Socioeconomic Inequalities in Secondhand Smoke Exposure at Home and at Work in 15 Low- and Middle-Income Countries.

INTRODUCTION: In high-income countries, secondhand smoke (SHS) exposure is higher among disadvantaged groups. We examine socioeconomic inequalities in SHS exposure at home and at workplace in 15 low- and middle-income countries (LMICs). METHODS: Secondary analyses of cross-sectional data from 15 LMICs participating in Global Adult Tobacco Survey (participants ≥ 15 years; 2008-2011) were used. Country-specific analyses using regression-based methods were used to estimate the magnitude of socioeconomic inequalities in SHS exposure: (1) Relative Index of Inequality and (2) Slope Index of Inequality. RESULTS: SHS exposure at home ranged from 17.4% in Mexico to 73.1% in Vietnam; exposure at workplace ranged from 16.9% in Uruguay to 65.8% in Bangladesh. In India, Bangladesh, Thailand, Malaysia, Philippines, Vietnam, Uruguay, Poland, Turkey, Ukraine, and Egypt, SHS exposure at home reduced with increasing wealth (Relative Index of Inequality range: 1.13 [95% confidence interval [CI] 1.04-1.22] in Turkey to 3.31 [95% CI 2.91-3.77] in Thailand; Slope Index of Inequality range: 0.06 [95% CI 0.02-0.11] in Turkey to 0.43 [95% CI 0.38-0.48] in Philippines). In these 11 countries, and in China, SHS exposure at home reduced with increasing education. In India, Bangladesh, Thailand, and Philippines, SHS exposure at workplace reduced with increasing wealth. In India, Bangladesh, Thailand, Philippines, Vietnam, Poland, Russian Federation, Turkey, Ukraine, and Egypt, SHS exposure at workplace reduced with increasing education. CONCLUSION: SHS exposure at homes is higher among the socioeconomically disadvantaged in the majority of LMICs studied; at workplaces, exposure is higher among the less educated. Pro-equity tobacco control interventions alongside targeted efforts in these groups are recommended to reduce inequalities in SHS exposure. IMPLICATIONS: SHS exposure is higher among the socioeconomically disadvantaged groups in high-income countries. Comprehensive smoke-free policies are pro-equity for certain health outcomes that are strongly influenced by SHS exposure. Using nationally representative Global Adult Tobacco Survey (2008-2011) data from 15 LMICs, we studied socioeconomic inequalities in SHS exposure at homes and at workplaces. The study showed that in most LMICs, SHS exposure at homes is higher among the poor and the less educated. At workplaces, SHS exposure is higher among the less educated groups. Accelerating implementation of pro-equity tobacco control interventions and strengthening of efforts targeted at the socioeconomically disadvantaged groups are needed to reduce inequalities in SHS exposure in LMICs

Association of Oral Health with Multimorbidity among Older Adults:Findings from the Longitudinal Ageing Study in India, Wave-1, 2017–2019

India is witnessing an increase in the prevalence of multimorbidity. Oral health is related to overall health but is seldom included in the assessment of multimorbidity. Hence, this study aimed to estimate the prevalence of oral morbidity and explore its association with physical multimorbidity using data from Longitudinal Ageing Study in India (LASI). LASI is a nationwide survey amongst adults aged ≥ 45 years conducted in 2018. Descriptive analysis was performed on included participants (n = 59,764) to determine the prevalence of oral morbidity. Multivariable logistic regression assessed the association between oral morbidity and physical multimorbidity. Self-rated health was compared between multimorbid participants with and without oral morbidity. Oral morbidity was prevalent in 48.56% of participants and physical multimorbidity in 50.36%. Those with multimorbidity were at a higher risk of having any oral morbidity (AOR: 1.60 (1.48–1.73)) than those without multimorbidity. Participants who had only oral morbidity rated their health to be good more often than those who had physical multimorbidity and oral morbidity (40.84% vs. 32.98%). Oral morbidity is significantly associated with physical multimorbidity. Multimorbid participants perceived their health to be inferior to those with only oral morbidity. The findings suggest multidisciplinary health teams in primary care should include the management of oral morbidity and physical multimorbidity

The Effects of Pay for Performance on Disparities in Stroke, Hypertension, and Coronary Heart Disease Management: Interrupted Time Series Study

Background Pay-for-performance rewards health-care providers by paying them more if they succeed in meeting performance targets. A new contract for general practitioners in the United Kingdom represents the most radical shift towards pay-for-performance seen in any health-care system. The contract provides an important opportunity to address disparities in chronic disease management between ethnic and socioeconomic groups. We examined disparities in management of people with diabetes and intermediate clinical outcomes within a multiethnic population in primary care before and after the introduction of the new contract in April 2004. Methods and Findings We conducted a population-based longitudinal survey, using electronic general practice records, in an ethnically diverse part of southwest London. Outcome measures were prescribing levels and achievement of national treatment targets (HbA1c ≤ 7.0%; blood pressure [BP] < 140/80 mm Hg; total cholesterol ≤ 5 mmol/l or 193 mg/dl). The proportion of patients reaching treatment targets for HbA1c, BP, and total cholesterol increased significantly after the implementation of the new contract. The extents of these increases were broadly uniform across ethnic groups, with the exception of the black Caribbean patient group, which had a significantly lower improvement in HbA1c (adjusted odds ratio [AOR] 0.75, 95% confidence interval [CI] 0.57–0.97) and BP control (AOR 0.65, 95% CI 0.53–0.81) relative to the white British patient group. Variations in prescribing and achievement of treatment targets between ethnic groups present in 2003 were not attenuated in 2005. Conclusions Pay-for-performance incentives have not addressed disparities in the management and control of diabetes between ethnic groups. Quality improvement initiatives must place greater emphasis on minority communities to avoid continued disparities in mortality from cardiovascular disease and the other major complications of diabetes

Low physical activity is associated with adverse health outcome and higher costs in Indonesia: A national panel study

AimsTo assess the association between low physical activity, cardiovascular disease (CVD) and risk factors, health service utilization, risk of catastrophic health expenditure, and work productivity in Indonesia.MethodsIn this population-based, panel data analysis, we used data from two waves of the Indonesian Family Life Survey (IFLS) for 2007/2008 and 2014/2015. Respondents aged 40–80 years who participated in both waves were included in this study (n = 5,936). Physical activity was assessed using the International Physical Activity Questionnaire (IPAQ-SF). Multinomial logistic regression model was used to examine factors associated with physical activity levels (low, moderate, and high). We applied a series of multilevel mixed-effect panel regression to examine the associations between physical activity and outcome variables.ResultsThe prevalence of low physical activity increased from 18.2% in 2007 to 39.6% in 2014. Compared with those with high physical activity, respondents with low physical activity were more likely to have a 10-year high CVD risk (AOR: 2.11, 95% CI: 1.51–2.95), use outpatient care (AOR: 1.26, 95% CI: 1.07–1.96) and inpatient care (AOR 1.45, 95% CI: 1.07–1.96), experience catastrophic health expenditure of 10% of total household expenditure (AOR: 1.66, 95% CI: 1.21–2.28), and have lower labor participation (AOR: 0.24, 95% 0.20–0.28).ConclusionsLow physical activity is associated with adverse health outcomes and considerable costs to the health system and wider society. Accelerated implementation of public health policies to reduce physical inactivity is likely to result in substantial population health and economic benefits

Multimorbidity and out-of-pocket expenditure on medicine in Europe:longitudinal analysis of 13 European countries between 2013-2015

BACKGROUND: Many European Health Systems are implementing or increasing levels of cost-sharing for medicine in response to the growing constrains on public spending on health despite their negative impact on population health due to delay in seeking care. OBJECTIVE: This study aims to examine the relationships between multimorbidity (two or more coexisting chronic diseases, CDs), complex multimorbidity (three or more CDs impacting at least three different body systems), and out-of-pocket expenditure (OOPE) for medicine across European nations. METHODS: This study utilized data on participants aged 50 years and above from two recent waves of the Survey of Health, Aging, and Retirement in Europe conducted in 2013 (n = 55,806) and 2015 (n = 51,237). Pooled cross-sectional and longitudinal study designs were used, as well as a two-part model, to analyse the association between multimorbidity and OOPE for medicine. RESULTS: The prevalence of multimorbidity was 50.4% in 2013 and 48.2% in 2015. Nearly half of those with multimorbidity had complex multimorbidity. Each additional CD was associated with a 34% greater likelihood of incurring any OOPE for medicine (Odds ratio = 1.34, 95% CI = 1.31–1.36). The average incremental OOPE for medicine was 26.4 euros for each additional CD (95% CI = 25.1–27·7), and 32.1 euros for each additional body system affected (95% CI 30.6–33.7). In stratified analyses for country-specific quartiles of household income the average incremental OOPE for medicine was not significantly different across groups. CONCLUSION: Between 2013 and 2015 in 13 European Health Systems increased prevalence of CDs was associated with greater likelihood of having OOPE on medication and an increase in the average amount spent when one occurred. Monitoring this indicator is important considering the negative association with treatment adherence and subsequent effects on health

Patients with more comorbidities have better detection of chronic conditions, but poorer management and control:findings from six middle-income countries

Background The burden of non-communicable diseases (NCDs) is rising rapidly in middle-income countries (MICs), where NCDs are often undiagnosed, untreated and uncontrolled. How comorbidity impacts diagnosis, treatment, and control of NCDs is an emerging area of research inquiry and have important clinical implications as highlighted in the recent National Institute for Health and Care Excellence guidelines for treating patients suffering from multiple NCDs. This is the first study to examine the association between increasing numbers of comorbidities with being undiagnosed, untreated, and uncontrolled for NCDs, in 6 large MICs. Methods Cross-sectional analysis of the World Health Organisation Study of Global Ageing and Adult Health (WHO SAGE) Wave 1 (2007–10), which consisted of adults aged ≥18 years from 6 populous MICs, including China, Ghana, India, Mexico, Russia and South Africa (overall n = 41, 557). Results A higher number of comorbidities was associated with better odds of diagnosis for hypertension, angina, and arthritis, and higher odds of having treatment for hypertension and angina. However, more comorbidities were associated with increased odds of uncontrolled hypertension, angina, arthritis, and asthma. Comorbidity with concordant conditions was associated with improved diagnosis and treatment of hypertension and angina. Conclusion Patients with more comorbidities have better diagnosis of chronic conditions, but this does not translate into better management and control of these conditions. Patients with multiple NCDs are high users of health services and are at an increased risk of adverse health outcomes. Hence, improving their access to care is a priority for healthcare systems

Physical multimorbidity, health service use and catastrophic health expenditure by socio-economic groups in China::a population-based panel data analysis

Background Multimorbidity, the presence of two or more mental or physical chronic non-communicable diseases (NCDs), is a major challenge for the health system in China, which faces unprecedented ageing of its population. This study examined: (1) the distribution of physical multimorbidity in relation to socio-economic status, (2) the relationships between physical multimorbidity, healthcare service use, and catastrophic health expenditures, and (3) whether these relationships varied by socio-economic groups and social health insurance schemes. Methods Panel data study design utilized three waves of the nationally-representative China Health and Retirement Longitudinal Study (CHARLS 2011, 2013, 2015), which included 11 718 participants aged ≥50 years, and 11 physical NCDs. Findings Overall, 62% of participants had physical multimorbidity in China in 2015. Multimorbidity increased with age, female gender, higher per capita household expenditure, and higher educational level. However, multimorbidity was more common in poorer regions compared with the most affluent regions. An additional chronic NCD was associated with an increase in the number of outpatient visits of 28.8% (IRR=1.29, 95% CI: 1.27 to 1.31), and days of hospitalisation (IRR=1.38, 95% CI: 1.35 to 1.41). There were similar effects in different socio-economic groups and among those covered by different social health insurance programmes. Overall, multimorbidity was associated with a substantially greater odds of experiencing CHE (AOR=1·29 for the overall population, 95% CI=1·26, 1·32). The effect of multimorbidity on catastrophic health expenditures persisted even among the higher socio-economic groups and those with more generous health insurance coverage. Interpretation Multimorbidity was associated with higher levels of health service use and greater financial burden. Concerted efforts are needed to reduce health inequalities that arise due to multimorbidity, and its adverse economic impact in population groups in China. Social health insurance reforms must place emphasis on reducing out-of-pocket spending for patients with multimorbidity to provide greater financial risk protection

The impact of depression and physical multimorbidity on health-related quality of life in China:a national longitudinal quantile regression study

Abstract The co-occurrence of mental and physical chronic conditions is a growing concern and a largely unaddressed challenge in low-and-middle-income countries. This study aimed to investigate the independent and multiplicative effects of depression and physical chronic conditions on health-related quality of life (HRQoL) in China, and how it varies by age and gender. We used two waves of the China Health and Retirement Longitudinal Study (2011, 2015), including 9227 participants aged ≥ 45 years, 12 physical chronic conditions and depressive symptoms. We used mixed-effects linear regression to assess the effects of depression and physical multimorbidity on HRQoL, which was measured using a proxy measure of Physical Component Scores (PCS) and Mental Component Scores (MCS) of the matched SF-36 measure. We found that each increased number of physical chronic conditions, and the presence of depression were independently associated with lower proxy PCS and MCS scores. There were multiplicative effects of depression and physical chronic conditions on PCS (− 0.83 points, 95% CI − 1.06, − 0.60) and MCS scores (− 0.50 points, 95% CI − 0.73, − 0.27). The results showed that HRQoL decreased markedly with multimorbidity and was exacerbated by the presence of co-existing physical and mental chronic conditions

Multimorbidity and out-of-pocket expenditure for medicines in China and India

Using nationally representative survey data from China and India, this study examined (1) the distribution and patterns of multimorbidity in relation to socioeconomic status and (2) association between multimorbidity and out-of-pocket expenditure (OOPE) for medicines by socioeconomic groups