NO POVERTY: End poverty in all its forms everywhere.
Total number of research : 34 Publications
Palileo-Villanueva L.M., Palafox B., Amit A.M.L., Pepito V.C.F., Ab-Majid F., Ariffin F., Balabanova D., Isa M.-R., Mat-Nasir N., My M., Renedo A., Seguin M.L., Yusoff K., Dans A.L., Mckee M. (2022)
Background: Traditional, complementary and alternative medicine (TCAM) is used to treat a broad range of conditions. In low- and middle-income countries (LMICs), TCAM use is particularly common among those with low socio-economic status. To better understand the patterns and impact of TCAM use on the management of non-communicable diseases in these populations, this study examines the prevalence and characteristics of TCAM use for hypertension, its determinants, and its association with hypertension management outcomes and wellbeing among low-income adults in two Southeast Asian countries at different levels of economic and health system development, Malaysia and the Philippines. Methods: We analysed cross-sectional data from 946 randomly selected adults diagnosed with hypertension from low-income rural and urban communities in Malaysia (n = 495) and the Philippines (n = 451). We compared the prevalence, characteristics and household expenditure on TCAM use between countries and used multi-level, mixed-effects regression to estimate associations between TCAM use and its determinants, and five hypertension management outcomes and wellbeing. Results: The prevalence of TCAM use to manage hypertension was higher in the Philippines than in Malaysia (18.8% vs 8.8%, p < 0.001). Biologically-based modalities, e.g. herbal remedies, were the most common type of TCAM used in both countries, mainly as a complement, rather than an alternative to conventional treatment. Households allocated around 10% of health spending to TCAM in both countries. Belief that TCAM is effective for hypertension was a positive predictor of TCAM use, while belief in conventional medicine was a negative predictor. TCAM use was not strongly associated with current use of medications for hypertension, self-reported medication adherence, blood pressure level and control, or wellbeing in either country. Conclusions: A small, but significant, proportion of individuals living in low-income communities in Malaysia and the Philippines use TCAM to manage their hypertension, despite a general lack of evidence on efficacy and safety of commonly used TCAM modalities. Recognising that their patients may be using TCAM to manage hypertension will enable health care providers to deliver safer, more patient-centred care. © 2022, The Author(s).
Alabbadi I., Massad E., Taani N., Dababneh S., Shersheer Q., Nimri O., Mahmoud R., Hijazeen R., Ishaq A. (2022)
Thalassemia are inherited hematological disorders considered among the most common genetic disorders worldwide, occurring more frequently in the Mediterranean Region. The WHO estimates that Beta-thalassemia affects 2.9% of the world’s population. In Jordan, the carrier prevalence rate of thalassemia is from 2-4%. Patients with thalassemia need a lifelong care, devastating their quality of life and imposing overwhelming psychological and financial burden on patients and their families. The Jordanian Ministry of Health (MOH) is the sole facility responsible for treating these patients from the pre-marital program until required medications regardless of their nationality. This study aimed to estimate the economic burden of thalassemia in Jordan in 2019. All 680 thalassemia patients admitted to thalassemia centers in Jordan and coming to out-patients’ clinics from July 1st to Aug 31st, 2019 are included. Data were collected using a pre-developed questionnaire from the electronic medical records. The economic burden was estimated from MOH perspective and societal perspective. The average annual cost was estimated to be 2,674 JOD for a single thalassemia Jordanian insured patient and 4,627 JOD for un-insured, while the non-Jordanian patient’ annual cost was estimated 4,751 JOD if insured and 6,651 JOD if un-insured. The total economic burden of thalassemia in Jordan in 2019 was estimated to be 2,148,741 JOD. Of this amount, 1,393,329 JOD was for Jordanians and 755,412 JOD for non-Jordanians. In conclusion, this high burden of thalassemia in Jordan requires adopting new controlling policies; pre-marriage counseling, education and raising awareness should be encouraged. © 2022 DSR Publishers/The University of Jordan. All Rights Reserved.
Syasyila K., Gin L.L., Mohamad Z.S. (2022)
The COVID-19 pandemic has disrupted everyone’s routines, including frontline workers, causing psychological distress and lowering their quality of life. As a result, this research was conducted to determine the meaning of life and the courage of Malaysian COVID-19 frontliners. Using purposive and snowball sampling, twenty-one frontliners from Kuala Lumpur and Selangor were recruited for this interpretative phenomenology study. The findings indicate that Malaysian frontliners derive meaning from the human connection in their professional and personal lives, which instills a feeling of dedication as they contribute to social welfare, particularly during this critical period. In addition, they engage in spiritual activities and maintain a positive attitude to achieve life satisfaction, which is regarded as a component of their life’s meaning. Furthermore, frontline workers are courageous in fighting the pandemic because it is their obligation, and they have a strong family and coworkers’ support system. While frontliners must maintain their psychological well-being, they are subjected to work hazards daily, contributing to their impression of courage. The findings could provide an outreach program organized by the government through webinars. In that manner, it would allocate a sense of reassurance to the frontliners. Therefore, it is necessary to identify the perception of meaning in life and the courage of the Malaysian COVID-19 frontliners to rekindle their work spirit despite experiencing an overwhelming workload objectively. © Universiti Putra Malaysia Press
Amin S., Mehmood W., Sharif A. (2022)
This paper analyses the effects of ethnic and religious diversity on renewable and non-renewable energy consumption for 187 countries worldwide (categorised into high-, middle-, and low-income countries) from 1990 to 2020. This study determines the long-run relationship between the variables using panel fixed effects and generalized method of moments (GMM) models. The results show that ethnic and religious diversity have significant positive impacts on renewable energy consumption and vice versa on non-renewable energy consumption. Furthermore, the results are more significant for high- and middle-income countries than for low-income countries. This study suggests that diversity is a natural phenomenon; however, its disastrous effects may be curtailed by providing equal opportunities and promoting a peaceful society, as done in high-income countries, to ensure the well-being of the people through cohesiveness. Policymakers need to promote collective action and communication among different groups while acknowledging that investment for public benefits often requires broad social consensus and solidarity. © 2022 Elsevier Ltd
Zhong X., Ferrand C. (2022)
The rapid development of Internet technology promotes the ecological renewal of traditional industries. China's 14th Five-Year Plan clearly proposes to vigorously develop the Internet industry. Farmers are still the mainstay of China's population, and "agriculture, rural areas, and farmers"have always been highly valued by the party and the state. However, the rural economy has always been a weak link in China's economy, and agricultural products often have problems such as increasing production but not increasing income, relying on the weather, and having difficulties in sales. The root causes are the slow development of rural areas, farmers' economic awareness and lack of economic information. The Internet has broken this existing situation with the idea of flat network, breaking through the restrictions of traditional agricultural products trading channels, enabling farmers to directly connect with the market, and effectively improving trading profits. Firstly, this paper points out the influence of the Internet on the global economy and industry and further summarizes the development of e-commerce. Then, the advantages and characteristics of e-commerce are explained, and the theoretical basis and present situation of e-commerce development of agricultural products in China are expounded. Finally, the paper puts forward the imagination of China's e-commerce system of agricultural products, focuses on accelerating the standardization and systematization of agricultural products, and puts forward some suggestions and measures for the ecological evolution guarantee of agricultural products e-commerce. This paper is a research on the integration of agricultural products and ecological construction of e-commerce under the background of "internet plus."It is aimed at offering suggestions and suggestions for promoting agricultural product sales and rural development and promoting rural economic development, which is of great help to China's poverty alleviation cause and an effective way to achieve common prosperity. © 2022 Xuemei Zhong and Clermont Ferrand.
Ezeh O.K., Abir T., Zainol N.R., Mamun A.A., Milton A.H., Haque M.R., Agho K.E. (2021)
Every year in Nigeria, malnutrition contributes to more than 33% of the deaths of children below 5 years, and these deaths mostly occur in the northern geopolitical zones (NGZs), where nearly 50% of all children below 5 years are stunted. This study examined the trends in the prevalence of stunting and its associated factors among children aged 0–23 months, 24–59 months and 0–59 months in the NGZs. The data of 33,682 recent live births in the NGZs, extracted from the Nigeria Demographic and Health Surveys from 2008 to 2018, were used to investigate the factors associated with stunting using multilevel logistic regression. Children aged 24–59 months reported the highest prevalence of stunting, with 53.3% (95% confidence interval: 52.0–54.6%). Multivariable analyses revealed four common factors that increased the odds of a child’s stunting across all age subgroups: poor households, geopolitical zone (northwest or northeast), being a male and maternal height (<145 cm). Interventional strategies focused on poverty mitigation through cash transfer and educating low socioeconomic mothers on the benefits of gender-neutral supplementary feeding and the timely monitoring of the offspring of short mothers would substantially reduce stunting across all age subgroups in the NGZs. © 2021 by the authors. Licensee MDPI, Basel, Switzerland.
Al Mamun A., Thurasamy R., Fazal S.A. (2021)
Even though development organizations provide access to working capital and enterprise development training, they often fail to improve the socio-economic condition of low-income households. One of the factors contributing to the failure of development programs is their lack of capacity to measure the entrepreneurial potentials among the low-income participants. This study focused on the development of an entrepreneurial index that measures the entrepreneurial potentials among low-income households. Adopting a cross-sectional design, a total of 403 micro-entrepreneurs were approached from the list provided by ‘Majlis Amanah Rakyat’ and ‘Majlis Agama Islam Dan Adat Istiadat’, Kelantan. This study used formative hierarchial model to determine the local and global weights for all the items used to develop the index. Further, the nomological validity revealed a positive effect of entrepreneurial index on entrepreneurial competency, enterprise performance, and enterprise sustainability. © 2021 Elsevier Ltd
Al-Shami S.A., Mamun A.A., Rashid N., Al-Shami M. (2021)
Microcredit financing is extensively considered as an effective development method for poverty mitigation and women empowerment. Nevertheless, relevant studies reflected opposing outcomes on microfinance effects consisting of positive, zero, and negative impacts. Thus, this research investigated Al-Amal Bank’s microcredit impacts on women empowerment in Yemen, one of the poorest Middle Eastern nations. A panel dataset and primary and secondary data were gath-ered through household surveys and propensity score matching to restrict intangible variables’ possible effects. The empirical results revealed that microcredit had a significant positive effect on monthly household incomes and accumulated asset values. Although microcredit facilitated female entrepreneurship and income generation for improved household incomes and expenditure, no influence was found on female household decisions and mobility following the patriarchal system practised in many Arabian nations, including Yemen. Hence, the study finding has theoretically and practically contributed to the body of knowledge in three ways. First, a novel proof of how microcredit interactions affected several Yemeni women empowerment elements was identified. This study also provides new insight into the empowerment theory by explaining how access to microcredit influences numerous features of women’s economic and social empowerment. Lastly, social and family traditions significantly influenced female attributes and lifestyles by reflecting how communal and family rituals affected microcredit impacts on women empowerment and vice versa. Conversely, this study guides Yemeni policymakers and those from other nations on extend-ing financial services for self-development to reduce poverty and drive women empowerment ra-ther than relying on government and international agencies. © 2021 by the authors. Licensee MDPI, Basel, Switzerland.
Tse L.A., Wang C., Rangarajan S., Liu Z., Teo K., Yusufali A., Avezum Á., Wielgosz A., Rosengren A., Kruger I.M., Chifamba J., Calik K.B.T., Yeates K., Zatońska K., Alhabib K.F., Yusoff K., Kaur M., Ismail N., Seron P., Lopez-Jaramillo P., Poirier P., Gup (2021)
Importance: Obesity is a growing public health threat leading to serious health consequences. Late bedtime and sleep loss are common in modern society, but their associations with specific obesity types are not well characterized. Objective: To assess whether sleep timing and napping behavior are associated with increased obesity, independent of nocturnal sleep length. Design, Setting, and Participants: This large, multinational, population-based cross-sectional study used data of participants from 60 study centers in 26 countries with varying income levels as part of the Prospective Urban Rural Epidemiology study. Participants were aged 35 to 70 years and were mainly recruited during 2005 and 2009. Data analysis occurred from October 2020 through March 2021. Exposures: Sleep timing (ie, bedtime and wake-up time), nocturnal sleep duration, daytime napping. Main Outcomes and Measures: The primary outcomes were prevalence of obesity, specified as general obesity, defined as body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 30 or greater, and abdominal obesity, defined as waist circumference greater than 102 cm for men or greater than 88 cm for women. Multilevel logistic regression models with random effects for study centers were performed to calculate adjusted odds ratios (AORs) and 95% CIs. Results: Overall, 136652 participants (81652 [59.8%] women; mean [SD] age, 51.0 [9.8] years) were included in analysis. A total of 27195 participants (19.9%) had general obesity, and 37024 participants (27.1%) had abdominal obesity. The mean (SD) nocturnal sleep duration was 7.8 (1.4) hours, and the median (interquartile range) midsleep time was 2:15 am (1:30 am-3:00 am). A total of 19660 participants (14.4%) had late bedtime behavior (ie, midnight or later). Compared with bedtime between 8 pm and 10 pm, late bedtime was associated with general obesity (AOR, 1.20; 95% CI, 1.12-1.29) and abdominal obesity (AOR, 1.20; 95% CI, 1.12-1.28), particularly among participants who went to bed between 2 am and 6 am (general obesity: AOR, 1.35; 95% CI, 1.18-1.54; abdominal obesity: AOR, 1.38; 95% CI, 1.21-1.58). Short nocturnal sleep of less than 6 hours was associated with general obesity (eg, <5 hours: AOR, 1.27; 95% CI, 1.13-1.43), but longer napping was associated with higher abdominal obesity prevalence (eg, ≥1 hours: AOR, 1.39; 95% CI, 1.31-1.47). Neither going to bed during the day (ie, before 8pm) nor wake-up time was associated with obesity. Conclusions and Relevance: This cross-sectional study found that late nocturnal bedtime and short nocturnal sleep were associated with increased risk of obesity prevalence, while longer daytime napping did not reduce the risk but was associated with higher risk of abdominal obesity. Strategic weight control programs should also encourage earlier bedtime and avoid short nocturnal sleep to mitigate obesity epidemic.. © 2021 American Medical Association. All rights reserved.
O'Donnell M., Hankey G.J., Rangarajan S., Chin S.L., Rao-Melacini P., Ferguson J., Xavier D., Lisheng L., Zhang H., Pais P., Lopez-Jaramillo P., Damasceno A., Langhorne P., Rosengren A., Dans A.L., Elsayed A., Avezum A., Mondo C., Smyth A., Judge C., Dien (2021)
Objective Hypertension is the most important modifiable risk factor for stroke globally. We hypothesised that country-income level variations in knowledge, detection and treatment of hypertension may contribute to variations in the association of blood pressure with stroke. Methods We undertook a standardised case-control study in 32 countries (INTERSTROKE). Cases were patients with acute first stroke (n=13 462) who were matched by age, sex and site to controls (n=13 483). We evaluated the associations of knowledge, awareness and treatment of hypertension with risk of stroke and its subtypes and whether this varied by gross national income (GNI) of country. We estimated OR and population attributable risk (PAR) associated with treated and untreated hypertension. Results Hypertension was associated with a graded increase in OR by reducing GNI, ranging from OR 1.92 (99% CI 1.48 to 2.49) to OR 3.27 (2.72 to 3.93) for highest to lowest country-level GNI (p-heterogeneity<0.0001). Untreated hypertension was associated with a higher OR for stroke (OR 5.25; 4.53 to 6.10) than treated hypertension (OR 2.60; 2.32 to 2.91) and younger age of first stroke (61.4 vs 65.4 years; p<0.01). Untreated hypertension was associated with a greater risk of intracerebral haemorrhage (OR 6.95; 5.61 to 8.60) than ischaemic stroke (OR 4.76; 3.99 to 5.68). The PAR associated with untreated hypertension was higher in lower-income regions, PAR 36.3%, 26.3%, 19.8% to 10.4% by increasing GNI of countries. Lifetime non-measurement of blood pressure was associated with stroke (OR 1.80; 1.32 to 2.46). Conclusions Deficits in knowledge, detection and treatment of hypertension contribute to higher risk of stroke, younger age of onset and larger proportion of intracerebral haemorrhage in lower-income countries. © Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.
Al Mamun A., Muniady R., Nasir N.A.B.M. (2021)
This study assessed the impact of micro-enterprise development initiatives (commonly provide access to financial services and micro-enterprise development training programs to low-income households) upon competitive advantages, performance, and sustainability of micro-enterprises owned and managed by selected low-income households in Peninsular Malaysia. Upon the adoption of cross-sectional design, data were randomly gathered from 300 micro-entrepreneurs residing in four states of Peninsular Malaysia selected from the eKasih database (national poverty data bank). The quantitative data had been collected by holding structured interview sessions with the participants from October until November 2017. The study outcomes revealed that the total amount of economic loan received, the total number of training hours and the number of center meetings/discussion attended exerted significantly positive effects upon competitive advantage, while marital status (control variable) was found to affect competitive advantage in a significantly positive manner. As for micro-enterprise performance, length of participation and number of center meetings/discussions attended as well as marital status as the control variable exhibited significantly positive effects. Meanwhile, the impact of participation duration, total amount of economic loan received, and number of center meetings/discussions attended upon micro-enterprise sustainability seemed to be inconclusive. Additionally, age of entrepreneurs and duration of enterprises establishment (micro-enterprise established) appeared to affect the aspect of sustainability. The findings appear to em-phasize on the mixed effects of participation in development initiatives on competitive advantage, per-formance, and sustainability of micro-enterprises. Hence, this study recommends that the government of Malaysia formulate and adopt more specific strategies and policies in advocating development initiatives to ensure positive progression amongst micro-entrepreneurs and micro-enterprise owners. © 2021, University of Economics and Human Sciences in Warsaw. All rights reserved.
Zainol N.R., Aidara S., Yang M., Al Mamun A., Mohd F. (2021)
This study is designed to investigate the effects of capital equity fund accessibility and the development of microenterprise training programmes on micro-entrepreneurship, economic vulnerability, and household income among members of Amanah Ikhtiar Malaysia (AIM). This research adopted a cross-sectional study design and collected data through questionnaires and structured interviews. The participants were 523 impoverished families and low-income households in Peninsular Malaysia who were selected based on the information provided by AIM. Multiple regression analysis was used to analyse the collected data. The outcomes of this study presented some concrete evidence that access to the working capital generated a positive impact on low-income households and decreased the economic vulnerability among low-income urban and rural members of AIM. Furthermore, it was also found that the elongation of the participation period had a negative impact on microenterprise income and lowered the economic vulnerability level among the urban participants but displayed an opposite effect among the rural participants. In contrast, economic loan received had a positive impact on urban participants but negatively impacted the microenterprise income of rural participants. This study has extended the assets and financial approach of the neoclassical theory and also the understanding of low-income communities by offering some policy development to increase poverty eradication among the urban and rural low-income members of AIM in an emerging economy. © 2021, The Author(s), under exclusive license to Springer Nature Switzerland AG.
Al Mamun A., Fazal S.A., Masud M.M., Selvachandran G., Zainol N.R., Gai Q.S. (2020)
In acknowledging the significant role of forestry on the environmental, social, and economic sustainability of local communities, this study focused on examining how different factors affect the intentional behavior towards community forestry among the poor households in Malaysia. Employing theory of planned behavior (TPB) in an expanded model, this study collected data from 420 underprivileged households from 10 states in Malaysia using a survey questionnaire. Final analysis is performed using two methods, one being the well-established, conventional way of partial least square-structural equation modelling (PLS-SEM); the other being a frontier technology of computing using artificial neural network (ANN), which is generated through a deep learning algorithm to achieve the maximum possible accuracy for each of the five scenarios aforementioned. The study found that perceived benefits (PB) and eco-literacy (EL) have a significant positive effect on the attitude towards environment (ATE) while normative belief (NB) and motivation (MO) have a significant positive effect on subjective norms (SUN). Perceived control (PC) has a significant positive effect on perceived behavioral control (PBC). ATE, SUN, and PBC have a significant positive effect on the intention towards community forestry (ITCF), whereas the ITCF has a significant positive effect on community forestry adoption behavior (CFAB). When formulating and enforcing carbon reduction and poverty elevating programs through community forestry, the Malaysian government should consider the perceptions of poor families and the prerogative from their special reference groups to enhance the perceived ability of the vulnerable groups for positive and effective pro-environmental behavior that can lead to sustainable forestry management. © 2020 by the authors.
Mamun A.A., Hayat N., Malarvizhi C.A.N., Zainol N.R.B. (2020)
Climate change hinders economic growth across the globe, whereas green products and/or the adoption of green practices can effctively mitigate the deteriorating conditions of climate. A large proportion of the world population is living in remote areas with low income, and they should be included in the mitigation efforts to reduce the damaging effcts of climate change. Therefore, this study intends to examine the intentions and behaviors towards green composting among low-income rural households to generate income, improve agricultural productivity, and reduce dependency on chemical fertilizers. This study adopted a cross-sectional research design and used structured interviews to collect quantitative data from 420 low-income households living in rural areas in Peninsular Malaysia. This study adopted the Theory of Planned Behavior (TPB) and extended the TPB by embedding the constructs of perceived benefits and eco-literacy into the attitude towards the environment, normative beliefs by extending the subjective norms, and perception of startup resources by extending the perceived behavioral control. The study outcomes revealed that eco-literacy and perceived benefits had a significantly positive effct on attitude towards the environment; normative belief on subjective norms; perception of startup resources on perceived behavioral control; attitude towards the environment on subjective norms; perceived behavioral control on intention towards green composting; and intention towards green composting on green composting adoption behavior. The findings may serve as a guideline to policymakers for the adoption of composting, which can mitigate environmental issues in addition to generating economic activities for low-income residents in Peninsular Malaysia. The study's limitations and future research opportunities are reported as well. © 2020 by the authors.
Mohiuddin M., Mazumder M.N.H., Al Mamun A., Su Z. (2020)
Micro-entrepreneurial activities in small-scale trading in an urban context generate incomes and reduce poverty of marginal city dwellers. They are viable but need to adapt to the socio-economic system where they operate. The types of micro-entrepreneurial activities vary between rural and urban contexts. The delivery cost of microfinance services in urban areas is cheaper than in rural areas. © 2020 John Wiley & Sons, Ltd.
Hystad P., Larkin A., Rangarajan S., AlHabib K.F., Avezum Á., Calik K.B.T., Chifamba J., Dans A., Diaz R., du Plessis J.L., Gupta R., Iqbal R., Khatib R., Kelishadi R., Lanas F., Liu Z., Lopez-Jaramillo P., Nair S., Poirier P., Rahman O., Rosengren A., Sw (2020)
Background: Most studies of long-term exposure to outdoor fine particulate matter (PM2·5) and cardiovascular disease are from high-income countries with relatively low PM2·5 concentrations. It is unclear whether risks are similar in low-income and middle-income countries (LMICs) and how outdoor PM2·5 contributes to the global burden of cardiovascular disease. In our analysis of the Prospective Urban and Rural Epidemiology (PURE) study, we aimed to investigate the association between long-term exposure to PM2·5 concentrations and cardiovascular disease in a large cohort of adults from 21 high-income, middle-income, and low-income countries. Methods: In this multinational, prospective cohort study, we studied 157 436 adults aged 35–70 years who were enrolled in the PURE study in countries with ambient PM2·5 estimates, for whom follow-up data were available. Cox proportional hazard frailty models were used to estimate the associations between long-term mean community outdoor PM2·5 concentrations and cardiovascular disease events (fatal and non-fatal), cardiovascular disease mortality, and other non-accidental mortality. Findings: Between Jan 1, 2003, and July 14, 2018, 157 436 adults from 747 communities in 21 high-income, middle-income, and low-income countries were enrolled and followed up, of whom 140 020 participants resided in LMICs. During a median follow-up period of 9·3 years (IQR 7·8–10·8; corresponding to 1·4 million person-years), we documented 9996 non-accidental deaths, of which 3219 were attributed to cardiovascular disease. 9152 (5·8%) of 157 436 participants had cardiovascular disease events (fatal and non-fatal incident cardiovascular disease), including 4083 myocardial infarctions and 4139 strokes. Mean 3-year PM2·5 at cohort baseline was 47·5 μg/m3 (range 6–140). In models adjusted for individual, household, and geographical factors, a 10 μg/m3 increase in PM2·5 was associated with increased risk for cardiovascular disease events (hazard ratio 1·05 [95% CI 1·03–1·07]), myocardial infarction (1·03 [1·00–1·05]), stroke (1·07 [1·04–1·10]), and cardiovascular disease mortality (1·03 [1·00–1·05]). Results were similar for LMICs and communities with high PM2·5 concentrations (>35 μg/m3). The population attributable fraction for PM2·5 in the PURE cohort was 13·9% (95% CI 8·8–18·6) for cardiovascular disease events, 8·4% (0·0–15·4) for myocardial infarction, 19·6% (13·0–25·8) for stroke, and 8·3% (0·0–15·2) for cardiovascular disease mortality. We identified no consistent associations between PM2·5 and risk for non-cardiovascular disease deaths. Interpretation: Long-term outdoor PM2·5 concentrations were associated with increased risks of cardiovascular disease in adults aged 35–70 years. Air pollution is an important global risk factor for cardiovascular disease and a need exists to reduce air pollution concentrations, especially in LMICs, where air pollution levels are highest. Funding: Full funding sources are listed at the end of the paper (see Acknowledgments). © 2020 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND 4.0 license
Dehghan M., Mente A., Rangarajan S., Mohan V., Lear S., Swaminathan S., Wielgosz A., Seron P., Avezum A., Lopez-Jaramillo P., Turbide G., Chifamba J., Alhabib K.F., Mohammadifard N., Szuba A., Khatib R., Altuntas Y., Liu X., Iqbal R., Rosengren A., Yusuf (2020)
Eggs are a rich source of essential nutrients, but they are also a source of dietary cholesterol. Therefore, some guidelines recommend limiting egg consumption. However, there is contradictory evidence on the impact of eggs on diseases, largely based on studies conducted in high-income countries. Objectives: Our aim was to assess the association of egg consumption with blood lipids, cardiovascular disease (CVD), and mortality in large global studies involving populations from low-, middle-, and high-income countries. Methods: We studied 146,011 individuals from 21 countries in the Prospective Urban Rural Epidemiology (PURE) study. Egg consumption was recorded using country-specific validated FFQs. We also studied 31,544 patients with vascular disease in 2 multinational prospective studies: ONTARGET (Ongoing Telmisartan Alone and in Combination with Ramipril Global End Point Trial) and TRANSCEND (Telmisartan Randomized Assessment Study in ACEI Intolerant Subjects with Cardiovascular Disease). We calculated HRs using multivariable Cox frailty models with random intercepts to account for clustering by study center separately within each study. Results: In the PURE study, we recorded 14,700 composite events (8932 deaths and 8477 CVD events). In the PURE study, after excluding those with history of CVD, higher intake of egg (≥7 egg/wk compared with <1 egg/wk intake) was not significantly associated with blood lipids, composite outcome (HR: 0.96; 95% CI: 0.89, 1.04; P-trend = 0.74), total mortality (HR: 1.04; 95% CI: 0.94, 1.15; P-trend = 0.38), or major CVD (HR: 0.92; 95% CI: 0.83, 1.01; P-trend = 0.20). Similar results were observed in ONTARGET/TRANSCEND studies for composite outcome (HR 0.97; 95% CI: 0.76, 1.25; P-trend = 0.09), total mortality (HR: 0.88; 95% CI: 0.62, 1.24; P-trend = 0.55), and major CVD (HR: 0.97; 95% CI: 0.73, 1.29; P-trend = 0.12). Conclusions: In 3 large international prospective studies including ∼177,000 individuals, 12,701 deaths, and 13,658 CVD events from 50 countries in 6 continents, we did not find significant associations between egg intake and blood lipids, mortality, or major CVD events. The ONTARGET and TRANSCEND trials were registered at clinicaltrials.gov as NCT00153101. The PURE trial was registered at clinicaltrials.gov as NCT03225586. © The Author(s) 2020.
Yusuf S., Joseph P., Rangarajan S., Islam S., Mente A., Hystad P., Brauer M., Kutty V.R., Gupta R., Wielgosz A., AlHabib K.F., Dans A., Lopez-Jaramillo P., Avezum A., Lanas F., Oguz A., Kruger I.M., Diaz R., Yusoff K., Mony P., Chifamba J., Yeates K., Kel (2020)
Background: Global estimates of the effect of common modifiable risk factors on cardiovascular disease and mortality are largely based on data from separate studies, using different methodologies. The Prospective Urban Rural Epidemiology (PURE) study overcomes these limitations by using similar methods to prospectively measure the effect of modifiable risk factors on cardiovascular disease and mortality across 21 countries (spanning five continents) grouped by different economic levels. Methods: In this multinational, prospective cohort study, we examined associations for 14 potentially modifiable risk factors with mortality and cardiovascular disease in 155 722 participants without a prior history of cardiovascular disease from 21 high-income, middle-income, or low-income countries (HICs, MICs, or LICs). The primary outcomes for this paper were composites of cardiovascular disease events (defined as cardiovascular death, myocardial infarction, stroke, and heart failure) and mortality. We describe the prevalence, hazard ratios (HRs), and population-attributable fractions (PAFs) for cardiovascular disease and mortality associated with a cluster of behavioural factors (ie, tobacco use, alcohol, diet, physical activity, and sodium intake), metabolic factors (ie, lipids, blood pressure, diabetes, obesity), socioeconomic and psychosocial factors (ie, education, symptoms of depression), grip strength, and household and ambient pollution. Associations between risk factors and the outcomes were established using multivariable Cox frailty models and using PAFs for the entire cohort, and also by countries grouped by income level. Associations are presented as HRs and PAFs with 95% CIs. Findings: Between Jan 6, 2005, and Dec 4, 2016, 155 722 participants were enrolled and followed up for measurement of risk factors. 17 249 (11·1%) participants were from HICs, 102 680 (65·9%) were from MICs, and 35 793 (23·0%) from LICs. Approximately 70% of cardiovascular disease cases and deaths in the overall study population were attributed to modifiable risk factors. Metabolic factors were the predominant risk factors for cardiovascular disease (41·2% of the PAF), with hypertension being the largest (22·3% of the PAF). As a cluster, behavioural risk factors contributed most to deaths (26·3% of the PAF), although the single largest risk factor was a low education level (12·5% of the PAF). Ambient air pollution was associated with 13·9% of the PAF for cardiovascular disease, although different statistical methods were used for this analysis. In MICs and LICs, household air pollution, poor diet, low education, and low grip strength had stronger effects on cardiovascular disease or mortality than in HICs. Interpretation: Most cardiovascular disease cases and deaths can be attributed to a small number of common, modifiable risk factors. While some factors have extensive global effects (eg, hypertension and education), others (eg, household air pollution and poor diet) vary by a country's economic level. Health policies should focus on risk factors that have the greatest effects on averting cardiovascular disease and death globally, with additional emphasis on risk factors of greatest importance in specific groups of countries. Funding: Full funding sources are listed at the end of the paper (see Acknowledgments). © 2020 Elsevier Ltd
Cheng Y.T., Keshavarzi F., Farrukh M.J., Mahmoud S.S.L.A. (2020)
Due to the increasing proportions of aging populations in the Asian region, osteoporosis has become more prevalent and increases the health care expenditure in this region. The majority of osteoporotic fractures occur in postmenopausal women. It is important to identify women at the highest risk and to prevent further fractures. We aimed to assess knowledge, attitude and practice towards osteoporosis among Malaysian women in Klang Valley.A cross-sectional study was conducted in 384 Malaysian women aged above 18 years. A researcher-administered questionnaire was used to collect data. The participants were selected conveniently from obstetrics and gynecology (O&G) or orthopedic clinics from 6 districts of Klang Valley. Data analysis was done by SPSS version 22, using ANOVA, t-test, Chi-square test and Pearson correlation. The findings show participants had a poor score of knowledge towards osteoporosis. There was a significant association between the level of osteoporosis knowledge and education level, employment status and occupation of participants (P<0.05). The participants had a moderate attitude towards osteoporosis. Age, race and education level of participants was significantly associated with the attitude towards osteoporosis. Most participants had poor preventive practices against osteoporosis. The level of practice to prevent osteoporosis was significantly associated with races, education level, occupation and monthly income of participants. Both knowledge and attitude towards osteoporosis were correlated with the practices to prevent osteoporosis.The participants had inadequate knowledge, moderate attitude and poor practice towards osteoporosis. This could serve as a stimulant for policymakers to increase the education of osteoporosis among younger women. Furthermore, the practice against osteoporosis among high-income participants was higher than low-income. This indicates that poverty should be addressed in Malaysia. © 2020, Association of Biotechnology and Pharmacy. All rights reserved.
Asif N., Utaberta N. (2020)
Providing emergency shelter for the victims of natural disasters is part of disaster risk reduction (DRR) strategies. It is essential for the proper management of resources in the communities during emergency time. The approach toward providing emergency shelter to the victims varies in different contexts depending on the availability of suitable places. Organizations like IOM and FEMA have proposed a framework for appropriate planning and design of emergency shelters. These bodies also encourage local disaster management authorities in their guideline to utilize existing structures like schools, community centers, etc., as an emergency shelter for the victims. However, recent flood occurrence in India, UK, and Malaysia showed that the institution of the mosque is highly appropriate to be used as an emergency disaster shelter. This study analyzes the compatibility of mosque institution as a potential place for emergency shelter. The analysis follows the criteria set by IOM and FEMA to design properly functioning emergency shelter. Then, based on these criteria the design of common mosques is discussed considering different aspects such as location, capacity, and facilities. The institution of the mosque is also analyzed from the perspective of Islamic theology and how it is recommended for mosques to provide social and welfare services to the community. This paper recommends further study in this regard to proposing specific guidelines for the mosque so that it can be utilized as an existing structure for providing emergency shelter for disaster victims. © Springer Nature Switzerland AG 2020.
Anjana R.M., Mohan V., Rangarajan S., Gerstein H.C., Venkatesan U., Sheridan P., Dagenais G.R., Lear S.A., Teo K., Karsidag K., Alhabib K.F., Yusoff K., Ismail N., Mony P.K., Lopez-Jaramillo P., Chifamba J., Palileo-Villanueva L.M., Iqbal R., Yusufali A., (2020)
OBJECTIVE We aimed to compare cardiovascular (CV) events, all-cause mortality, and CV mortality rates among adults with and without diabetes in countries with differing levels of income. RESEARCH DESIGN AND METHODS The Prospective Urban Rural Epidemiology (PURE) study enrolled 143,567 adults aged 35–70 years from 4 high-income countries (HIC), 12 middle-income countries (MIC), and 5 low-income countries (LIC). The mean follow-up was 9.0 ± 3.0 years. RESULTS Among those with diabetes, CVD rates (LIC 10.3, MIC 9.2, HIC 8.3 per 1,000 person-years, P < 0.001), all-cause mortality (LIC 13.8, MIC 7.2, HIC 4.2 per 1,000 person-years, P < 0.001), and CV mortality (LIC 5.7, MIC 2.2, HIC 1.0 per 1,000 person-years, P < 0.001) were considerably higher in LIC compared with MIC and HIC. Within LIC, mortality was higher in those in the lowest tertile of wealth index (low 14.7%, middle 10.8%, and high 6.5%). In contrast to HIC and MIC, the increased CV mortality in those with diabetes in LIC remained unchanged even after adjustment for behavioral risk factors and treatments (hazard ratio [95% CI] 1.89 [1.58–2.27] to 1.78 [1.36–2.34]). CONCLUSIONS CVD rates, all-cause mortality, and CV mortality were markedly higher among those with diabetes in LIC compared with MIC and HIC with mortality risk remaining unchanged even after adjustment for risk factors and treatments. There is an urgent need to improve access to care to those with diabetes in LIC to reduce the excess mortality rates, particularly among those in the poorer strata of society. © 2020 by the American Diabetes Association.
Win P.P. (2020)
Helicobacter pylori infects 50% of children aged 5 years in developing countries. The infection is associated with socio-economic background and family composition. The aim of this study was to determine the seroprevalence and associated factors of Helicobacter pylori infection among Myanmar children in Insein Township, which is a peri-urban community situated in the northern region of Yangon. A cross-sectional study was carried out in Insein Township on 193 children, aged 2 to 13 years, who were tested for H. pylori antibody by enzyme-linked immunosorbent assay (ELISA) test. Parents were interviewed using a questionnaire. Statistical analyses were done using chi-square test and two-sample t-test. The prevalence of H. pylori infections was 67.36%. The mean age of the participants was 7.6 +/-3.85 years. Those positive for H. pylori antibody were significantly older (8.18+/-3.8) than those with negative results (6.41+/-3.7). There is no gender preponderance. The sero-positive rate was higher among low socio-economic group. The children who tested positive for H. pylori antibody had a mean family member of 5.97+/-2.22 and those who tested negative had 6.06+/-2.17. Thus, there was no association between H. pylori infection and number of family members. There was no association between H. pylori infection and overcrowding, type of drinking water, type of latrine used and type of housing. Our findings suggest that the prevalence of H. pylori infection among Myanmar children is common, as it is in other developing countries, and also highlight its association with socioeconomic status. Over time, the prevalence of H. pylori infections in children is expected to decline worldwide in parallel with the improvement in socioeconomic status of the nations. There is a need to intensify efforts of improving sanitation and living conditions in order to protect children against H. pylori infection. © 2020 Malaysian Public Health Physicians Association.
Irawati L., Alrasheedy A.A., Hassali M.A., Saleem F. (2019)
Background: Understanding community perspectives on antibiotics and antibiotic resistance (ABR) is a key component in designing educational interventions to combat ABR at the community level in Malaysia. Therefore, this study aimed to explore community residents' knowledge, attitudes and perceptions regarding antibiotics and ABR in Jelutong District, Penang, Malaysia. Moreover, it intended to identify areas of focus to be addressed when designing an educational intervention to increase residents' knowledge and change their attitudes and perceptions. Methods: A qualitative approach was adopted to gain a deeper understanding of community residents' knowledge, attitudes and perceptions regarding antibiotics and ABR. A purposive sampling was employed. Twenty-two residents (aged ≥18 years) were interviewed with the aid of a semi-structured interview guide. All interviews were audio recorded, transcribed verbatim and thematically analysed. Results: The majority of the participants asserted that antibiotics could be effective against viral infections. Moreover, many participants were unaware that antibiotics have adverse effects. Some acquired antibiotics from a community pharmacy without a prescription, took antibiotics given to them by their family or friends, or took leftover antibiotics prescribed for a previous illness. A few indicated that they would request antibiotics from their physician when they had viral infections. More than half of the participants discontinued taking antibiotics when their symptoms improved. The majority stated that ABR occurs when the body becomes used to antibiotics. Most participants were unaware of the causes, consequences and prevention of ABR. In fact, they were not concerned about it. As a result, only a few perceived themselves as having responsibility for preventing this problem. Conclusions: The community residents had misconceptions about antibiotics and ABR, negative attitudes towards antibiotics and negative perceptions of ABR. The areas of focus that need to be addressed when designing an educational intervention to increase the general public knowledge and change their attitudes and perceptions are the appropriate use of antibiotics and their adverse effects; the importance of adhering to antibiotic therapy; and the definition, causes, consequences and prevention of ABR. © 2019 The Author(s).
Rosengren A., Smyth A., Rangarajan S., Ramasundarahettige C., Bangdiwala S.I., AlHabib K.F., Avezum A., Bengtsson Boström K., Chifamba J., Gulec S., Gupta R., Igumbor E.U., Iqbal R., Ismail N., Joseph P., Kaur M., Khatib R., Kruger I.M., Lamelas P., Lanas (2019)
Background: Socioeconomic status is associated with differences in risk factors for cardiovascular disease incidence and outcomes, including mortality. However, it is unclear whether the associations between cardiovascular disease and common measures of socioeconomic status—wealth and education—differ among high-income, middle-income, and low-income countries, and, if so, why these differences exist. We explored the association between education and household wealth and cardiovascular disease and mortality to assess which marker is the stronger predictor of outcomes, and examined whether any differences in cardiovascular disease by socioeconomic status parallel differences in risk factor levels or differences in management. Methods: In this large-scale prospective cohort study, we recruited adults aged between 35 years and 70 years from 367 urban and 302 rural communities in 20 countries. We collected data on families and households in two questionnaires, and data on cardiovascular risk factors in a third questionnaire, which was supplemented with physical examination. We assessed socioeconomic status using education and a household wealth index. Education was categorised as no or primary school education only, secondary school education, or higher education, defined as completion of trade school, college, or university. Household wealth, calculated at the household level and with household data, was defined by an index on the basis of ownership of assets and housing characteristics. Primary outcomes were major cardiovascular disease (a composite of cardiovascular deaths, strokes, myocardial infarction, and heart failure), cardiovascular mortality, and all-cause mortality. Information on specific events was obtained from participants or their family. Findings: Recruitment to the study began on Jan 12, 2001, with most participants enrolled between Jan 6, 2005, and Dec 4, 2014. 160 299 (87·9%) of 182 375 participants with baseline data had available follow-up event data and were eligible for inclusion. After exclusion of 6130 (3·8%) participants without complete baseline or follow-up data, 154 169 individuals remained for analysis, from five low-income, 11 middle-income, and four high-income countries. Participants were followed-up for a mean of 7·5 years. Major cardiovascular events were more common among those with low levels of education in all types of country studied, but much more so in low-income countries. After adjustment for wealth and other factors, the HR (low level of education vs high level of education) was 1·23 (95% CI 0·96–1·58) for high-income countries, 1·59 (1·42–1·78) in middle-income countries, and 2·23 (1·79–2·77) in low-income countries (pinteraction<0·0001). We observed similar results for all-cause mortality, with HRs of 1·50 (1·14–1·98) for high-income countries, 1·80 (1·58–2·06) in middle-income countries, and 2·76 (2·29–3·31) in low-income countries (pinteraction<0·0001). By contrast, we found no or weak associations between wealth and these two outcomes. Differences in outcomes between educational groups were not explained by differences in risk factors, which decreased as the level of education increased in high-income countries, but increased as the level of education increased in low-income countries (pinteraction<0·0001). Medical care (eg, management of hypertension, diabetes, and secondary prevention) seemed to play an important part in adverse cardiovascular disease outcomes because such care is likely to be poorer in people with the lowest levels of education compared to those with higher levels of education in low-income countries; however, we observed less marked differences in care based on level of education in middle-income countries and no or minor differences in high-income countries. Interpretation: Although people with a lower level of education in low-income and middle-income countries have higher incidence of and mortality from cardiovascular disease, they have better overall risk factor profiles. However, these individuals have markedly poorer health care. Policies to reduce health inequities globally must include strategies to overcome barriers to care, especially for those with lower levels of education. Funding: Full funding sources are listed at the end of the paper (see Acknowledgments). © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license
Muslim A., Sofian S.M., Shaari S.A., Hoh B.-P., Lim Y.A.-L. (2019)
Background Formerly known as the Malaysian hunter gatherers, the Negrito Orang Asli (OA) were heavily dependent on the forest for sustenance and early studies indicated high prevalence of intestinal parasitism. Initiation of a redevelopment program in the 1970s aimed to demarginalize the OA was expected to reduce soil transmitted helminth (STH) infections. Gradually, the OA were relocated to new resettlement areas at the peripheries. The aim of this study was to compare STH infections between Negritos who are still living in the inland jungle with those living in resettlements. Methodology/Principal findings A total of 416 Negrito participants were grouped into two categories of communities based on location; Inland Jungle Villages (IJV); and Resettlement Plan Scheme (RPS). Iodine wet mount, formalin-ether sedimentation, modified Trichrome and modified Ziehl-Neelsen staining and Kato-Katz methods were performed on stool samples. A questionnaire was used to collect information regarding demographic, socioeconomic, environmental and hygiene behaviors. Prevalence of STH was significantly higher in IJV (91.3%) versus RPS (83.1%) (P = 0.02). However, the percentage of individuals with severe intensity of Trichuris trichiura infections was significantly higher in the RPS (17.2%) compared to IJV (6.5%) (P = 0.01). Severe Ascaris lumbricoides infection was observed at 20.0% amongst RPS Negritos and 15.0% amongst IJV (P = 0.41). Whilst for hookworm infection, both prevalence and individuals with moderate to severe infections were higher in the IJV (26.2%, 41.0%) versus RPS (18.7%, 24.0%) (P values = 0.08, 0.09), accordingly. The prevalence other intestinal parasitic infections (e.g. Entamoeba sp., Blastocystis and flukes) was also higher in IJV versus RPS. Apart from poor hygienic behaviors as significant risk factors in both communities, low socio-economic status was highly associated with STH infections in RPS (P<0.001) but not significantly associated in IJV. Conclusions The findings showed that ex situ development plan by RPS has not profoundly contributed to the STH reduction among the OA. Conversely, burden rate of T. trichiura infections increased due to their extreme poverty and poor hygienic behaviors. Here, we are suggesting biannual mass albendazole intervention (triple dose regimens in RPS, but a single dose in IJV) and community empowerment to both communities. For a long-term and better uptake, these strategies must be done together with the community input and participation, respecting their traditional customs and accompanied by recruitment of more OA people in the health-care taskforce. © 2019 Muslim et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
O'Donnell M., Mente A., Rangarajan S., McQueen M.J., O'Leary N., Yin L., Liu X., Swaminathan S., Khatib R., Rosengren A., Ferguson J., Smyth A., Lopez-Jaramillo P., Diaz R., Avezum A., Lanas F., Ismail N., Yusoff K., Dans A., Iqbal R., Szuba A., Mohammadi (2019)
Objective: To evaluate the joint association of sodium and potassium urinary excretion (as surrogate measures of intake) with cardiovascular events and mortality, in the context of current World Health Organization recommendations for daily intake (<2.0 g sodium, >3.5 g potassium) in adults. Design: International prospective cohort study. Setting: 18 high, middle, and low income countries, sampled from urban and rural communities. Participants: 103 570 people who provided morning fasting urine samples. Main outcome measures: Association of estimated 24 hour urinary sodium and potassium excretion (surrogates for intake) with all cause mortality and major cardiovascular events, using multivariable Cox regression. A six category variable for joint sodium and potassium was generated: sodium excretion (low (<3 g/day), moderate (3-5 g/day), and high (>5 g/day) sodium intakes) by potassium excretion (greater/equal or less than median 2.1 g/day). Results: Mean estimated sodium and potassium urinary excretion were 4.93 g/day and 2.12 g/day, respectively. After a median follow-up of 8.2 years, 7884 (6.1%) participants had died or experienced a major cardiovascular event. Increasing urinary sodium excretion was positively associated with increasing potassium excretion (unadjusted r=0.34), and only 0.002% had a concomitant urinary excretion of <2.0 g/day of sodium and >3.5 g/day of potassium. A J-shaped association was observed of sodium excretion and inverse association of potassium excretion with death and cardiovascular events. For joint sodium and potassium excretion categories, the lowest risk of death and cardiovascular events occurred in the group with moderate sodium excretion (3-5 g/day) and higher potassium excretion (21.9% of cohort). Compared with this reference group, the combinations of low potassium with low sodium excretion (hazard ratio 1.23, 1.11 to 1.37; 7.4% of cohort) and low potassium with high sodium excretion (1.21, 1.11 to 1.32; 13.8% of cohort) were associated with the highest risk, followed by low sodium excretion (1.19, 1.02 to 1.38; 3.3% of cohort) and high sodium excretion (1.10, 1.02 to 1.18; 29.6% of cohort) among those with potassium excretion greater than the median. Higher potassium excretion attenuated the increased cardiovascular risk associated with high sodium excretion (P for interaction=0.007). Conclusions: These findings suggest that the simultaneous target of low sodium intake (<2 g/day) with high potassium intake (>3.5 g/day) is extremely uncommon. Combined moderate sodium intake (3-5 g/day) with high potassium intake is associated with the lowest risk of mortality and cardiovascular events. © 2019 Published by the BMJ Publishing Group Limited.
Chow C.K., Ramasundarahettige C., Hu W., AlHabib K.F., Avezum A., Jr, Cheng X., Chifamba J., Dagenais G., Dans A., Egbujie B.A., Gupta R., Iqbal R., Ismail N., Keskinler M.V., Khatib R., Kruger L., Kumar R., Lanas F., Lear S., Lopez-Jaramillo P., McKee M. (2018)
Background: Data are scarce on the availability and affordability of essential medicines for diabetes. Our aim was to examine the availability and affordability of metformin, sulfonylureas, and insulin across multiple regions of the world and explore the effect of these on medicine use. Methods: In the Prospective Urban Rural Epidemiology (PURE) study, participants aged 35–70 years (n=156 625) were recruited from 110 803 households, in 604 communities and 22 countries; availability (presence of any dose of medication in the pharmacy on the day of audit) and medicine cost data were collected from pharmacies with the Environmental Profile of a Community's Health audit tool. Our primary analysis was to describe the availability and affordability of metformin and insulin and also commonly used and prescribed combinations of two medicines for diabetes management (two oral drugs, metformin plus a sulphonylurea [either glibenclamide (also known as glyburide) or gliclazide] and one oral drug plus insulin [metformin plus insulin]). Medicines were defined as affordable if the cost of medicines was less than 20% of capacity-to-pay (the household income minus food expenditure). Our analyses included data collected in pharmacies and data from representative samples of households. Data on availability were ascertained during the pharmacy audit, as were data on cost of medications. These cost data were used to estimate the cost of a month's supply of essential medicines for diabetes. We estimated affordability of medicines using income data from household surveys. Findings: Metformin was available in 113 (100%) of 113 pharmacies from high-income countries, 112 (88·2%) of 127 pharmacies in upper-middle-income countries, 179 (86·1%) of 208 pharmacies in lower-middle-income countries, 44 (64·7%) of 68 pharmacies in low-income countries (excluding India), and 88 (100%) of 88 pharmacies in India. Insulin was available in 106 (93·8%) pharmacies in high-income countries, 51 (40·2%) pharmacies in upper-middle-income countries, 61 (29·3%) pharmacies in lower-middle-income countries, seven (10·3%) pharmacies in lower-income countries, and 67 (76·1%) of 88 pharmacies in India. We estimated 0·7% of households in high-income countries and 26·9% of households in low-income countries could not afford metformin and 2·8% of households in high-income countries and 63·0% of households in low-income countries could not afford insulin. Among the 13 569 (8·6% of PURE participants) that reported a diagnosis of diabetes, 1222 (74·0%) participants reported diabetes medicine use in high-income countries compared with 143 (29·6%) participants in low-income countries. In multilevel models, availability and affordability were significantly associated with use of diabetes medicines. Interpretation: Availability and affordability of essential diabetes medicines are poor in low-income and middle-income countries. Awareness of these global differences might importantly drive change in access for patients with diabetes. Funding: Full funding sources listed at the end of the paper (see Acknowledgments). © 2018 Elsevier Ltd
Langhorne P., O'Donnell M.J., Chin S.L., Zhang H., Xavier D., Avezum A., Mathur N., Turner M., MacLeod M.J., Lopez-Jaramillo P., Damasceno A., Hankey G.J., Dans A.L., Elsayed A., Mondo C., Wasay M., Czlonkowska A., Weimar C., Yusufali A.H., Hussain F.A., (2018)
Background: Stroke disproportionately affects people in low-income and middle-income countries. Although improvements in stroke care and outcomes have been reported in high-income countries, little is known about practice and outcomes in low and middle-income countries. We aimed to compare patterns of care available and their association with patient outcomes across countries at different economic levels. Methods: We studied the patterns and effect of practice variations (ie, treatments used and access to services) among participants in the INTERSTROKE study, an international observational study that enrolled 13 447 stroke patients from 142 clinical sites in 32 countries between Jan 11, 2007, and Aug 8, 2015. We supplemented patient data with a questionnaire about health-care and stroke service facilities at all participating hospitals. Using univariate and multivariate regression analyses to account for patient casemix and service clustering, we estimated the association between services available, treatments given, and patient outcomes (death or dependency) at 1 month. Findings: We obtained full information for 12 342 (92%) of 13 447 INTERSTROKE patients, from 108 hospitals in 28 countries; 2576 from 38 hospitals in ten high-income countries and 9766 from 70 hospitals in 18 low and middle-income countries. Patients in low-income and middle-income countries more often had severe strokes, intracerebral haemorrhage, poorer access to services, and used fewer investigations and treatments (p<0·0001) than those in high-income countries, although only differences in patient characteristics explained the poorer clinical outcomes in low and middle-income countries. However across all countries, irrespective of economic level, access to a stroke unit was associated with improved use of investigations and treatments, access to other rehabilitation services, and improved survival without severe dependency (odds ratio [OR] 1·29; 95% CI 1·14–1·44; all p<0·0001), which was independent of patient casemix characteristics and other measures of care. Use of acute antiplatelet treatment was associated with improved survival (1·39; 1·12–1·72) irrespective of other patient and service characteristics. Interpretation: Evidence-based treatments, diagnostics, and stroke units were less commonly available or used in low and middle-income countries. Access to stroke units and appropriate use of antiplatelet treatment were associated with improved recovery. Improved care and facilities in low-income and middle-income countries are essential to improve outcomes. Funding: Chest, Heart and Stroke Scotland. © 2018 Elsevier Ltd
Miller V., Mente A., Dehghan M., Rangarajan S., Zhang X., Swaminathan S., Dagenais G., Gupta R., Mohan V., Lear S., Bangdiwala S.I., Schutte A.E., Wentzel-Viljoen E., Avezum A., Altuntas Y., Yusoff K., Ismail N., Peer N., Chifamba J., Diaz R., Rahman O., (2017)
Background The association between intake of fruits, vegetables, and legumes with cardiovascular disease and deaths has been investigated extensively in Europe, the USA, Japan, and China, but little or no data are available from the Middle East, South America, Africa, or south Asia. Methods We did a prospective cohort study (Prospective Urban Rural Epidemiology [PURE] in 135 335 individuals aged 35 to 70 years without cardiovascular disease from 613 communities in 18 low-income, middle-income, and high-income countries in seven geographical regions: North America and Europe, South America, the Middle East, south Asia, China, southeast Asia, and Africa. We documented their diet using country-specific food frequency questionnaires at baseline. Standardised questionnaires were used to collect information about demographic factors, socioeconomic status (education, income, and employment), lifestyle (smoking, physical activity, and alcohol intake), health history and medication use, and family history of cardiovascular disease. The follow-up period varied based on the date when recruitment began at each site or country. The main clinical outcomes were major cardiovascular disease (defined as death from cardiovascular causes and non-fatal myocardial infarction, stroke, and heart failure), fatal and non-fatal myocardial infarction, fatal and non-fatal strokes, cardiovascular mortality, non-cardiovascular mortality, and total mortality. Cox frailty models with random effects were used to assess associations between fruit, vegetable, and legume consumption with risk of cardiovascular disease events and mortality. Findings Participants were enrolled into the study between Jan 1, 2003, and March 31, 2013. For the current analysis, we included all unrefuted outcome events in the PURE study database through March 31, 2017. Overall, combined mean fruit, vegetable and legume intake was 3·91 (SD 2·77) servings per day. During a median 7·4 years (5·5–9·3) of follow-up, 4784 major cardiovascular disease events, 1649 cardiovascular deaths, and 5796 total deaths were documented. Higher total fruit, vegetable, and legume intake was inversely associated with major cardiovascular disease, myocardial infarction, cardiovascular mortality, non-cardiovascular mortality, and total mortality in the models adjusted for age, sex, and centre (random effect). The estimates were substantially attenuated in the multivariable adjusted models for major cardiovascular disease (hazard ratio [HR] 0·90, 95% CI 0·74–1·10, ptrend=0·1301), myocardial infarction (0·99, 0·74–1·31; ptrend=0·2033), stroke (0·92, 0·67–1·25; ptrend=0·7092), cardiovascular mortality (0·73, 0·53–1·02; ptrend=0·0568), non-cardiovascular mortality (0·84, 0·68–1·04; ptrend =0·0038), and total mortality (0·81, 0·68–0·96; ptrend<0·0001). The HR for total mortality was lowest for three to four servings per day (0·78, 95% CI 0·69–0·88) compared with the reference group, with no further apparent decrease in HR with higher consumption. When examined separately, fruit intake was associated with lower risk of cardiovascular, non-cardiovascular, and total mortality, while legume intake was inversely associated with non-cardiovascular death and total mortality (in fully adjusted models). For vegetables, raw vegetable intake was strongly associated with a lower risk of total mortality, whereas cooked vegetable intake showed a modest benefit against mortality. Interpretation Higher fruit, vegetable, and legume consumption was associated with a lower risk of non-cardiovascular, and total mortality. Benefits appear to be maximum for both non-cardiovascular mortality and total mortality at three to four servings per day (equivalent to 375–500 g/day). Funding Full funding sources listed at the end of the paper (see Acknowledgments). © 2017 Elsevier Ltd
Attaei M.W., Khatib R., McKee M., Lear S., Dagenais G., Igumbor E.U., AlHabib K.F., Kaur M., Kruger L., Teo K., Lanas F., Yusoff K., Oguz A., Gupta R., Yusufali A.M., Bahonar A., Kutty R., Rosengren A., Mohan V., Avezum A., Yusuf R., Szuba A., Rangarajan (2017)
Background Hypertension is considered the most important risk factor for cardiovascular diseases, but its control is poor worldwide. We aimed to assess the availability and affordability of blood pressure-lowering medicines, and the association with use of these medicines and blood pressure control in countries at varying levels of economic development. Methods We analysed the availability, costs, and affordability of blood pressure-lowering medicines with data recorded from 626 communities in 20 countries participating in the Prospective Urban Rural Epidemiological (PURE) study. Medicines were considered available if they were present in the local pharmacy when surveyed, and affordable if their combined cost was less than 20% of the households' capacity to pay. We related information about availability and affordability to use of these medicines and blood pressure control with multilevel mixed-effects logistic regression models, and compared results for high-income, upper-middle-income, lower-middle-income, and low-income countries. Data for India are presented separately because it has a large generic pharmaceutical industry and a higher availability of medicines than other countries at the same economic level. Findings The availability of two or more classes of blood pressure-lowering drugs was lower in low-income and middle-income countries (except for India) than in high-income countries. The proportion of communities with four drug classes available was 94% in high-income countries (108 of 115 communities), 76% in India (68 of 90), 71% in upper-middle-income countries (90 of 126), 47% in lower-middle-income countries (107 of 227), and 13% in low-income countries (nine of 68). The proportion of households unable to afford two blood pressure-lowering medicines was 31% in low-income countries (1069 of 3479 households), 9% in middle-income countries (5602 of 65 471), and less than 1% in high-income countries (44 of 10 880). Participants with known hypertension in communities that had all four drug classes available were more likely to use at least one blood pressure-lowering medicine (adjusted odds ratio [OR] 2·23, 95% CI 1·59–3·12); p<0·0001), combination therapy (1·53, 1·13–2·07; p=0·054), and have their blood pressure controlled (2·06, 1·69–2·50; p<0·0001) than were those in communities where blood pressure-lowering medicines were not available. Participants with known hypertension from households able to afford four blood pressure-lowering drug classes were more likely to use at least one blood pressure-lowering medicine (adjusted OR 1·42, 95% CI 1·25–1·62; p<0·0001), combination therapy (1·26, 1·08–1·47; p=0·0038), and have their blood pressure controlled (1·13, 1·00–1·28; p=0·0562) than were those unable to afford the medicines. Interpretation A large proportion of communities in low-income and middle-income countries do not have access to more than one blood pressure-lowering medicine and, when available, they are often not affordable. These factors are associated with poor blood pressure control. Ensuring access to affordable blood pressure-lowering medicines is essential for control of hypertension in low-income and middle-income countries. Funding Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Canadian Institutes of Health Research Strategy for Patient Oriented Research through the Ontario SPOR Support Unit, the Ontario Ministry of Health and Long-Term Care, pharmaceutical companies (with major contributions from AstraZeneca [Canada], Sanofi Aventis [France and Canada], Boehringer Ingelheim [Germany amd Canada], Servier, and GlaxoSmithKline), Novartis and King Pharma, and national or local organisations in participating countries. © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license
Khan M.U., Arief M., Ahmad A., Malik S., Gogoi L.J., Kalita M., Saleem F., Hassali M.A.A. (2017)
Background Shortage of qualified medical doctors and little or no access to basic medicines and medical facilities are the major rural health concerns in India. Expanding the role of pharmacists to provide prescribing services could improve rural health outcomes. Objective To assess the attitudes of rural population towards pharmacist prescribing and their interest in using expanded pharmacist prescribing services. Setting Rural population of Assam, India. Methods A descriptive, cross-sectional survey was conducted for a period of 2 months from March to April 2016 in the State of Assam, India. A multi-stage sampling was used to recruit (n = 410) eligible participants. Main outcome measure Rural population attitudes towards, and interests in using, pharmacist prescribing services. Results The attitudes of participants were generally positive towards pharmacist prescribing. A large proportion of participants (81.5%) agreed that pharmacists should have a prescribing role in rural India. Participants indicated their interest in using expanded pharmacist prescribing services, with greater interests in receiving medications in emergency situations (79.7%) and getting a treatment plan for their medical problem (75.6%). Participants with low income and tertiary education had better attitudes and showed more interest towards expanded pharmacist prescribing services (p < 0.05). Conclusions Most participants had positive attitudes towards pharmacist prescribing and were interested in using expanded pharmacist prescribing services. © 2017, Springer International Publishing.
Vedanthan R., Bernabe-Ortiz A., Herasme O.I., Joshi R., Lopez-Jaramillo P., Thrift A.G., Webster J., Webster R., Yeates K., Gyamfi J., Ieremia M., Johnson C., Kamano J.H., Lazo-Porras M., Limbani F., Liu P., McCready T., Miranda J.J., Mohan S., Ogedegbe O (2017)
Elevated blood pressure, a major risk factor for ischemic heart disease, heart failure, and stroke, is the leading global risk for mortality. Treatment and control rates are very low in low- and middle-income countries. There is an urgent need to address this problem. The Global Alliance for Chronic Diseases sponsored research projects focus on controlling hypertension, including community engagement, salt reduction, salt substitution, task redistribution, mHealth, and fixed-dose combination therapies. This paper reviews the rationale for each approach and summarizes the experience of some of the research teams. The studies demonstrate innovative and practical methods for improving hypertension control. © 2016 Elsevier Inc.