Development, validation & pilot testing of a questionnaire to assess healthcare seeking behaviour, healthcare service utilization & out-of-pocket expenditure of Particularly Vulnerable Tribal Groups of Odisha, India.

Background & objectives: Assessing healthcare seeking behaviour (HSB), healthcare utilization and related out-of-pocket expenditures of Particularly Vulnerable Tribal Groups (PVTGs) of India through a prism of the health system may help to achieve equitable health outcomes. Therefore, this comprehensive study was envisaged to examine these issues among PVTGs of Odisha, India. However, there exists no validated questionnaire to measure these variables among PVTGs. Therefore, a study questionnaire was developed for this purpose and validated. Methods: Questionnaire was constructed in four phases: questionnaire development, validity assessment, pilot testing and reliability assessment. Nine domain experts face validated questionnaire in two rounds, followed by a single round of quantitative content validity. Next, the questionnaire was pretested in three rounds using cognitive interviews and pilot-tested among 335 and 100 eligible individuals for the two sections healthcare seeking behaviour (HSB-Q) and maternal and child healthcare service utilization (MCHSU-Q). Internal consistency reliability was assessed for de novo HSB-Q. Results: On two rounds of expert-driven face validity, 55 items were eliminated from 200 items. Questionnaire showed moderate to high content validity (item-level content validity index range: 0.78 to 1, scale-level content validity index/universal agreement: 0.73; scale-level content validity index/average: 0.96 and multirater kappa statistics range: 0.6 to 1). During the pre-test, items were altered until saturation was achieved. Pilot testing helped to refine interview modalities. The Cronbach alpha and McDonald's omega assessing internal consistency of HSB-Q were 0.8 and 0.85, respectively. Interpretation & conclusions: The questionnaire was found to be valid and reliable to explore healthcare seeking behaviour, maternal and child healthcare utilization and related out-of-pocket expenditure incurred by PVTGs of Odisha, India.

Family-Level Multimorbidity among Older Adults in India: Looking through a Syndemic Lens.

Most evidence on multimorbidity is drawn from an individual level assessment despite the fact that multimorbidity is modulated by shared risk factors prevailing within the household environment. Our study reports the magnitude of family-level multimorbidity, its correlates, and healthcare expenditure among older adults using data from the Longitudinal Ageing Study in India (LASI), wave-1. LASI is a nationwide survey amongst older adults aged ≥45 years conducted in 2017-2018. We included (n = 22,526) families defined as two or more members coresiding in the same household. We propose a new term, "family-level multimorbidity", defined as two or more members of a family having multimorbidity. Multivariable logistic regression was used to assess correlates, expressed as adjusted odds ratios with a 95% confidence interval. Family-level multimorbidity was prevalent among 44.46% families, whereas 41.8% had conjugal multimorbidity. Amongst siblings, 42.86% reported multimorbidity and intergenerational (three generations) was 46.07%. Family-level multimorbidity was predominantly associated with the urban and affluent class. Healthcare expenditure increased with more multimorbid individuals in a family. Our findings depict family-centred interventions that may be considered to mitigate multimorbidity. Future studies should explore family-level multimorbidity to help inform programs and policies in strategising preventive as well as curative services with the family as a unit.

Multimorbidity and Complex Multimorbidity in India: Findings from the 2017-2018 Longitudinal Ageing Study in India (LASI).

Complex multimorbidity refers to the co-occurrence of three or more chronic illnesses across >2 body systems, which may identify persons in need of additional medical support and treatment. There is a scarcity of evidence on the differences in patient outcomes between non-complex (≥2 conditions) and complex multimorbidity groups. We evaluated the prevalence and patient outcomes of complex multimorbidity and compared them to non-complex multimorbidity. We included 30,489 multimorbid individuals aged ≥45 years from the Longitudinal Ageing Study in India (LASI) from wave-1 conducted in 2017−2018. We employed a log link in generalised linear models (GLM) to identify possible risk factors presenting the adjusted prevalence−risk ratio (APRR) and adjusted prevalence−risk difference (APRD) with 95% confidence interval. The prevalence of complex multimorbidity was 34.5% among multimorbid individuals. Participants residing in urban areas [APRR: 1.10 (1.02, 1.20)], [APRD: 0.04 (0.006, 0.07)] were more likely to report complex multimorbidity. Participants with complex multimorbidity availed significantly higher inpatient department services and had higher expenditure as compared to the non-complex multimorbidity group. Our findings have major implications for healthcare systems in terms of meeting the requirements of people with complicated multimorbidity, as they have significantly higher inpatient health service utilisation, higher medical costs, and poorer self-rated health.

Multimorbidity Among Urban Poor in India: Findings From LASI, Wave-1.

Background: Multimorbidity has become a norm in low-and middle-income countries such as India requiring notable health system improvements to combat. Urban population is a heterogeneous group where poor are at a risk of facing inequity in accessing healthcare services which can jeopardize our efforts to attain universal health coverage (UHC). We aimed to estimate the prevalence, assess correlates and patterns of multimorbidity among urban poor. Further, we assessed the outcomes of multimorbidity such as healthcare utilization, expenditure and self-rated health. Methods: Longitudinal Aging Study in India (LASI), wave-1 is a nationally representative survey conducted amongst participants aged ≥45 years in 2017-18. We included 9,327 participants residing in urban areas, categorized as poor based on monthly per capita expenditure. Descriptive statistics computed prevalence with 95% uncertainty interval. Multivariable logistic regression was executed to assess the association between multimorbidity and various correlates, expressed as adjusted odds ratio. An ordinal regression model was run between self-rated health and number of chronic conditions. Results: The prevalence of multimorbidity was 45.26% among the urban poor. Hypertension and oral morbidities were the most commonly observed dyad. Respondents who were poorer [AOR: 1.27 (1.06-1.51)] had higher chances of having multimorbidity than the poorest. Respondents with a health insurance [AOR: 1.40 (1.14-1.70)] had a higher risk of having multimorbidity. In-patient admission was significantly higher among participants having multimorbidity. Out of pocket expenditure increased while self-rated health deteriorated with each additional morbid condition. Conclusion: Multimorbidity is found to be increasingly prevalent among urban poor and individuals having health insurance which demonstrates the need to expand healthcare insurance schemes such as Ayushman Bharat for urban poor to achieve UHC.

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.