Characterizing Multimorbidity Prevalence and Adverse Outcomes in Ethnically and Culturally Diverse Sub-Populations in India: Gaps, Opportunities, and Future Directions.

India is a large middle-income country and has surpassed China in overall population, comprising 20% of the global population (over 1.43 billion people). India is experiencing a major demographic shift in its aging population. Chronic diseases are common among older adults and can be persistent over the life course, lead to the onset of disability, and be costly. Among older adults in India, the existence of multiple comorbid chronic conditions (i.e., multimorbidity) is rapidly growing and represents a burgeoning public health burden. Prior research identified greater rates of multimorbidity (e.g., overweight/obesity diabetes, hypertension, cardiovascular disease, stroke, and malignancies) in minority populations in the United States (U.S.); however, limited studies have attempted to characterize multimorbidity among older adult sub-populations residing in India. To address this gap, we conducted a narrative review of studies on multimorbidity using the data from the Longitudinal Aging Study of India (LASI), the largest nationally representative longitudinal survey study of adults in India. Our definition of multimorbidity was the presence of more than two conditions in the same person. Our findings, based on 15 reviewed studies, aim to (1) characterize the definition and measurement of multimorbidity and to ascertain its prevalence in ethnically and culturally diverse sub-populations in India; (2) identify adverse outcomes associated with multimorbidity in the Indian adult population; and (3) identify gaps, opportunities, and future directions.

The role of age inequalities in cause of death in the slow pace of epidemiological transition in India.

In developed countries, low disparity in lifespan contributed by the reduction in the burden of noncommunicable diseases (NCDs) is the key to advances in epidemiological transition. Contrarily, India passing through a phase of the dual burden of CDs and NCDs shows a heavy burden of NCDs responsible for the high disparity in lifespan. The Gini coefficient was decomposed for examining the contribution of 22 causes of death and their repercussions for inequality in age at death for 30 years between 1990-1994 and 2015-2019, using Global Burden of Disease data. The outcomes of the study reveal that India's epidemiological transition has been just modest on account of high inequality in mortality by NCDs emplaced in the middle through old age despite a consistent mortality decline at infant through old age for communicable diseases (CDs). The structural changes in causes of death structure is shaped by CDs rather than NCDs, but overall bolstered by the adult mortality decline, especially in women. However, the process is restrained by the small contribution of the middle age group and a benign contribution of old mortality decline owing to the low threshold age. India needs to target health interventions in seeking significant mortality decline in the middle age group of 50-69 years that is warranted for epidemiological transition apace as evident in the developed nations.

Sub-national patterns and correlates of depression among adults aged 45 years and older: findings from wave 1 of the Longitudinal Ageing Study in India.

BACKGROUND: Depression is a major public health challenge linked with several poor health outcomes and disabilities among adults aged 45 years and older in India. We aimed to describe the prevalence of depression and its association with a variety of sociodemographic correlates and co-existing health conditions for this age group in India and its states. METHODS: In this prospective cohort study, data from wave 1 (baseline) of the Longitudinal Ageing Study in India were used to estimate the national and subnational state level age-standardised prevalence of depression-major depressive episodes-using the internationally validated Composite International Diagnostic Interview-Short Form (CIDI-SF) scale. Hierarchical mixed effect multivariate logistic regression models were used to study the sociodemographic correlates and co-existing health conditions of major depressive episodes among the nationally representative sample of 72 250 adults aged 45 years and older from 35 states or union territories (except the state of Sikkim). Associations between depression and self-rated health, co-morbid conditions, functional health, and life satisfaction measures were also examined. FINDINGS: A total of 40 335 (58·3%) females and 29 407 (41·7%) males aged 45 to 116 years (median age 58 years) participated. The overall age-standardised prevalence of depression based on CIDI-SF scale was 5·7% (95% CI 5·5-5·8) compared with 0·5% (0·5-0·6) self-reported prevalence of depression among adults aged 45 years and older in India. Wide sub-national variations were seen in depression prevalence, ranging from 0·8% (95% CI 0·3-1·3) in Mizoram state to 12·9% (11·6-14·2) in Madhya Pradesh. Prevalence was higher in females (6·3% [95% CI 6·1-6·6] vs 4·3% [4·1-4·6]) for India, and this higher prevalence was more pronounced in some of the northern states. The risk of depression was higher in those residing in rural areas, widowed, with no or low education, and in the poorest quintile. Depression showed a strong positive association with poor self-rated health (OR 2·39 [95% CI 2·21-2·59]; p<0·0001), with one or more limitations in the activities of daily living (ADL; OR 1·60 [1·46-1·75]; p<0·0001), instrumental ADL limitations (OR 1·51 [1·40-1·64]; p<0·0001), and low cognitive judgment of life satisfaction (OR 1·94 [95% CI 1·78-2·10]; p<0·0001). INTERPRETATION: Despite the substantial burden, depression remains undiagnosed and strongly linked with poor health and wellbeing outcomes in adults aged 45 years and older in India. The ageing population of India and the subnational variations amplify the implications of this new evidence to address the substantial gaps in prevention and treatment of depression. FUNDING: LASI was funded by the Ministry of Health and Family Welfare, Government of India, the National Institute of Ageing, USA and the United Nations Population Fund, India.

Multimorbidity matters in low and middle-income countries.

Multimorbidity is a complex challenge affecting individuals, families, caregivers, and health systems worldwide. The burden of multimorbidity is remarkable in low- and middle-income countries (LMICs) given the many existing challenges in these settings. Investigating multimorbidity in LMICs poses many challenges including the different conditions studied, and the restriction of data sources to relatively few countries, limiting comparability and representativeness. This has led to a paucity of evidence on multimorbidity prevalence and trends, disease clusters, and health outcomes, particularly longitudinal outcomes. In this paper, based on our experience of investigating multimorbidity in LMICs contexts, we discuss how the structure of the health system does not favor addressing multimorbidity, and how this is amplified by social and economic disparities and, more recently, by the COVID-19 pandemic. We argue that generating epidemiologic data around multimorbidity with similar methods and definition is essential to improve comparability, guide clinical decision-making and inform policies, research priorities, and local responses. We call for action on policy to refinance and prioritize primary care and integrated care as the center of multimorbidity.

Design and Methodology of the Longitudinal Aging Study in India-Diagnostic Assessment of Dementia (LASI-DAD).

BACKGROUND/OBJECTIVES: To provide high-quality data on older adults in India that will enable an in-depth study of late-life cognition and dementia in India and cross-country analysis of risk factors for cognitive aging and dementia. DESIGN: The Longitudinal Aging Study in India (LASI) is a nationally representative survey of health, economic, and social well-being of the Indian population aged 45 and older. Its large sample of more than 70,000 older adults represents not only the country as a whole but also each state. LASI-Diagnostic Assessment of Dementia (DAD) is an in-depth study of late-life cognition and dementia, drawing a subsample of over 3,000 LASI respondents aged 60 and older. SETTING: Participants were interviewed at home or in a participating hospital according to their preferences. PARTICIPANTS: Adults aged 60 and older (N = 3,224), along with 3,191 informants. MEASUREMENTS: Respondents underwent a battery of cognitive tests, and informants were interviewed about their cognitive and health conditions. A common set of cognitive tests was selected to enable international comparisons, and additional cognitive tests suitable for illiterate and innumerate populations were also selected. Rich data on risk factors of dementia were collected through health examination, venous blood assays, and genotyping. RESULTS: The response rate was 82.9%, varying across sex, education, and urbanicity. Data are available to other researchers. CONCLUSION: LASI-DAD provides an opportunity to study late-life cognition and dementia and their risk factors in the older population in India and to gain further insights through cross-country analysis by pooling data from its international sister studies. J Am Geriatr Soc 68:S5-S10, 2020.

Pathways of economic inequalities in maternal and child health in urban India: a decomposition analysis.

BACKGROUND/OBJECTIVE: Children and women comprise vulnerable populations in terms of health and are gravely affected by the impact of economic inequalities through multi-dimensional channels. Urban areas are believed to have better socioeconomic and maternal and child health indicators than rural areas. This perception leads to the implementation of health policies ignorant of intra-urban health inequalities. Therefore, the objective of this study is to explain the pathways of economic inequalities in maternal and child health indicators among the urban population of India. METHODS: Using data from the third wave of the National Family Health Survey (NFHS, 2005-06), this study calculated relative contribution of socioeconomic factors to inequalities in key maternal and child health indicators such as antenatal check-ups (ANCs), institutional deliveries, proportion of children with complete immunization, proportion of underweight children, and Infant Mortality Rate (IMR). Along with regular CI estimates, this study applied widely used regression-based Inequality Decomposition model proposed by Wagstaff and colleagues. RESULTS: The CI estimates show considerable economic inequalities in women with less than 3 ANCs (CI = -0.3501), institutional delivery (CI = -0.3214), children without fully immunization (CI = -0.18340), underweight children (CI = -0.19420), and infant deaths (CI = -0.15596). Results of the decomposition model reveal that illiteracy among women and her partner, poor economic status, and mass media exposure are the critical factors contributing to economic inequalities in maternal and child health indicators. The residuals in all the decomposition models are very less; this implies that the above mentioned factors explained maximum inequalities in maternal and child health of urban population in India. CONCLUSION: Findings suggest that illiteracy among women and her partner, poor economic status, and mass media exposure are the critical pathways through which economic factors operate on inequalities in maternal and child health outcomes in urban India.