The prevalence of cardiovascular disease risk factors among adults living in extreme poverty.

Evidence on cardiovascular disease (CVD) risk factor prevalence among adults living below the World Bank's international line for extreme poverty (those with income <$1.90 per day) globally is sparse. Here we pooled individual-level data from 105 nationally representative household surveys across 78 countries, representing 85% of people living in extreme poverty globally, and sorted individuals by country-specific measures of household income or wealth to identify those in extreme poverty. CVD risk factors (hypertension, diabetes, smoking, obesity and dyslipidaemia) were present among 17.5% (95% confidence interval (CI) 16.7-18.3%), 4.0% (95% CI 3.6-4.5%), 10.6% (95% CI 9.0-12.3%), 3.1% (95% CI 2.8-3.3%) and 1.4% (95% CI 0.9-1.9%) of adults in extreme poverty, respectively. Most were not treated for CVD-related conditions (for example, among those with hypertension earning <$1.90 per day, 15.2% (95% CI 13.3-17.1%) reported taking blood pressure-lowering medication). The main limitation of the study is likely measurement error of poverty level and CVD risk factors that could have led to an overestimation of CVD risk factor prevalence among adults in extreme poverty. Nonetheless, our results could inform equity discussions for resource allocation and design of effective interventions.

Co-occurrence of and factors associated with health risk behaviors among adolescents: a multi-center study in sub-Saharan Africa, China, and India.

Background: Despite lifelong and detrimental effects, the co-occurrence of health risk behaviors (HRBs) during adolescence remains understudied in low- and middle-income countries. This study examines the co-occurrence of HRBs and its correlates among adolescents in sub-Saharan Africa, China, and India. Methods: A multi-country cross-sectional study was conducted in 2021-2022, involving 9697 adolescents (aged 10-19 years) from eight countries, namely Burkina Faso, China, Ethiopia, India, Ghana, Nigeria, Tanzania, and Uganda. A standardized questionnaire was administered to examine five types of HRBs - physical inactivity, poor dietary habits, smoking, alcohol consumption, and risky sexual behavior. Latent class analysis was employed to identify clustering patterns among the behaviors, and logistic regression was used to identify the correlates of these patterns. Findings: Three clusters of HRBs were identified, with Cluster 1 (27.73%) characterized by the absence of any specific risky behavior, Cluster 2 (68.16%) characterized by co-occurrence of physical inactivity and poor dietary habits, and Cluster 3 (4.11%) characterized by engagement in smoking, alcohol consumption, and risky sexual behavior. Relative to Cluster 1, being in Cluster 2 was associated with being female (aOR 1.20, 95% CI 1.09-1.32), not enrolled in education (aOR 0.84, 95% CI 0.71-0.99), and not engaged in paid work (aOR 1.23, 95% CI 1.08-1.41). Compared with those Cluster 1, adolescents in Cluster 3 were less likely to be female (aOR 0.41, 95% CI 0.32-0.54), be engaged in paid work (aOR 0.54, 95% CI 0.41-0.71), more likely to be older (aOR 7.56, 95% CI 5.18-11.03), not be enrolled in educational institution (aOR 1.74, 95% CI 1.27-2.38), and more likely to live with guardians other than parents (aOR 1.56, 95% CI 1.19-2.05). Interpretation: The significant clustering patterns of HRBs among adolescents in sub-Saharan Africa, China, and India highlights the urgent need for convergent approaches to improve adolescent health behaviors. Early life and school-based programs aimed at promoting healthy behaviors and preventing risky and unhealthy behaviors should be prioritized to equip adolescents with the tools and skills for lifelong well-being. Funding: Fondation Botnar (Grant #INV-037672) and Harvard T.H. Chan School of Public Health, partially funded this study.

Pattern and predictors of non-adherence to diabetes self-management recommendations among patients in peripheral district of Bangladesh.

OBJECTIVES: This study was designed to determine the extent of non-adherence to the different dimensions of diabetes self-management and to identify the factors influencing non-adherence among peripheral patients in Bangladesh. METHODS: A cross-sectional study was conducted among 990 adult diabetic patients residing in Thakurgaon district, Bangladesh. Data were collected through face-to-face interviews including socio-demographic information, disease and therapeutic, health services, knowledge and adherence to self-management components. RESULTS: The proportion of non-adherence to drug prescription was 66.7%, dietary regimen (68.9%), physical exercise (58.0%), follow-up visit/blood glucose test (88.2%), stopping tobacco (50.6%), and regular foot care (93.9%). Significant predictors for non-adherence to drug were poorest socio-economic status (OR = 2.47), absence of diabetic complications (OR = 1.43), using non-clinical therapy (OR = 5.61), and moderate level of knowledge (OR = 1.87). Non-adherence to dietary recommendations was higher for women (OR = 1.72), poorest socio-economic status (OR = 3.17), and poor technical knowledge (OR = 4.68). Non-adherence to physical exercise was lower for women (OR = 0.62), combined family (OR = 0.63), middle socio-economic status (OR = 0.54), and moderate knowledge on physical exercise (OR = 0.55). Non-adherence to follow-up visits/blood glucose test was higher among patients who did not have diabetic complications (OR = 1.81) and with own transport (OR = 2.57), and respondents from high-income group (OR = 0.23) were less likely to be non-adherent. Non-adherence to stopping tobacco was higher for older individuals (OR = 1.86); but lower for women (OR = 0.48), individuals with higher education level (OR = 0.17) and patients sick for a longer time (OR = 0.52). Non-adherence to foot care was higher for patients who needed longer time to go to hospital (OR = 4.07) and had poor basic knowledge on diabetes (OR = 17.80). CONCLUSION: An alarmingly high proportion of diabetic patients did not adhere to diabetes self-management. Major predictors for non-adherence were related to patient's demographic characteristics and their experience with disease, treatment and health care services.

Quasi-experimental evaluation of a nationwide diabetes prevention programme.

Diabetes is a leading cause of morbidity, mortality and cost of illness1,2. Health behaviours, particularly those related to nutrition and physical activity, play a key role in the development of type 2 diabetes mellitus3. Whereas behaviour change programmes (also known as lifestyle interventions or similar) have been found efficacious in controlled clinical trials4,5, there remains controversy about whether targeting health behaviours at the individual level is an effective preventive strategy for type 2 diabetes mellitus6 and doubt among clinicians that lifestyle advice and counselling provided in the routine health system can achieve improvements in health7-9. Here we show that being referred to the largest behaviour change programme for prediabetes globally (the English Diabetes Prevention Programme) is effective in improving key cardiovascular risk factors, including glycated haemoglobin (HbA1c), excess body weight and serum lipid levels. We do so by using a regression discontinuity design10, which uses the eligibility threshold in HbA1c for referral to the behaviour change programme, in electronic health data from about one-fifth of all primary care practices in England. We confirm our main finding, the improvement of HbA1c, using two other quasi-experimental approaches: difference-in-differences analysis exploiting the phased roll-out of the programme and instrumental variable estimation exploiting regional variation in programme coverage. This analysis provides causal, rather than associational, evidence that lifestyle advice and counselling implemented at scale in a national health system can achieve important health improvements.

The influence of depressive symptoms and school-going status on risky behaviors: a pooled analysis among adolescents in six sub-Saharan African countries.

Background: Evidence from sub-Saharan Africa (SSA) regarding risky behaviors among adolescents remains scarce, despite the large population (approximately 249 million out of 1.2 billion globally in 2019) of adolescents in the region. We aimed to examine the potential influence of depressive symptoms and school-going status on risky behaviors among adolescents in six SSA countries. Methods: We used individual cross-sectional data from adolescents aged 10-19 based in eight communities across six SSA countries, participating in the ARISE Network Adolescent Health Study (N = 7,661). Outcomes of interest were cigarette or tobacco use, alcohol use, other substance use, getting into a physical fight, no condom use during last sexual intercourse, and suicidal behavior. We examined the proportion of adolescents reporting these behaviors, and examined potential effects of depressive symptoms [tertiles of 6-item Kutcher Adolescent Depression Scale (KADS-6) score] and school-going status on these behaviors using mixed-effects Poisson regression models. We also assessed effect modification of associations by sex, age, and school-going status. Results: The proportion of adolescents reporting risky behaviors was varied, from 2.2% for suicidal behaviors to 26.2% for getting into a physical fight. Being in the higher tertiles of KADS-6 score was associated with increased risk of almost all risky behaviors [adjusted risk ratio (RR) for highest KADS-6 tertile for alcohol use: 1.70, 95% confidence interval (95% CI): 1.48-1.95, p < 0.001; for physical fight: 1.52, 95% CI: 1.36-1.70, p < 0.001; for suicidal behavior: 7.07, 95% CI: 2.69-18.57, p < 0.001]. Being in school was associated with reduced risk of substance use (RR for alcohol use: 0.73, 95% CI: 0.53-1.00, p = 0.047), and not using a condom (RR: 0.81, 95% CI: 0.66-0.99, p = 0.040). There was evidence of modification of the effect of school-going status on risky behaviors by age and sex. Conclusion: Our findings reinforce the need for a greater focus on risky behaviors among adolescents in SSA. Addressing depressive symptoms among adolescents, facilitating school attendance and using schools as platforms to improve health may help reduce risky behaviors in this population. Further research is also required to better assess the potential bidirectionality of associations.

High prevalence of self-reported sexually transmitted infections among older adults in Tanzania: results from a list experiment in a population-representative survey.

PURPOSE: Self-report of sensitive or stigmatized health states is often subject to social desirability and interviewer biases. To reduce such biases, we estimated the rate of sexually transmitted infections (STIs) using a list experiment. METHODS: This population-representative study was nested within the Dar es Salaam Urban Cohort Study, a Health and Demographic Surveillance System (HDSS) in the Ukonga ward of Dar es Salaam, Tanzania. Men and women aged ≥40years were randomly assigned to receive a list of either four control items (i.e., the control group) or four control items plus an additional item on having had a disease through sexual contacts in the past 12months (i.e., the treatment group). We calculated the mean difference in the total number of items to which respondents answered "yes" in the treatment versus control group and compared this prevalence estimate to the one measured by the direct question. RESULTS: A total of 2310 adults aged ≥40years were enrolled in the study: 32% were male and 48% were aged 40-49years. The estimated prevalence of having STIs in the past 12months was 17.8% (95% confidence interval [CI] 12.3-23.3) in the list experiment, almost 10 times higher than the estimated prevalence of 1.8% (95%CI 1.3-2.4) based on the direct question (P < .001). STI prevalence remained high after adjusting for age, the number of lifetime sex partners, alcohol consumption and smoking in multivariate linear regression (15.6%; 95% CI 7.3-23.9). CONCLUSIONS: We found a substantially higher prevalence of STIs among older adults in urban Tanzania when we based our estimation on a list experiment rather than a direct question in a population-representative survey. List experiments should be considered to elimnate social desirability and interviewer biases in surveys of sensitive or stigmatized health states. The very high prevalence of STIs highlights the need for improved access to STI screening, prevention and treatment for older adults in urban Africa.

Exploring computer-aided health decision-making on cervical cancer interventions through deliberative interviews in Ethiopia.

Cervical cancer is a significant disease burden in Ethiopia. Mathematical models and computer simulations on disease dynamics can support effective resource allocation. The objectives of this work are (i) to explore the perspectives of health decision-makers on computer-aided predictions supporting cervical cancer interventions, (ii) to identify their information needs from these predictions, and (iii) their willingness to apply the results in their work. We conducted deliberative interviews with 15 health decision-makers and advisors in Ethiopia in autumn 2019. We analyze the data using a five steps framework approach drawing on thematic analysis and find that Ethiopian health decision-makers are willing to use computer-aided predictions in their decisions. Data on HPV prevalence and the cervical cancer burden are scarce but valued highly and decision-makers are particularly interested in the identification of local HPV hotspots. Data-driven mathematical models and computer simulations may increasingly influence health decision-making in Ethiopia.

Estimates and Projections of the Global Economic Cost of 29 Cancers in 204 Countries and Territories From 2020 to 2050.

Importance: Cancers are a leading cause of mortality, accounting for nearly 10 million annual deaths worldwide, or 1 in 6 deaths. Cancers also negatively affect countries' economic growth. However, the global economic cost of cancers and its worldwide distribution have yet to be studied. Objective: To estimate and project the economic cost of 29 cancers in 204 countries and territories. Design, Setting, and Participants: A decision analytical model that incorporates economic feedback in assessing health outcomes associated with the labor force and investment. A macroeconomic model was used to account for (1) the association of cancer-related mortality and morbidity with labor supply; (2) age-sex-specific differences in education, experience, and labor market participation of those who are affected by cancers; and (3) the diversion of cancer treatment expenses from savings and investments. Data were collected on April 25, 2022. Main Outcomes and Measures: Economic cost of 29 cancers across countries and territories. Costs are presented in international dollars at constant 2017 prices. Results: The estimated global economic cost of cancers from 2020 to 2050 is $25.2 trillion in international dollars (at constant 2017 prices), equivalent to an annual tax of 0.55% on global gross domestic product. The 5 cancers with the highest economic costs are tracheal, bronchus, and lung cancer (15.4%); colon and rectum cancer (10.9%); breast cancer (7.7%); liver cancer (6.5%); and leukemia (6.3%). China and the US face the largest economic costs of cancers in absolute terms, accounting for 24.1% and 20.8% of the total global burden, respectively. Although 75.1% of cancer deaths occur in low- and middle-income countries, their share of the economic cost of cancers is lower at 49.5%. The relative contribution of treatment costs to the total economic cost of cancers is greater in high-income countries than in low-income countries. Conclusions and Relevance: In this decision analytical modeling study, the macroeconomic cost of cancers was found to be substantial and distributed heterogeneously across cancer types, countries, and world regions. The findings suggest that global efforts to curb the ongoing burden of cancers are warranted.

Mapping age- and sex-specific HIV prevalence in adults in sub-Saharan Africa, 2000-2018.

BACKGROUND: Human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) is still among the leading causes of disease burden and mortality in sub-Saharan Africa (SSA), and the world is not on track to meet targets set for ending the epidemic by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United Nations Sustainable Development Goals (SDGs). Precise HIV burden information is critical for effective geographic and epidemiological targeting of prevention and treatment interventions. Age- and sex-specific HIV prevalence estimates are widely available at the national level, and region-wide local estimates were recently published for adults overall. We add further dimensionality to previous analyses by estimating HIV prevalence at local scales, stratified into sex-specific 5-year age groups for adults ages 15-59 years across SSA. METHODS: We analyzed data from 91 seroprevalence surveys and sentinel surveillance among antenatal care clinic (ANC) attendees using model-based geostatistical methods to produce estimates of HIV prevalence across 43 countries in SSA, from years 2000 to 2018, at a 5 × 5-km resolution and presented among second administrative level (typically districts or counties) units. RESULTS: We found substantial variation in HIV prevalence across localities, ages, and sexes that have been masked in earlier analyses. Within-country variation in prevalence in 2018 was a median 3.5 times greater across ages and sexes, compared to for all adults combined. We note large within-district prevalence differences between age groups: for men, 50% of districts displayed at least a 14-fold difference between age groups with the highest and lowest prevalence, and at least a 9-fold difference for women. Prevalence trends also varied over time; between 2000 and 2018, 70% of all districts saw a reduction in prevalence greater than five percentage points in at least one sex and age group. Meanwhile, over 30% of all districts saw at least a five percentage point prevalence increase in one or more sex and age group. CONCLUSIONS: As the HIV epidemic persists and evolves in SSA, geographic and demographic shifts in prevention and treatment efforts are necessary. These estimates offer epidemiologically informative detail to better guide more targeted interventions, vital for combating HIV in SSA.

Framework and baseline examination of the German National Cohort (NAKO).

The German National Cohort (NAKO) is a multidisciplinary, population-based prospective cohort study that aims to investigate the causes of widespread diseases, identify risk factors and improve early detection and prevention of disease. Specifically, NAKO is designed to identify novel and better characterize established risk and protection factors for the development of cardiovascular diseases, cancer, diabetes, neurodegenerative and psychiatric diseases, musculoskeletal diseases, respiratory and infectious diseases in a random sample of the general population. Between 2014 and 2019, a total of 205,415 men and women aged 19-74 years were recruited and examined in 18 study centres in Germany. The baseline assessment included a face-to-face interview, self-administered questionnaires and a wide range of biomedical examinations. Biomaterials were collected from all participants including serum, EDTA plasma, buffy coats, RNA and erythrocytes, urine, saliva, nasal swabs and stool. In 56,971 participants, an intensified examination programme was implemented. Whole-body 3T magnetic resonance imaging was performed in 30,861 participants on dedicated scanners. NAKO collects follow-up information on incident diseases through a combination of active follow-up using self-report via written questionnaires at 2-3 year intervals and passive follow-up via record linkages. All study participants are invited for re-examinations at the study centres in 4-5 year intervals. Thereby, longitudinal information on changes in risk factor profiles and in vascular, cardiac, metabolic, neurocognitive, pulmonary and sensory function is collected. NAKO is a major resource for population-based epidemiology to identify new and tailored strategies for early detection, prediction, prevention and treatment of major diseases for the next 30 years.

Patterns of tobacco use in low and middle income countries by tobacco product and sociodemographic characteristics: nationally representative survey data from 82 countries.

OBJECTIVES: To determine the prevalence and frequency of using any tobacco product and each of a detailed set of tobacco products, how tobacco use and frequency of use vary across countries, world regions, and World Bank country income groups, and the socioeconomic and demographic gradients of tobacco use and frequency of use within countries. DESIGN: Secondary analysis of nationally representative, cross-sectional, household survey data from 82 low and middle income countries collected between 1 January 2015 and 31 December 2020. SETTING: Population based survey data. PARTICIPANTS: 1 231 068 individuals aged 15 years and older. MAIN OUTCOME MEASURES: Self-reported current smoking, current daily smoking, current smokeless tobacco use, current daily smokeless tobacco use, pack years, and current use and use frequencies of each tobacco product. Products were any type of cigarette, manufactured cigarette, hand rolled cigarette, water pipe, cigar, oral snuff, nasal snuff, chewing tobacco, and betel nut (with and without tobacco). RESULTS: The smoking prevalence in the study sample was 16.5% (95% confidence interval 16.1% to 16.9%) and ranged from 1.1% (0.9% to 1.3%) in Ghana to 50.6% (45.2% to 56.1%) in Kiribati. The user prevalence of smokeless tobacco was 7.7% (7.5% to 8.0%) and prevalence was highest in Papua New Guinea (daily user prevalence of 65.4% (63.3% to 67.5%)). Although variation was wide between countries and by tobacco product, for many low and middle income countries, the highest prevalence and cigarette smoking frequency was reported in men, those with lower education, less household wealth, living in rural areas, and higher age. CONCLUSIONS: Both smoked and smokeless tobacco use and frequency of use vary widely across tobacco products in low and middle income countries. This study can inform the design and targeting of efforts to reduce tobacco use in low and middle income countries and serve as a benchmark for monitoring progress towards national and international goals.

Accuracy of HPV testing on self-collected and clinician-collected samples for different screening strategies in African settings: A systematic review and meta-analysis.

OBJECTIVES: Cervical cancer still poses a considerable threat to women in low- and middle-income countries, particularly on the African continent. Self-collection of a vaginal sample promises advantages over the established sampling by clinicians. We aimed to assess the accuracy of self-sampling compared to clinician sampling in order to inform its application in primary care in the African context. METHODS: We searched Pubmed, Livivo, Web of Science, Cochrane Library and African Index Medicus on the 07th of February 2022. The eligibility criteria were: reporting (i) self-sampling against clinician-sampling, (ii) study location in Africa, (iii) relevant outcome-measures: (a) Cohen's kappa (b) sensitivity and specificity of self-sampling tests. We combined Cohen's kappa effects, additionally sensitivity and specificity estimates using random-effects models. The study is registered with PROSPERO (CRD42020218081). RESULTS: We included 28 studies in the systematic review and 21 studies in the meta-analysis. Self-sampling was used to test for high-risk HPV infections. Two studies additionally tested for low-risk HPV infections. The pooled Cohen's kappa was 0.66 (95%CI: 0.61-0.71). Populations at risk yielded 0.63 (95%CI: 0.56-0.71). Target amplification tests based on PCR performed best with a kappa of 0.68 (95%CI: 0.63-0.73) compared to isothermal mRNA tests, 0.61 (95%CI: 0.51-0.71). Point of care tests performed exceptionally well, 0.73 (95%CI: 0.67-0.80). Sensitivities are close to 80% and specificities close to 90% of self-sampling to detect high-risk HPV. CONCLUSIONS: Self-sampling agrees moderately to substantially with clinician sampling in the African context. Point of care tests might be particularly suited for application in cervical cancer primary screening in low- and middle-income countries. Populations at risk should get special attention while using self-sampling. Screening protocols should be established.

Increased vitamin B6 turnover is associated with greater mortality risk in the general US population: A prospective biomarker study.

BACKGROUND & AIMS: Vitamin B6 status and mortality risk are inversely associated in different patient groups, while prospective studies in the general population are lacking. Here, for the first time, we evaluated the association between biomarkers of vitamin B6 status and mortality risk in a large population-based study. METHODS: The vitamin B6 vitamers pyridoxal-5'-phosphat (PLP) and 4-pyridoxic acid (4-PA) were measured by high-performance liquid chromatography in the National Health and Nutrition Examination Survey (NHANES) between 2005 and 2010. Participants' vital status and causes of death were recorded until December 2015. Multivariable Cox regression analyses were carried out to estimate Hazard Ratios (HRs) and 95% confidence intervals (CIs) of mortality across quintiles of PLP, 4-PA, and the ratio of 4-PA and PLP. RESULTS: Out of 15,304 study participants aged between 20 and 85 years at baseline, 1666 (7.7%) died during a median follow-up time of 7.8 years. An inverse association between PLP and mortality was found in a multivariable model adjusted for socioeconomic and lifestyle factors but became statistically non-significant upon adjustment for routine biomarkers (C-reactive protein, creatinine, albumin, and alkaline phosphatase). There was a significant linear trend for a positive association between 4-PA levels and mortality risk in the fully adjusted regression model, although a comparison of extreme quintiles (quintile 5 vs. quintile 1) did not show a significant difference (HRQ5vs.Q1 (95% CI): 1.19 (0.93, 1.51), plinear trend = 0.02). A positive association between the 4-PA/PLP ratio and all-cause mortality was observed in the multivariable model, with an HRsQ5vs.Q1 of 1.45 (95% CI: 1.14, 1.85; plinear trend<0.0001). There were no significant associations between the biomarkers and cardiovascular or cancer mortality. The association between 4-PA/PLP and mortality risk was heterogeneous across age groups, and only statistically significant among participants older than 65 years at baseline (HRQ5vs.Q1 (95% CI): 1.72 (1.29, 2.29), plinear trend<0.0001). In this group, 4-PA/PLP was also associated with cancer mortality, with an HR Q5vs.Q1 of 2.16 (1.20, 3.90), plinear trend = 0.02). CONCLUSION: Increased vitamin B6 turnover, as indicated by a higher 4-PA/PLP ratio, was associated with all-cause and cancer mortality among the older U.S. general population. Intervention trials are needed to assess whether older individuals with a high 4-PA/PLP ratio would benefit from increased vitamin B6 intake.

Testing the contextual Interaction theory in a UHC pilot district in South Africa.

BACKGROUND: World-wide, there is growing universal health coverage (UHC) enthusiasm. The South African government began piloting policies aimed at achieving UHC in 2012. These UHC policies have been and are being rolled out in the ten selected pilot districts. Our study explored policy implementation experiences of 71 actors involved in UHC policy implementation, in one South African pilot district using the Contextual Interaction Theory (CIT) lens. METHOD: Our study applied a two-actor deductive theory of implementation, Contextual Interaction Theory (CIT) to analyse 71 key informant interviews from one National Health Insurance (NHI) pilot district in South Africa. The theory uses motivation, information, power, resources and the interaction of these to explain implementation experiences and outcomes. The research question centred on the utility of CIT tenets in explaining the observed implementation experiences of actors and outcomes particularly policy- practice gaps. RESULTS: All CIT central tenets (information, motivation, power, resources and interactions) were alluded to by actors in their policy implementation experiences, a lack or presence of these tenets were explained as either a facilitator or barrier to policy implementation. This theory was found as very useful in explaining policy implementation experiences of both policy makers and facilitators. CONCLUSION: A central tenet that was present in this context but not fully captured by CIT was leadership. Leadership interactions were revealed as critical for policy implementation, hence we propose the inclusion of leadership interactions to the current CIT central tenets, to become motivation, information, power, resources, leadership and interactions of all these.

Health System Performance for Multimorbid Cardiometabolic Disease in India: A Population-Based Cross-Sectional Study.

Background: The prevalence of multimorbidity in low- and middle-income countries (LMICs) is thought to be rising rapidly. Research on the state of healthcare for multimorbidity in LMICs is needed to provide an impetus for integration of care across conditions, a baseline to monitor progress, and information for targeting of interventions to those most in need. Focusing on multimorbid cardiometabolic disease in India, this study thus aimed to determine 1) the proportion of adults with co-morbid diabetes and hypertension who successfully completed each step of the chronic disease care continuum from diagnosis to control for both conditions, and 2) how having additional cardiovascular disease (CVD) risk factors is associated with health system performance along the care continuum for diabetes, hypertension, and co-morbid diabetes and hypertension. Methods: Using a nationally representative household survey carried out in 2015 and 2016 among women aged 15-49 years and men aged 15-54 years, we created a 'cascade of care' for diabetes, hypertension, and co-morbid diabetes and hypertension by determining the proportion of those with the condition who had been diagnosed, were on treatment, and achieved control. We used Poisson regression with a robust error structure to estimate how having additional cardiovascular disease (CVD) risk factors (diabetes, hypertension, current smoking, and obesity) was associated with reaching each cascade step for diabetes, hypertension, and co-morbid diabetes and hypertension. Findings: Seven hundred thirty-four thousand seven hundred ninety-four adults were included in the analysis. Among individuals with co-morbid diabetes and hypertension, 28·8% (95% CI, 26·7%-31·0%), 16·1% (95% CI, 14·4%-17·9%), and 3·7% (95% CI, 2·8%-4·9%) - with these proportions varying between states by a factor of 4·8, 7·9, and 56·8 - were aware, treated, and achieved control of both conditions, respectively. Men, adults with lower household wealth, and those living in rural areas were less likely to reach each cascade step. Having additional CVD risk factors generally did not increase the probability of reaching each cascade step for diabetes, hypertension, and co-morbid diabetes and hypertension, except that having concurrent diabetes increased the probability of successfully transitioning through the hypertension care cascade. Interpretation: While varying widely between states and population groups, health system performance for co-morbid diabetes and hypertension is generally low in India, and there appears to be little integration of care across CVD risk factors. Funding: European Research Council.

Reaching for the 'first 95': a cross-country analysis of HIV self-testing in nine countries in sub-Saharan Africa.

OBJECTIVES: HIV self-testing (HIVST) offers a promising approach to increase HIV diagnosis and advance progress towards the UNAIDS 95-95-95 targets. We aimed to understand patterns of HIVST awareness and utilization in nine sub-Saharan African (SSA) countries, with the goal of identifying populations to target in disseminating this technology. DESIGN: A cross-sectional study. METHODS: We pooled individual-level population-based data from nine Demographic and Health Surveys (DHS) in SSA conducted 2015-2019 (Burundi, Cameroon, Guinea, Malawi, Senegal, Sierra Leone, South Africa, Zambia, Zimbabwe). Primary outcomes were HIVST awareness and utilization. We used logistic regression with survey fixed effects to explore the relationship between sociodemographic characteristics and these outcomes. Models were adjusted for sex, age, rural/urban residence, education, wealth, and marital status. We accounted for complex survey design. RESULTS: The study sample included 177 572 people (66.0% women, mean age 29 ±â€Š10 years), of whom 86.6% [95% confidence interval (95% CI) 86.4-86.7] were unaware of HIVST, 11.7% (95% CI 11.6-11.9) were aware of but never used HIVST, and 1.7% (95% CI 1.6-1.8) had used HIVST. In adjusted models, women were less likely to be aware of HIVST [odds ratio (OR) 0.75, 95% CI 0.71-0.79], but more likely to have used HIVST (OR 1.17, 95% CI 1.03-1.32) compared with men. Rural residents, those who were least educated, and poorest were less likely to have heard of or used HIVST. CONCLUSION: HIVST awareness and uptake were low. Rural, less educated, and lower income populations were least likely to have heard of or used HIVST. Efforts to scale-up HIVST in these settings should aim to reach these less advantaged groups.

Patterns of multimorbidity in India: A nationally representative cross-sectional study of individuals aged 15 to 49 years.

There is a dearth of evidence on the epidemiology of multimorbidity in low- and middle-income countries. This study aimed to determine the prevalence of multimorbidity in India and its variation among states and population groups. We analyzed data from a nationally representative household survey conducted in 2015-2016 among individuals aged 15 to 49 years. Multimorbidity was defined as having two or more conditions out of five common chronic morbidities in India: anemia, asthma, diabetes, hypertension, and obesity. We disaggregated multimorbidity prevalence by condition, state, rural versus urban areas, district-level wealth, and individual-level sociodemographic characteristics. 712,822 individuals were included in the analysis. The prevalence of multimorbidity was 7·2% (95% CI, 7·1% - 7·4%), and was higher in urban (9·7% [95% CI, 9·4% - 10·1%]) than in rural (5·8% [95% CI, 5·7% - 6·0%]) areas. The three most prevalent morbidity combinations were hypertension with obesity (2·9% [95% CI, 2·8% - 3·1%]), hypertension with anemia (2·2% [95% CI, 2·1%- 2·3%]), and obesity with anemia (1·2% [95% CI, 1·1%- 1·2%]). The age-standardized multimorbidity prevalence varied from 3·4% (95% CI: 3·0% - 3·8%) in Chhattisgarh to 16·9% (95% CI: 13·2% - 21·5%) in Puducherry. Being a woman, being married, not currently smoking, greater household wealth, and living in urban areas were all associated with a higher risk of multimorbidity. Multimorbidity is common among young and middle-aged adults in India. This study can inform screening guidelines for chronic conditions and the targeting of relevant policies and interventions to those most in need.

Know-do gaps for cardiovascular disease care in Cambodia: Evidence on clinician knowledge and delivery of evidence-based prevention actions.

Cardiovascular diseases (CVD) are the leading cause of death in Cambodia. However, it is unknown whether clinicians in Cambodia provide evidence-based CVD preventive care actions. We address this important gap and provide one of the first assessments of clinical care for CVD prevention in an LMIC context. We determined the proportion of primary care visits by adult patients that resulted in evidence-based CVD preventive care actions, identified which care actions were most frequently missed, and estimated the know-do gap for each clinical action. We used data on 190 direct clinician-patient observations and 337 clinician responses to patient vignettes from 114 public primary care health facilities. Our main outcomes were the proportion of patient consultations and responses to care vignettes where clinicians measured blood pressure, blood glucose, body mass index, and asked questions regarding alcohol, tobacco, physical activity, and diet. There were very large clinical care shortfalls for all CVD care actions. Just 6.4% (95% CI: 3.0%, 13.0%) of patients had their BMI measured, 8.0% (4.6%, 13.6%) their blood pressure measured at least twice, only 4.7% (1.9%, 11.2%) their blood glucose measured. Less than 21% of patients were asked about their physical activity (11.7% [7.0%, 18.9%]), smoking (18.0% [11.8%, 26.5%]), and alcohol-related behaviors (20.2% [13.7%, 28.9%]). We observed the largest know-do gaps for blood glucose and BMI measurements with smaller but important know-do gaps for the other clinical actions. CVD care did not vary across clinician cadre or by years of experience. We find large CVD care delivery gaps in primary-care facilities across Cambodia. Our results suggest that diabetes is being substantially underdiagnosed and that clinicians are losing CVD prevention potential by not identifying individuals who would benefit from behavioral changes. The large overall and know-do gaps suggest that interventions for improving preventive care need to target both clinical knowledge and the bottlenecks between knowledge and care behavior.

Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys.

BACKGROUND: As the prevalence of hypercholesterolemia is increasing in low- and middle-income countries (LMICs), detailed evidence is urgently needed to guide the response of health systems to this epidemic. This study sought to quantify unmet need for hypercholesterolemia care among adults in 35 LMICs. METHODS AND FINDINGS: We pooled individual-level data from 129,040 respondents aged 15 years and older from 35 nationally representative surveys conducted between 2009 and 2018. Hypercholesterolemia care was quantified using cascade of care analyses in the pooled sample and by region, country income group, and country. Hypercholesterolemia was defined as (i) total cholesterol (TC) ≥240 mg/dL or self-reported lipid-lowering medication use and, alternatively, as (ii) low-density lipoprotein cholesterol (LDL-C) ≥160 mg/dL or self-reported lipid-lowering medication use. Stages of the care cascade for hypercholesterolemia were defined as follows: screened (prior to the survey), aware of diagnosis, treated (lifestyle advice and/or medication), and controlled (TC <200 mg/dL or LDL-C <130 mg/dL). We further estimated how age, sex, education, body mass index (BMI), current smoking, having diabetes, and having hypertension are associated with cascade progression using modified Poisson regression models with survey fixed effects. High TC prevalence was 7.1% (95% CI: 6.8% to 7.4%), and high LDL-C prevalence was 7.5% (95% CI: 7.1% to 7.9%). The cascade analysis showed that 43% (95% CI: 40% to 45%) of study participants with high TC and 47% (95% CI: 44% to 50%) with high LDL-C ever had their cholesterol measured prior to the survey. About 31% (95% CI: 29% to 33%) and 36% (95% CI: 33% to 38%) were aware of their diagnosis; 29% (95% CI: 28% to 31%) and 33% (95% CI: 31% to 36%) were treated; 7% (95% CI: 6% to 9%) and 19% (95% CI: 18% to 21%) were controlled. We found substantial heterogeneity in cascade performance across countries and higher performances in upper-middle-income countries and the Eastern Mediterranean, Europe, and Americas. Lipid screening was significantly associated with older age, female sex, higher education, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Awareness of diagnosis was significantly associated with older age, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Lastly, treatment of hypercholesterolemia was significantly associated with comorbid hypertension and diabetes, and control of lipid measures with comorbid diabetes. The main limitations of this study are a potential recall bias in self-reported information on received health services as well as diminished comparability due to varying survey years and varying lipid guideline application across country and clinical settings. CONCLUSIONS: Cascade performance was poor across all stages, indicating large unmet need for hypercholesterolemia care in this sample of LMICs-calling for greater policy and research attention toward this cardiovascular disease (CVD) risk factor and highlighting opportunities for improved prevention of CVD.