the Data Envelopment Analysis method with output-orientation was applied to calculate efficiency scores by selecting multiple input and output variables. Secondly, a tobit regression was performed to analyze potential explanatory variables that could influence the inefficiency of health centers.

RESULTS

Study findings showed that 18 (43%) health centers were operating inefficiently with reference to the variable returns to scale efficiency frontier and had a mean pure technical efficiency score of 0.87. Overall, 22 (51%) revealed deficits in producing outputs at an optimal scale size. Distance to the next referral hospital, size and quality performance of the health centers were significantly correlated with health center inefficiencies.

CONCLUSION

Differences in efficiency exist among health centers in Cambodia. Inefficient health centers can improve their technical efficiency by increasing the utilization and quality of health services, even if it involves higher costs. Technical efficiency should be continuously monitored to observe changes in health center performance over time.

Prognostic Nutritional Index (PNI) as a potential predictor and intervention target for perioperative ischemic stroke: a retrospective cohort study

BACKGROUND

The prognostic nutritional index (PNI) is a nutritional indicator and predictor of various diseases. However it is unclear whether PNI can be a predictor of perioperative ischemic stroke. This study aims to evaluate the association of the preoperative PNI and ischemic stroke in patients undergoing non-cardiac surgery.

METHODS

The retrospective cohort study included patients who underwent noncardiac surgery between January 2008 and August 2019. The patients were divided into PNI ≥ 38.8 and PNI < 38.8 groups according to the cut-off value of PNI. Univariate and multivariate logistic regression analyses were performed to explore the association between PNI and perioperative ischemic stroke. Subsequently, propensity score matching (PSM) analysis was performed to eliminate the confounding factors of covariates and further validate the results. Subgroup analyses were completed to assess the predictive utility of PNI for perioperative ischemic stroke in different groups.

RESULTS

Amongst 221,542 hospitalized patients enrolled, 485 (0.22%) experienced an ischemic stroke within 30 days of the surgery, 22.1% of patients were malnourished according to PNI < 38.8, and the occurrence of perioperative ischemic stroke was 0.34% (169/49055) in the PNI < 38.8 group. PNI < 38.8 was significantly associated with an increased incidence of perioperative ischemic stroke whether in univariate logistic regression analysis (OR = 1.884, 95% CI: 1.559-2.267, P < 0.001) or multivariate logistic regression analysis (OR = 1.306, 95% CI: 1.061-1.602, P = 0.011). After PSM analysis, the ORs of PNI < 38.8 group were 1.250 (95% CI: 1.000-1.556, P = 0.050) and 1.357 (95% CI: 1.077-1.704, P = 0.009) in univariate logistic regression analysis and multivariate logistic regression analysis respectively. The subgroup analysis indicated that reduced PNI was significantly associated to an increased risk of perioperative ischemic stroke in patients over 65 years old, ASA II, not taking aspirin before surgery, without a history of stroke, who had neurosurgery, non-emergency surgery, and were admitted to ICU after surgery.

CONCLUSIONS

Our study indicates that low preoperative PNI is significantly associated with a higher incidence of ischemic stroke in patients undergoing non-cardiac surgery. Preoperative PNI, as a preoperative nutritional status evaluation index, is an independent risk factor useful to predict perioperative ischemic stroke risk, which could be used as an intervenable preoperative clinical biochemical index to reduce the incidence of perioperative ischemic stroke.

Cross-cultural adaptation and psychometric evaluation of the Thai version of Self-Care of Chronic Illness Inventory Version 4.c

Objectives

To translate and validate the Thai Self-Care of Chronic Illness Inventory version 4.c (Thai SC-CII v4.c) in individuals with chronic illnesses.

Methods

A scale translation and cross-sectional validation study was conducted. The English version was translated for Thai involved nine steps: preparation, forward translation, reconciliation, back-translation, back-translation review, harmonization, cognitive debriefing, review of cognitive debriefing and finalization, and proofreading. A cross-sectional study was conducted from July to November 2022 at 16 primary care centers in southern Thailand, involving 410 participants with at least one chronic condition. Validity assessments included structural, convergent, and discriminant validity. Concurrent validity examined correlations between SC-CII v4.c with the Self-Care Self-Efficacy Scale (SCSES) and self-perceived health. Internal coherence reliability was calculated using Cronbach's α coefficient, item-total correlation coefficients, and the composite reliability (CR) index.

Results

Thai SC-CII v4.c demonstrated excellent translational validity (κ = 0.99). The specified Self-Care Maintenance model fit well, with minor differences in health promoting behavior and illness-related behavior items compared to the original model. The original Self-Care Monitoring, and Self-Care Management models fit well with Thai data. Simultaneous confirmatory factor analysis confirmed a satisfactory fit of the full SC-CII v4.c. Convergent validity had partial support (average variance extracted = 0.23-0.51), and discriminant validity was established (heterotrait-monotrait ratios = 0.37-0.88). Concurrent validity was supported by positive correlations between each scale and overall SC-CII v.4c with SCSES (r = 0.25-0.65) and self-perceived health (r = 0.09-0.35). The Cronbach's α coefficient were adequate for all scales except the Self-Care Maintenance scale (Cronbach's α = 0.68), but the CR estimate improved the reliability of all three scales (ranging 0.80-0.82). All items had satisfactory item-total correlation coefficients (ranging 0.34-0.71), except the one pertaining to sleep.

Conclusions

The Thai SC-CII v4.c is valid and reliable for assessing self-care in various chronic illnesses. Further testing is recommended for patients with specific diseases.

Risk Factors of Secondary Cardiovascular Events in a Multi-Ethnic Asian Population with Acute Myocardial Infarction: A Retrospective Cohort Study from Malaysia

This retrospective cohort study investigated the incidence and risk factors of major adverse cardiovascular events (MACE) after 1 year of first-documented myocardial infarctions (MIs) in a multi-ethnic Asian population. Secondary MACE were observed in 231 (14.3%) individuals, including 92 (5.7%) cardiovascular-related deaths. Both histories of hypertension and diabetes were associated with secondary MACE after adjustment for age, sex, and ethnicity (HR 1.60 [95%CI 1.22-2.12] and 1.46 [95%CI 1.09-1.97], respectively). With further adjustments for traditional risk factors, individuals with conduction disturbances demonstrated higher risks of MACE: new left-bundle branch block (HR 2.86 [95%CI 1.15-6.55]), right-bundle branch block (HR 2.09 [95%CI 1.02-4.29]), and second-degree heart block (HR 2.45 [95%CI 0.59-10.16]). These associations were broadly similar across different age, sex, and ethnicity groups, although somewhat greater for history of hypertension and BMI among women versus men, for HbA1c control in individuals aged >50 years, and for LVEF ≤ 40% in those with Indian versus Chinese or Bumiputera ethnicities. Several traditional and cardiac risk factors are associated with a higher risk of secondary major adverse cardiovascular events. In addition to hypertension and diabetes, the identification of conduction disturbances in individuals with first-onset MI may be useful for the risk stratification of high-risk individuals.

Elevated visceral adiposity index is associated with increased stroke prevalence and earlier age at first stroke onset: Based on a national cross-sectional study

Objective

The purpose of this study was to examine the association between the VAI (visceral adiposity index) and stroke prevalence and age at stroke in US adults.

Methods

We examined the association between VAI and stroke prevalence and age at stroke using logistic regression, subgroup analysis, and dose-response curves using participants from the National Health and Nutrition Examination Survey (NHANES) database from 2007-2018.

Results

This study ultimately included 29,337 participants aged >20 years, of whom 1022 self-reported a history of stroke, and after adjusting for all confounders, each unit increase in corrected VAI was associated with a 12% increase in the prevalence of stroke (OR= 1.12, 95% CI: 1.01, 1.24) along with an earlier age at stroke 1.64 years (β= -1.64, 95% CI: -2.84, -0.45), stratified analysis showed that the prevalence of stroke was 20% higher in the female group (OR= 1.20, 95% CI: 1.04, 1.39), black group (OR= 1.22, 95% CI: 1.01, 1.48), age ≤60 years group (OR= 1.25, 95% CI: 1.05, 1.48), hypertensive group (OR=1.15, 95% CI:1.01, 1.31), and diabetic group (OR=1.23, 95% CI:1.02, 1.48) VAI increase was positively correlated with stroke prevalence increase. The dose-response curves showed a positive linear correlation between increased VAI and stroke prevalence, while a negative linear correlation was observed between increased VAI and age at stroke.

Conclusion

Although a causal relationship cannot be proven, higher VAI was positively associated with stroke prevalence and can lead to earlier stroke onset.

Pharmacy students' preparation to provide pharmaceutical care for patients with non-communicable diseases in six ASEAN countries: A qualitative study

INTRODUCTION

Pharmacy education programs prepare graduates to promote health for patients with noncommunicable disease (NCDs), but there is limited information concerning Association of South East Asia Nations (ASEAN) countries. The study aim was to synthesize academic staff's, alumni's, and alumni supervisors' perspectives on preparation for students to provide pharmaceutical care in NCDs.

METHODS

A qualitative research design was used. In-depth interviews with structured questions following the Context, Input, Process, and Product/Outcomes model framework were conducted with four academic staff, three alumni, and three alumni supervisors from six study sites in six countries. Interview questions were constructed in Thai and translated to English by using forward and backward translation. Verbatim transcriptions were used to perform thematic analysis with investigator triangulation.

RESULTS

Sixty participants were included. The context showed three main themes related to Burden of NCDs, Pharmacist Roles in NCDs, and Goals. The input showed three main themes of Teaching Methods, Development Plans for Academic Staff, and Budgets and Infrastructure. The process showed one main theme of Struggles in Teaching Methods. The outcomes/outputs showed three main themes of Individual, Organizational, and Professional Levels. Schools need curricula that focus on NCDs, pharmacist competency and skills, and academic preparation of students for practice. Gaps limiting achievement of goals included lack of well-trained academic staff, limited learning facilities, self-learning opportunities, acceptance from other health professionals, and career ladders.

CONCLUSIONS

The preparation of pharmacy students varied in six ASEAN countries. Pharmacy education programs must address existing gaps that limit achievement of goals related to NCDs.

Vitamin D deficiency in South-East Asian children: a systematic review

OBJECTIVE

To describe the prevalence and determinants of vitamin D deficiency (VDD) among healthy children aged between 0 and 18 years living in South-East Asia (SEA).

DESIGN

We systematically searched Ovid MEDLINE and Ovid EMBASE for observational studies assessing VDD among healthy children in the SEA region as the primary or secondary outcome from database inception to 6 April 2021. PubMed was used for e-pubs and publications not indexed in Medline. Publications that included abstracts in English were included. We performed a systematic review to describe the prevalence of VDD in SEA children.

RESULTS

Our initial search identified 550 publications with an additional 2 publications from manual screening. Of those, 21 studies from 5 different countries (Thailand, Indonesia, Vietnam, Malaysia and Cambodia) were summarised and included in forest plots. The prevalence of VDD (<50 nmol/L) ranged from 0.9% to 96.4%, with >50% of newborns having VDD, and severe VDD (<30 nmol/L) ranged from 0% to 55.8%. Female sex and urban living were the most common determinants of VDD.

CONCLUSIONS

VDD among healthy children living in the SEA region is common. Efforts to detect VDD and the implementation of preventive measures, including education on safe sun exposure and oral vitamin D supplementation or food fortification, should be considered for key target groups, including adolescent females and pregnant and lactating women to improve the vitamin D status of newborns.

PROTOCOL REGISTRATION NUMBER

This study is registered with PROSPERO (CRD42020181600).

Prevalence, determinants and outcomes of traditional, complementary and alternative medicine use for hypertension among low-income households in Malaysia and the Philippines

BACKGROUND

Traditional, complementary and alternative medicine (TCAM) is used to treat a broad range of conditions. In low- and middle-income countries (LMICs), TCAM use is particularly common among those with low socio-economic status. To better understand the patterns and impact of TCAM use on the management of non-communicable diseases in these populations, this study examines the prevalence and characteristics of TCAM use for hypertension, its determinants, and its association with hypertension management outcomes and wellbeing among low-income adults in two Southeast Asian countries at different levels of economic and health system development, Malaysia and the Philippines.

METHODS

We analysed cross-sectional data from 946 randomly selected adults diagnosed with hypertension from low-income rural and urban communities in Malaysia (n = 495) and the Philippines (n = 451). We compared the prevalence, characteristics and household expenditure on TCAM use between countries and used multi-level, mixed-effects regression to estimate associations between TCAM use and its determinants, and five hypertension management outcomes and wellbeing.

RESULTS

The prevalence of TCAM use to manage hypertension was higher in the Philippines than in Malaysia (18.8% vs 8.8%, p < 0.001). Biologically-based modalities, e.g. herbal remedies, were the most common type of TCAM used in both countries, mainly as a complement, rather than an alternative to conventional treatment. Households allocated around 10% of health spending to TCAM in both countries. Belief that TCAM is effective for hypertension was a positive predictor of TCAM use, while belief in conventional medicine was a negative predictor. TCAM use was not strongly associated with current use of medications for hypertension, self-reported medication adherence, blood pressure level and control, or wellbeing in either country.

CONCLUSIONS

A small, but significant, proportion of individuals living in low-income communities in Malaysia and the Philippines use TCAM to manage their hypertension, despite a general lack of evidence on efficacy and safety of commonly used TCAM modalities. Recognising that their patients may be using TCAM to manage hypertension will enable health care providers to deliver safer, more patient-centred care.

The relative impact of underweight, overweight, smoking, and physical inactivity on health and associated costs in Indonesia: propensity score matching of a national sample

Background

Indonesia is in the middle of a rapid epidemiological transition with an ageing population and increasing exposure to risk factors for chronic conditions. This study examines the relative impacts of obesity, tobacco consumption, and physical inactivity, on non-communicable diseases multimorbidity, health service use, catastrophic health expenditure (CHE), and loss in employment productivity in Indonesia.

Methods

Secondary analyses were conducted of cross-sectional data from adults aged ≥ 40 years (n = 12,081) in the Indonesian Family Life Survey 2014/2015. We used propensity score matching to assess the associations between behavioural risk factors and health service use, CHE, employment productivity, and multimorbidity.

Results

Being obese, overweight and a former tobacco user was associated with a higher number of chronic conditions and multimorbidity (p < 0.05). Being a former tobacco user contributed to a higher number of outpatient and inpatient visits as well as CHE incidences and work absenteeism. Physical inactivity relatively increased the number of outpatient visits (30% increase, p < 0.05) and work absenteeism (21% increase, P < 0.06). Although being underweight was associated with an increased outpatient care utilisation (23% increase, p < 0.05), being overweight was negatively associated with CHE incidences (50% decrease, p < 0.05).

Conclusion

Combined together, obesity, overweight, physical inactivity and tobacco use contributed to an increased number of NCDs as well as medical costs and productivity loss in Indonesia. Interventions addressing physical and behavioural risk factors are likely to have substantial benefits for individuals and the wider society in Indonesia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08546-6.

Co-occurrence of non-communicable disease risk factors and its determinants among school-going adolescents of Kathmandu Metropolitan City

Background

Adolescence is a critical transition in human growth and adolescents tend to engage in various risky behaviors which are likely to continue into adulthood. Co-occurrence of non-communicable disease risk factors has the potential to increase risks of chronic disease comorbidity and increased mortality in later life. Behavioral risk factors are adopted due to changes in lifestyle and adolescents are more prone to acquire them. This study aimed to determine the prevalence and associated factors of co-occurrence of non-communicable disease risk factors among school-going adolescents of Kathmandu Metropolitan City.

Methods

We conducted a cross-sectional study among school-going adolescents of Kathmandu Metropolitan City in January/February 2020. We used stratified random sampling to select 1108 adolescents studying in 9, 10, 11, and 12 grades. We used Global Schools Health Survey tools to collect data. We entered data in EpiData 3.1 and exported it into Statistical Package for Social Science (SPSS) version 20 for statistical analysis. We estimated prevalence of NCDs risk factors and co-occurrence of risk factors. We applied multivariate multinomial logistic regression analysis adjusting for age, gender, ethnicity, religion, education, type of school, and parental education to determine factors associated with co-occurrence of NCDs risk factors.

Results

The prevalence of physical inactivity, unhealthy diet, harmful use of alcohol and tobacco among school-going adolescents were 72.3% (95%CI: 69.6–74.9), 41.1% (95%CI: 38.2–44.0), 14.8% (95%CI: 12.8–17.0) and 7.8% (95%CI:6.3–9.5) respectively. The adolescent with co-occurrence of two or more risk factors was 40.7% (95%CI: 37.8–43.7). The school-going adolescents who were in higher age group (AOR = 1.72, 95% CI- 1.06, 2.77), Hindus (AOR = 1.78, 95% CI-1.09, 2.89), other than Brahmin/Chhetri by ethnicity (AOR = 2.11, 95% CI-1.39, 2.22) and with lower education level of mothers (AOR = 2.40, 95% CI- 1.46,3.98) were more likely to have co-occurrence of NCDs risk factors after adjusting for all socio-demographic variables.

Conclusion

The co-occurrence of non-communicable disease risk factors was high among school going adolescents and was associated with age, religion, ethnicity and mother’s education. Integrated and comprehensive interventional programs should be developed by concerned authorities.

Systematic review and meta-analysis of prognostic models in Southeast Asian populations with acute myocardial infarction

Background

The cultural and genetic diversity of the Southeast Asian population has contributed to distinct cardiovascular disease risks, incidence, and prognosis compared to the Western population, thereby raising concerns about the accuracy of predicted risks of existing prognostic models.

Objectives

We aimed to evaluate the predictive performances of validated, recalibrated, and developed prognostic risk prediction tools used in the Southeast Asian population with acute myocardial infarction (AMI) events for secondary events

Methods

We searched MEDLINE and Cochrane Central databases until March 2022. We included prospective and retrospective cohort studies that exclusively evaluated populations in the Southeast Asian region with a confirmed diagnosis of an AMI event and evaluated for risk of secondary events such as mortality, recurrent AMI, and heart failure admission. The CHARMS and PRISMA checklists and PROBAST for risk of bias assessment were used in this review.

Results

We included 7 studies with 11 external validations, 3 recalibrations, and 3 new models from 4 countries. Both short- and long-term outcomes were assessed. Overall, we observed that the external validation studies provided a good predictive accuracy of the models in the respective populations. The pooled estimate of the C-statistic in the Southeast Asian population for GRACE risk score is 0.83 (95%CI 0.72–0.90, n = 6 validations) and for the TIMI risk score is 0.80 (95%CI: 0.772–0.83, n = 5 validations). Recalibrated and new models demonstrated marginal improvements in discriminative values. However, the method of predictive accuracy measurement in most studies was insufficient thereby contributing to the mixed accuracy effect. The evidence synthesis was limited due to the relatively low quality and heterogeneity of the available studies.

Conclusion

Both TIMI and GRACE risk scores demonstrated good predictive accuracies in the population. However, with the limited strength of evidence, these results should be interpreted with caution. Future higher-quality studies spanning various parts of the Asian region will help to understand the prognostic utility of these models better.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?%20RecordID=228486.

Diabetes, Hypertension, Atrial Fibrillation and Subsequent Stroke-Shift towards Young Ages in Brunei Darussalam

Southeast Asia harbors a young population of more than 600 million people. Socioeconomic transition within the last decades, driven by globalization and rapid economic growth, has led to significant changes in lifestyle and nutrition in many countries of this region. Hence, an increase in the number of non-communicable diseases is seen in most populations of Southeast Asia. Brunei Darussalam is the smallest country in this region, with a population of around 400,000 inhabitants. Vast hydrocarbon resources have transformed Brunei into a wealthy industrialized country within the last few decades. We compared the age distribution and prevalence of cardiovascular risk factors in ischemic stroke patients between the only stroke unit in Brunei Darussalam and a tertiary stroke center from Frankfurt/Germany. Between 2011 and 2016, a total number of 3877 ischemic stroke patients were treated in both institutions. Even after adjusting for age due to different population demographics, stroke patients in Brunei were younger compared to their German counterparts. The prevalence of hypertension and diabetes mellitus was significantly higher in young age groups in Brunei, whereas no difference was observed for older patients. The rapid socioeconomic transition might be a significant risk factor for the development of non-communicable diseases, including stroke.

A Guideline for Contextual Adaptation of Community-Based Health Interventions

In Southeast Asia, community-based health interventions (CBHIs) are often used to target non-communicable diseases (NCDs). CBHIs that are tailored to sociocultural aspects of health and well-being: local language, religion, customs, traditions, individual preferences, needs, values, and interests, may promote health more effectively than when no attention is paid to these aspects. In this study, we aimed to develop a guideline for the contextual adaption of CBHIs. We developed the guideline in two stages: first, a checklist for contextual and cultural adaptation; and second, a guideline for adaptation. We performed participatory action research, and used the ‘Appraisal of Guidelines for Research & Evaluation (AGREE) II’ tool as methodological basis to develop the guideline. We conducted a narrative literature review, using a conceptual framework based on the six dimensions of ‘Positive Health’ and its determining contexts to theoretically underpin a checklist. we pilot tested a draft version of the guideline and included a total of 29 stakeholders in five informal meetings, two stakeholder meetings, and an expert review meeting. This yielded a guideline, addressing three phases: the preparation phase, the assessment phase, and the adoption phase, with integrated checklists comprising 34 cultural and contextual aspects for the adaption of CBHIs based on general health directives or health models. The guideline provides insight into how CBHIs can be tailored to the health perspectives of community members, and into the context in which the intervention is implemented. This tool can help to effect behavioral change, and improve the prevention and management of NCDs.

Network characteristics of a referral system for patients with hypertension in Western Kenya: results from the Strengthening Referral Networks for Management of Hypertension Across the Health System (STRENGTHS) study

BACKGROUND

Health system approaches to improve hypertension control require an effective referral network. A national referral strategy exists in Kenya; however, a number of barriers to referral completion persist. This paper is a baseline assessment of a hypertension referral network for a cluster-randomized trial to improve hypertension control and reduce cardiovascular disease risk.

METHODS

We used sociometric network analysis to understand the relationships between providers within a network of nine geographic clusters in western Kenya, including primary, secondary, and tertiary care facilities. We conducted a survey which asked providers to nominate individuals and facilities to which they refer patients with controlled and uncontrolled hypertension. Degree centrality measures were used to identify providers in prominent positions, while mixed-effect regression models were used to determine provider characteristics related to the likelihood of receiving referrals. We calculated core-periphery correlation scores (CP) for each cluster (ideal CP score = 1.0).

RESULTS

We surveyed 152 providers (physicians, nurses, medical officers, and clinical officers), range 10-36 per cluster. Median number of hypertensive patients seen per month was 40 (range 1-600). While 97% of providers reported referring patients up to a more specialized health facility, only 55% reported referring down to lower level facilities. Individuals were more likely to receive a referral if they had higher level of training, worked at a higher level facility, were male, or had more job experience. CP scores for provider networks range from 0.335 to 0.693, while the CP scores for the facility networks range from 0.707 to 0.949.

CONCLUSIONS

This analysis highlights several points of weakness in this referral network including cluster variability, poor provider linkages, and the lack of down referrals. Facility networks were stronger than provider networks. These shortcomings represent opportunities to focus interventions to improve referral networks for hypertension.

TRIAL REGISTRATION

Trial Registered on ClinicalTrials.gov NCT03543787 , June 1, 2018.

How to dampen the surge of non-communicable diseases in Southeast Asia: insights from a systematic review and meta-analysis

Non-communicable diseases (NCDs), such as diabetes, cancer, cardiovascular diseases and chronic respiratory diseases, have overtaken infectious diseases as the number one cause of death worldwide. The rise of these diseases is especially grave in Southeast Asia, where existing research however falls short on offering guidance on how policy can best prevent and control NCDs in the region. Additionally, low- and middle-income countries in Southeast Asia cannot directly incorporate lessons drawn from interventions in richer countries, since health system capacities and human and financial resources are thoroughly different. Preventive interventions, thus, need to correspond to local capacities and require contextual solutions. In this article, we provide a systematic review of a wide scope of NCD interventions conducted in Southeast Asia to inform about existing intervention designs and to derive sound evidence of their effectiveness. Our literature search results in 51 studies from five Southeast Asian countries from which we can extract 204 estimates. We sort the studies into six intervention categories and analyse them with respect to 23 different health and behavioural outcomes. While we find positive and significant average effects across all six types of interventions, we also document evidence of substantial publication bias. Using a meta-regression approach in which we correct for the publication bias, we instead fail to confirm positive average effects for some interventions. Especially dietary and physical activity interventions fail to achieve improvements in analysed health outcomes, while programs focusing on smoking cessation, on the take-up of preventive screening activities or educating patients on how to cope with NCDs achieve sizeable effects. We also present evidence that the size of the effect differs with the participants' characteristics as well as with design features of the intervention. For local policymakers, the results provide important knowledge on how to address the increasing NCD burden in the coming years.

A Qualitative Study of Pictorial Health Warnings on Malaysian Cigarette Packs: How Do the Adults Understand Them?

The WHO recommended pictorial health warnings (PHWs) on cigarette packs in 2003 to educate and warn the public of smoking effects. Malaysia too has implemented this policy since 2009. This study explored the public’s understanding of the gazetted PHWs depicted on cigarette packs available in Malaysia. A qualitative study using four focus group discussions (FGDs) was conducted among smokers and non-smokers aged 18–40 in Malacca, Peninsular Malaysia. Thematic analyses were performed using the Atlas Ti version 8.0 software. Six themes have emerged reflecting the public’s understanding of the existing PHWs in Malaysia, namely, (i) awareness and exposures, (ii) recall and attention, (iii) perceived goals, (iv) perceived target groups, (v) attitude in understanding, and (vi) knowledge and meaning of PHWs. All participants were aware of the PHWs depicted on legal cigarettes but not seen on most illicit cigarettes. PHWs were perceived to give awareness and warning about the smoking effects targeting smokers and non-smokers. Participants understood the lung and oral health-related images easily than other body parts such as gangrene foot, miscarriages, etc. Besides enforcement on illicit cigarettes without PHWs, policymakers or relevant authorities should emphasize creating relevant and clear pictorial messages in educating the public to avoid confusion affecting the public’s understanding of the PHWs.

Daily sitting time and its association with non-communicable diseases and multimorbidity in Catalonia

Background

Non-communicable diseases (NCDs) account for 71% of deaths worldwide and individual behaviours such as sedentariness play an important role on their development and management. However, the detrimental effect of daily sitting on multiple NCDs has rarely been studied. This study sought (i) to investigate the association between sitting time and main NCDs and multimorbidity in the population of Catalonia and (ii) to explore the effect of physical activity as a modifier of the associations between sitting time and health outcomes.

Methods

Cross-sectional data from the 2016 National Health Survey of Catalonia were analyzed, and multivariable logistic regression, adjusting for socio-demographics and individual risk factors (tobacco and alcohol consumption, diet, hyperlipidaemia, hypertension, body mass index) was used to estimated odds ratios (ORs) and 95% confidence intervals (CIs) of the association between sitting time and NCDs.

Results

A total of 3320 people ≥15 years old were included in the study. Sitting more than 5 h/day was associated with a higher risk of cardiovascular disease (OR 1.90, 95% CI: 1.21–2.97), respiratory disease (OR 1.61, 95% CI: 1.13–2.30) and multimorbidity (OR 2.80, 95% CI: 1.53–5.15). Sitting more than 3 h/day was also associated with a higher risk of multimorbidity (OR 2.26, 95% CI: 1.23–4.16). Physical activity did not modify the associations between sitting time and any of the outcomes.

Conclusions

Daily sitting time might be an independent risk factor for some NCDs, such as cardiovascular disease, respiratory disease and multimorbidity, independently of the level risk of physical inactivity.

Association between physical activity and activity space in different farming seasons among rural Lao PDR residents

Background

Southeast Asia is experiencing a health transition, where non-communicable diseases (NCD) are exceeding communicable diseases. Despite NCDs accounting for roughly 60–85% of deaths in the region, many developing Southeast Asian countries are beginning to address the impacts of a physically inactive lifestyle for the first time. Our study aims to bridge this gap by objectively measuring physical activity in rural Lao PDR to reveal the association among physical activity, activity space, and seasonal variation.

Methods

Multiple waves of survey data were collected in Songkhon District, Lao PDR between March 2010 and March 2011. Adults aged between 18 and 65 were recruited (n = 48). A portable GPS recorded participants’ activity and farmland locations and an accelerometer recorded participants’ physical activity level and daily steps for seven consecutive days. Using a directional distribution tool in ArcGIS 10.5, the activity space area of each participant in each wave was calculated. Concurrently, participants recorded time spent on each daytime activity. Linear mixed models with the fixed effects as the observations from different waves and the random effects as individual participants were developed to identify factors associated with areas of activity space and counts of daily steps, respectively.

Results

A total of 48 respondents aged between 19 and 57 took part in the study. Half of the participants were females. Walking was found to be the most frequent travel mode. Females were physically less active, with a smaller activity space, and were more overweight than the males in the study. Participants were physically less active during the off-farming seasons.

Conclusions

Findings contribute to the surveillance of risk factors needed to create healthy living environments. Our research is also one of the first to use empirical evidence demonstrating seasonal variations of rural residents’ activities in mainland Southeast Asia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41182-021-00364-6.

Predicting length of stay and mortality among hospitalized patients with type 2 diabetes mellitus and hypertension

BACKGROUND

Type 2 diabetes mellitus (T2DM) and hypertension (HTN), both non-communicable diseases, are leading causes of death globally, with more imbalances in lower middle-income countries. Furthermore, poor treatment and management are known to lead to intensified healthcare utilization and increased medical care costs and impose a significant societal burden, in these countries, including Indonesia. Predicting future clinical outcomes can determine the line of treatment and value of healthcare costs, while ensuring effective patient care. In this paper, we present the prediction of length of stay (LoS) and mortality among hospitalized patients at a tertiary referral hospital in Tasikmalaya, Indonesia, between 2016 and 2019. We also aimed to determine how socio-demographic characteristics, and T2DM- or HTN-related comorbidities affect inpatient LoS and mortality.

METHODS

We analyzed insurance claims data of 4376 patients with T2DM or HTN hospitalized in the referral hospital. We used four prediction models based on machine-learning algorithms for LoS prediction, in relation to disease severity, physician-in-charge, room type, co-morbidities, and types of procedures performed. We used five classifiers based on multilayer perceptron (MLP) to predict inpatient mortality and compared them according to training time, testing time, and Area under Receiver Operative Curve (AUROC). Classifier accuracy measures, which included positive predictive value (PPV), negative predictive value (NPV), F-Measure, and recall, were used as performance evaluation methods.

RESULTS

A Random forest best predicted inpatient LoS (R2, 0.70; root mean square error [RMSE], 1.96; mean absolute error [MAE], 0.935), and the gradient boosting regression model also performed similarly (R2, 0.69; RMSE, 1.96; MAE, 0.935). For inpatient mortality, best results were observed using MLP with back propagation (AUROC 0.899; 69.33 and 98.61 for PPV and NPV, respectively). The other classifiers, stochastic gradient descent with regression loss function, Huber, and random forest models all showed an average performance.

CONCLUSIONS

Linear regression model best predicted LoS and mortality was best predicted using MLP. Patients with primary diseases such as T2DM or HTN may have comorbidities that can prolong inpatient LoS. Physicians play an important role in disseminating health related information. These predictions could assist in the development of health policies and strategies that reduce disease burden in resource-limited settings.

Commercial determinants of youth smoking in ASEAN countries: A narrative review of research investigating the influence of tobacco advertising, promotion, and sponsorship

INTRODUCTION

Tobacco smoking is one of the leading causes of death and disability in the Association of Southeast Asian Nations (ASEAN). Despite implementation of some tobacco control measures, youth continue to initiate smoking. This narrative review outlines how tobacco advertising, promotion, and sponsorship (TAPS) may influence smoking attitudes and uptake among youth in the region.

METHODS

Nine electronic databases were searched on EBSCOhost to identify studies published up until December 2019. All studies published in English that investigated youth smoking and TAPS in ASEAN countries were included. Thematic analysis was used to investigate the influence of TAPS on youth smoking.

RESULTS

Thirty-seven studies were identified. This research showed that youth were exposed and receptive to tobacco advertising, which may contribute to positive attitudes towards tobacco brands and smoking. Studies also demonstrated that youth were exposed to point-of-sale (POS) advertisements or promotions and individual sales promotions. However, little research has explored how these strategies influence attitudes and consumption behaviors among youth, or, how online advertising and cigarette packet branding may influence youth smoking.

CONCLUSIONS

Youth in ASEAN countries continue to be exposed to TAPS, particularly through POS advertisements or promotions and individual sales promotions. There is also cause for concern about ‘below-the-line’ advertising and the increasing role of cigarette packaging as a promotional tool. These findings support calls for all ASEAN countries to ratify the Framework Convention on Tobacco Control (FCTC), introduce comprehensive bans on all forms of tobacco advertising, including POS advertising and cigarette pack displays, and implement plain packaging legislation for tobacco products.

Incidence of non-communicable diseases (NCDs) in HIV patients on ART in a developing country: Case of Zimbabwe's Chitungwiza Central Hospital-A retrospective cohort study (2010-2019)

Introduction

The incidence of non-communicable diseases (NCDs) has been reported to be rising over the years leading up to 2010. In Zimbabwe, there are few studies done to examine the incidence of NCDs in people living with HIV (PLHIV) on anti-retroviral treatment (ART).

Objective

To determine the incidence of NCDs in HIV patients on ART at the Chitungwiza Central Hospital over ten years and the associated risk factors.

Methods

This was a retrospective cohort study using data from 203 patients enrolled on ART at the Chitungwiza Central Hospital between 2010 and 2019. All 500 records were considered and the selection was based on participants’ consenting to the study and their strict adherence to ART without absconding. The incidence of NCDs was determined and generalized estimating equations (GEE) were used to estimate the association between NCDs and the selected risk factors.

Findings

Data collected at the study’s baseline (2010) showed that the most prevalent NCD was hypertension, found in (18/203) 8.9% of the study participants, followed by diabetes (6.9%), then followed by cardiovascular diseases (CVD) (3.9%), and the least common NCD was cancer (1.9%). Incidences of all of these NCDs showed an increasing trend as the time of follow-up progressed. The factors found to be significantly associated with the development of NCDs were gender (p = 0.002) and follow-up time (p<0.001). Geographical location was a significant risk factor as urban patients were more likely to develop hypertension as compared to the peri-urban patients (p = 0.001).

Conclusions

NCDs and HIV comorbidity is common with women more likely than males to develop NCDs as they advance in age. There is need to devise targeted intervention approach to the respective NCDs and risk factors since they affect differently in relation to the demographic details of the participants.

Recommendations

This paper recommends a multi-stakeholder approach to the management of NCDs, with researchers, clinicians and the government and its various arms taking a leading role.

Pitfalls in comparison of coronary artery measurements of Indian population with different geographical area studies

Introduction

Coronary artery disease (CAD) is the most common cause of morbidity and mortality especially in the developing countries. Coronary artery measurements (CAM) are the most important factor affecting the procedure and outcome of coronary angioplasty (PCI) as well as coronary by-pass operations (CABG). In this study, we aimed to establish a database for the normal CAM as well as for gender difference among the Indian population using quantitative coronary angiography (QCA) with an objective of assessing normal coronary vessel morphology of patients with normal coronaries.

Materials and methods

Four thousand angiograms from patients of Indian origin were studied prospectively after procuring the sanction for the same from the ethical committee of the pre-selected hospitals of four states in India. Informed consents were obtained. Post CABG, post PCI patients and patient being diabetic for ≥5 years were also excluded from the study.

Results

Ten segments from right and left coronary arteries were taken for diameter measurements. These coronary diameters were indexed to body surface area (BSA) (mean diameter mm/m² BSA). Among, 4000 patients, 933(23.3%) [M:F-521:412] had normal coronaries and 3067 (76.7%) were diseased.

Discussion and conclusion

The dimensions of the coronary artery segments of Indians were smaller (in BSA indexed and non-indexed data), compared to studies from other continents which can be due to their smaller BSA.

Application of DEA-Based Malmquist Productivity Index on Health Care System Efficiency of ASEAN Countries

This study assesses and compares the productive efficiency of the national healthcare system of the ASEAN region which includes Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand and Vietnam amidst rising mortality rate from noncommunicable diseases (NCDs) in the Sustainable Development Goals (SDGs) era. Nonparametric data envelopment analysis technique based on the Malmquist Productivity Index is performed and its components, total factor productivity change, technical change and technological change are compared across the region. Two different models are considered in assessing and comparing the technical efficiency of the national healthcare system across the region with life expectancy at birth and mortality rate from NCDs as parallel health care output for both the models. The mean value of total factor productivity is 0.983 and 0.974 which suggests that national healthcare system productivity efficiency decays by 1.7% for Model I and 2.6% for Model II, respectively. This suggests that the health care system inefficiencies across the ASEAN region have not made life expectancy to improve as much as it should be and curtailed the mortality rate from growing chronic NCDs within a decade. The region is likely to lag behind in achieving SDGs 3 target 4 on reducing by one-third premature mortality from chronic NCDs unless the health care system's technical efficiency is improved across the region. The finding suggests a microlevel study on each country to identify major sources of healthcare system inefficiency in a bid to ameliorate it.

Factors associated with the progression and prevention of noncommunicable diseases in community-dwelling Filipino adults: A cross-sectional study

Noncommunicable diseases (NCDs) are an important cause of disability and death in Muntinlupa, Manila, Philippines. However, there is little community-based research on lifestyle behaviors that affect the progression of NCDs or on the hindrances to NCD prevention.This cross-sectional study investigated the lifestyle behaviors associated with the progression and prevalence of NCDs and clarified factors associated with health promotion for the NCDs prevention among 168 Filipino adults aged 50 years and above in the community setting.The prevalence of diabetes, cardiovascular disease, cancer, chronic respiratory disease, hypertension, and overweight/obesity found 13.1%, 8.9%, 1.8%, 4.2%, 59.5%, and 36.9%, respectively. Of 63 adults who underwent blood tests, high blood glucose and abnormal lipids found 20.6% and 80.9%, respectively. Filipino adults ate breakfast, lunch, and dinner more than 5 days a week, Merienda 4.2 days a week, and a midnight snack 1.7 days a week. The mean frequencies of physical activity at vigorous, moderate, and light intensity levels were 2.6 times a week, 1.9 times a week, and 3.8 times a week, respectively. Men were more likely to be smokers than women. Mean frequencies of alcohol consumption were 0.6 days a week. Filipino adults who practiced diet control, regular physical activities, no smoking, limited alcohol intake, stress control, and regular health checkups were 68.3%, 34.1%, 35.9%, 35.3%, 32.9%, and 24.6%, respectively. Hypertension was positively associated with the duration of tobacco use and frequency of salt intake. Overweight/obesity was positively associated with the frequency of Merienda. Diet control was positively related with internal Multidimensional Health Locus of Control scale. Smoking and alcohol control were significantly related with income level.Community-dwelling Filipino adults in this study had a high prevalence of NCD progression and insufficient awareness of preventative behaviors. Diet control is associated with self-awareness of health and smoking and alcohol control are associated with economic status. These findings ought to contribute to develop the effective strategies for NCD prevention in community-dwelling Filipino adults.

The Threat of Multiple Liver Carcinogens in the Population of Laos: A Review

Laos is a landlocked country in South East Asia, ranking fifth for primary liver cancer incidence worldwide. Risk factors that might explain this worrying situation are poorly known. We conducted a review of the literature concerning the etiologies of terminal liver diseases in Laos. A double infectious burden with hepatitis B and C viruses and the liver fluke Opisthorchis viverrini seems to be the main cause of the high liver cancer incidence. Moreover, it was also suggested that mutagenic substances frequently found in tobacco, alcoholic beverages, fermented fish, and mold-contaminated cereals or nuts, which are all substances heavily consumed by Lao people, lead to the accumulation of DNA mutations in the liver cell genome causing tumor processes. However, the respective proportions of liver cancer cases attributable to each category of infections and substances consumed, as well as the histological nature of the neoplasia are still not precisely documented in Laos. The international medical and scientific communities as well as public health stakeholders should urgently consider the alarming situation of liver health in Laos to stimulate both research and subsequent implementation of prevention policies.

Gestational Diabetes Mellitus in Southeast Asia: A Scoping Review

A rapid increase in the prevalence of gestational diabetes mellitus (GDM) has been associated with various factors such as urbanization, lifestyle changes, adverse hyperglycemic intrauterine environment, and the resulting epigenetic changes. Despite this, the burden of GDM has not been well-assessed in Southeast Asia. We comprehensively reviewed published Southeast Asian studies to identify the current research trend in GDM in this region. Joanna Briggs Institute's methodology was used to guide the scoping review. The synthesis of literature findings demonstrates almost comparable clinical evidence in terms of risk factors and complications, challenges presented in diagnosing GDM, and its disease management, given the similarities of the underlying population characteristics in Southeast Asia. Evidence suggests that a large proportion of GDM risk in women may be preventable by lifestyle modifications. However, the GDM burden across countries is expected to rise, given the heterogeneity in screening approaches and diagnostic criteria, mainly influenced by economic status. There is an urgent need for concerted efforts by government and nongovernmental sectors to implement national programs to prevent, manage, and monitor the disease.

Process evaluation of the 'Singapore Physical Activity and Nutrition Study'

INTRODUCTION

The Singapore Physical Activity and Nutrition Study (SPANS) aimed to improve the physical activity (PA) and nutrition behaviours of Singaporean women aged 50 years and over. The SPANS program consisted of PA classes, nutrition workshops, telephone dietary counselling, health booklets, a health calendar and program ambassadors. This study aimed to assess and understand the implementation of the program strategies and gain insight into process evaluation components to inform future programs.

METHODS

The evaluation was guided by a process evaluation framework and collected data via questionnaires (n = 209), program ambassador documentation and exit interviews with program completers (n = 13) and non-completers (n = 12).

RESULTS

In total, 295 participants completed the program (response rate = 84 %). Participants reported high levels of satisfaction with the overall program (99.5 %) and program activities (96.7 %), and also rated program ambassadors highly. Participation rates were highest for telephone dietary counselling sessions. The main reason for not attending program activities was having a 'busy schedule' (n = 158). Participants cited a need for improved recreational centre facilities and increased flexibility around program delivery.

CONCLUSIONS

The process evaluation showed that the program strategies were implemented as planned and were deemed suitable for supporting behaviour change among Singaporean women aged 50 years and over. The program reached and involved the majority of participants throughout the six months. The combination of practical educational resources and supportive program ambassadors were key strategies that facilitated positive PA and dietary behaviours. However, there needs to be some flexibility in the delivery of programs. The findings of this research may inform other programs in the region.

Interaction between the genetic risk score and dietary protein intake on cardiometabolic traits in Southeast Asian

Background

Cardiometabolic diseases are complex traits which are influenced by several single nucleotide polymorphisms (SNPs). Thus, analysing the combined effects of multiple gene variants might provide a better understanding of disease risk than using a single gene variant approach. Furthermore, studies have found that the effect of SNPs on cardiometabolic traits can be influenced by lifestyle factors, highlighting the importance of analysing gene-lifestyle interactions.

Aims

In the present study, we investigated the association of 15 gene variants with cardiometabolic traits and examined whether these associations were modified by lifestyle factors such as dietary intake and physical activity.

Methods

The study included 110 Minangkabau women [aged 25–60 years and body mass index (BMI) 25.13 ± 4.2 kg/m²] from Padang, Indonesia. All participants underwent a physical examination followed by anthropometric, biochemical and dietary assessments and genetic tests. A genetic risk score (GRS) was developed based on 15 cardiometabolic disease-related SNPs. The effect of GRS on cardiometabolic traits was analysed using general linear models. GRS-lifestyle interactions on continuous outcomes were tested by including the interaction term (e.g. lifestyle factor*GRS) in the regression model. Models were adjusted for age, BMI and location (rural or urban), wherever appropriate.

Results

There was a significant association between GRS and BMI, where individuals carrying 6 or more risk alleles had higher BMI compared to those carrying 5 or less risk alleles (P = 0.018). Furthermore, there were significant interactions of GRS with protein intake on waist circumference (WC) and triglyceride concentrations (P_interaction = 0.002 and 0.003, respectively). Among women who had a lower protein intake (13.51 ± 1.18% of the total daily energy intake), carriers of six or more risk alleles had significantly lower WC and triglyceride concentrations compared with carriers of five or less risk alleles (P = 0.0118 and 0.002, respectively).

Conclusions

Our study confirmed the association of GRS with higher BMI and further showed a significant effect of the GRS on WC and triglyceride levels through the influence of a low-protein diet. These findings suggest that following a lower protein diet, particularly in genetically predisposed individuals, might be an effective approach for addressing cardiometabolic diseases among Southeast Asian women.

Impact of National Drug Pricing Policy 2018 on access to medicines in Lahore division, Pakistan: a pre-post survey study using WHO/HAI methodology

OBJECTIVE

To evaluate the impact of new National Drug Pricing Policy (NDPP) 2018 on access to medicines in terms of prices, availability and affordability.

DESIGN

Two cross-sectional surveys were undertaken before and after the launch of NDPP 2018, using a modified WHO/Health Action International (WHO/HAI) methodology.

SETTING

Four districts of Lahore division, Pakistan.

PARTICIPANTS

16 public sector hospitals and 16 private sector retail pharmacies.

MEASURES

The pre and post survey data on prices and availability of lowest price generics (LPGs) and originator brands (OBs) of 50 medicines were obtained by visiting the same public and private sector health facilities (n=32). Out of 50, 46 surveyed medicines were from the National Essential Medicines List. Inflation-adjusted median unit prices (MUPs) and median price ratios (MPRs) from 2019 were used for price comparison. Affordability was calculated in terms of number of days' wages required to get a standard treatment by the lowest paid unskilled government worker.

RESULTS

The overall mean percent availabilities remained poor in both years, that is, far less than 80%. In the public sector, the mean percent availability of OBs improved from 6.8% to 33.1%, whereas, in the case of LPGs, it was reduced from 35.1% to 9%. In the private sector, the mean percent availability of both OBs and LPGs demonstrated slight improvements in 2019, that is, 55.0%-58.3% and 20.3%-32.3%. The adjusted MUPs and MPRs of OBs significantly increased by a median of 4.29% (Wilcoxon test p=0.001, p=0.0001), whereas the adjusted MUPs and MPRs of LPGs increased by a median of 15.7% (p=0.002, p=0.0002). Overall, the affordability of many medicines for common ailments was reduced significantly in 2019.

CONCLUSIONS

The availability of medicines slightly improved, except in the case of LPGs, which was reduced in the public sector. The implementation of NDPP 2018 led to increase in drug prices, making the standard treatment for some of the most prevalent ailments unaffordable. So verily, the drug pricing policy must be reviewed to ensure access to essential medicines.

Prevalence and factors associated with false hyperkalaemia in Asians in primary care: a cross-sectional study (the Unlysed Hyperkalaemia- the Unseen Burden (UHUB) study)

Serum potassium is part of routine laboratory tests done for patients with hypertension or diabetes mellitus in primary care. Those found to have raised potassium (K>5.5 mmol/L) are recalled for repeat potassium in emergency departments or primary care clinics. Repeat potassium are often normal (≤5.5 mmo/L), that is, false hyperkalaemia. Haemolysis is known to cause false hyperkalaemia. We postulated that unlysed false hyperkalamia was prevalent and was associated with factors such as delayed processing time.

OBJECTIVE

We aimed to determine the prevalence of unlysed false hyperkalaemia and the factors associated with false-and-true-hyperkalaemia.

SETTING

Outpatients in a cluster of public primary care clinics (polyclinics) in Singapore.

PARTICIPANTS

All patients of any ethnicity aged ≥21 with serum potassium test done.

METHODS

Electronic health records of index patients with potassium >5.5 mmol/L and its corresponding laboratory processing time in seven local polyclinics were reviewed between August 2015 and August 2017. Haemolysed specimens and patients on sodium polystyrene sulfonate (SPS) suspension were excluded. If repeat potassium level was ≤5.5 mmol/L within 8 days, the case was defined as false hyperkalaemia. The proportion of such patients was computed to determine its prevalence. Linear and logistic regressions were used to identify the associated factors.

RESULTS

The study population comprised of 3014 index cases, of which 1575 had repeat potassium tests without preceding SPS. 86.4% (1362/1575) of them had potassium ≤5.5 mmol/L. The average processing time among specimens with potassium ≥6.0 mmol/L was 50 min longer, compared with those with potassium <5.1 mmol/L. Risk factors significantly associated with false hyperkalaemia included estimated glomerular filtration rate (eGFR) (60-89 mL/min/1.73 m², OR=3.25, p<0.001;>90 mL/min/1.73 m², OR=3.77, p<0.001) and delayed laboratory processing time (beta coefficient 0.001, p<0.001).

CONCLUSION

The prevalence of false hyperkalaemia was 86.4%. Recommendation to repeat potassium tests may target those with eGFR<60ml/min/1.73m².

Feasibility and acceptability of a dietary intervention study to reduce salt intake and increase high-nitrate vegetable consumption among middle-aged and older Malaysian adults with elevated blood pressure: a study protocol

INTRODUCTION

Global population ageing is one of the key factors linked to the projected rise of dementia incidence. Hence, there is a clear need to identify strategies to overcome this expected health burden and have a meaningful impact on populations' health worldwide. Current evidence supports the role of modifiable dietary and lifestyle risk factors in reducing the risk of dementia. In South-East Asia, changes in eating and lifestyle patterns under the influence of westernised habits have resulted in significant increases in the prevalence of metabolic, cardiovascular and neurodegenerative non-communicable diseases (NCDs). Low vegetable consumption and high sodium intake have been identified as key contributors to the increased prevalence of NCDs in these countries. Therefore, nutritional and lifestyle strategies targeting these dietary risk factors are warranted. The overall objective of this randomised feasibility trial is to demonstrate the acceptability of a dietary intervention to increase the consumption of high-nitrate green leafy vegetables and reduce salt intake over 6 months among Malaysian adults with raised blood pressure.

METHODS AND ANALYSIS

Primary outcomes focus on feasibility measures of recruitment, retention, implementation and acceptability of the intervention. Secondary outcomes will include blood pressure, cognitive function, body composition and physical function (including muscle strength and gait speed). Adherence to the dietary intervention will be assessed through collection of biological samples, 24-hour recall and Food Frequency Questionnaire. A subgroup of participants will also complete postintervention focus groups to further explore the feasibility considerations of executing a larger trial, the ability of these individuals to make dietary changes and the barriers and facilitators associated with implementing these changes.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from Monash University Human Research Ethics Committee and Medical Research and Ethics Committee of Malaysia. Results of the study will be disseminated via peer-reviewed publications and presentations at national and international conferences.ISRCTN47562685; Pre-results.

Are We Living Longer and Healthier?

Objective: To examine whether we live healthier as we live longer in Hong Kong, which has one of the highest life expectancies in the world. Methods: Sullivan's method was used to evaluate the chronic disease-free life expectancy (CDFLE), life expectancy in good self-perceived health (GPHLE), and impairment-free life expectancy (IFLE) among population aged 50 years and older in Hong Kong in 2007-2016. Results: In spite of the marked improvement in life expectancy in Hong Kong, the increase in GPHLE was much smaller, while CDFLE and IFLE even declined for both genders. The situation was more severe among older population. Discussion: People in Hong Kong live longer but with worsening health. The expansion of chronic diseases, self-perceived poor health, and impairments among older adults calls for more fiscal investments, government attention, and public health policies.

Addressing the COVID-19 Nutrition Crisis in Vulnerable Communities: Applying a Primary Care Perspective

The coronavirus disease (COVID-19) pandemic and subsequent public health interventions have disrupted food systems all over the world. In the Philippines, where stringent lockdown rules have been implemented, households living in poverty have had to rely largely on food aid in the form of food packs distributed by local governments and private donors. An evaluation of the commonly distributed food items reveals a diet that addresses acute hunger but does not contain sufficient nutrients to promote and maintain health. Such a diet puts low-income households at a greater risk of acute and chronic disease. The negative health impact of commonly distributed food packs on food aid-dependent households shine a light on how the COVID-19 pandemic and public health policies exacerbate health inequities. A primary care perspective is essential in creating food security policies that can effectively address acute hunger and malnutrition without contributing to the long-term deleterious effects of inadequate nutrition on the health of indigent communities.