Chronic disease concordance within Indian households: A cross-sectional study

Background: The household is a potentially important but understudied unit of analysis and intervention in chronic disease research. We sought to estimate the association between living with someone with a chronic condition and one’s own chronic condition status. Methods and findings We conducted a cross-sectional analysis of population-based household- and individual-level data collected in 4 socioculturally and geographically diverse settings across rural and urban India in 2013 and 2014. Of 10,703 adults ages 18 years and older with coresiding household members surveyed, data from 7,522 adults (mean age 39 years) in 2,574 households with complete covariate information were analyzed. The main outcome measures were diabetes (fasting plasma glucose ≥ 126 mg/dL or taking medication), common mental disorder (General Health Questionnaire score ≥ 12), hypertension (blood pressure ≥ 140/90 mmHg or taking medication), obesity (body mass index ≥ 30 kg/m2), and high cholesterol (total blood cholesterol ≥ 240 mg/dL or taking medication). Logistic regression with generalized estimating equations was used to model associations with adjustment for a participant’s age, sex, education, marital status, religion, and study site. Inverse probability weighting was applied to account for missing data. We found that 44% of adults had 1 or more of the chronic conditions examined. Irrespective of familial relationship, adults who resided with another adult with any chronic condition had 29% higher adjusted relative odds of having 1 or more chronic conditions themselves (adjusted odds ratio [aOR] = 1.29; 95% confidence interval [95% CI] 1.10–1.50). We also observed positive statistically significant associations of diabetes, common mental disorder, and hypertension with any chronic condition (aORs ranging from 1.19 to 1.61) in the analysis of all coresiding household members. Associations, however, were stronger for concordance of certain chronic conditions among coresiding household members. Specifically, we observed positive statistically significant associations between living with another adult with diabetes (aOR = 1.60; 95% CI 1.23–2.07), common mental disorder (aOR = 2.69; 95% CI 2.12–3.42), or obesity (aOR = 1.82; 95% CI 1.33–2.50) and having the same condition. Among separate analyses of dyads of parents and their adult children and dyads of spouses, the concordance between the chronic disease status was striking. The associations between common mental disorder, hypertension, obesity, and high cholesterol in parents and those same conditions in their adult children were aOR = 2.20 (95% CI 1.28–3.77), 1.58 (95% CI 1.15–2.16), 4.99 (95% CI 2.71–9.20), and 2.57 (95% CI 1.15–5.73), respectively. The associations between diabetes and common mental disorder in husbands and those same conditions in their wives were aORs = 2.28 (95% CI 1.52–3.42) and 3.01 (95% CI 2.01–4.52), respectively. Relative odds were raised even across different chronic condition phenotypes; specifically, we observed positive statistically significant associations between hypertension and obesity in the total sample of all coresiding adults (aOR = 1.24; 95% CI 1.02–1.52), high cholesterol and diabetes in the adult-parent sample (aOR = 2.02; 95% CI 1.08–3.78), and hypertension and diabetes in the spousal sample (aOR = 1.51; 95% CI 1.05–2.17). Of all associations examined, only the relationship between hypertension and diabetes in the adult-parent dyads was statistically significantly negative (aOR = 0.62; 95% CI 0.40–0.94). Relatively small samples in the dyadic analysis and site-specific analysis call for caution in interpreting qualitative differences between associations among different dyad types and geographical locations. Because of the cross-sectional nature of the analysis, the findings do not provide information on the etiology of incident chronic conditions among household members. Conclusions: We observed strong concordance of chronic conditions within coresiding adults across diverse settings in India. These data provide early evidence that a household-based approach to chronic disease research may advance public health strategies to prevent and control chronic conditions. Trial registration Clinical Trials Registry India CTRI/2013/10/004049; http://ctri.nic.in/Clinicaltrials/login.ph

Structured Lifestyle Modification Interventions Involving Frontline Health Workers for Population-Level Blood Pressure Reduction: Results of a Cluster Randomized Controlled Trial in India (DISHA Study).

Background: Population-wide reduction in mean blood pressure is proposed as a key strategy for primary prevention of cardiovascular disease. We evaluated the effectiveness of a task-sharing strategy involving frontline health workers in the primary prevention of elevated blood pressure. Methods and Results: We conducted DISHA (Diet and lifestyle Interventions for Hypertension Risk reduction through Anganwadi Workers and Accredited Social Health Activists) study, a cluster randomized controlled trial involving 12 villages each from 4 states in India. Frontline health workers delivered a custom-made and structured lifestyle modification intervention in the selected villages. A baseline survey was conducted in 23 and 24 clusters in the control (n=6663) and intervention (n=7150) groups, respectively. The baseline characteristics were similar between control and intervention clusters. In total 5616 participants from 23 clusters in the control area and 5699 participants from 24 clusters in the intervention area participated in a repeat cross-sectional survey conducted immediately after the intervention phase of 18-months. The mean (SD) systolic blood pressure increased from 125.7 (18.1) mm Hg to 126.1 (16.8) mm Hg in the control clusters, and it increased from 124.4 (17.8) mm Hg to 126.7 (17.5) mm Hg in the intervention clusters. The population average adjusted mean difference in difference in systolic blood pressure was 1.75 mm Hg (95% CI, -0.21 to 3.70). Conclusions: Task-sharing interventions involving minimally trained nonphysician health workers are not effective in reducing population average blood pressure in India. Expanding the scope of task sharing and intensive training of health workers such as nurses, nutritionists, or health counselors in management of cardiovascular risk at the population level may be more effective in primary prevention of cardiovascular disease. Registration: URL: https://www.ctri.nic.in; Unique identifier: CTRI/2013/10/004049

Task shifting of frontline community health workers for cardiovascular risk reduction: design and rationale of a cluster randomised controlled trial (DISHA study) in India

Abstract Background Effective task-shifting interventions targeted at reducing the global cardiovascular disease (CVD) epidemic in low and middle-income countries (LMICs) are urgently needed. Methods DISHA is a cluster randomised controlled trial conducted across 10 sites (5 in phase 1 and 5 in phase 2) in India in 120 clusters. At each site, 12 clusters were randomly selected from a district. A cluster is defined as a small village with 250–300 households and well defined geographical boundaries. They were then randomly allocated to intervention and control clusters in a 1:1 allocation sequence. If any of the intervention and control clusters were <10 km apart, one was dropped and replaced with another randomly selected cluster from the same district. The study included a representative baseline cross-sectional survey, development of a structured intervention model, delivery of intervention for a minimum period of 18 months by trained frontline health workers (mainly Anganwadi workers and ASHA workers) and a post intervention survey in a representative sample. The study staff had no information on intervention allocation until the completion of the baseline survey. In order to ensure comparability of data across sites, the DISHA study follows a common protocol and manual of operation with standardized measurement techniques. Discussion Our study is the largest community based cluster randomised trial in low and middle-income country settings designed to test the effectiveness of ‘task shifting’ interventions involving frontline health workers for cardiovascular risk reduction. Trial registration CTRI/2013/10/004049 . Registered 7 October 2013

Adjusted association between living with a spouse with a given chronic condition and having that same or another chronic condition (<i>n</i> = 1,598).

<p>Adjusted association between living with a spouse with a given chronic condition and having that same or another chronic condition (<i>n</i> = 1,598).</p

Adjusted association between living with a parent with a given chronic condition and having that same or another chronic condition (<i>n</i> = 1,660).

<p>Adjusted association between living with a parent with a given chronic condition and having that same or another chronic condition (<i>n</i> = 1,660).</p

Site-specific adjusted relative odds (95% confidence interval) of having a chronic condition if any other member of the household has that same chronic condition (reference: no other member of the household has that same condition) and test for interaction between sites.

<p>Site-specific associations were computed by including an interaction term between the site and the exposure condition. The <i>P</i> values shown are from generalized score tests for Type III contrasts for the site x exposure interaction term. The horizontal line marks the null value. Madhya Pradesh data were excluded from the common mental disorder analysis because of poor performance of the survey tool. Chronic conditions were defined as follows: diabetes (prior diagnosis, fasting plasma glucose ≥ 126 mg/dL, or taking medication); common mental disorder (General Health Questionnaire score ≥ 12); hypertension (prior diagnosis, blood pressure ≥ 140/90 mmHg, or taking medication); obesity (body mass index ≥ 30 kg/m²); and high cholesterol (prior diagnosis, total blood cholesterol ≥ 240 mg/dL, or taking medication). See <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1002395#pmed.1002395.s003" target="_blank">S3 Table</a> for these data in table form.</p

Adjusted association between living with someone with a given chronic condition and having that same or another chronic condition (<i>n</i> = 7,572).

<p>Adjusted association between living with someone with a given chronic condition and having that same or another chronic condition (<i>n</i> = 7,572).</p

Characteristics of the analytic sample.

<p>Characteristics of the analytic sample.</p

Additional file 1: of Task shifting of frontline community health workers for cardiovascular risk reduction: design and rationale of a cluster randomised controlled trial (DISHA study) in India

Study questionnaire. http://www.ccdcindia.org//Disha_study/DISHA_STUDY_QUESTIONNAIRE.pdf . (DOC 22 kb