Capacity of the Ethiopian primary health care system to achieve universal health coverage: a primary health care progression approach.

Comprehensive and globally comparable evidence about primary health care (PHC) capacity is needed to inform policies and decisions. We carried out a study to assess the Ethiopian PHC capacity in terms of governance, inputs, and population health and facility management domains. The PHC capacity of all the regions, city administrations and the Ministry of Health was assessed using the PHC progression model. The model has 33 measures categorized into three domains. Data were collected and synthesized from all relevant national and regional documents, datasets and key informants. A team of trained evaluation experts conducted external assessments at national and regional levels followed by an internal assessment and a validation workshop. All 33 measures were scored from 1 (lowest) to 4 (highest). The inter-rater reliability test indicated that the overall agreement between internal and external scores was 65%. We found the highest consistency in the internal assessment with a score of 0.84. The findings of this study indicated that the governance domain score was 2.8 out of 4, showing varying scores in quality management, priority setting as well as innovation and learning. The inputs domain score was 2.3 for drugs, supplies and facility infrastructure. The score for the population health and facility management domain was 2. A comparison of federal and national average scores for all measures indicated no significant difference between the two (P-value = 0.69). There are relevant PHC policies and leadership structures at the federal and regional levels. However, the capacity to effectively implement these policies and strategies at sub-national levels is sub-optimal. The challenges related to major inputs coupled with data-quality problems reduced the capacity of the PHC system at the local level. Periodic assessment of the PHC system and closely working with subnational units will potentially improve the capacity of PHC in Ethiopia.

Low physical activity is associated with adverse health outcome and higher costs in Indonesia: A national panel study.

Aims: To assess the association between low physical activity, cardiovascular disease (CVD) and risk factors, health service utilization, risk of catastrophic health expenditure, and work productivity in Indonesia. Methods: In this population-based, panel data analysis, we used data from two waves of the Indonesian Family Life Survey (IFLS) for 2007/2008 and 2014/2015. Respondents aged 40-80 years who participated in both waves were included in this study (n = 5,936). Physical activity was assessed using the International Physical Activity Questionnaire (IPAQ-SF). Multinomial logistic regression model was used to examine factors associated with physical activity levels (low, moderate, and high). We applied a series of multilevel mixed-effect panel regression to examine the associations between physical activity and outcome variables. Results: The prevalence of low physical activity increased from 18.2% in 2007 to 39.6% in 2014. Compared with those with high physical activity, respondents with low physical activity were more likely to have a 10-year high CVD risk (AOR: 2.11, 95% CI: 1.51-2.95), use outpatient care (AOR: 1.26, 95% CI: 1.07-1.96) and inpatient care (AOR 1.45, 95% CI: 1.07-1.96), experience catastrophic health expenditure of 10% of total household expenditure (AOR: 1.66, 95% CI: 1.21-2.28), and have lower labor participation (AOR: 0.24, 95% 0.20-0.28). Conclusions: Low physical activity is associated with adverse health outcomes and considerable costs to the health system and wider society. Accelerated implementation of public health policies to reduce physical inactivity is likely to result in substantial population health and economic benefits.

Disparities in the implementation of the Health Extension Program in Ethiopia: Doing more and better towards universal health coverage.

Introduction: Large-scale implementation of the Health Extension Program (HEP) has enabled Ethiopia to make significant progress in health services coverage and health outcomes. However, evidence on equity and disparities in the implementation of the HEP is limited. The aim of this study was to examine disparities in the implementation of the HEP in Ethiopia. Methods: We used data from the 2019 National HEP assessment which was conducted between Oct 2018 and Sept 2019 in nine regions in the country. Data were collected from 62 districts, 343 Health posts, 179 Health centres, 584 Health Extension Workers (HEWs), and 7043 women from 7122 Households. This study focused on selected input, service delivery, and coverage indicators. We used rate differences, rate ratios and index of disparity to assess disparities in HEP implementation across regions. Results: We found wide inter-regional disparities in HEP implementation. Developing regional states (DRS) had significantly lower availability of qualified HEWs (Rate Ratio (RR) = 0.54), proportion of households visited by Health Extension workers (RR = 0.40), and proportion of mothers who received education on child nutrition (RR = 0.45) as compared national average. There were also significant disparities in HEP implementation among DRS in the proportion of households visited by HEWs in the past 12 months (Index of disparity = 1.58) and proportion of adolescents who interacted with HEWs (Index of disparity = 1.43). Despite low overall coverage of health services in DRS, the contribution of the HEP for maternal health services was relatively high. Conclusion: There were significant inter-regional disparities in the implementation HEP in Ethiopia. The level of disparity among DRS was also remarkable. To achieve Universal Health Coverage, it is important that these disparities are addressed systematically and strategically. We recommend a tailored approach in HEP implementation in DRS.

Urban-rural differences in the impacts of multiple chronic disease on functional limitations and work productivity among Chinese adults.

BACKGROUND: Chronic disease multimorbidity has become a major challenge for health systems. While a lot of research has evaluated the direct economic burden of multimorbidity on health care utilization and cost, little attention has been given to the impacts on work productivity and functional limitations, as indirect indicators of disease burden. OBJECTIVES: This study aims to examine the prevalence of multimorbidity among Chinese adults and its impact on functional disability and work productivity. It also investigates urban-rural differences in these relationships. METHOD: This study utilized the data from the China Health and Retirement Longitudinal Study (CHARLS) in 2015, including 11,176 participants aged 45 years and older. Multivariable logistic regression models were used to estimate the effect of multimorbidity on functional disability (i.e. ADL: activities of daily life; IADL: instrumental activities of daily life), and work productivity loss due to health problems. Negative binomial regression models were used to assess the association of multimorbidity with sickness absences from agricultural work and employed non-agricultural work. RESULTS: 68.8% of total participants in CHARLS had multimorbidity in China in 2015. Rural residents with multimorbidity reported higher proportions of physical functions and days of sick leave than urban residents. Multimorbidity was positively associated with ADL limitation (odds ratio 1.924, 95% CI 1.656-2.236), IADL limitation (1.522, 1.326-1.748), limited work due to health problems (1.868, 1.601-2.178) and days of sick leave (for agricultural work, incidence rate ratio 1.676, 95% CI 1.390-2.020; for employed non-agricultural work, 2.418, 1.245-4.696). For the rural group, the impact of multimorbidity on functional limitations and work productivity loss (except for early retirement), was less than the urban group. CONCLUSIONS: Multimorbidity poses significant challenges for functional health and work productivity These have significant negative economic consequences for individuals, the Chinese health system and the society.

Impacts of multimorbidity on medication treatment, primary healthcare and hospitalization among middle-aged and older adults in China: evidence from a nationwide longitudinal study.

BACKGROUND: Multimorbidity is a significant contributor to inequalities in healthcare and has become a major unaddressed challenge for the health system in China. The aim of this study is to assess the socio-demographic distribution of multimorbidity and the relationships between multimorbidity, primary healthcare, hospitalization and healthcare spending. METHODS: We conducted this nationwide population-based panel data study in China. Study participants included 12,306 residents aged ≥45 years from the China Health and Retirement Longitudinal Study in 2011, 2013 and 2015. Random-effects logistic regression models were applied to estimate the association between multimorbidity and primary healthcare as well as admission to the hospital. We used log-linear regression models to investigate the association between multimorbidity and health spending. RESULTS: Overall, 46.2% of total interviewees reported multimorbidity. Random-effects logistic regression analyses showed that multimorbidity was associated with a higher likelihood of medication use (Adjusted odds ratio (AOR) =19.19, 95% CI = 17.60, 20.93), health check (AOR = 1.51, 95% CI = 1.43, 1.59), outpatient care (AOR = 2.39, 95% CI = 2.23, 2.56) and admission to hospital (AOR = 2.94, 95% CI = 2.68, 3.21). Log-linear regression models showed that multimorbidity was also positively associated with spending for outpatient care (coefficient = 0.64, 95% CI = 0.59, 0.68) and hospitalization (coefficient = 0.65, 95% CI = 0.60, 0.71). CONCLUSIONS: Multimorbidity is associated with higher levels of primary care, hospitalization and greater financial burden to individuals in China. Health systems need to shift from single-disease models to new financing and service delivery models to more effectively manage multimorbidity.

The Prevalence of Metabolic Disease Multimorbidity and Its Associations With Spending and Health Outcomes in Middle-Aged and Elderly Chinese Adults.

Objective: Metabolic diseases have been a clinical challenge worldwide and a major public health issue. Very few studies from China investigated the impact of metabolic multimorbidity on healthcare and health outcomes at the national level. This study aims to examine the association of metabolic multimorbidity with health service utilization, spending, functional and mental health. Materials and Methods: This is a nationally representative cross-sectional study, utilizing the data from the China Health and Retirement Longitudinal Study in 2015, including 11,377 participants aged 45 years and older. Multivariable regression models were used to assess the association of metabolic multimorbidity with healthcare, out-of-pocket expenditure (OOPE), the activities of daily living (ADL) limitation, the instrumental activities of daily living (IADL) limitation, and depression. Results: Overall, 30.50% of total participants had metabolic multimorbidity in 2015 in China. Compared with single disease, metabolic multimorbidity were associated with the number of outpatient visits [incident rate ratio (IRR) = 1.30, 95% CI = 1.05, 1.62] and days of inpatient care (IRR = 1.52, 95% CI = 1.28, 1.81). Metabolic multimorbidity was positively associated with the OOPE on outpatient care (coefficient = 82.99, 95% CI = 17.70, 148.27) and physical functional difficulties, including ADL limitation (odds ratio = 1.36, 95% CI = 1.18, 1.57). Conclusions: Metabolic multimorbidity is associated with higher levels of health-care service use, greater expenditure for outpatient care, and more difficulties in ADL among Chinese adults. China's health-care systems need to shift from single-disease models to new financing and service delivery models to effectively manage metabolic multimorbidity.

Associations between mental health disorder and management of physical chronic conditions in China: a pooled cross-sectional analysis.

Physical non-communicable diseases (NCDs) and mental health disorders are a rapidly increasing health burden in low-and middle-income countries. This study aims to examine the relationships between mental health disorders and cascade of care in managing four common physical NCDs (hypertension, diabetes, dyslipidemia, chronic kidney disease) in China. We utilized two waves of nationally-representative China Health and Retirement Longitudinal Study (CHARLS 2011, 2015) of older adult population aged 45 and above. A series of unadjusted and adjusted mixed-effect logistic regression was applied to evaluate the association between presence of mental health disorder and physical chronic disease awareness, treatment, and control. We found that the odds of dyslipidemia (AOR 1.81, 95% CI 1.36-2.39) and kidney disease awareness (AOR 2.88, 95% CI 2.12-3.92) were higher for individuals with mental chronic conditions, compared to those without mental chronic conditions. The odds of having hypertension treatment was higher for subjects with mental health disorder, compared to those without (AOR 1.32, 95% CI 1.02-1.70). The odds of having physical chronic conditions controlled was not significantly associated with having mental chronic conditions (P > 0.05). These results indicated that adults with mental health disorder have a greater likelihood of awareness of having dyslipidemia and kidney disease, and receiving treatment for hypertension. Strategies to address the growing burden of physical-mental NCDs in China should include efforts to improve management of patients with comorbid health condition and improve access to continual high-quality treatment after the first diagnosis.

Multimorbidity from Chronic Conditions among Adults in Urban Slums: The AWI-Gen Nairobi Site Study Findings.

Background: In the era of double burden of infectious and non-communicable diseases in sub-Saharan Africa, the burden of multimorbidity is likely to be common. However, there is limited evidence on the burden and its associated factors in the sub-Saharan African context. Objective: The aim of this study was to determine the levels and identify determinants of multimorbidity from chronic conditions in two urban slums in Nairobi. Methods: Data collected from 2003 study participants aged 40-60 years in two urban slums of the Nairobi Urban Health and Demographic Surveillance System in 2015 were used. Using self-report, anthropometry and key biomarkers, data on 16 conditions including chronic diseases, behavioral disorders and metabolic abnormalities were gathered. Lifetime multimorbidity defined by the occurrence of at least two chronic conditions in an individual at any time during their life course was computed. Factors associated with lifetime multimorbidity were identified using multiple logistic regression. Findings: A total of 2,081 chronic conditions were identified among 1,302 individuals. While 701 (35.0%) had no chronic condition, single morbidity was reported in 726 (36.2%) of the study population. The overall prevalence of lifetime multimorbidity was 28.7%. The prevalence of dyads and triads of simultaneous occurrences of conditions (episodic multimorbidity) was 20.8% and 6.1%, respectively. Single morbidity was positively associated with gender and alcohol consumption; and negatively associated with employment. Women, older people, the unemployed, current smokers and current alcohol consumers had higher levels of lifetime multimorbidity in the study population. Interpretation: The findings of this study indicate that a considerable proportion of adults living in urban slums experience multimorbidity from chronic conditions. Further studies with a better rigor to establish temporal associations between socio-demographic factors and the occurrence of chronic conditions are needed to explore the impacts and implications on health status and health system.

The effect of multimorbidity on functional limitations and depression amongst middle-aged and older population in China: a nationwide longitudinal study.

BACKGROUND: multimorbidity contributes to a large portion of the disease burden in low- and middle-income countries. However, limited research has been undertaken in China. This study has investigated the prevalence of multimorbidity and the associations of multimorbidity with activities of daily living (ADL), instrumental activities of daily living (IADL) and depression in China. METHODS: the study participants included 10,055 adults aged 45 years and older from three rounds of the China Health and Retirement Longitudinal Study 2011-2015. Random-effects logistic regression models were used to examine the association of multimorbidity with ADL limitation, IADL limitation and mental disease. RESULTS: the prevalence of multimorbidity amongst adults in China aged 45 years and older was 62.1% in 2015. The prevalence of multimorbidity was increased with older age, among women, in a higher socio-economic group and in the most deprived regions. Multimorbidity is associated with an increased likelihood of experiencing ADL limitation (adjusted odds ratio [AOR] = 5.738, 95% confidence intervals (CI) = 5.733, 5.744) and IADL limitation (AOR = 2.590, 95% CI = 2.588, 2.592) and depression (AOR = 3.352, 95% CI = 3.350, 3.354). Rural-urban disparities in functional difficulties and depression were also found amongst patients with multimorbidity. CONCLUSIONS: the burden of multimorbidity is high in China, particularly amongst the older population. Multimorbidity is associated with higher levels of functional limitations and depression. China healthcare reforms should introduce integrated care models and patient-centred healthcare delivery. The increasing need for reorientation of healthcare resources considering the distribution of multimorbidity and its adverse effect requires more attention from health policymakers in China and other developing countries.

The impact of mental and physical multimorbidity on healthcare utilization and health spending in China: A nationwide longitudinal population-based study.

BACKGROUND: In China, little evidence exists on the effect of mental and physical multimorbidity on individuals and the health system. This study aims to examine the prevalence of mental-physical multimorbidity and its impact on health service utilization and health expenditures. METHODS: We conducted a panel study using two waves of data (in 2011 and 2015) from the China Health and Retirement Longitudinal Study, including 10,181 participants aged 45 years and older. Generalized linear regression models were used to assess the association of multimorbidity with total health expenditure and out-of-pocket expenditure (OOPE) on outpatient and inpatient care. Random-effects logistic regression models were used to examine the impact of multimorbidity on outpatient visits, admission to hospital and incidence of catastrophic health expenditure (CHE). RESULTS: Overall, 3210 participants (31.53% of 10,181) had mental-physical multimorbidity in 2015 in China. Compared to patients with a single physical disease, individuals with physical-mental multimorbidity had over 150% of the increase in the number of outpatient visits and days of hospitalization. The percentage change of OOPE for outpatient and inpatient care was 156.8% and 163.6%, respectively. Mental-physical multimorbidity was associated with an increased likelihood of experiencing CHE (OR = 2.205, 95% CI = 2.048, 2.051). CONCLUSION: Multimorbidity, particularly mental-physical multimorbidity, is associated with higher levels of health service use and a greater financial burden to individuals in China. Healthcare system needs to shift from single-disease models to new financing and service delivery models to more effectively manage mental-physical multimorbidity.

Comorbid Depression and Obesity: Correlates and Synergistic Association With Noncommunicable Diseases Among Australian Men.

INTRODUCTION: Obesity and depression are among the leading causes of disease worldwide. Their bidirectional relationship often results in comorbid depression and obesity, which further increases the risk of adverse health outcomes. Further evidence is needed on the correlates and synergistic association with other noncommunicable diseases. The objective of our study was to examine the correlates and synergistic association of comorbid depression and obesity with other noncommunicable diseases in a large sample of Australian men. METHODS: Our cross-sectional study used data on 13,763 men aged 18 to 55 from the first wave (2013-2014) of the Australian Ten to Men study. Body mass index was calculated from self-reported weight and height. The Patient Health Questionnaire-9 was used to assess depression. We calculated the weighted prevalence of depression, obesity, and comorbid depression and obesity and examined correlates of comorbid depression and obesity by using logistic regression. We used the synergy index to measure the synergistic association of depression and obesity with other noncommunicable diseases. RESULTS: The weighted prevalence of depression, obesity, and comorbid depression and obesity among Australian men were 12.5%, 22.2%, and 3.7%, respectively. Age, marital status, area-level socioeconomic index, educational attainment, household income, employment status, and physical activity were significantly associated with comorbid depression and obesity. Men with comorbid depression and obesity, compared with men without comorbid depression and obesity, had 7.6 times the risk of diabetes and 6.7 times the risk of hypertension. CONCLUSION: Co-occurrence of depression and obesity among Australian men is associated with a set of individual- and area-level correlates and a higher risk of noncommunicable diseases. The correlates identified in our study are useful in planning interventions and screening in primary care settings.

Effective coverage for hypertension treatment among middle-aged adults and the older population in China, 2011 to 2013: A nationwide longitudinal study.

METHODS: We used the baseline survey and first follow-up surveys of the China Health and Retirement Longitudinal Study of middle-aged and older populations conducted between 2011 and 2013. Correlates of effective coverage and treatment coverage for hypertension were analysed using multivariate logistic regression models, after controlling for demographic characteristics. RESULTS: In 2011, 38.40% of 13 702 individuals surveyed were identified with hypertension. Overall, the effective treatment coverage among the middle-aged and older population in China from 2011 to 2013 was only 22.40% compared to the treatment coverage of 55.86%. Variations in effective coverage among patients enrolled in the three public health insurance schemes ranged from 22.60% to 29.31%. CONCLUSIONS: The level of effective coverage for hypertension treatment in China was still very low, and that health insurance schemes play a significant role in improving treatment coverage and effective coverage for hypertension treatment. In the implementation of China's health system reform, health equity and health care equality should be emphasised and enhanced by offering more equitable benefits packages across social health insurance schemes.

The Baker Biobank: Understanding Cardiovascular Outcomes.

BACKGROUND: Cardiovascular diseases (CVDs) and diabetes are two of the most important public health problems. Outcomes for patients with these disorders vary considerably, likely due to the added influence of a range of interacting clinical, metabolic, environmental, lifestyle, genetic and psychosocial risk factors associated with these diseases. The Baker Biobank study was designed to characterise these factors to inform better risk prediction, earlier diagnosis and better treatment of CVDs and diabetes. METHODS: This paper describes the detailed methods for the establishment of the Baker Biobank. The study collected extensive phenotypic detail about the participants recruited from Victoria, Australia. Data and samples were collected at the Departments of Cardiology and Respiratory Medicine at the Alfred Hospital and Healthy Hearts Program at the Baker Institute. RESULTS: A total of 6,530 adults with age 18-69 years were recruited into the Biobank. The majority of these participants (63%) were male. The mean (standard deviation [SD]) age of the Biobank Cohort at the time of data collection was 57(15) years. The study collected data on socio-demographic characteristics, behavioural and lifestyle factors, anthropometric measurements, medical and medication history, and blood levels of various biomarkers. The study also collected and stored Guthrie cards, serum, plasma, buffy coat, whole blood collected in Tempus tubes (for RNA extraction). For some samples extracted DNA and RNA is stored. The Biobank data is also linked to echocardiogram, hospital admission, pathology and mortality datasets. The Baker Biobank data and samples are available for health researchers with approval of Biobank Steering Group and Human Research Ethics Committee. CONCLUSION: The Baker Biobank provides valuable data and samples into the study of the interplay among cardiovascular diseases risk factors and their impact on morbidity and mortality in Australia.

Temporal Trends and Geographic Disparity in Hypertension Care in China.

BACKGROUND: This study examines trends and geographic disparities in the diagnosis, treatment, and control of hypertension in China and investigates the association between regional factors and hypertension care. METHODS: Blood pressure data and data relating to health care for hypertension were used for this study. The data were sourced from baseline and follow-up surveys of the China Health and Retirement Longitudinal Study, which was conducted in 2011, 2013, and 2015. To estimate the geographical disparities in diagnosis, treatment, and control of hypertension, random-effects models were also applied after controlling for sociodemographic characteristics. RESULTS: Among hypertensive individuals in China, the trends showed decreases in undiagnosed, untreated, and uncontrolled hypertension: 44.1%, 51.6%, and 80.7% in 2011; 40.0%, 47.4%, and 77.8% in 2013; and 31.7%, 38.0%, and 71.4% in 2015, respectively. The number of undiagnosed, untreated, and uncontrolled hypertensive residents living in urban areas in 2015 was more than 10% lower than the number in rural areas and among rural-to-urban immigrant individuals in China. The poorest socio-economic regions across China were 8.5 times more likely to leave their residents undiagnosed, 2.8 times more likely to leave them untreated, and 2.6 times more likely to leave hypertension uncontrolled. CONCLUSIONS: Although China has made impressive progress in addressing regional inequalities in hypertension care over time, it needs to increase its effort to reduce geographic disparities and to provide more effective treatments and higher quality care for patients with hypertension.

Levels and determinants of perceived health risk from solid wastes among communities living near to dumpsites in Kenya.

Many countries in sub-Saharan Africa have poor solid waste management systems, putting people living near dumpsites at higher risk of disease infections. Good risk perception could enhance individual- and community-level protection and prevention efforts. The objective of this study was to examine the levels and determinants of perceived health risk associated with exposure to solid waste dumpsites in Kenya. The level of risk was measured on a five-point Likert scale. The results showed that about 27% and 42% of the study population in Nairobi and Mombasa, respectively, perceive that they have little or no health risk from the nearby dumpsites. Study site, family size and wealth index were associated with risk perception in the multivariate analysis. A sizable proportion (42%) of the population living near dumpsites has lower risk perception. Health promotion interventions are needed to enhance risk awareness and perception in these communities.

A scoping review of non-communicable disease research capacity strengthening initiatives in low and middle-income countries.

INTRODUCTION: As the epidemic of non-communicable diseases (NCDs) is rapidly developing in low and middle-income countries (LMICs), the importance of local research capacity and the role of contextually relevant research in informing policy and practice is of paramount importance. In this regard, initiatives in research capacity strengthening (RCS) are very important. The aim of this study was to review and summarize NCD research capacity strengthening strategies that have been undertaken in LMICs. METHODS: Using both systematic and other literature search, we identified and reviewed NCD-RCS initiatives that have been implemented in LMICs and reported since 2000. Information was extracted from published papers and websites related to these initiatives using a semi-structured checklist. We extracted information on program design, stakeholders involved, and countries of focus, program duration, targeted researchers, disease focus, skill/capacity areas involved and sources of funding. The extracted information was refined through further review and then underwent a textual narrative synthesis. RESULTS: We identified a number of different strategies used by research capacity strengthening programs and in the majority of initiatives, a combination of approaches was utilized. Capacity strengthening and training approaches were variously adapted locally and tailored to fit with the identified needs of the targeted researchers and health professionals. Most initiatives focused on individual level capacity and not system level capacity, although some undoubtedly benefited the research and health systems of LMICs. For most initiatives, mid-term and long-term outcomes were not evaluated. Though these initiatives might have enhanced research capacity in the immediate term, the sustainability of the results in the long-term remains unknown. CONCLUSION: Most of NCD-RCS initiatives in LMICs focused on building individual capacity and only a few focused explicitly on institutional level capacity strengthening. Though many of the initiatives appear to have had promising short-term outcomes, evidence on their long-term impact and sustainability is lacking.

Feasibility assessment of invigorating grassrooTs primary healthcare for prevention and management of cardiometabolic diseases in resource-limited settings in China, Kenya, Nepal, Vietnam (the FAITH study): rationale and design.

BACKGROUND: Cardiometabolic diseases are the leading cause of death and disability in many low- and middle-income countries. As the already severe burden from these conditions continues to increase in low- and middle-income countries, cardiometabolic diseases introduce new and salient public health challenges to primary health care systems. In this mixed-method study, we aim to assess the capacity of grassroots primary health care facilities to deliver essential services for the prevention and control of cardiometabolic diseases. Built on this information, our goal is to propose evidence-based recommendations to promote a stronger primary health care system in resource-limited settings. METHODS: The study will be conducted in resource-limited settings in China, Kenya, Nepal, and Vietnam using a mixed-method approach that incorporates a literature review, surveys, and in-depth interviews. The literature, statistics, and document review will extract secondary data on the burden of cardiometabolic diseases in each country, the existing policies and interventions related to strengthening primary health care services, and improving care related to non-communicable disease prevention and control. We will also conduct primary data collection. In each country, ten grassroots primary health care facilities across representative urban-rural regions will be selected. Health care professionals and patients recruited from these facilities will be invited to participate in the facility assessment questionnaire and patients' survey. Stakeholders - including patients, health care professionals, policymakers at the local, regional, and national levels, and local authorities - will be invited to participate in in-depth interviews. A standard protocol will be designed to allow for adaption and localization in data collection instruments and procedures within each country. DISCUSSION: With a special focus on the capacity of primary health care facilities in resource-limited settings in low- and middle-income countries, this study has the potential to add new evidence for policymakers and academia by identifying the most common and significant barriers primary health care services face in managing and preventing cardiometabolic diseases. With these findings, we will generate evidence-based recommendations on potential strategies that are feasible for resource-limited settings in combating the increasing challenges of cardiometabolic diseases.

Trends and Inequalities in the Health Care and Hypertension Outcomes in China, 2011 to 2015.

Background: Hypertension is one of the most significant and common risk factors for cardiovascular disease, yet it remains poorly controlled in China. This study aims to examine trends and socioeconomic inequalities in the management of hypertension between 2011 and 2015 in China and to investigate the association between antihypertensive medication treatment and reduction of blood pressure, using nationally representative data. Methods: Concentration curve and concentration index were used to assess socioeconomic-related inequalities in hypertension care and health service utilisation. The fixed-effects analysis was performed to measure the impact of medication treatment on reduction of blood pressure among people with hypertension by using linear regression models. Results: Among hypertensive individuals, there were growing trends in the rates of awareness and treatment from 55.87% and 48.44% in 2011, to 68.31% in 2013 and 61.97% in 2015, respectively. The proportion of hypertension control was still below 30%. The fixed-effects models indicated that medication treatment was statistically significant and associated with the patients' systolic blood pressure (ß: -13.483; 95% CI: -15.672, -11.293) and diastolic blood pressure (ß: -5.367; 95% CI: -6.390, -4.344). Conclusions: China has made good progress in the hypertension diagnosis, medication treatment and coverage of health services over the last 10 years; however, pro-rich inequalities in hypertension care still exist, and there is considerable progress to be made in the prevention, treatment and effective control of hypertension.

Magnitude and predictors of normal-weight central obesity- the AWI-Gen study findings.

Background: Normal-weight central obesity is associated with higher mortality than general obesity as defined by body mass index, particularly in the absence of central fat distribution.Objective: The aim of this study was to examine the magnitude and predictors of normal-weight central obesity in an urban informal settlement setting in Kenya.Methods: We used data from the AWI-Gen study, a cross-sectional survey targeting randomly selected consenting adults between the ages of 40-60 in two urban informal settlements of Nairobi between 2014 and 2016. Central obesity was determined using waist circumference, waist to hip ratio, visceral fat thickness, and subcutaneous fat thickness. General obesity was determined using body mass index (BMI).Results: About 20.0% of participants in the study had general obesity. The prevalence of central obesity as measured by waist circumference was 52.0%, by waist-to-hip ratio was 53.5%, by visceral fat thickness was 32.4% and by subcutaneous fat thickness was 49.2%. The prevalence of normal-weight central obesity in the study population was highest when measured by waist to hip ratio (38.1%) and lowest when measured by visceral fat thickness (18.1%). Factors associated with normal-weight central obesity as assesses by waist circumference were being female, of older age, and in full-time employment. Older age was associated with normal-weight central obesity as assessed by waist to hip ratio.Conclusion: The findings highlight a significant prevalence of normal-weight central obesity among adults in a poor urban setting in Kenya, pointing to women as a key target group for focused interventions. Longitudinal studies are needed to establish whether there is a link between normal-weight central obesity and mortality in such settings as has been found in other settings.