Non-optimal apparent temperature and cardiovascular mortality: the association in Puducherry, India between 2011 and 2020.

BACKGROUND: Cardiovascular diseases (CVDs), the leading cause of death worldwide, are sensitive to temperature. In light of the reported climate change trends, it is important to understand the burden of CVDs attributable to temperature, both hot and cold. The association between CVDs and temperature is region-specific, with relatively few studies focusing on low-and middle-income countries. This study investigates this association in Puducherry, a district in southern India lying on the Bay of Bengal, for the first time. METHODS: Using in-hospital CVD mortality data and climate data from the Indian Meteorological Department, we analyzed the association between apparent temperature (Tapp) and in-hospital CVD mortalities in Puducherry between 2011 and 2020. We used a case-crossover model with a binomial likelihood distribution combined with a distributed lag non-linear model to capture the delayed and non-linear trends over a 21-day lag period to identify the optimal temperature range for Puducherry. The results are expressed as the fraction of CVD mortalities attributable to heat and cold, defined relative to the optimal temperature. We also performed stratified analyses to explore the associations between Tapp and age-and-sex, grouped and considered together, and different types of CVDs. Sensitivity analyses were performed, including using a quasi-Poisson time-series approach. RESULTS: We found that the optimal temperature range for Puducherry is between 30°C and 36°C with respect to CVDs. Both cold and hot non-optimal Tapp were associated with an increased risk of overall in-hospital CVD mortalities, resulting in a U-shaped association curve. Cumulatively, up to 17% of the CVD deaths could be attributable to non-optimal temperatures, with a slightly higher burden attributable to heat (9.1%) than cold (8.3%). We also found that males were more vulnerable to colder temperature; females above 60 years were more vulnerable to heat while females below 60 years were affected by both heat and cold. Mortality with cerebrovascular accidents was associated more with heat compared to cold, while ischemic heart diseases did not seem to be affected by temperature. CONCLUSION: Both heat and cold contribute to the burden of CVDs attributable to non-optimal temperatures in the tropical Puducherry. Our study also identified the age-and-sex and CVD type differences in temperature attributable CVD mortalities. Further studies from India could identify regional associations, inform our understanding of the health implications of climate change in India and enhance the development of regional and contextual climate-health action-plans.

A review of climate change and cardiovascular diseases in the Indian policy context.

There is growing evidence that climate change adversely affects human health. Multiple diseases are sensitive to climate change, including cardiovascular diseases (CVDs), which are also the leading cause of death globally. Countries such as India face a compounded challenge, with a growing burden of CVDs and a high vulnerability to climate change, requiring a co-ordinated, multi-sectoral response. In this framework synthesis, we analysed whether and how CVDs are addressed with respect to climate change in the Indian policy space. We identified 10 relevant national-level policies, which were analysed using the framework method. Our analytical framework consisted of four themes: (i) political commitment; (ii) health information systems; (iii) capacity building; and (iv) cross-sectoral actions. Additionally, we analysed a subset of these policies and 29 state-level climate change and health action plans using content analysis to identify health priorities. Our analyses revealed a political commitment in addressing the health impacts of climate change; however, CVDs were poorly contextualized with most of the efforts focusing on vector-borne and other communicable diseases, despite their recognized burden. Heat-related illnesses and cardiopulmonary diseases were also focused on but failed to encompass the most climate-sensitive aspects. CVDs are insufficiently addressed in the existing surveillance systems, despite being mentioned in several policies and interventions, including emergency preparedness in hospitals and cross-sectoral actions. CVDs are mentioned as a separate section in only a small number of state-level plans, several of which need an impetus to complete and include CVD-specific sections. We also found several climate-health policies for specific diseases, albeit not for CVDs. This study identified important gaps in India's disease-specific climate change response and might aid policy makers in strengthening future versions of these policies and boost research and context-specific interventions on climate change and CVDs.

Improving medication adherence among persons with cardiovascular disease through m-health and community health worker-led interventions in Kerala; protocol for a type II effectiveness-implementation research-(SHRADDHA-ENDIRA).

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of mortality worldwide, and at present, India has the highest burden of acute coronary syndrome and ST-elevation myocardial infarction (MI). A key reason for poor outcomes is non-adherence to medication. METHODS: The intervention is a 2 × 2 factorial design trial applying two interventions individually and in combination with 1:1 allocation ratio: (i) ASHA-led medication adherence initiative comprising of home visits and (ii) m-health intervention using reminders and self-reporting of medication use. This design will lead to four potential experimental conditions: (i) ASHA-led intervention, (ii) m-health intervention, (iii) ASHA and m-health intervention combination, (iv) standard of care. The cluster randomized trial has been chosen as it randomizes communities instead of individuals, avoiding contamination between participants. Subcenters are a natural subset of the health system, and they will be considered as the cluster/unit. The factorial cluster randomized controlled trial (cRCT) will also incorporate a nested health economic evaluation to assess the cost-effectiveness and return on investment (ROI) of the interventions on medication adherence among patients with CVDs. The sample size has been calculated to be 393 individuals per arm with 4-5 subcenters in each arm. A process evaluation to understand the effect of the intervention in terms of acceptability, adoption (uptake), appropriateness, costs, feasibility, fidelity, penetration (integration of a practice within a specific setting), and sustainability will be done. DISCUSSION: The effect of different types of intervention alone and in combination will be assessed using a cluster randomized design involving 18 subcenter areas. The trial will explore local knowledge and perceptions and empower people by shifting the onus onto themselves for their medication adherence. The proposal is aligned to the WHO-NCD aims of improving the availability of the affordable basic technologies and essential medicines, training the health workforce and strengthening the capacity of at the primary care level, to address the control of NCDs. The proposal also helps expand the use of digital technologies to increase health service access and efficacy for NCD treatment and may help reduce cost of treatment. TRIAL REGISTRATION: The trial has been registered with the Clinical Trial Registry of India (CTRI), reference number CTRI/2023/10/059095.

Barriers to climate change and health research in India: a qualitative study.

OBJECTIVES: Almost a quarter of the global burden of disease and mortalities is attributable to environmental causes, the magnitude of which is projected to increase in the near future. However, in many low- and middle-income settings, there remains a large gap in the synthesis of evidence on climate-sensitive health outcomes. In India, now the world's most populous country, little remains known about the impacts of climate change on various health outcomes. The objective of this study is to better understand the challenges faced in conducting climate change and health research in Puducherry, India. DESIGN AND SETTING: In this study, we employed key informant interviews to deepen the understanding of the perceived research barriers in Puducherry. The findings were analysed using data-driven qualitative thematic analysis to elaborate the major perceived barriers to conducting environmental health research. PARTICIPANTS: This study was conducted among 16 public health professionals, including medical researchers, and professionals involved in environmental policies and planning in Puducherry. RESULTS: We identify three key barriers faced by public health professionals as key stakeholders, namely: (1) political and institutional barriers; (2) education and awareness barriers; and (3) technical research barriers. We show there is a need, from the professionals' perspective, to improve community and political awareness on climate change and health; strengthen technical research capacity and collaboration among researchers; and strengthen health surveillance, resource allocation and access to health data for research. CONCLUSION: Evidence informed policies and interventions are a key element in the adaptation response for countries. In the context of the paucity of data on environmental health from India, despite recognised climate change related health vulnerabilities, these findings could contribute to the development and improvement of relevant interventions conducive to a strong research environment.

"Climate Change and Health?": Knowledge and Perceptions among Key Stakeholders in Puducherry, India.

Climate change has far-reaching impacts on human health, with low- and middle-income countries, including India, being particularly vulnerable. While there have been several advances in the policy space with the development of adaptation plans, little remains known about how stakeholders who are central to the strengthening and implementation of these plans perceive this topic. We conducted a qualitative study employing key interviews with 16 medical doctors, researchers, environmentalists and government officials working on the climate change agenda from Puducherry, India. The findings were analysed using the framework method, with data-driven thematic analysis. We elucidated that despite elaborating the direct and indirect impacts of climate change on health, there remains a perceived gap in education and knowledge about the topic among participants. Knowledge of the public health burden and vulnerabilities influenced the perceived health risks from climate change, with some level of scepticism on the impacts on non-communicable diseases, such as cardiovascular diseases. There was also a felt need for multi-level awareness and intervention programmes targeting all societal levels along with stakeholder recommendations to fill these gaps. The findings of this study should be taken into consideration for strengthening the region's climate change and health adaptation policy. In light of limited research on this topic, our study provides an improved understanding of how key stakeholders perceive the impacts of climate change on health in India.