Smokeless tobacco in South Asia – the measurement of dependence, sociocultural influences and cardiovascular consequences

Introduction: Despite very high smokeless tobacco (ST) consumption in South Asia (SA), there are significant gaps in our knowledge regarding the measurement of ST dependence, sociocultural influences, and consequences associated with the use of South Asian ST products. Aim: To improve our understanding of ST use and dependency, sociocultural determinants and consequences associated with their use in South Asia. Methods: My thesis comprised of three empirical studies. I carried out psychometric assessments of three ST dependency scales, using data collected from a convenience sample of adult ST users in India. In the same sample, I quantitatively measured selected sociocultural variables and assessed their association with ST use and quit practices. Finally, I conducted meta-analyses of longitudinal observational studies to examine causal associations between ever use of ST and cardiovascular outcomes, both globally and by geographical subgroups. Results: Among the scales, internal consistency was highest for Oklahoma Scale for Smokeless Tobacco Dependence (OSSTD). The scales were significantly correlated with each other, and showed positive associations with heaviness and consistency of ST use. Based on exploratory factor analyses (EFA), OSSTD was a unidimensional measure of ST dependence in an Indian context. The sociocultural survey showed that having ST users as close peers and no household restrictions on use adversely influenced quit attempts and quit intentions respectively, in adjusted models. In the meta-analyses, ever use of ST was associated with a 40% increased risk of incident ischaemic health disease (IHD) in SA, which was not found in other geographical regions. Conclusions: South Asian ST products are likely highly addictive, and sociocultural factors may be associated with fewer quit attempts made. In addition to cancer, ST use also increases the risk of cardiovascular disease outcomes. More research relevant to ST control is needed from SA, particularly given the adverse health consequences associated with use

Core outcome sets for trials of interventions to prevent and to treat multimorbidity in low- and middle-income countries: the COSMOS study

Introduction: The burden of multimorbidity is recognised increasingly in low- and middle-income countries (LMICs), creating a strong emphasis on the need for effective evidence-based interventions. A core outcome set (COS) appropriate for the study of multimorbidity in LMIC contexts does not presently exist. This is required to standardise reporting and contribute to a consistent and cohesive evidence-base to inform policy and practice. We describe the development of two COS for intervention trials aimed at the prevention and treatment of multimorbidity in LMICs. Methods: To generate a comprehensive list of relevant prevention and treatment outcomes, we conducted a systematic review and qualitative interviews with people with multimorbidity and their caregivers living in LMICs. We then used a modified two-round Delphi process to identify outcomes most important to four stakeholder groups with representation from 33 countries (people with multimorbidity/caregivers, multimorbidity researchers, healthcare professionals, and policy makers). Consensus meetings were used to reach agreement on the two final COS. Registration: https://www.comet-initiative.org/Studies/Details/1580. Results: The systematic review and qualitative interviews identified 24 outcomes for prevention and 49 for treatment of multimorbidity. An additional 12 prevention, and six treatment outcomes were added from Delphi round one. Delphi round two surveys were completed by 95 of 132 round one participants (72.0%) for prevention and 95 of 133 (71.4%) participants for treatment outcomes. Consensus meetings agreed four outcomes for the prevention COS: (1) Adverse events, (2) Development of new comorbidity, (3) Health risk behaviour, and (4) Quality of life; and four for the treatment COS: (1) Adherence to treatment, (2) Adverse events, (3) Out-of-pocket expenditure, and (4) Quality of life. Conclusion: Following established guidelines, we developed two COS for trials of interventions for multimorbidity prevention and treatment, specific to LMIC contexts. We recommend their inclusion in future trials to meaningfully advance the field of multimorbidity research in LMICs

Prevalence of mental disorders in South Asia: a systematic review of reviews

Mental disorders are increasing in South Asia (SA), but their epidemiological burden is under-researched. We carried out a systematic umbrella review to estimate the prevalence of mental disorders and intentional self-harm in the region. Multiple databases were searched and systematic reviews reporting the prevalence of at least one mental disorder from countries in SA were included. Review data were narratively synthesised; primary studies of common mental disorders (CMDs) among adults were identified from a selected subset of reviews and pooled. We included 124 reviews. The majority (n = 65) reported on mood disorders, followed by anxiety disorders (n = 45). High prevalence of mental disorders and intentional self-harm was found in general adult and vulnerable populations. Two reviews met our pre-defined criteria for identifying primary studies of CMDs. Meta-analysis of 25 primary studies showed a pooled prevalence of 16.0% (95% CI = 11.0–22.0%, I 2 = 99.9%) for depression, 12.0% (5.0–21.0%, I 2 = 99.9%) for anxiety, and 14.0% (10.0–19.0, I 2 = 99.9%) for both among the general adult population; pooled estimates varied by country and assessment tool used. Overall, reviews suggest high prevalence for mental disorders in SA, but evidence is limited on conditions other than CMDs

Global impact of tobacco control policies on smokeless tobacco use : A systematic review protocol

Introduction Smokeless tobacco (ST) was consumed by 356 million people globally in 2017. Recent evidence shows that ST consumption is responsible for an estimated 652 494 all-cause deaths across the globe annually. The WHO Framework Convention on Tobacco Control (FCTC) was negotiated in 2003 and ratified in 2005 to implement effective tobacco control measures. While the policy measures enacted through various tobacco control laws have been effective in reducing the incidence and prevalence of smoking, the impact of ST-related policies (within WHO FCTC and beyond) on ST use is under-researched and not collated. Methods and analysis A systematic review will be conducted to collate all available ST-related policies implemented across various countries and assess their impact on ST use. The following databases will be searched: Medline, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Scopus, EconLit, ISI Web of Science, Cochrane Library (CENTRAL), African Index Medicus, LILACS, Scientific Electronic Library Online, Index Medicus for the Eastern Mediterranean Region, Index Medicus for South-East Asia Region, Western Pacific Region Index Medicus and WHO Library Database, as well as Google search engine and country-specific government websites. All ST-related policy documents (FCTC and non-FCTC) will be included. Results will be limited to literature published since 2005 in English and regional languages (Bengali, Hindi and Urdu). Two reviewers will independently employ two-stage screening to determine inclusion. The Effective Public Health Practice Project's 'Quality Assessment Tool for Quantitative Studies' will be used to record ratings of quality and risk of bias among studies selected for inclusion. Data will be extracted using a standardised form. Meta-analysis and narrative synthesis will be used. Ethics and dissemination Permission for ethics exemption of the review was obtained from the Centre for Chronic Disease Control's Institutional Ethics Committee, India (CCDC-IEC-06-2020; dated 16 April 2020). The results will be disseminated through publications in a peer-reviewed journal and will be presented in national and international conferences. PROSPERO registration number CRD42020191946

Assessment of Public-Private Partnership (PPP) Models in Health Systems in Least Developed, Low Income and Lower-Middle-Income Countries and Territories : A Protocol for a Systematic Review.

Background: Private sectors play a significant role in health provision along with the public sector in both developed and developing countries. Given the limited resources of the public sector, Public-Private Partnerships (PPPs) are considered as a good solution to address the growing public health challenges. But inadequate assessment of various health-related PPPs has resulted in a failure to gather knowledge and evidence that would facilitate the establishment of effective partnerships, sustain, and systematize them over time, as well as determine the role of PPPs in health system strengthening, particularly in terms of urban health provision. The objective of this research is to systematically review the effectiveness of PPPs on the utilization of urban health provision to achieve health outcomes in the urban contexts of least developed, low income, and lower-middle-income countries and territories.Methods: This systematic review will follow PRISMA-P guidelines for reporting. Relevant databases-EMBASE, MEDLINE, Health Management Information Consortium, Social Sciences Citation Index, Science Citation Index, Emerging Sources, CENTRAL, i.e., Database of disability and inclusion information resources, and WHO Library Database–will be searched for published articles in the urban context. Reference lists of relevant systematic reviews and commentaries and citations of key included studies will be checked for additional studies. Two reviewers will independently screen the studies in covidence following the exclusion and inclusion criteria. Data will be thematically analysed and narratively synthesized.Discussion: This review will comprehensively assess and appraise all the existing PPP models for urban health provision in the least developed, low income, and lower-middle-income countries and territories. The findings of the review will help to understand the modalities of the existing health related PPPs in urban areas, their functionalities, and their contribution in achieving health outcomes.Protocol registration: This protocol is registered with the International Prospective Register of Systematic Reviews, PROSPERO (ID-CRD42021289509, 23 November 2021)

The economics of healthcare access: a scoping review on the economic impact of healthcare access for vulnerable urban populations in low‑ and middle‑income countries

Background: The growing urban population imposes additional challenges for health systems in low- and middle income countries (LMICs). We explored the economic burden and inequities in healthcare utilisation across slum, non-slum and levels of wealth among urban residents in LMICs. Methods: This scoping review presents a narrative synthesis and descriptive analysis of studies conducted in urban areas of LMICs. We categorised studies as conducted only in slums, city-wide studies with measures of wealth and conducted in both slums and non-slums settlements. We estimated the mean costs of accessing healthcare, the incidence of catastrophic health expenditures (CHE) and the progressiveness and equity of health expenditures. The definitions of slums used in the studies were mapped against the 2018 UN-Habitat definition. We developed an evidence map to identify research gaps on the economics of healthcare access in LMICs. Results: We identified 64 studies for inclusion, the majority of which were from South-East Asia (59%) and classified as city-wide (58%). We found severe economic burden across health conditions, wealth quintiles and study types. Compared with city-wide studies, slum studies reported higher direct costs of accessing health care for acute conditions and lower costs for chronic and unspecified health conditions. Healthcare expenditures for chronic conditions were highest amongst the richest wealth quintiles for slum studies and more equally distributed across all wealth quintiles for city-wide studies. The incidence of CHE was similar across all wealth quintiles in slum studies and concentrated among the poorest residents in city-wide studies. None of the definitions of slums used covered all characteristics proposed by UN-Habitat. The evidence map showed that city-wide studies, studies conducted in India and studies on unspecified health conditions dominated the current evidence on the economics of healthcare access. Most of the evidence was classified as poor quality. Conclusions: Our findings indicated that city-wide and slums residents have different expenditure patterns when accessing healthcare. Financial protection schemes must consider the complexity of healthcare provision in the urban context. Further research is needed to understand the causes of inequities in healthcare expenditure in rapidly expanding and evolving cities in LMICs

Global burden of disease due to smokeless tobacco consumption in adults : analysis of data from 113 countries

BACKGROUND: Smokeless tobacco is consumed in most countries in the world. In view of its widespread use and increasing awareness of the associated risks, there is a need for a detailed assessment of its impact on health. We present the first global estimates of the burden of disease due to consumption of smokeless tobacco by adults. METHODS: The burden attributable to smokeless tobacco use in adults was estimated as a proportion of the disability-adjusted life-years (DALYs) lost and deaths reported in the 2010 Global Burden of Disease study. We used the comparative risk assessment method, which evaluates changes in population health that result from modifying a population's exposure to a risk factor. Population exposure was extrapolated from country-specific prevalence of smokeless tobacco consumption, and changes in population health were estimated using disease-specific risk estimates (relative risks/odds ratios) associated with it. Country-specific prevalence estimates were obtained through systematically searching for all relevant studies. Disease-specific risks were estimated by conducting systematic reviews and meta-analyses based on epidemiological studies. RESULTS: We found adult smokeless tobacco consumption figures for 115 countries and estimated burden of disease figures for 113 of these countries. Our estimates indicate that in 2010, smokeless tobacco use led to 1.7 million DALYs lost and 62,283 deaths due to cancers of mouth, pharynx and oesophagus and, based on data from the benchmark 52 country INTERHEART study, 4.7 million DALYs lost and 204,309 deaths from ischaemic heart disease. Over 85 % of this burden was in South-East Asia. CONCLUSIONS: Smokeless tobacco results in considerable, potentially preventable, global morbidity and mortality from cancer; estimates in relation to ischaemic heart disease need to be interpreted with more caution, but nonetheless suggest that the likely burden of disease is also substantial. The World Health Organization needs to consider incorporating regulation of smokeless tobacco into its Framework Convention for Tobacco Control