Perceptions of the determinants of health across income and urbanicity levels in eight countries.

BACKGROUND: A clear understanding of public perceptions of the social determinants of health remains lacking. This paper aimed to describe the relationship between income and urbanicity levels and public views of the determinants of health in eight middle-and high-income countries that varied across multiple characteristics. METHODS: We conducted a cross-sectional online survey in Brazil, China, Germany, Egypt, India, Indonesia, Nigeria, and the United States. Respondents were asked to select what they considered to be most important for health out of a list of ten determinants. We stratified the results by income and urbanicity levels and tested significance of differences between groups using two-tailed χ2 tests. Multivariable logistic regression models tested associations between demographic factors and the likelihood of respondents selecting the genetics, healthcare, income and wealth, or social support determinants. RESULTS: Here we show 8753 respondents across eight countries. Rankings of determinants are similar across income groups, except for two determinants. Respondents in the highest income group rank genetics in higher proportions (32.4%, 95%CI: 29.0%,35.8%) compared to other income groups. Conversely, those in lowest income group rank social support more frequently (27.9%, 95%CI: 25.3%,30.7%) than other income groups. Those living in urban settings rank healthcare in higher proportions (61.2%, 95%CI: 59.0%,63.4%) compared to non-urban respondents; meanwhile, higher proportions (26.6%, 95%CI: 24.9%,28.3%) of non-urban respondents rank social support as important for health compared to urban respondents. CONCLUSION: Demographic factors play a role in shaping public views of what affects health. Advancing public understanding about determinants of health requires tailoring public health messaging to account for socioeconomic position within a population.

Various factors determine our health, such as our environment, education, and genetics. Here, we explore how people from different income and urban backgrounds view the factors that affect health. We surveyed participants from Brazil, China, Germany, Egypt, India, Indonesia, Nigeria, and the United States. Respondents selected the most important factors for health from a list of ten choices. Overall, people's views on these factors were comparable across income groups, with exceptions. Those with higher incomes tended to emphasize the importance of genetics more, while lower-income individuals valued social support. People in urban areas prioritized healthcare, while those in non-urban areas valued social support. These findings suggest that factors such as income and where people live influence their views about health determinants. These factors should be considered in public health messaging and strategies to promote health amongst different groups.

Rapid response teams in the Eastern Mediterranean Region: Results from the baseline survey of country-level capacities, operations and outbreak response capabilities.

The aim of this study is to assess WHO/Eastern Mediterranean region (WHO/EMR) countries capacities, operations and outbreak response capabilities. Cross-sectional study was conducted targeting 22 WHO/EMR countries from May to June 2021. The survey covers 8 domains related to 15 milstones and key performance indicators (KPIs) for RRT. Responses were received from 14 countries. RRTs are adequately organised in 9 countries (64.3%). The mean retention rate of RRT members was 85.5% ± 22.6. Eight countries (57.1%) reported having standard operating procedures, but only three countries (21.4%) reported an established mechanism of operational fund allocation. In the last 6 months, 10,462 (81.9%) alerts were verified during the first 24 h. Outbreak response was completed by the submission of final RRT response reports in 75% of analysed outbreaks. Risk Communication and Community Engagement (RCCE) activities were part of the interventional response in 59.5% of recent outbreaks. Four countries (28.6%) reported an adequate system to assess RRTs operations. The baseline data highlights four areas to focus on: developing and maintaining the multidisciplinary nature of RRTs through training, adequate financing and timely release of funds, capacity and system building for implementing interventions, for instance, RCCE, and establishing national monitoring and evaluation systems for outbreak response.

Determinants of private-sector antibiotic consumption in India: findings from a quasi-experimental fixed-effects regression analysis using cross-sectional time-series data, 2011-2019.

The consumption of antibiotics varies between and within countries. However, our understanding of the key drivers of antibiotic consumption is largely limited to observational studies. Using Indian data that showed substantial differences between states and changes over years, we conducted a quasi-experimental fixed-effects regression study to examine the determinants of private-sector antibiotic consumption. Antibiotic consumption decreased by 10.2 antibiotic doses per 1000 persons per year for every ₹1000 (US$12.9) increase in per-capita gross domestic product. Antibiotic consumption decreased by 46.4 doses per 1000 population per year for every 1% increase in girls' enrollment rate in tertiary education. The biggest determinant of private sector antibiotic use was government spending on health-antibiotic use decreased by 461.4 doses per 1000 population per year for every US$12.9 increase in per-capita government health spending. Economic progress, social progress, and increased public investment in health can reduce private-sector antibiotic use.

Pandemic stressors and mental health indicators in eight countries.

PURPOSE: The Covid-19 pandemic has exacted a significant physical, financial, social, and emotional toll on populations throughout the world. This study aimed to document the association between pandemic stressors and mental health during the pandemic across countries that differ in cultural, geographic, economic, and demographic factors. METHODS: We administered an online survey randomly in Brazil, China, Germany, Egypt, India, Indonesia, Nigeria, and the United States from September 2020 to November 2020. This survey included questions on Covid-19-related stressors as well as the Patient Health Questionnaire-2 and the Primary Care PTSD Checklist to screen for depression and post-traumatic stress disorder (PTSD) symptoms, respectively. We performed bivariable and multivariable regression analyses to assess the prevalence and odds ratios of overall depression symptoms and probable PTSD and in relation to stressors across countries. RESULTS: Among 8754 respondents, 28.9% (95% CI 27.5-30.0%) experienced depression symptoms, and 5.1% (95% CI 4.5-6.0%) experienced probable PTSD. The highest prevalence of depression symptoms was in Egypt (41.3%, 95% CI 37.6-45.0%) and lowest in the United States (24.9%, 95% CI 22.3-27.7%). The highest prevalence of probable PTSD was in Brazil (7.3%, 95% CI 5.6-9.4%) and the lowest in China (1.2%, 95% CI 0.7-2.0%). Overall, experiencing six or more Covid-19-related stressors was associated with both depression symptoms (OR 1.90, 95% CI 1.46-2.48) and probable PTSD (OR 13.8, 95% CI 9.66-19.6). CONCLUSION: The association between pandemic related stressors and the burden of adverse mental health indicators early in the Covid-19 pandemic transcended geographic, economic, cultural, and demographic differences between countries. The short-term and long-term impacts of the pandemic on mental health should be incorporated in efforts to tackle the consequences of Covid-19.

Medical Oxygen as a Life-Saving Medicine: A rapid review of the oxygen landscape and innovative efforts in the World Health Organization Eastern Mediterranean Region in Response to COVID-19 and Beyond.

Background: Medical oxygen is an essential treatment for life-threatening hypoxemic conditions and is commonly indicated for the clinical management of many leading causes of mortality. Many countries of the World Health Organization (WHO) Eastern Mediterranean Region (EMR) lacked robust medical oxygen systems prior to the COVID-19 (corona virus disease) pandemic and this situation was exacerbated by increased needs, particularly in remote and rural health facilities, resulting in many unfortunate deaths. The aim of this article is to describe the oxygen landscape in the region and the regional initiatives undertaken by countries and WHO. Methodology: We conducted a rapid review to synthesize the available literature on the needs and availability of oxygen and its related resources and the regional initiatives undertaken. We conducted search in PubMed, relevant WHO and World Bank websites, and in general using google to understand the health of conditions that could benefit from the availability of medical oxygen, oxygen related resources including health workforce available for support and usage of medical oxygen, and the initiatives by WHO, countries and partners to improve the situation. We used a snowballing technique and reviewed all available databases for reports, surveys, assessments, and studies related to medical oxygen, besides WHO internal records, assessments, and consultation reports. Results: The data on oxygen availability, supply demand gap, infrastructure facilities, and human resources were sparse. The regional initiatives have led to increase in resources, including human resources and oxygen production infrastructure. The Live Oxygen Platform (LOP), contributed to improved availability of quality data needed for supply demand assessments. Conclusion: A regional enterprise strategy to promote sustainable, decentralized, and contextualized production, supply, and monitoring of oxygen together with human resource support including training and placement by WHO, partners, and governments contributed to improved availability of oxygen in the region. Additionally, with the LOP, governments, WHO, and partners have access to better data availability for policy decision making and timely resource allocation.

Hypertension control rate in India: systematic review and meta-analysis of population-level non-interventional studies, 2001-2022.

Background: Hypertension is a significant contributor to mortality in India. Achieving better hypertension control rate at the population level is critical in reducing cardiovascular morbidity and mortality. Methods: Hypertension control rate was defined as the proportion of patients with their blood pressure under control (systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg). We conducted a systematic review and meta-analysis of community-based, non-interventional studies published after 2001 that reported hypertension control rates. We searched PubMed, Embase, and Web of Science databases, and grey literature, and extracted data using a common framework, and summarized the study characteristics. We conducted random-effects meta-analysis using untransformed hypertension control rates and reported the overall summary estimates and subgroup estimates of control rates as percentages and 95% confidence intervals. We also conducted mixed-effects meta-regression with sex, region, and study period as covariates. The risk of bias was assessed, and level of evidence was summarized using SIGN-50 methodology. The protocol was pre-registered with PROSPERO, CRD42021267973. Findings: The systematic review included 51 studies (n = 338,313 hypertensive patients). 21 studies (41%) reported poorer control rates among males than females, and six studies (12%) reported poorer control rates among rural patients. The pooled hypertension control rate in India during 2001-2020 was 17.5% (95% CI: 14.3%-20.6%)-with significant increase over the years, reaching 22.5% (CI: 16.9-28.0%) in 2016-2020. Sub-group analysis showed significantly better control rates in the South and West regions, and significantly poorer control rates among males. Very few studies reported data on social determinants or lifestyle risk factors. Interpretation: Less than one-fourth of hypertensive patients in India had their blood pressure under control during 2016-2020. Although the control rate has improved compared to previous years, substantial differences exist across regions. Very few studies have examined the lifestyle risk factors and social determinants relevant to hypertension control in India. The country needs to develop and evaluate sustainable, community-based strategies and programs to improve hypertension control rates. Funding: Not applicable.

Vector-Borne and Zoonotic Diseases in the Eastern Mediterranean Region: A Systematic Review.

BACKGROUND AND OBJECTIVE: World Health Organization Eastern Mediterranean Region (WHO EMR) has 40% people in the world in need of humanitarian assistance. This systematic review explores selected vector-borne and zoonotic diseases (VBZDs) of importance to EMR in terms of disease burden across countries and periods, disaggregated across sex, age groups, education levels, income status, and rural/urban areas, related vector or animal source reduction measures, and public health, social and economic impacts and related interventions. METHODS: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and reviewed articles in PubMed, Embase, and WHO Global Index Medicus published between 1st of January 2011 and 27th of June 2022. Thirteen VBZDs with at least one reported outbreak in the last five years in the region or prioritized as per previous analysis at the WHO global and regional level and based on expert consultations, were included as part of the analysis. RESULTS: The review included 295 studies-55% on leishmaniasis and dengue combined, and 75% studies from Pakistan, Kingdom of Saudi Arabia, and Iran combined. Hospital-based and nationally representative studies constituted 60% and 10% respectively. Males were predominantly affected in most diseases; children reported high burden of Leishmaniasis, whereas elderly had a higher burden of Dengue Fever and Middle East Respiratory Syndrome. Although very few studies reported on socioeconomic differences in burden, the ones that reported showed higher burden of diseases among the disadvantaged socioeconomic groups such as the poor and the less educated. More than 80% studies reported an increase in burden over the years. CONCLUSION: The literature is scanty for most of the diseases reviewed and the number of studies from countries with humanitarian challenges is very low. The need for more nationally representative, population-based studies calls for prioritizing research investments.

Prevalence and associated factors of cardiovascular diseases among men and women aged 45 years and above: Analysis of the longitudinal ageing study in India, 2017-2019.

OBJECTIVE: Epidemiological studies on the prevalence and associated factors of cardiovascular diseases (CVDs) representative of all states of India among middle-aged and elderly are not much reported. The present study estimates the prevalence and associated factors of cardiovascular diseases across Indian states among men and women aged ≥45 years. METHODS: We used data from the Longitudinal Ageing Study in India wave 1 (2017-2019), which included a final analytical sample size of 56,935 adults and their spouses aged 45 years and above. We estimated CVDs prevalence for sociodemographic and behavioural variables, and multivariable logistic regression was used to assess the association between behavioural factors and CVDs in both men and women. RESULTS: The prevalence of CVDs was 5.2% among adults ≥45 years (women: 4.6%; men: 5.9%), hypertension was 46.7% (women:48.9%; men:44%). Men and women have a similar prevalence of diabetes (11.9%) and cholesterol (2.3%). Prevalence of physical inactivity was 30.3% (women:27%; men:34.1%). Hypertension (adjusted odds ratio; aOR women:2.60, 95% CI: 2.08-3.25, men:1.88, 95% CI 1.54-2.29), hypercholesterolemia (aOR women:1.70; 95% CI 1.07-2.69, men 3.55; 95% CI 2.66-4.74), diabetes (aOR women:2.53; 95% CI 1.83-3.51, men:1.77 95% CI 1.44-2.17), obesity, physical inactivity, and smoking in men were significantly associated with CVDs. CONCLUSION: The prevalence of CVDs and lifestyle risk factors among middle-aged and elderly poses severe concerns regarding noncommunicable disease (NCD) healthcare services provided in a lower-middle-income country like India. The key to preventing CVDs is controlling hypertension, diabetes, hypercholesterolemia, and increasing physical activity among adults aged ≥45 years.

Antibiotic consumption in India: geographical variations and temporal changes between 2011 and 2019.

Objectives: To describe and compare private sector systemic (J01) antibiotic consumption across Indian states from 2011 to 2019. Methods: We used the nationally representative PharmaTrac dataset to describe the consumption rates in DDD across national, state and state-group [high focus (HF) and non-high focus (nHF)] levels. We used median and IQRs to describe and compare across states and state groups, and relative change and compound annual growth rate (CAGR) to examine temporal changes. Results: The annual consumption rate decreased by 3.6% between 2011 and 2019. The share of Access antibiotics decreased (13.1%) and the Access/Watch ratio declined from 0.59 to 0.49. State consumption rates varied widely (HF states reported lower rates) and the inappropriate use increased over the years, especially among HF states. The HF and nHF states showed convergence in the share of the Access and the Access/Watch ratio, while they showed divergence in the use of Discouraged fixed-dose combinations. Conclusions and implications: India's private-sector antibiotic consumption rate was lower than global rates. The rates varied across states and appropriateness of use decreased in most states over the years. States with an increase in appropriate use over time could serve as best practice examples. Studies to understand the factors affecting inappropriate use are required alongside improved data systems to monitor the public-sector provision of antibiotics to understand the total consumption.

Quantifying antibiotic use in typhoid fever in India: a cross-sectional analysis of private sector medical audit data, 2013-2015.

OBJECTIVES: To estimate the antibiotic prescription rates for typhoid in India. DESIGN: Cross-sectional study. SETTING: Private sector primary care clinicians in India. PARTICIPANTS: The data came from prescriptions of a panel of 4600 private sector primary care clinicians selected through a multistage stratified random sampling accounting for the region, specialty type and patient turnover. The data had 671 million prescriptions for antibiotics extracted from the IQVIA database for the years 2013, 2014 and 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: Mean annual antibiotic prescription rates; sex-specific and age-specific prescription rates; distribution of antibiotic class. RESULTS: There were 8.98 million antibiotic prescriptions per year for typhoid, accounting for 714 prescriptions per 100 000 population. Children 10-19 years of age represented 18.6% of the total burden in the country in absolute numbers, 20-29 year age group had the highest age-specific rate, and males had a higher average rate (844/100 000) compared with females (627/100 000). Ten different antibiotics accounted for 72.4% of all prescriptions. Cefixime-ofloxacin combination was the preferred drug of choice for typhoid across all regions except the south. Combination antibiotics are the preferred choice of prescribers for adult patients, while cephalosporins are the preferred choice for children and young age. Quinolones were prescribed as monotherapy in 23.0% of cases. CONCLUSIONS: Nationally representative private sector antibiotic prescription data during 2013-2015 indicate a higher disease burden of typhoid in India than previously estimated. The total prescription rate shows a declining trend. Young adult patients account for close to one-third of the cases and children less than 10 years account for more than a million cases annually.

Clinico-epidemiological profile and outcomes of adults with COVID-19: A hospital-based retrospective study in Kerala, India.

Introduction: The clinical and epidemiological presentations of patients with coronavirus disease 2019 (COVID-19) in India is still not well explored. We studied the epidemiological and clinical profile and outcomes of COVID-19 patients admitted to a tertiary care private hospital in Kerala, India. Methods: In this retrospective study, we analyzed data of 476 adult (≥18 years) COVID-19 patients admitted to a tertiary care hospital in Kerala from September 1, 2020 to March 31, 2021. The patients were categorized into mild, moderate, and severe cases and followed till discharge or death. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 23.0 with a significance set at P < 0.05. Results: The median age was 57 years (56% men). Mild, moderate, and severe cases accounted for 17%, 65%, and 18%, respectively. Around 75% had at least one comorbidity, and 51% had multiple comorbidities. The most common comorbidities were diabetes (45%), hypertension (44%), dyslipidemia (15%), and cardiac problems (12%). The elevated D-dimer values among patients in different categories were significantly different, with 74% in severe, 46% in moderate, and 19% in mild category patients. Serum ferritin, C-reactive protein, lactic acid dehydrogenase, and neutrophil to lymphocyte ratio values were significantly higher for severely ill patients. Thirty deaths (67% men) occurred during the study period, with a case fatality rate of 6.3%. Mortality mainly happened in the older age group (80%) and those with multimorbidity (90%). Conclusion: Age and multimorbidity are the major contributing factors for death in hospitalized COVID-19 patients. Generalization of the findings necessitates well-designed large-scale studies.

What matters for health? Public views from eight countries.

INTRODUCTION: Despite growing scholarship on the social determinants of health (SDoH), wider action remains in its early stages. Broad public understanding of SDoH can help catalyse such action. This paper aimed to document public perception of what matters for health from countries with broad geographic, cultural, linguistic, population composition, language and income level variation. METHODS: We conducted an online survey in Brazil, China, Germany, Egypt, India, Indonesia, Nigeria and the USA to assess rankings of what respondents thought matters for health and what they perceived decision makers think matters for health. We analysed the percentages of each determinant rated as the most important for good health using two metrics: the top selection and a composite of the top three selections. We used two-tailed χ2 test for significance testing between groups. RESULTS: Of 8753 respondents, 56.2% (95% CI 55.1% to 57.2%) ranked healthcare as the most important determinant of good health using the composite metric. This ranking was consistent across countries except in China where it appeared second. While genetics was cited as the most important determinant by 22.3% (95% CI 21.5% to 23.2%) of the overall sample with comparable rates in most countries, the percentage increased to 33.3% (95% CI 30.5% to 36.3%) in Germany and 35.9% (95% CI 33.0% to 38.8%) in the USA. Politics was the determinant with the greatest absolute difference (18.5%, 95% CI 17.3% to 19.6%) between what respondents considered matters for health versus what they perceived decision makers think matters for health. CONCLUSION: The majority of people consider healthcare the most important determinant of health, well above other social determinants. This highlights the need for more investment in communication efforts around the importance of SDoH.

Tuberculosis and Diabetes in India: Stakeholder Perspectives on Health System Challenges and Opportunities for Integrated Care.

BACKGROUND: India has a dual burden of tuberculosis (TB) and diabetes mellitus (DM). Integrated care for TB/DM is still in the early phase in the country and can be considerably enhanced by understanding and addressing the challenges identified from stakeholders' perspectives. This study explored the challenges and opportunities at individual, health system and policy level for integrated care of TB/DM comorbidities in India. METHODS: We used an outlier case study approach and conducted stakeholder interviews and focus group discussions with relevant program personnel including field staff and program managers of TB and DM control programs as well as officials of partners in Indian states, Kerala and Bihar. RESULTS: The integrated management requires strengthening the laboratory diagnosis and drug management components of the two individual programs for TB and DM. Focused training and sensitization of healthcare workers in public and private sector across all levels is essential. A district level management unit that coordinates the two vertical programs with a horizontal integration at the primary care level is the way forward. Substantial improvement in data infrastructure is essential to improve decision-making process. CONCLUSION: Bi-directional screening and management of TB/DM comorbidities in India requires substantial investment in human resources, infrastructure, drug availability, and data infrastructure.

Consumption of systemic antibiotics in India in 2019.

Background: Inappropriate use of antibiotics is a significant driver of antibiotic resistance in India. Largely unrestricted over-the-counter sales of most antibiotics, manufacturing and marketing of many fixed-dose combinations (FDC) and overlap in regulatory powers between national and state-level agencies complicate antibiotics availability, sales, and consumption in the country. Methods: We analyzed cross-sectional data from PharmaTrac, a nationally representative private-sector drug sales dataset gathered from a panel of 9000 stockists across India. We used the AWaRe (Access, Watch, Reserve) classification and the defined daily dose (DDD) metrics to calculate the per capita private-sector consumption of systemic antibiotics across different categories: FDCs vs single formulations; approved vs unapproved; and listed vs not listed in the national list of essential medicines (NLEM). Findings: The total DDDs consumed in 2019 was 5071 million (10.4 DDD/1000/day). Watch contributed 54.9% (2783 million) DDDs, while Access contributed 27.0% (1370 million). Formulations listed in the NLEM contributed 49.0% (2486 million DDDs); FDCs contributed 34.0% (1722 million), and unapproved formulations contributed 47.1% (2408 million DDDs). Watch antibiotics constituted 72.7% (1750 million DDDs) of unapproved products and combinations discouraged by the WHO constituted 48.7% (836 million DDDs) of FDCs. Interpretation: Although the per-capita private-sector consumption rate of antibiotics in India is relatively low compared to many countries, India consumes a large volume of broad-spectrum antibiotics that should ideally be used sparingly. This, together with significant share of FDCs from formulations outside NLEM and a large volume of antibiotics not approved by the central drug regulators, call for significant policy and regulatory reform. Funding: Not applicable.

Media Exposure and the Risk of Post-Traumatic Stress Disorder Following a Mass traumatic Event: An In-silico Experiment.

Introduction: Following mass traumatic events, greater exposure to traditional media like television (TV) about the event is associated with higher burden of post-traumatic stress disorder (PTSD). However, we know little about how social media exposure, combined with other media sources, shapes the population burden of PTSD following mass traumatic events. Materials and Methods: We built a microsimulation of 1,18,000 agents that was demographically comparable to the population of Parkland and Coral Springs, Florida that experienced the Stoneman Douglas High School shooting in 2018. We parametrized the model using data from prior traumatic events and built an internal social network structure to facilitate the estimation of community PTSD prevalence following exposure to TV and social media coverage of the shooting. Results: Overall, PTSD prevalence in the community due to exposure to TV coverage of the shooting was 3.1%. Shifting the whole population's hours of TV watching to the lower half of the population distribution decreased PTSD prevalence to 1.3% while increasing TV watching to the upper half of the distribution increased the prevalence to 3.5%. Casual (i.e., viewing posts) social media use in addition to exposure to TV coverage increased PTSD prevalence to 3.4%; overall prevalence increased to 5.3% when agents shared videos related to the shooting on social media. Conclusion: This microsimulation shows that availability and exposure to media coverage of mass traumatic events, particularly as social media becomes more ubiquitous, has the potential to increase community PTSD prevalence following these events. Future research could fruitfully examine the mechanisms that might explain these associations and potential interventions that can mitigate the role of media in shaping the mental health of populations following traumatic events.

India needs a resilient cancer program.

BACKGROUND: We analyzed the trends for two important cancers affecting females, breast cancer and cervical cancer, using the Indian cancer registry data and correlated the findings with selected relevant sociodemographic and behavioral indicators. METHODS: We examined National Family Health Survey data for the respective states in which registries are located, on relevant indicators like multiparity, early childbearing, cervical examination, multiple sexual partners/high-risk sexual behavior, and HIV prevalence (for cervical cancer), multiparity, early childbearing, duration of breastfeeding, overweight, alcohol use, and clinical breast examination (for breast cancer). We used Global Adult Tobacco Survey smoking data. RESULTS: The top four positions in cancer cervix were all in registries from northeast India with a higher proportion of multiparous women (≥3 births; around 40%), whereas three major metros in the south and the national capital of Delhi, all with a relatively low proportion of multiparous women (11-25%) topped the chart for breast cancer. Overweight/obesity was higher in states with a higher incidence of breast cancer (23.3-31%) compared to states with a lower incidence (12.2-16%). No clear patterns emerged with regard to alcohol consumption, duration of breastfeeding or clinical breast examination. CONCLUSION: The shift in the childbearing age group explains the increasing breast cancer rates in urban areas, whereas the persisting higher rate of multiparity explains higher cervical cancer rates especially in underserved states in the northeast. India needs to invest in transforming its cancer control program to be a more resilient one with a focus on screening and prevention.

Data Sources for Understanding the Social Determinants of Health: Examples from Two Middle-Income Countries: the 3-D Commission.

The expansion in the scope, scale, and sources of data on the wider social determinants of health (SDH) in the last decades could bridge gaps in information available for decision-making. However, challenges remain in making data widely available, accessible, and useful towards improving population health. While traditional, government-supported data sources and comparable data are most often used to characterize social determinants, there are still capacity and management constraints on data availability and use. Conversely, privately held data may not be shared. This study reviews and discusses the nature, sources, and uses of data on SDH, with illustrations from two middle-income countries: Kenya and the Philippines. The review highlights opportunities presented by new data sources, including the use of big data technologies, to capture data on social determinants that can be useful to inform population health. We conducted a search between October 2010 and September 2020 for grey and scientific publications on social determinants using a search strategy in PubMed and a manual snowball search. We assessed data sources and the data environment in both Kenya and the Philippines. We found limited evidence of the use of new sources of data to study the wider SDH, as most of the studies available used traditional sources. There was also no evidence of qualitative big data being used. Kenya has more publications using new data sources, except on the labor determinant, than the Philippines. The Philippines has a more consistent distribution of the use of new data sources across the HEALTHY determinants than Kenya, where there is greater variation of the number of publications across determinants. The results suggest that both countries use limited SDH data from new data sources. This limited use could be due to a number of factors including the absence of standardized indicators of SDH, inadequate trust and acceptability of data collection methods, and limited infrastructure to pool, analyze, and translate data.

Use of Data to Understand the Social Determinants of Depression in Two Middle-Income Countries: the 3-D Commission.

Depression accounts for a large share of the global disease burden, with an estimated 264 million people globally suffering from depression. Despite being one of the most common kinds of mental health (MH) disorders, much about depression remains unknown. There are limited data about depression, in terms of its occurrence, distribution, and wider social determinants. This work examined the use of novel data sources for assessing the scope and social determinants of depression, with a view to informing the reduction of the global burden of depression.This study focused on new and traditional sources of data on depression and its social determinants in two middle-income countries (LMICs), namely, Brazil and India. We identified data sources using a combination of a targeted PubMed search, Google search, expert consultations, and snowball sampling of the relevant literature published between October 2010 and September 2020. Our search focused on data sources on the following HEALTHY subset of determinants: healthcare (H), education (E), access to healthy choices (A), labor/employment (L), transportation (T), housing (H), and income (Y).Despite the emergence of a variety of data sources, their use in the study of depression and its HEALTHY determinants in India and Brazil are still limited. Survey-based data are still the most widely used source. In instances where new data sources are used, the most commonly used data sources include social media (twitter data in particular), geographic information systems/global positioning systems (GIS/GPS), mobile phone, and satellite imagery. Often, the new data sources are used in conjunction with traditional sources of data. In Brazil, the limited use of new data sources to study depression and its HEALTHY determinants may be linked to (a) the government's outsized role in coordinating healthcare delivery and controlling the data system, thus limiting innovation that may be expected from the private sector; (b) the government routinely collecting data on depression and other MH disorders (and therefore, does not see the need for other data sources); and (c) insufficient prioritization of MH as a whole. In India, the limited use of new data sources to study depression and its HEALTHY determinants could be a function of (a) the lack of appropriate regulation and incentives to encourage data sharing by and within the private sector, (b) absence of purposeful data collection at subnational levels, and (c) inadequate prioritization of MH. There is a continuing gap in the collection and analysis of data on depression, possibly reflecting the limited priority accorded to mental health as a whole. The relatively limited use of data to inform our understanding of the HEALTHY determinants of depression suggests a substantial need for support of independent research using new data sources. Finally, there is a need to revisit the universal health coverage (UHC) frameworks, as these frameworks currently do not include depression and other mental health-related indicators so as to enable tracking of progress (or lack thereof) on such indicators.