The burden of premature adult mortality associated with lack of access to electricity in India.

BACKGROUND: The impact of electricity access on all-cause premature mortality is unknown. METHODS: We use a national dataset from India to compare districts with high access to electricity (>90% of households) to districts with middle (50-90%) and low (<50%) access to electricity and estimate the effect of lack of electricity access on all-cause premature mortality. RESULTS: In 2014, out of 597 districts in India, 174 districts had high access, 228 had middle access, and 195 had low access to electricity. When compared to districts with high access, districts with low access had higher rates of age-standardized premature mortality in both women (2.09, 95% CI: 1.43-2.74) and men (0.99, 0.10-1.87). Similarly, these districts had higher rates of conditional probability of premature death in both women (9.16, 6.19-12.13) and men (4.04, 0.77-7.30). Middle access districts had higher rates of age-standardized premature mortality and premature death in women, but not men. The total excess deaths attributable to reduced electricity access were 444,225 (45,195 in middle access districts and 399,030 in low access districts). In low access districts, the proportion of premature adult deaths attributable to low electricity access was 21.3% (14.4%- 28.1%) in women and 7.9% (1.5%- 14.3%) in men. CONCLUSION: Poor access to electricity is associated with nearly half a million premature adult deaths. One out of five premature deaths in adult women were linked to low electricity access making it a major social determinant of health.

Global Variations in Heart Failure Etiology, Management, and Outcomes.

Importance: Most epidemiological studies of heart failure (HF) have been conducted in high-income countries with limited comparable data from middle- or low-income countries. Objective: To examine differences in HF etiology, treatment, and outcomes between groups of countries at different levels of economic development. Design, Setting, and Participants: Multinational HF registry of 23 341 participants in 40 high-income, upper-middle-income, lower-middle-income, and low-income countries, followed up for a median period of 2.0 years. Main Outcomes and Measures: HF cause, HF medication use, hospitalization, and death. Results: Mean (SD) age of participants was 63.1 (14.9) years, and 9119 (39.1%) were female. The most common cause of HF was ischemic heart disease (38.1%) followed by hypertension (20.2%). The proportion of participants with HF with reduced ejection fraction taking the combination of a ß-blocker, renin-angiotensin system inhibitor, and mineralocorticoid receptor antagonist was highest in upper-middle-income (61.9%) and high-income countries (51.1%), and it was lowest in low-income (45.7%) and lower-middle-income countries (39.5%) (P < .001). The age- and sex- standardized mortality rate per 100 person-years was lowest in high-income countries (7.8 [95% CI, 7.5-8.2]), 9.3 (95% CI, 8.8-9.9) in upper-middle-income countries, 15.7 (95% CI, 15.0-16.4) in lower-middle-income countries, and it was highest in low-income countries (19.1 [95% CI, 17.6-20.7]). Hospitalization rates were more frequent than death rates in high-income countries (ratio = 3.8) and in upper-middle-income countries (ratio = 2.4), similar in lower-middle-income countries (ratio = 1.1), and less frequent in low-income countries (ratio = 0.6). The 30-day case-fatality rate after first hospital admission was lowest in high-income countries (6.7%), followed by upper-middle-income countries (9.7%), then lower-middle-income countries (21.1%), and highest in low-income countries (31.6%). The proportional risk of death within 30 days of a first hospital admission was 3- to 5-fold higher in lower-middle-income countries and low-income countries compared with high-income countries after adjusting for patient characteristics and use of long-term HF therapies. Conclusions and Relevance: This study of HF patients from 40 different countries and derived from 4 different economic levels demonstrated differences in HF etiologies, management, and outcomes. These data may be useful in planning approaches to improve HF prevention and treatment globally.

Variations in the financial impact of the COVID-19 pandemic across 5 continents: A cross-sectional, individual level analysis.

BACKGROUND: COVID-19 has caused profound socio-economic changes worldwide. However, internationally comparative data regarding the financial impact on individuals is sparse. Therefore, we conducted a survey of the financial impact of the pandemic on individuals, using an international cohort that has been well-characterized prior to the pandemic. METHODS: Between August 2020 and September 2021, we surveyed 24,506 community-dwelling participants from the Prospective Urban-Rural Epidemiology (PURE) study across high (HIC), upper middle (UMIC)-and lower middle (LMIC)-income countries. We collected information regarding the impact of the pandemic on their self-reported personal finances and sources of income. FINDINGS: Overall, 32.4% of participants had suffered an adverse financial impact, defined as job loss, inability to meet financial obligations or essential needs, or using savings to meet financial obligations. 8.4% of participants had lost a job (temporarily or permanently); 14.6% of participants were unable to meet financial obligations or essential needs at the time of the survey and 16.3% were using their savings to meet financial obligations. Participants with a post-secondary education were least likely to be adversely impacted (19.6%), compared with 33.4% of those with secondary education and 33.5% of those with pre-secondary education. Similarly, those in the highest wealth tertile were least likely to be financially impacted (26.7%), compared with 32.5% in the middle tertile and 30.4% in the bottom tertile participants. Compared with HICs, financial impact was greater in UMIC [odds ratio of 2.09 (1.88-2.33)] and greatest in LMIC [odds ratio of 16.88 (14.69-19.39)]. HIC participants with the lowest educational attainment suffered less financial impact (15.1% of participants affected) than those with the highest education in UMIC (22.0% of participants affected). Similarly, participants with the lowest education in UMIC experienced less financial impact (28.3%) than those with the highest education in LMIC (45.9%). A similar gradient was seen across country income categories when compared by pre-pandemic wealth status. INTERPRETATION: The financial impact of the pandemic differs more between HIC, UMIC, and LMIC than between socio-economic categories within a country income level. The most disadvantaged socio-economic subgroups in HIC had a lower financial impact from the pandemic than the most advantaged subgroup in UMIC, with a similar disparity seen between UMIC and LMIC. Continued high levels of infection will exacerbate financial inequity between countries and hinder progress towards the sustainable development goals, emphasising the importance of effective measures to control COVID-19 and, especially, ensuring high vaccine coverage in all countries. FUNDING: Funding for this study was provided by the Canadian Institutes of Health Research and the International Development Research Centre.

The Effectiveness of Community Health Workers for CVD Prevention in LMIC.

Community health workers (CHW) may be effective in tackling the burden of cardiovascular diseases in low- and middle-income countries (LMIC). This review examines whether CHWs can improve the identification and control of cardiovascular risk factors in LMIC. We searched for studies that used CHW as a basis for cardiovascular risk factor management. Our search yielded 11 articles that targeted cardiovascular risk factor assessment, hypertension, diabetes, smoking, diet and physical activity. There were 4 randomized controlled trials, 3 quasi-experimental studies, 3 cross-sectional studies, and 1 retrospective analysis. Eight studies reported positive results with CHW being able to effectively screen for cardiovascular risk factors, decrease systolic blood pressure, decrease fasting blood glucose, increase quit rates of smoking, decrease weight, and improve diet and physical activity. Our review demonstrates that CHW may be effective in helping tackle the burden of cardiovascular disease in LMIC.