Social and Economic Implications of Noncommunicable diseases in India

Risk correlates of cardiovascular diseases, diabetes, and periodontal diseases: a cross-sectional study in India

BACKGROUND

Quantifying shared risk factors among periodontal disease (PD), cardiovascular disease (CVD), type 2 diabetes (DM2) can bolster Common Risk Factor Approach (CRFA), enabling integration of PD prevention into non-communicable disease (NCD) prevention strategies. The objective of the study is to assess extent of overlap of shared risk factors between CVD, DM2, PD.

MATERIALS AND METHODS

This is an analytical cross-sectional study conducted at a tertiary care medical and dental teaching hospital in South India, from July 2022 to April 2024. Study included 600 participants (ages 18-75) divided into three groups: Group A: DM2, CVD, or both and PD; Group B: DM2 or CVD; and Group C: PD alone. Various demographic, metabolic, habit related, dietary and periodontal disease severity related risk factors were evaluated in the study.

RESULTS

Among 600 participants, 55.5% were male, 58.8% were under 50 years. Statistically significant odds ratios (ORs) for shared risk factors between Group A and Group B were observed for age > 50 (0.58), sedentary lifestyle (0.43), fat intake > 41 g/d (1.87), HbA1C ≥ 6.5% (0.56), FBS > 126 mg/dL (2.35) and family history of NCDs (9.8). For Group A versus Group C, statistically significant ORs were seen for age > 50 (0.55), HbA1c 5.7%-6.4% (0.34), triglycerides > 150 mg/dL (0.04), education (0.52), alcohol use (1.53) and poor oral hygiene (3.01). Severity of periodontal disease assessed using PSR, HbA1c, triglycerides, fat intake, age, education, obesity were identified as vital shared risk factors. CONCLUSION AND RELEVANCE: Age, education, obesity, PSR, HbA1c, triglycerides emerged as significant shared risk factors. Integrating these factors into surveillance tools may enhance NCD and PD risk identification, supporting CRFA-based healthcare approach.

TRIAL REGISTRATION

CTRI/ 2022/06/043279 registered on 15th of June 2022.

Development of a New Questionnaire to Assess the Social Impact of Non-communicable Diseases

Background

Non-communicable diseases (NCDs) have a considerable impact on an individual's social life. Life-long medication, fear of death, dietary restrictions, hospital admissions, dependency on caregivers, and strained interpersonal relationships play a role. The available questionnaires measure only individual aspects of social impact. The aim of the study was to develop and validate a comprehensive questionnaire to assess the social impact of NCDs.

Material and Methods

A cross-sectional study was conducted among patients and caregivers seeking care at a tertiary care hospital for diabetes, hypertension, chronic obstructive pulmonary disease (COPD), stroke, coronary artery disease (CAD), and cancer. Thirty patients each with the above diseases were administered Cousineau Self-Perceived Burden Scale to assess perceived burden among patients, Caregiver Burden Scale to assess caregiver burden, EuroQol-5D-3L to assess the quality of life, and face validated questions of sociodemographic details, cost of healthcare, and stress due to disease. Rasch analysis was performed to identify items that lie within the traditional bounds of mean-square item fit. The Delphi method with 10 subject experts was used to identify the questions that would be included in the final tool.

Results

The data consists of 150 observations, with 77 categorical questions subdivided into various domains. From this, a total of 30 questions were extracted by Rasch analysis. The new questionnaire had good internal consistency (Cronbach's alpha: 0.969, 95% confidence interval: 0.96-0.98). The questionnaire was finalized after reaching a consensus among subject experts.

Conclusion

The social impact questionnaire developed consisted of 30 questions, has good internal consistency, and can be used to measure the social impact of NCDs.

Social and economic impacts of non-communicable diseases by gender and its correlates: a literature review

BACKGROUND

Tackling social impacts derived from gender disparities is a pathway to universal health coverage (UHC). Gender intersects with other factors behind social and health inequalities, exacerbates them and influences health systems' performance. However, there is scarcity of gender-based studies that assess the social and economic impacts of non-communicable diseases (NCDs). This study aims to identify economic and social impacts of NCDs by gender and its correlates.

METHODS

Following the guidelines proposed in the Cochrane Manual for Systematic Reviews of Interventions and the PRISMA Statement, we conducted a narrative and structured literature review to identify the economic (direct medical and non-medical, and indirect costs) and social (right to health, employment, poverty, social exclusion, and others) impacts of NCDs by gender, and its structural, sociodemographic, health conditions, political and health systems correlates, for the period 2002-2022, in English and Spanish. Reviewed studies were described according to country and research context, temporal evolution, gender, impacts of NCDs and correlates.

FINDINGS

Five thousand five hundred fifty-one publications by title and abstract were reviewed, and 185 articles were selected. There is limited evidence with gender perspective addressing the social and economic impacts of NCDs (around 10% of publications) that helps to better understand the difference in the burden of these conditions between men and women. We identified that the social burden primarily affects women in their quality of life, where gender inequities are observed in aspects such as: health care, employment status and living conditions. In addition, a greater responsibility falls on them as caregivers. On the other hand, the economic burden affects more to men, both in terms of direct medical costs and indirect costs. Among the factors that most influenced the identified impacts, we found gender, age, and socioeconomic level. We also identified that access to health insurance that offers financial protection against these conditions is essential to reduce these impacts.

CONCLUSIONS

NCDs pose a significant social and economic burden due to their impact on the health of the population, healthcare systems, and the economies of households and nations, which will likely increase over time. This impact is closely related to gender, although it has been scarcely documented. Public policies aimed at enhancing access and achieving UHC are essential to guarantee effective financial protection in health, especially for the most vulnerable sectors of the population.

A Comprehensive Review on Trends and Patterns of Non-communicable Disease Risk Factors in India

This review explores the trends and patterns of non-communicable disease (NCD) risk factors in India, with a focus on tobacco use, unhealthy diet, physical inactivity, and air pollution. Drawing upon existing literature and data, the review highlights the substantial burden imposed by NCDs and their associated risk factors on public health and healthcare systems in India. Key findings reveal the widespread prevalence of these risk factors, particularly among certain demographic groups and in urban areas. Socioeconomic disparities also play a significant role in shaping the distribution of NCD risk factors across the population. The review underscores the importance of addressing NCD risk factors through evidence-based interventions and policies tailored to the Indian context. Furthermore, it emphasizes the need for multi-sectoral collaboration among government agencies, healthcare providers, civil society organizations, academia, industry partners, and communities to mitigate the NCD epidemic effectively. By mobilizing collective efforts and resources, India can make significant strides in preventing and controlling NCDs, thereby enhancing population health and well-being.

Financial burden of coronary artery bypass grafting in India: implications for catastrophic health expenditure and healthcare access

Cardiovascular diseases (CVD) have become a leading cause of mortality in India. High costs of coronary artery bypass grafting (CABG) impose a financial burden in patients often resulting in catastrophic health expenditure (CHE). CHE and distressed financing have significant microeconomic and macroeconomic implications. CHE depletes savings, forces asset disposal, and perpetuates poverty. At a macroeconomic level, the burden of CVD impacts gross domestic product, economic productivity, healthcare budgets, and social welfare. Addressing these challenges requires a multifaceted approach. Prioritizing accessible and affordable healthcare systems with robust financial risk protection is essential. Widespread adoption of health insurance, including government-sponsored schemes, can provide financial protection. Expanding public healthcare infrastructure, implementing price regulations, promoting generic medicines, and encouraging preventive measures for coronary artery disease (CAD) are crucial steps to reduce the burden of CABG costs and improve healthcare access.

Small Area Geographic Estimates of Cardiovascular Disease Risk Factors in India

Importance

With an aging population, India is facing a growing burden of cardiovascular diseases (CVDs). Existing programs on CVD risk factors are mostly based on state and district data, which overlook health disparities within macro units.

Objective

To quantify and geovisualize the extent of small area variability within districts in CVD risk factors (hypertension, diabetes, and obesity) in India.

Design, Setting, and Participants

This cross-sectional study analyzed nationally representative data from the National Family Health Survey 2019-2021, encompassing individuals aged 15 years or older, for hypertension (n = 1 715 895), diabetes (n = 1 807 566), and obesity (n = 776 023). Data analyses were conducted from July 1, 2022, through August 1, 2023.

Exposures

Geographic units consisting of more than 30 000 small areas, 707 districts, and 36 states or Union Territories across India.

Main Outcomes and Measures

For primary outcomes, CVD risk factors, including hypertension, diabetes, and obesity, were considered. Four-level logistic regression models were used to partition the geographic variability in each outcome by state or Union Territory (level 4), district (level 3), and small area (level 2) and compute precision-weighted small area estimates. Spatial distribution of district-wide means, within-district small area variability, and their correlation were estimated.

Results

The final analytic sample consisted of 1 715 895 individuals analyzed for hypertension (mean [SD] age, 39.8 [17.3] years; 921 779 [53.7%] female), 1 807 566 for diabetes (mean [SD] age, 39.5 [17.2] years; 961 977 [53.2%] female), and 776 023 for obesity (mean [SD] age, 30.9 [10.2] years; 678 782 [87.5%] women). Overall, 21.2% of female and 24.1% of male participants had hypertension, 5.0% of female and 5.4% of men had diabetes, and 6.3% of female and 4.0% of male participants had obesity. For female participants, small areas (32.0% for diabetes, 34.5% for obesity, and 56.2% for hypertension) and states (30.0% for hypertension, 46.6% for obesity, and 52.8% for diabetes) accounted for the majority of the total geographic variability, while districts accounted for the least (13.8% for hypertension, 15.2% for diabetes, and 18.9% for obesity). There were moderate to strong positive correlations between district-wide mean and within-district variability (r = 0.66 for hypertension, 0.94 for obesity, and 0.96 for diabetes). For hypertension, a significant discordance between district-wide mean and within-district small area variability was found. Results were largely similar for male participants across all categories.

Conclusions and Relevance

This cross-sectional study found a substantial small area variability, suggesting the necessity of precise policy attention specifically to small areas in program formulation and intervention to prevent and manage CVD risk factors. Targeted action on policy-priority districts with high prevalence and substantial inequality is required for accelerating India's efforts to reduce the burden of noncommunicable diseases.

Vitalizing Community for Health Promotion Against Modifiable Risk Factors of Noncommunicable Diseases (V-CaN) in Rural Central India: Protocol for a Hybrid Type II Implementation Effectiveness Trial

BACKGROUND

Low- and middle-income countries are facing the emerging burden of chronic noncommunicable diseases (NCDs). Apart from loss of human lives and premature deaths, NCDs result in huge costs for treatment to individuals and the health system. Although NCDs develop in later life, the risk factors begin at an early age. The key to the control of the global epidemic of NCDs is primary prevention based on comprehensive community-based programs.

OBJECTIVE

This study aims to develop, implement, and evaluate the effect of a participatory health promotion initiative utilizing the existing mechanisms of Village Health Nutrition and Sanitation Committees (VHNSCs), women's self-help groups (SHGs), and schools on modifiable risk factors for NCDs among young people aged 10-30 years.

METHODS

The proposed type II hybrid effectiveness implementation cluster randomized field trial will be conducted in the catchment area of 4 primary health centers (PHCs) in Wardha district, India, comprising 100 villages with a population of 144,000. Each PHC will be randomly allocated to one of the 3 intervention arms or the control arm. The 3-intervention arm PHCs will utilize a unique strategy with either VHNSC or SHG members or school students as change agents for health action against common modifiable NCD risk factors. This study will be implemented in 3 phases from January 2022 to December 2024. First, the preparatory phase for baseline assessments includes anthropometry, behavioral and biochemical risk factors for NCDs, and participatory development of the health promotion intervention modules. Second, the implementation phase will focus on capacity building of the change agents and implementation of the participatory health promotion initiative. The implementation will include organization of community-based events, 6-monthly participatory assessment of change, and preparation of a sustainability and exit plan toward the end of this phase. Third, the evaluation phase will consist of studying the effectiveness of each intervention strategy in the reduction of risk factor prevalence at the population level.

RESULTS

We will assess 12,000 (3000 in each arm) randomly selected individuals for behavioral risk factors and 1600 (400 in each arm) individuals for biochemical risk factors during baseline as well as endline assessments. Difference in differences, ANOVA or multivariate analysis of covariance, and regression analysis will be performed to assess the effectiveness of the interventions. Qualitative methods such as focus group discussions and stories of change will be documented and analyzed using thematic framework analysis. The implementation outcomes will be reported using the PRISM (Practical Robust Implementation and Sustainability Model) RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. The results are expected to be published by mid-2025.

CONCLUSIONS

This study will show the magnitude of risk factors for NCDs, its determinants, feasibility, effectiveness of community-based interventions, and health promotion models for NCD prevention.

TRIAL REGISTRATION

Clinical Trials Registration India CTRI/2020/10/028700; https://ctri.nic.in/Clinicaltrials/showallp.php?mid1=47597&EncHid=&userName=V-CaN.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42450.

Role of health literacy and primary health-care access in self-care management of hypertension

Background

Globally, hypertension is the leading risk factor for men and women and the largest contributor to premature deaths and diseases in India. Health literacy (HL) and health-care access are important determinants for self-care management of hypertension.

Objectives

The purpose of this study was to estimate the prevalence of HL, health-care access, and their importance in the self-care management of hypertension.

Materials and

Methods

A community-based cross-sectional study was conducted among 104 known hypertensive patients for 2 months from May to June 2022. Data were collected by face-to-face interviews using a pretested, preformed, and validated questionnaire, and tabulated and analyzed using Microsoft Excel and SPSS version 20 software.

Results

Most of the participants (80, 76.9%) have low levels of HL. However, more than half of the (62, 59.6%) participants were satisfied with their access to primary health care. The age of the participants ranged from 38 to 80 years, and half of them (54, 51.9%) were middle-aged adults. The majority (66, 63.5%) of the patients belonged to lower-middle socioeconomic status, and 15.4% (16) were living alone. We found poor HL, and primary health-care access is statistically significantly associated with poor self-care management.

Conclusion

Our findings confirm that HL and access to primary health care are crucial factors in the self-care management of hypertension in hypertensive patients.

Financial toxicity of cancer treatment in India: towards closing the cancer care gap

Background

The rising economic burden of cancer on patients is an important determinant of access to treatment initiation and adherence in India. Several publicly financed health insurance (PFHI) schemes have been launched in India, with treatment for cancer as an explicit inclusion in the health benefit packages (HBPs). Although, financial toxicity is widely acknowledged to be a potential consequence of costly cancer treatment, little is known about its prevalence and determinants among the Indian population. There is a need to determine the optimal strategy for clinicians and cancer care centers to address the issue of high costs of care in order to minimize the financial toxicity, promote access to high value care and reduce health disparities.

Methods

A total of 12,148 cancer patients were recruited at seven purposively selected cancer centres in India, to assess the out-of-pocket expenditure (OOPE) and financial toxicity among cancer patients. Mean OOPE incurred for outpatient treatment and hospitalization, was estimated by cancer site, stage, type of treatment and socio-demographic characteristics. Economic impact of cancer care on household financial risk protection was assessed using standard indicators of catastrophic health expenditures (CHE) and impoverishment, along with the determinants using logistic regression.

Results

Mean direct OOPE per outpatient consultation and per episode of hospitalization was estimated as ₹8,053 (US$ 101) and ₹39,085 (US$ 492) respectively. Per patient annual direct OOPE incurred on cancer treatment was estimated as ₹331,177 (US$ 4,171). Diagnostics (36.4%) and medicines (45%) are major contributors of OOPE for outpatient treatment and hospitalization, respectively. The overall prevalence of CHE and impoverishment was higher among patients seeking outpatient treatment (80.4% and 67%, respectively) than hospitalization (29.8% and 17.2%, respectively). The odds of incurring CHE was 7.4 times higher among poorer patients [Adjusted Odds Ratio (AOR): 7.414] than richest. Enrolment in PM-JAY (CHE AOR = 0.426, and impoverishment AOR = 0.395) or a state sponsored scheme (CHE AOR = 0.304 and impoverishment AOR = 0.371) resulted in a significant reduction in CHE and impoverishment for an episode of hospitalization. The prevalence of CHE and impoverishment was significantly higher with hospitalization in private hospitals and longer duration of hospital stay (p < 0.001). The extent of CHE and impoverishment due to direct costs incurred on outpatient treatment increased from 83% to 99.7% and, 63.9% to 97.1% after considering both direct and indirect costs borne by the patient and caregivers, respectively. In case of hospitalization, the extent of CHE increased from 23.6% (direct cost) to 59.4% (direct+ indirect costs) and impoverishment increased from 14.1% (direct cost) to 27% due to both direct and indirect cost of cancer treatment.

Conclusion

There is high economic burden on patients and their families due to cancer treatment. The increase in population and cancer services coverage of PFHI schemes, creating prepayment mechanisms like E-RUPI for outpatient diagnostic and staging services, and strengthening public hospitals can potentially reduce the financial burden among cancer patients in India. The disaggregated OOPE estimates could be useful input for future health technology analyses to determine cost-effective treatment strategies.

Development of a multi-component tobacco cessation training package utilizing multiple approaches of intervention development for health care providers and patients attending non-communicable disease clinics of Punjab, India

Background

Providing patients with personalized tobacco cessation counseling that is culturally sensitive, and disease-specific from healthcare providers (HCPs) as part of their routine consultations is an approach that could be incorporated, using existing healthcare systems such as the Non-Communicable Disease (NCD) clinics. This paper describes the development of a multi-component culturally tailored, patient-centric, disease-specific tobacco cessation package utilizing multiple approaches of intervention development for healthcare providers and patients attending these clinics in Punjab, India, along with a proposed framework for implementation.

Methods

The proposed intervention package was developed in 6 stages. These included a review of literature for identifying successful cessation interventions for ethnic minority groups, co-production of the package with all stakeholders involved via a series of consultative meetings and workshops, understanding contextual factors of the state and 'factor-in' these in the package, pre-test of the package among HCPs and tobacco users using in-depth interviews, micro detailing and expansion of the package by drawing on existing theories of the Cascade Model and Trans-Theoretical Model and developing an evolving analysis plan through real-world implementation at two pilot districts by undertaking a randomized controlled trial, assessing implementer's experiences using a mixed-method with a primary focus on qualitative and economic evaluation of intervention package.

Results

A multi-component package consisting of a booklet (for HCPs), disease-specific pamphlets and short text messages (for patients; bilingual), and an implementation framework was developed using the 6-step process. A major finding from the in-depth interviews was the need for a specific capacity-building training program on tobacco cessation. Therefore, using this as an opportunity, we trained the in-service human resource and associated program managers at the state and district-level training workshops. Based on the feedback, training objectives were set and supported with copies of intervention package components. In addition, the role and function of each stakeholder were defined in the proposed framework.

Conclusion

Consideration of tobacco users' socio-cultural and patient-centric approach makes a robust strategy while developing and implementing an intervention providing an enlarged scope to improve care services for diversified socio-cultural communities.

Integration of Non Alcoholic Fatty Liver Diseases (NAFLD) into NPCDCS programme: A recent initiative in India

Non-alcoholic fatty liver disease (NAFLD) is an emerging public health problem globally. NAFLD is one of the most common liver diseases worldwide and is the most common cause of abnormal liver enzymes in many developed countries. NAFLD is estimated to afflict approximately 1 billion individuals worldwide. An estimated 20-30 % of general population is afflicted from it globally. In India NAFLD could be a silent epidemic with its prevalence ranging from 9-32%. Studies have shown, strong association of NAFLD with major Non Communicable diseases (NCD) like Diabetes, Obesity, CVD, Chronic Kidney diseases, Cancers, etc. Perceiving the threat of NAFLD and the central role of hepatic accumulation of fat in the pathogenesis of other NCD, the Government of India (GoI) has taken steps to include NAFLD in the public health agenda. It has included it in the national NCD programme, i.e., National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) in 2021. India has become the first country in the world to start a national programme for preventive efforts for NAFLD. The present review describes public health relevance of NAFLD and the process of integration of Non Alcoholic Fatty Liver Diseases (NAFLD) into NPCDCS programme in India.

Cancer in the older Indian population: Understanding the current context in an emerging economy

India is considered a demographically young country with over 65% of the population aged below 35 years. However, improvements in maternal and child health, and infectious diseases, have created a rapid epidemiological transition with an aging population (8.6% in 2011) with a projected increase (19% by 2050), equating to 104 million. In addition to the well-articulated issues surrounding the care of the older patients with cancer, the Indian context as an emerging economy provides additional social, political, economic and clinical challenges. This review addresses the key issues and possible solutions germane to both policymakers in India and other emerging economies. Extension of cancer prevention, equal, optimal treatment opportunities, and inclusion in clinical trials, akin to the younger population, must be encouraged. Various national health initiatives require effective implementation, to provide uniform, evidence-based, cancer care across India. Designated geriatric oncology departments, and required care at the primary healthcare level are essential.

Intersecting sex-related inequalities in self-reported testing for and prevalence of Non-Communicable Disease (NCD) risk factors in Kerala

BACKGROUND

Non-Communicable Diseases (NCDs) are among India's top burdens, particularly in states like Kerala, which is at an advanced stage of the epidemiological transition. Evidence in India points towards intersectional inequalities in risk factors of NCDs and testing, both of which are understudied in Kerala. We estimated the self-reported testing and prevalence of key NCD risk factors-blood pressure (BP) and blood glucose (BG) comparing Kerala men and women across educational, wealth, religion, as well as caste and tribal status subgroups.

METHOD

A multistage random sample survey of 3398 women and 2982 men aged 30 years and over was administered in 4 districts of Kerala from July to October 2019. Descriptive analysis for men and women was undertaken using survey weights. Slope index of Inequality and Relative Concentration Index for wealth and education related inequalities, and, Weighted Mean Difference from Mean and Index of Disparity for caste and tribal status, as well as religion related inequalities were calculated using World Health Organisation's Health Equity Assessment Toolkit Plus and Stata 12.

RESULTS

A significantly higher proportion of women reported BP and BG testing by medical personnel in the previous year than men (BP Testing among Women (BPT_w): 90.3% vs BP Testing among Men (BPT_M):80.8%, BG Testing among Women (BGT_w): 86.2% vs BG Testing among Women (BGT_M):78.3%). Among those tested, more women (11.2%) than men (7.9%) reported High Blood Pressure (HBP) but not High Blood Glucose (HBG). Testing for BP was concentrated among less-educated women while BG testing was concentrated among both less educated women and men. HBP and HBG were concentrated among less educated and wealthier groups. Although sex differences were insignificant across caste and tribal status and religion subgroups, magnitude of inequalities was high for HBP and HBG.

CONCLUSION

Distinct patterns of sex inequalities were present in self-reported testing and prevalence of NCD risk factors in Kerala. Education and wealth seem to be associated with testing while prevalence appeared to vary by religious groups. Given the low rates of illiteracy, it is encouraging but maybe a data artefact that a small population of less-educated persons was getting tested; however, exclusion of poor groups and inequalities by other dimensions raise concerns. Further exploration is needed to understand underlying mechanisms of these inequalities to ensure we leave no one behind.

Assessment of Common Risk Factors of Non-Communicable Diseases (NCDs) and Periodontal Disease in Indian Adults: An Analytical Cross-Sectional Study

Risk factors that predispose individuals towards major non-communicable diseases (NCDs) and periodontal disease (PD) often co-occur in the same individual. The common risk factor approach (CRFA) for controlling the risk factors associated with NCDs and PD ensures that modifying a few risk factors has an incredible impact on regulating many chronic conditions. To apply CRFA to NCDs and PD, it is essential to quantify the common risk factors of these conditions. The proposed hospital-based analytical cross-sectional study aims to assess the proportion overlap of risk factors that are common or shared between NCDs (cardiovascular diseases (CVD) and diabetes mellitus (DM) type 2) and PD. The risk factors for PD and NCDs will be estimated in subjects aged 18 years and above, diagnosed with NCDs (DM type 2, CVD) or PD. This will be a non-directional study. The dependent variables analyzed will be PD and NCDs (DM type 2, CVD). The explanatory variables that are assessed will be: age, gender, address, occupation, access and affordability of care, familial pattern, family size, insurance, socioeconomic status, obesity, tobacco usage, physical activity, alcohol consumption, food frequency, stress, and oral hygiene. The research is expected to provide data which will aid in the development of advocacy initiatives to implement CRFA for PD and NCDs.

Effectiveness of lifestyle modification on quality of life among uncontrolled diabetics and hypertensives in India – Community based intervention study

Background:

Diabetes and hypertension contribute to more than half of morbidity, mortality and years lived with disability in developing countries like India. It impacts the quality of life (QoL) of patients and their family. Management of these diseases is in infancy and emphasis is laid on pharmacological interventions. Though nonpharmacological measures are crucial for management, their implementation is questionable. Hence, this study was conducted to measure the effectiveness of lifestyle modifications on QoL among uncontrolled hypertensives and diabetics in rural India.

Methods:

An interventional study was done in 3 villages with 100 participants each, where village one received lifestyle modification as intervention and village two physical activity and village three control receiving standard care. The baseline data included socio-demographic characteristics such as awareness of hypertension, diabetes, lifestyle pattern and physical activity, and WHO QoL. The participants were trained, followed up, and assessed after 12 months following intervention. QoL scores between groups and pre- and post-intervention in the group were compared using Mann–Whitney U and Wilcoxon signed-rank test, respectively.

Results:

In this study, there was a significant improvement in overall QoL and in all the four domains, namely physical, psychological, social relationship, and environmental domains in both the intervention villages. QoL was significantly better in both the intervention groups following intervention than compared to the control group.

Conclusions:

QoL improves with intervention on uncontrolled diabetics and hypertensives. It is time to emphasize on the collaboration among physicians and on the holistic integrative health services delivery for non-communicable diseases.

Do Non-Communicable Diseases Influence Sustainable Development in Sub-Saharan Africa? A Panel Autoregressive Distributive Lag (ARDL) Model

The burden of non-communicable diseases (NCDs) in Sub-Saharan Africa has been on the surge during the last two decades. This study examines the relationship between NCDs, measured by disability adjusted life years (DALYs), and sustainable development in Sub-Saharan African (SSA) countries. We adopt a panel Autoregressive Distributed Lag model to evaluate the association between NCDs and sustainability of development, alternately measured by adjusted net savings and gross domestic savings, in 24 SSA countries, from 1990 to 2017. The results show that NCDs adversely affect sustainable development in the long run. The findings demonstrate an urgent need to mitigate the rapidly rising burden of NCDs. We argue that reducing the current trend of NCDs in the sub-region is necessary for countries to be on a sustainable development trajectory.

Improving access to medicines for non-communicable diseases in rural primary care: results from a quasi-randomized cluster trial in a district in South India

BACKGROUND

A large proportion of non-communicable diseases (NCDs) are treatable within primary health care (PHC) settings in a cost-effective manner. However, the utilization of PHCs for NCD care is comparatively low in India. The Access-to-Medicines (ATM) study examined whether (and how) interventions aimed at health service optimization alone or combined with community platform strengthening improve access to medicines at the primary health care level within the context of a local health system.

METHOD

A quasi-randomized cluster trial was used to assess the effectiveness of the intervention (18 months) implemented across 39 rural PHCs (clusters) of three sub-districts of Tumkur in southern India. The intervention was allocated randomly in a 1:1:1 sequence across PHCs and consisted of three arms: Arm A with a package of interventions aimed at health service delivery optimization; B for strengthening community platforms in addition to A; and the control arm. Group allocation was not blinded to providers and those who assessed outcomes. A household survey was used to understand health-seeking behaviour, access and out-of-pocket expenditure (OOP) on key anti-diabetic and anti-hypertension medicines among patients; facility surveys were used to assess the availability of medicines at PHCs. Primary outcomes of the study are the mean number of days of availability of antidiabetic and antihypertensive medicines at PHCs, the mean number of patients obtaining medicines from PHC and OOP expenses.

RESULT

The difference-in-difference estimate shows a statistically insignificant increase of 31.5 and 11.9 in mean days for diabetes and hypertension medicines availability respectively in the study arm A PHCs beyond the increase in the control arm. We further found that there was a statistically insignificant increase of 2.2 and 3.8 percentage points in the mean proportion of patients obtaining medicines from PHC in arm A and arm B respectively, beyond the increase in the control arm.

CONCLUSION

There were improvements in NCD medicine availability across PHCs, the number of patients accessing PHCs and reduction in OOP expenditure among patients, across the study arms as compared to the control arm; however, these differences were not statistically significant.

TRIAL REGISTRATION

Trial registration number CTRI/2015/03/005640 . This trial was registered on 17/03/2015 in the Clinical Trial Registry of India (CTRI) after PHCs were enrolled in the study (retrospectively registered). The CTRI is the nodal agency of the Indian Council of Medical Research for registration of all clinical, experimental, field intervention and observation studies.

Assessing the household economic burden of non-communicable diseases in India: evidence from repeated cross-sectional surveys

BACKGROUND

Financing for NCDs is encumbered by out-of-pocket expenditure (OOPE) assuming catastrophic proportions. Therefore, it is imperative to investigate the extent of catastrophic health expenditure (CHE) on NCDs, which are burgeoning in India. Thus, our paper aims to examine the extent of CHE and impoverishment in India, in conjunction with socio-economic determinants impacting the CHE.

METHODS

We used cross-sectional data from nationwide healthcare surveys conducted in 2014 and 2017-18. OOPE on both outpatient and inpatient treatment was coalesced to estimate CHE on NCDs. Incidence of CHE was defined as proportion of households with OOPE exceeding 10% of household expenditure. Intensity of catastrophe was ascertained by the measure of Overshoot and Mean Positive Overshoot Indices. Further, impoverishing effects of OOPE were assessed by computing Poverty Headcount Ratio and Poverty Gap Index using India's official poverty line. Concomitantly, we estimated the inequality in incidence and intensity of catastrophic payments using Concentration Indices. Additionally, we delineated the factors associated with catastrophic expenditure using Multinomial Logistic Regression.

RESULTS

Results indicated enormous incidence of CHE with around two-third households with NCDs facing CHE. Incidence of CHE was concentrated amongst poor that further extended from 2014(CI = - 0.027) to 2017-18(CI = - 0.065). Intensity of CHE was colossal as households spent 42.8 and 34.9% beyond threshold in 2014 and 2017-18 respectively with poor enduring greater overshoot vis-à-vis rich (CI = - 0.18 in 2014 and CI = - 0.23 in 2017-18). Significant immiserating impact of NCDs was unraveled as one-twelfth in 2014 and one-eighth households in 2017-18 with NCD burden were pushed to poverty with poverty deepening effect to the magnitude of 27.7 and 30.1% among those already below poverty on account of NCDs in 2014 and 2017-18 respectively. Further, large inter-state heterogeneities in extent of CHE and impoverishment were found and multivariate analysis indicated absence of insurance cover, visiting private providers, residing in rural areas and belonging to poorest expenditure quintile were associated with increased likelihood of incurring CHE.

CONCLUSION

Substantial proportion of households face CHE and subsequent impoverishment due to NCD related expenses. Concerted efforts are required to augment the financial risk protection to the households, especially in regions with higher burden of NCDs.

Food Dishes for Sustainable Development: A Swedish Food Retail Perspective

Current dietary patterns contribute negatively to greenhouse gas emissions and to the increased prevalence of non-communicable diseases. Earlier research on sustainable food consumption mainly focuses on diets, rather than single meals. Diets are difficult to measure, which is usually executed through self-reporting. This paper aims to identify frequently prepared dishes in a home setting through sales statistics, and how they can be altered to reduce climate impact and increase nutritional value. Commonly prepared food dishes in a home setting among customers of a major food retailer in Sweden were identified through sales statistics. The dishes were altered to reach nutritional and climate impact guidelines. Commonly prepared food dishes exceeded goals for climate boundaries by more than threefold and were not in line with nutritional guidelines. The content of fat, including saturated fat, was too high. Vegetables, fruits, wholegrains and fiber need to be increased. To reduce climate impact and increase nutritional value, the amount of animal-based product need to be reduced and/or exchanged to plant-based alternatives. This research contributes empirically to understandings of how portfolio management decisions influence food consumption based on sales statistics and how nutritional and climate impact guidelines can be applied from a single meal perspective.

Does Economic Support Have an Impact on the Health Status of Elderly Patients With Chronic Diseases in China? - Based on CHARLS (2018) Data Research

Objective: The economic support of elderly patients with chronic diseases may affect their health status. This study assessed the impact of economic support on the health status of elderly patients with chronic diseases in China and explored the relationship between regional economic differences and the impact of economic support on health status. Methods: This study used the data of 3,416 elderly patients with chronic diseases from the China Health and Retirement Longitudinal Study (CHARLS) in 2018. Logit model and stepwise regression method were used to analyze and compare the influence of economic support on self-rated health, mental health, and activities of daily living (ADL) of elderly patients with chronic diseases. Sub-regional comparison was used for the research of regional differences in the impact of economic support on health. Results: we find that economic support has a positive effect on the health status of elderly patients with chronic diseases in China. Socioeconomic support has a positive effect on self-rated health and mental health of elderly patients with chronic diseases, and the effect on activities of daily living (ADL) is no longer significant after the gradual inclusion of control variables. Family economic support has no significant impact on the health dimensions of elderly patients with chronic diseases. With respect to regional differences, socioeconomic support can improve mental health in central China and improve self-rated health in western China, while it can improve overall health status in eastern China. The influence of family economic support on different health dimensions in different regions is still insignificant. Conclusions: The health status of elderly patients with chronic diseases is affected by socioeconomic support in China. In order to improve the health of elderly patients with chronic diseases, it is necessary to increase socioeconomic support. Meanwhile, it is also essential to pay attention to the differences in economic support between different regions and increase the socioeconomic support for elderly patients with chronic diseases in undeveloped regions so as to improve their health status.

Determinants of behavioural and biological risk factors for cardiovascular diseases from state level STEPS survey (2017-19) in Madhya Pradesh

Background

National and statewide assessment of cardiovascular risk factors needs to be conducted periodically in order to inform public health policy and prioritise allocation of funds, especially in LMICs. Although there have been studies from India which have explored the determinants of cardiovascular risk factors, they have mostly been from high epidemiological transition states. The present study assessed the determinants of cardiovascular (CVD) risk factors in a low epidemiological transition state (Madhya Pradesh) using the WHO STEPwise approach to surveillance (STEPS).

Methods

A total of 5,680 persons aged 18–69 years were selected from the state of Madhya Pradesh through multi-stage cluster random sampling. Key CVD risk factors we sought to evaluate were from behavioural (tobacco, alcohol, physical activity, diet) and biological domains (overweight or obese, Hypertension, Diabetes, and Raised serum cholesterol). Key socio-demographic factors of interest were the caste and tribe groups, and rural vs urban location, in addition to known influencers of CVD risk such as age, gender and education level

Results

Those belonging to the scheduled tribes were more at risk of consuming tobacco (OR 2.13 (95% CI [1.52–2.98]), and a diet with less than five servings of fruits and vegetables (OR 2.78 (95% CI [1.06–7.24]), but had had the least risk of physical inactivity (OR 0.31 (95% CI [0.02–0.54]). Residence in a rural area also reduced the odds of physical inactivity (OR 0.65 (95% CI [0.46–0.92])). Lack of formal education was a risk factor for both tobacco consumption and alcohol intake (OR 1.40 (95% CI [1.08–1.82]) for tobacco use; 1.68 (95% CI [1.14–2.49]) for alcohol intake). Those belonging to schedules tribes had much lower risk of being obese (OR 0.25; 95% CI [0.17–0.37]), but were at similar risk of all other clinical CVD risk factors as compared to other caste groups.

Conclusion

In the current study we explored socio-demographic determinants of behavioural and biological CVD risks, and found that in Madhya Pradesh, belonging to a scheduled tribe or living in a rural location, protects against being physically inactive or being overweight or obese. Increasing age confers a greater CVD-risk in all domains. Being a male, and lack of formal education confers a greater risk for behavioural domains, but not for most clinical risk domains. Future efforts at curbing CVDs should be therefore two pronged –a population-based strategy targeting biological risk factors, and a more focussed approach directed at those displaying risky behaviour.

Assessing cardiovascular disease risk factor screening inequalities in India using Lot Quality Assurance Sampling

Background

Cardiovascular diseases (CVDs) are the leading cause of mortality in India. India has rolled out Comprehensive Primary Health Care (CPHC) reforms including population based screening for hypertension and diabetes, facilitated by frontline health workers. Our study assessed blood pressure and blood sugar coverage achieved by frontline workers using Lot Quality Assurance Sampling (LQAS).

Methods

LQAS Supervision Areas were defined as catchments covered by frontline workers in primary health centres in two districts each of Uttar Pradesh and Delhi. In each Area, 19 households for each of four sampling universes (males, females, Above Poverty Line (APL) and Below Poverty Line (BPL)) were visited using probability proportional to size sampling. Following written informed consent procedures, a short questionnaire was administered to individuals aged 30 or older using tablets related to screening for diabetes and hypertension. Using the LQAS hand tally method, coverage across Supervision Areas was determined.

Results

A sample of 2052 individuals was surveyed, median ages ranging from 42 to 45 years. Caste affiliation, education levels, and occupation varied by location; the sample was largely married and Hindu. Awareness of and interaction with frontline health workers was reported in Uttar Pradesh and mixed in Delhi. Greater coverage of CVD risk factor screening (especially blood pressure) was seen among females, as compared to males. No clear pattern of inequality was seen by poverty status; some SAs did not have adequate BPL samples. Overall, blood pressure and blood sugar screening coverage by frontline health workers fell short of targeted coverage levels at the aggregate level, but in all sites, at least one area was crossing this threshold level.

Conclusion

CVD screening coverage levels at this early stage are low. More emphasis may be needed on reaching males. Sex and poverty related inequalities must be addressed by more closely studying the local context and models of service delivery where the threshold of screening is being met. LQAS is a pragmatic method for measuring program inequalities, in resource-constrained settings, although possibly not for spatially segregated population sub-groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05914-y.

Towards the Development of an Intervention to Address Social Determinants of Non-Communicable Disease in Kerala, India: A Mixed Methods Study

In India, cardiovascular disease (CVD), with hypertension as its foremost risk factor, has the highest prevalence rate of non-communicable diseases (NCDs) and a rising mortality. Previous research has found a clustering of behavioural and social risks pertaining to NCDs, though the latter are infrequently addressed in public health interventions in India. This paper reaches toward the development of a social intervention to address social determinants of NCD relating to hypertension and diabetes. We used Theory of Change (ToC) as a theoretical approach to programme design. Mixed methods were used, including qualitative interviews with community members (n = 20), Accredited Social Health Activists (n = 6) and health professionals (n = 8), and a stakeholder workshop (n = 5 participants). The recruitment of participants from one local area in Kerala enabled us to map service provision and gain a holistic understanding of how to utilise the existing workforce to target social risk factors. The findings suggest that social interventions need to focus on ensuring health behaviour information reaches all parts of the community, and that those with more social risk factors are identified and supported to engage with treatment. Further research is required to test the resulting intervention model.

Factors Predisposing to the Unplanned Hospital Readmission (UHR) in Patients Undergoing Surgery for Oral Cavity Squamous Cell Carcinoma (OSCC): Experience from a Tertiary Cancer Centre

Unplanned hospital readmissions (UHR) are known to add to patient morbidity, increase the cost of the treatment, and negatively impact the postoperative quality of life. The objective of the study was to identify the UHR rates of oral cavity squamous cell carcinoma (OSCC) patients following surgery and identify the predisposing factors for UHR. We conducted this retrospective analysis of all patients who underwent surgery for OSCC in our (single) surgical unit from January 2016 to December 2018. A total of 804 patients satisfied the eligibility criteria. Majority of the patients were males (n = 650, 80.8%). The median age of the patients was 50 years (Range: 16-89 years). The most common oral cavity subsite was buccal mucosa gingivobuccal (BM-GBS) OSCC. Forty patients (5%) required an UHR after discharge. The most common reason for readmissions was flap-related issues (11/40) and orocutaneous fistula (10/40). Other causes included wound infection (7/40), chest infection (2/40), hematoma/bleeding (3/40), and other lesser prevalent causes (7/40). Factors that significantly predisposed patients for UHR were re-exploration following the initial surgery [p < 0.001, OR 7.9 (4.09-15.59)] and BM-GBS subsite [< 0.001, OR: 2.89(1.24-6.73)]. The UHR rate in our study was 5%. Patients requiring re-exploration following the initial surgery and those with BM-GBS cancer were most likely to have the UHR.

Integrating depression care within NCD provision in Bangladesh and Pakistan: a qualitative study

Background

Co-morbidity of depression with other non-communicable diseases (NCDs) worsens clinical outcomes for both conditions. Low- and middle-income countries need to strengthen mechanisms for detection and management of co-morbid depression within NCDs. The Behavioural Activation for Comorbid Depression in Non-communicable Disease (BEACON) study explored the acceptability and feasibility of integrating a brief depression intervention (behavioural activation, BA) into NCD services in healthcare facilities in Bangladesh and Pakistan.

Methods

Face-to-face qualitative interviews were conducted with 43 patients and 18 health workers attending or working in NCD centres in four healthcare facilities in Bangladesh and Pakistan, and with three policy makers in each country. The interviews addressed four research questions (1) how NCD care is delivered, (2) how NCD patients experience distress, (3) how depression care is integrated within NCD provision, and (4) the challenges and opportunities for integrating a brief depression intervention into usual NCD care. The data were analysed using framework analysis, organised by capability, opportunity and motivation factors, cross-synthesised across countries and participant groups.

Results

Patients and health workers described NCD centres as crowded and time pressured, with waiting times as long as five hours, and consultation times as short as five minutes; resulting in some patient frustration. They did not perceive direct links between their distress and their NCD conditions, instead describing worries about family and finance including affordability of NCD services. Health worker and policy maker accounts suggested these NCD centres lacked preparedness for treating depression in the absence of specific guidelines, standard screening tools, recording systems or training. Barriers and drivers to integrating a brief depression intervention reflected capability, opportunity and motivation factors for all participant groups. While generally valuing the purpose, significant challenges included the busy hospital environment, skill deficits and different conceptions of depression.

Conclusions

Given current resource constraints and priorities, integrating a brief psychological intervention at these NCD centres appears premature. An opportune first step calls for responding to patients’ expressed concerns on service gaps in provisioning steady and affordable NCD care. Acknowledging differences of conceptions of depression and strengthening psychologically informed NCD care will in turn be required before the introduction of a specific psychological intervention such as BA.

Prevalence of hypertension and diabetes morbidity among adults in a few urban slums of Bangalore city, determinants of its risk factors and opportunities for control - A cross-sectional study

Introduction:

In World Health Organization's(WHO) South-East Asia region(SEAR), India accounts for >2/3rd of total deaths due to non-communicable diseases(NCD). Annually, NCDs account for ~60% of all deaths in India. Apart from the known risk factors, an individual's physical environment, behavioral and biological susceptibility are known to associated with NCDs. Social factors tend to create barriers for accessing healthcare among the poor people.

Objectives:

i)To screen and diagnose hypertension and diabetes among individuals aged >30 years, and its associated risk factors such as obesity and tobacco consumption. ii) To deliberate on the social determinants influencing this survey, and suggest suitable recommendations for the National Programme for prevention and control of Cancer, Diabetes, Cardiovascular disease and Stroke (NPCDCS).

Methods:

As a component of NPCDCS, the present survey was conducted in a few urban slums of Bangalore city during 2010. The collaborators for the conduct of this survey include the Ministry of health and family welfare, Director of health and family welfare services and Medical colleges in Bangalore city.

Results:

In our study, we found a prevalence proportion of 21.5% for hypertension, 13.8% for diabetes and 30.4% were co-morbid with both the diseases. Consumption of tobacco(any form) was present in 5.1% of the study subjects, overweight among 32.4% and obesity among 20.0%. The study population comprises 18.96% of the source, and the main reason for inadequate utilization was lack of Programmatic awareness.

Conclusion:

NPCDCS program needs to conceptualize the relevant social factors which determine access to screening and diagnostic healthcare services, including behavior change initiatives. For Program effectiveness, changes at the level of healthcare system need to adopted.

A perspective of private health care providers in the state of Madhya Pradesh on adopting key strategies of the India hypertension control initiative

The India Hypertension Control Initiative (IHCI) has been implemented in public health facilities. This study assessed the perspective of private physicians (PPs) on adopting the core strategies of the IHCI in Bhopal district of Madhya Pradesh. A semi-structured interview was purposely applied to 30 PPs to obtain their opinions on standardized hypertension treatment protocols, patient-centered services, and easy-to-use information system in their private practices. Verbatim data were recorded and analyzed thematically. Only 11 PPs followed the state hypertension treatment protocol. Among the remaining 19 PPs, the major reasons for not adopting protocol were (1) limited availability of single component hypertension drugs, (2) preferences for fixed dose combinations (FDCs), and (3) fear of either losing patients due to a lack of immediate blood pressure control or causing drug-related adverse effects. None of the interviewed doctors had resources to provide patient-centered care and use a digital health information system. Overall, the interviewed doctors identified that free supply of hypertension treatment protocol drugs, inclusion of FDCs in treatment protocol, increasing number of staff for follow-up visits, and patient education, IT-based solutions for patient records, employee incentives, and need for national data sharing policies are the key actions to accelerate the adoption of IHCI strategies in the private sector. This exploratory qualitative study suggests that engagement of private sector in the IHCI is feasible. Plans to expand the IHCI to the private sector should consider ensuring the wider availability of hypertension treatment protocol drugs and developing a simple user-friendly digital platform for patient monitoring.

Affordability Assessment from a Static to Dynamic Concept: A Scenario-Based Assessment of Cardiovascular Medicines

The out-of-pocket payments for prescription medications can impose a financial burden on patients from low- and middle- incomes and who suffer from chronic diseases. The present study aims at evaluating the affordability of cardiovascular disease (CVD) medication in Iran. This includes measuring affordability through World Health Organization/Health Action International (WHO/HAI) methodology. In this method, affordability is characterized as the number of days’ wages of the lowest-paid unskilled government worker. The different medication therapy scenarios are defined in mono-and combination therapy approaches. This method adds on to WHO/HAI methodology to discover new approaches to affordability assessments. The results show the differences in the medicines affordability when different approaches are used in mono-and combination therapy between 6 main sub-therapeutic groups of CVD. It indicates the medicine affordability is not a static concept and it changes dynamically between CVD therapeutic subgroups when it used alone or in combination with other medicines regarding patients’ characteristics and medical conditions. Hypertension and anti-arrhythmia therapeutic groups had the most non-affordability and hyperlipidemia had the most affordable medicines. Therefore, affordability can be considered as a dynamic concept, which not only affected by the medicine price but significantly affected by a patient’s characteristics, the number of medical conditions, and insurance coverage.

Equity in distribution of public subsidy for noncommunicable diseases among the elderly in India: an application of benefit incidence analysis

Background

Rapid ageing of the population and increasing non-communicable diseases (NCDs) among the elderly is one of the major public health challenges in India. To achieve the Universal Health Coverage, ever-growing elderly population should have access to needed healthcare, and they should not face any affordability related challenge. As most of the elderly suffers from NCDs and achieving health-equity is a priority, this paper aims to - study the utilization pattern of healthcare services for treatment of NCDs among the elderly; estimate the burden of out-of-pocket expenditure for the treatment of NCDs among the elderly and analyze the extent of equity in distribution of public subsidy for the NCDs among the elderly.

Methods

National Sample Survey data (71st round) has been used for the study. Exploratory data analysis and benefit incidence analysis have been applied to estimate the utilization, out-of-pocket expenditure and distribution of public subsidy among economic classes. Concentration curves and indices are also estimated.

Results

Results show that public-sector hospitalization for NCDs among the elderly has a pro-rich trend in rural India. However, in urban sector, for both inpatient and outpatient care the poorest class has substantial share in utilization of public facilities. Same result is also observed for rural outpatient care. Analysis shows that out-of-pocket expenditure is very high for both medicine and medical care even in public facilities for all economic groups. It is also observed that medicine has the highest share in total medical expenses during treatment of NCDs among the elderly in both the region. Benefit incidence analysis shows that the public subsidy has a pro-rich distribution for inpatient care treatment in both the sectors. In case of outpatient care, subsidy share is the maximum among the richest in the urban sector and in the rural region the poorest class gets the maximum subsidy benefit.

Conclusions

It is evident that a substantial share of the public subsidies is still going to the richer sections for the treatment of NCDs among the elderly. Evidences also suggest that procuring medicines and targeted policies for the elderly are needed to improve utilization and equity in the public healthcare system.

Health related quality of life in multimorbidity: a primary-care based study from Odisha, India

BACKGROUND

Multimorbidity, the coexistence of two or more chronic conditions is increasingly prevalent in primary care populations. Despite reports on its adverse impact on health outcomes, functioning and well-being, it's association with quality of life is not well known in low and middle income countries. We assessed the health-related quality of life (HRQoL) of primary care patients with multimorbidity and identified the influencing factors.

METHODS

This cross-sectional study was done across 20 public and 20 private primary care facilities in Odisha, India. Data were collected from 1649 adult out-patients using a structured multimorbidity assessment questionnaire for primary care (MAQ-PC). HRQoL was assessed by the 12-item short-form health survey (SF-12). Both physical (PCS) and mental components scores (MCS) were calculated. Multiple regression analysis was performed to determine the association of HRQoL with socio-demographics, number, severity and typology of chronic conditions.

RESULTS

Around 28.3% [95% CI: 25.9-30.7] of patients had multimorbidity. Mean physical component scope (PCS) and mental component score (MCS) of QoL in the study population was 43.56 [95% CI: 43.26-43.86] and 43.69 [95% CI: 43.22-44.16], respectively. Patients with multimorbidity reported poorer mean PCS [43.23, 95% CI: 42.62-43.84] and MCS [41.58, 95% CI: 40.74-42.43] compared to those without. After adjusting for other variables, morbidity severity burden score was found to be negatively associated with MCS [adjusted coefficient: -0.24, 95% CI - 0.41 to - 0.08], whereas no significant association was seen with PCS. Hypertension and diabetes with arthritis and acid peptic diseases were found to be negatively related with MCS. Within multimorbidity, lower education was inversely associated with mental QoL and positively associated with physical QoL score after adjusting for other variables.

CONCLUSION

Our findings demonstrate the diverse negative effects of multimorbidity on HRQoL and reveal that apart from count of chronic conditions, severity and pattern also influence HRQoL negatively. Health care providers should consider severity as an outcome measure to improve QoL especially in individuals with physical multimorbidity. Given the differences observed between age groups, it is important to identify specific care needs for each group. Musculoskeletal clusters need prioritised attention while designing clinical guidelines for multimorbidity.

The Current Status of Peritoneal Surface Oncology in India

With the increasing acceptance of cytoreductive surgery and HIPEC as a potentially curative treatment for primary and secondary peritoneal surface malignancies, peritoneal surface oncology has emerged as a distinct sub-specialty of surgical oncology. In the last 10 years, the acceptance of a conceptually different approach towards the management of peritoneal metastases has increased in India. During this period, over 1000 combined procedures have been performed in the country and most of the major cities have centers performing offering this treatment. Indian surgeons have formed collaborative groups to promote research and development of this specialty across the country. This article provides a detailed account of current practices pertaining to peritoneal surface oncology in the country and a future perspective.

Funding sources and costs to deliver cardiac rehabilitation around the globe: Drivers and barriers

BACKGROUND

Cardiac rehabilitation (CR) reach is minimal globally, primarily due to financial factors. This study characterized CR funding sources, cost to patients to participate, cost to programs to serve patients, and the drivers of these costs.

METHODS

In this cross-sectional study, an online survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. Costs in each country were reported using purchasing power parity (PPP). Results were compared by World Bank country income classification using generalized linear mixed models.

RESULTS

111/203 (54.68%) countries in the world offer CR, of which data were collected in 93 (83.78% country response rate; N = 1082 surveys, 32.0% program response rate). CR was most-often publicly funded (more in high-income countries [HICs]; p < .001), but in 60.20% of countries patients paid some or all of the cost. Funding source impacted capacity (p = .004), number of patients per exercise session (p < .001), personnel (p = .037), and functional capacity testing (p = .039). The median cost to serve 1 patient was $945.91PPP globally. In low and middle-income countries (LMICs), exercise equipment and stress testing were perceived as the most expensive delivery elements, with front-line personnel costs perceived as costlier in HICs (p = .003). Modifiable factors associated with higher costs included CR team composition (p = .001), stress testing (p = .002) and telemetry monitoring in HICs (p = .01), and not offering alternative models in LMICs (p = .02).

CONCLUSIONS

Too many patients are paying out-of-pocket for CR, and more public funding is needed. Lower-cost delivery approaches are imperative, and include walk tests, task-shifting, and intensity monitoring via perceived exertion.

Prevalence and risk factors for prehypertension and hypertension among adults in Central China from 2000-2011

BACKGROUND

Hypertension is frequently studied in surveys; however, prehypertension, a new blood pressure status between normotension and hypertension, is rarely reported.

METHODS

All data were derived from the China Health and Nutrition Survey (CHNS) and were analysed by logistic regression for correlation.

RESULTS

The prehypertension prevalence was 27.4%, with a hypertension rate of 36.9%. The awareness, treatment, and uncontrolled rates among all hypertension participates were 19.8%, 83.6%, and 55.0%, respectively. The epidemic rate of hypertension increased with increasing age (p < 0.001), and prehypertension appeared to have an epidemic peak in the age group of 38-57 years (p < 0.001). In general, the incidence of hypertension in urban participants was higher than in rural subjects (p < 0.001), and prehypertension in urban subjects was lower than that in rural subjects (p < 0.001). According to the results of logistic regression, hypertension and prehypertension were associated with age, gender, location, body mass index (BMI), body fat rate (BFR), waist circumference (WC), education, and the intake of energy-yielding nutrients<0.05).

CONCLUSION

The current study reveals a high epidemic rate of hypertension and prehypertension in Central China. These results indicate the urgent need to develop strategies to improve the prevention of hypertension and prehypertension in Central China.

Preparedness for delivering non-communicable disease services in primary care: access to medicines for diabetes and hypertension in a district in south India

Introduction

Non-communicable diseases (NCDs) have become a major public health challenge worldwide; they account for 28 million deaths per year in low-and-middle-income countries (LMICs). Like many other LMICs, India is struggling to organise quality care for a large NCD-affected population especially at the primary healthcare level. The aim of this study was to assess local health system preparedness in a south Indian primary healthcare setting for addressing diabetes and hypertension.

Methods

This paper draws on a mixed-methods research study on access to medicines conducted in Tumkur, Karnataka, India. We used quantitative data from household and health facility surveys, and qualitative data from focus group discussions and in-depth interviews with health workers and patients. We identified systemic drivers that influence utilisation of services at government primary health centres (PHCs) using thematic analysis of qualitative data and a systems framework on access to medicines to assess supply and demand side factors.

Results

Majority of households depend on private facilities for diabetes and hypertension care because of the lack of laboratory facilities and frequent medicine stockouts at PHCs. Financial and managerial resource allocation for NCDs and prioritisation of care and processes related to NCDs was suboptimal compared to the prominence of this agenda at global and national levels. Primary healthcare has a limited role even in the activities under the national programme that addresses diabetes and hypertension.

Discussion

The study finds critical gaps in the preparedness of PHCs and district health systems in organising and managing care for diabetes and hypertension. Due to the lack of continuous care organised through PHCs, patients depend on expensive and often episodic care in the private sector. There is a need to improve managerial and financial resource allocation towards diabetes and hypertension (and other NCDs) at the district level.

Trial registration number

CTRI/2015/03/005640; Pre-results.

Health system preparedness in noncommunicable diseases: Findings from two states Odisha and Kerala in India

Introduction:

“Non-communicable diseases (NCDs) are the raging reality of today's world and have moved up the priority list of most countries worldwide including India. The government of India has launched programs such as National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular disease, and Stroke, but little is known about preparedness of health system to address NCDs.

Methods:

A qualitative study was conducted in the states of Odisha and Kerala to document the government stakeholder perspectives of health system preparedness for NCDs.

Results:

The study revealed that both the states have a NCD preparedness structure but need strengthening at various levels. The present human resource is inadequate, over-burdened, and requires specific skills. The lack of workforce adversely affects the service delivery mechanism. The study highlighted that there is a gap in the timely release of funds and also lack of evidence-based application if the information that is made available.

Conclusion:

There is a clear need to fill the gaps and strengthen the identified areas at various levels to address the increasing NCD burden. There is also a need to more in-depth and large-scale studies on such issues which act as external monitoring mechanisms thereby assisting the policy makers and program managers in with relevant and scientific evidence to bring reforms in the health system.

Health-care utilization and expenditure patterns in the rural areas of Punjab, India

Objective

To determine pattern of health care utilization and extent of out-of-pocket healthcare expenditure in rural areas of Punjab in India.

Methods

Using multi stage sampling procedure, 660 participants were selected from 110 villages, out of all 22 districts; 440 participants had utilized outpatient care in past 15 days, and 220 had been hospitalized in past one year. Pretested semistructured questionnaires were used to enquire about household and healthcare expenditures. Out-of-pocket (OoP) expenditure included only direct costs of healthcare. Sevety seven 77 (12%) participants could not provide expenditures, hence were excluded from analysis. More than 10% of total household expenditure on healthcare was considered catastrophic.

Results

Majority of the participants had used public sector health facilities for outpatient (57%) and inpatient (51.5%) care. Public sector facilities were utilized more often for communicable diseases and gynaecological problems whereas private sector services were used more commonly for accidents and non-communicable diseases. Mean healthcare expenditure on outpatient and inpatient healthcare services was Indian Rupees (INR) 8501 and INR 53889 respectively. Expenditure in private sector was significantly higher compared to the public sector facilities. Catastrophic expenditure was incurred by 7% of the households while seeking outpatient care and by 53% while seeking inpatient care. To pay for outpatient and inpatient care, 23.3% and 61.5% of the participants respectively had to borrow money or sell their assets.

Conclusions

Healthcare expenditure places households under considerable financial strain in rural areas of Punjab in India. Improvements of public hospitals may increase their utilization and decrease financial burden.

Pattern and impact of drugs targeted toward toxicity amelioration in patients receiving cancer chemotherapy

Background:

Drug therapy today is remarkably safe and efficacious. Still, some drugs - particularly anticancer drugs - are fraught with numerous adverse drug reactions (ADRs), severely jeopardizing quality of life of cancer patients. Fortunately, most of these ADRs are preventable provided adequate prophylactic drugs are administered along with chemotherapy.

Aims:

The aim of this study is to assess the pattern and impact of cytoprotective prophylactic drugs on anticancer ADRs in patients receiving cancer chemotherapy.

Subjects and Methods:

We included 200 patients receiving anticancer therapy for the first time. Patient details and for each cycle: details of baseline investigations, anticancer treatment given, ADRs observed and interventions done to prevent and manage the ADRs were recorded. Preventability and predictability scales were applied to assess the impact of drugs and strategies toward toxicity amelioration. Data were analyzed using descriptive statistics.

Results:

Adjuvant drugs were administered prophylactically along with anticancer drugs for the prevention of nausea and vomiting, gastritis, immediate allergic reactions, nephrotoxicity, ototoxicity, hemorrhagic cystitis, and other anticipated ADRs. About 94.80% reactions were found to be predictable and 5.20% unpredictable. Maximum reactions (56.47%) were probably preventable. Paracetamol, filgrastim, mucaine, etc., were used to manage a variety of ADRs.

Conclusions:

Although the predictability of ADRs was almost 95%, we could prevent only about 56% of them. Surprisingly, we have no ADRs that appear definitely preventable. This could be due to less attention being paid to the ADRs that could have been prevented by the appropriate use of prophylactic measures.

Knowledge attitude, and practice regarding dietary salt intake among urban slum population of North India

Introduction:

Hypertension is an important modifiable risk factor for cardiovascular disease. High salt intake is an etiological factor for hypertension. Any effective salt reduction strategy will be based on people's mind-set about salt use. Our objective for this study was to assess the knowledge, attitude, and practice for dietary salt intake by urban slum populations in Indira Colony, Chandigarh.

Methodology:

In 2015, we conducted a cross-sectional survey among a representative sample of 300 adults aged 18–69 years using a standardized questionnaire. Variations in the knowledge attitude and practice by gender and residence location were compared using the Chi-square tests.

Results:

Most of them (96%) took processed foods and 99% did not bother about the salt levels in the food. They also added salt on table. They did not buy low-sodium salts. Majority of them (75%) perceived that they are taking right amount of salt. They were clueless about the daily recommended allowance. Many participants (43%) did not know about the harmful effects of dietary salt. One-fifth (18%) of them had wrong information about dietary salt. Majority of the participants (64%) considered that lowering salt in diet is not important.

Conclusion:

Overall awareness level about optimal salt intake in diet was very poor among the slum residents.

Recommendation:

Development of effective public education initiative is the need of the hour for combatting hypertension.

The "homemade" HIPEC machine - a cost-effective alternative in low-resource countries

BACKGROUND

HIPEC using custom-made machines (CMM) remains unaffordable for many patients in low-income countries. We describe the assembly and use homemade HIPEC machine (HMM) as a cost-effective alternative.

METHODS

We evaluated the cost of setting up the HMM, maintenance, expenses per procedure as well as technical aspects including target temperature and flow rate, safety aspects, technical failures and the technical support required. The comparison with CMM was based on the manufacturer information and published reports and not on personal experience.

RESULTS

Form 2011 to 2017, we performed HIPEC (Coliseum technique) in 81 patients using HMM. HMM was a cardiopulmonary bypass machine available in our institution, with an additional water bath. Flow rate was 2 L/min and target temperature between 41 and 43 °C could be achieved in all cases. There were no technical failures and there was no safety issue recorded. Routine maintenance was provided yearly by an in-house technician. Chemotherapy costs (between 20 and 500 USD) were independent from the devices used. Cost of consumables was 450 USD/procedure, as compared to 1800 to 3500 USD/procedure for commercially available products. Investment cost for CMM is between 70,000 and 1,35,000 USD.

CONCLUSIONS

The HMM is a cost-effective option allowing access to HIPEC to patients in low-resource countries without loss of efficacy or additional safety concerns. The initial cost and cost per procedure were substantially less for HMM while the maintenance of both systems was similar in terms of complexity and cost. The CMM are more user-friendly and require less technical support.