Hypertension awareness, treatment, and control and their association with healthcare access in the middle-aged and older Indian population: A nationwide cohort study

Background Hypertension is the most important cardiovascular risk factor in India, and representative studies of middle-aged and older Indian adults have been lacking. Our objectives were to estimate the proportions of hypertensive adults who had been diagnosed, took antihypertensive medication, and achieved control in the middle-aged and older Indian population and to investigate the association between access to healthcare and hypertension management. Methods and findings We designed a nationally representative cohort study of the middle-aged and older Indian population, the Longitudinal Aging Study in India (LASI), and analyzed data from the 2017–2019 baseline wave (N = 72,262) and the 2010 pilot wave (N = 1,683). Hypertension was defined as self-reported physician diagnosis or elevated blood pressure (BP) on measurement, defined as systolic BP ≥ 140 mm Hg or diastolic BP ≥ 90 mm Hg. Among hypertensive individuals, awareness, treatment, and control were defined based on self-reports of having been diagnosed, taking antihypertensive medication, and not having elevated BP, respectively. The estimated prevalence of hypertension for the Indian population aged 45 years and older was 45.9% (95% CI 45.4%–46.5%). Among hypertensive individuals, 55.7% (95% CI 54.9%–56.5%) had been diagnosed, 38.9% (95% CI 38.1%–39.6%) took antihypertensive medication, and 31.7% (95% CI 31.0%–32.4%) achieved BP control. In multivariable logistic regression models, access to public healthcare was a key predictor of hypertension treatment (odds ratio [OR] = 1.35, 95% CI 1.14–1.60, p = 0.001), especially in the most economically disadvantaged group (OR of the interaction for middle economic status = 0.76, 95% CI 0.61–0.94, p = 0.013; OR of the interaction for high economic status = 0.84, 95% CI 0.68–1.05, p = 0.124). Having health insurance was not associated with improved hypertension awareness among those with low economic status (OR = 0.96, 95% CI 0.86–1.07, p = 0.437) and those with middle economic status (OR of the interaction = 1.15, 95% CI 1.00–1.33, p = 0.051), but it was among those with high economic status (OR of the interaction = 1.28, 95% CI 1.10–1.48, p = 0.001). Comparing hypertension awareness, treatment, and control rates in the 4 pilot states, we found statistically significant (p < 0.001) improvement in hypertension management from 2010 to 2017–2019. The limitations of this study include the pilot sample being relatively small and that it recruited from only 4 states. Conclusions Although considerable variations in hypertension diagnosis, treatment, and control exist across different sociodemographic groups and geographic areas, reducing uncontrolled hypertension remains a public health priority in India. Access to healthcare is closely tied to both hypertension diagnosis and treatment.

Exploring factors influencing patient mortality and loss to follow-up in two paediatric hospital wards in Zamfara, North-West Nigeria, 2016–2018

Introduction Child mortality has been linked to infectious diseases, malnutrition and lack of access to essential health services. We investigated possible predictors for death and patients lost to follow up (LTFU) for paediatric patients at the inpatient department (IPD) and inpatient therapeutic feeding centre (ITFC) of the Anka General Hospital (AGH), Zamfara State, Nigeria, to inform best practices at the hospital. Methods We conducted a retrospective cohort review study using routinely collected data of all patient admissions to the IPD and ITFC with known hospital exit status between 2016 and 2018. Unadjusted and adjusted rate ratios (aRR) and respective 95% confidence intervals (95% CI) were calculated using Poisson regression to estimate the association between the exposure variables and mortality as well as LTFU. Results The mortality rate in IPD was 22% lower in 2018 compared to 2016 (aRR 0.78; 95% CI 0.66–0.93) and 70% lower for patients coming from lead-affected villages compared to patients from other villages (aRR 0.30; 95% CI 0.19–0.48). The mortality rate for ITFC patients was 41% higher during rainy season (aRR 1.41; 95% CI 1.2–1.6). LTFU rates in ITFC increased in 2017 and 2018 when compared to 2016 (aRR 1.6; 95% CI 1.2–2.0 and aRR 1.4; 95% CI 1.1–1.8) and patients in ITFC had 2.5 times higher LTFU rates when coming from a lead-affected village. Conclusions Our data contributes clearer understanding of the situation in the paediatric wards in AGH in Nigeria, but identifying specific predictors for the multifaceted nature of mortality and LTFU is challenging. Mortality in paediatric patients in IPD of AGH improved during the study period, which is likely linked to better awareness of the hospital, but still remains high. Access to healthcare due to seasonal restrictions contributes to mortalities due to late presentation. Increased awareness of and easier access to healthcare, such as for patients living in lead-affected villages, which are still benefiting from an MSF lead poisoning intervention, decreases mortalities, but increases LTFU. We recommend targeted case audits and qualitative studies to better understand the role of health-seeking behaviour, and social and traditional factors in the use of formal healthcare in this part of Nigeria and potentially similar settings in other countries.

Women Empowerment in Punjab: Dimensions, Determinants, and Implications for Access to Healthcare

In developing countries like Pakistan, because of the complex cultural and socio-demographic milieu women empowerment always remained the contested issue. Overall major indicators of human development of women have been considered lower rather than men. In Pakistan, some considerable measures have focused on women's empowerment however, their status is still miserable specifically in rural areas. This study was aimed to find out, the extent of rural women empowerment and the effect of women empowerment regarding access to healthcare in the Vehari district of Southern Punjab, Pakistan. The study used data of 240 married women respondents and employed Cronbach’s alpha and OLS approaches for various analyses of the study components. Scores of various components regarding women's empowerment were regressed over the scores of women's access to healthcare in the final analysis of the study. The finding of the study indicated that the power of decision-making (0.87), self-esteem (0.79), and mobility (0.89) has positive and significant effects on access to health care whereas control over the resource (0.73) estimates indicated positive while the insignificant impact on health access. Education access, adequate job opportunities, and media information approach considered more appropriate and feasible measures for adequate women empowerment and health care access. Emergency-based State-based policy measures need to be applied such as women schooling at doorstep, increasing females' priority-based job opportunities, and proper access to media for increasing awareness regarding their rights and significant role in society.

Enabling Rural Telehealth: Focus Group Study with Older Adults in Underserved Rural Communities (Preprint)

BACKGROUND Telehealth is often suggested to improve access to healthcare and has had significant publicity internationally during the Covid-19 pandemic. However, there is limited research examining the telehealth needs of underserved populations such as rural communities. OBJECTIVE The aim of this study was to investigate enablers for telehealth use in rural underserved populations to improve access to healthcare for rural older adults. METHODS 7 focus group discussions and 13 individual interviews were held across 4 diverse underserved rural communities. 98 adults, aged 55 years and over, participated. Participants were asked if they had used telehealth, how they saw their community’s health service needs evolving, how telehealth might help provide these services, and perceived barriers and enablers to telehealth for older adults in rural communities. Focus group transcripts were thematically analysed. RESULTS The term ‘telehealth’ was not initially understood by many participants and required explanation. The likelihood of using telehealth varied between those who had used telehealth and those who had not. Those who had used telehealth reported very positive experiences (time and cost savings) and would be more likely to use telehealth again. Two main themes were identified through an equity lens. The first theme was “trust” with three sub-themes – trust in the telehealth technology, trust in the user (consumer and health provider) and trust in the health system. Having access to reliable and affordable internet connectivity and digital devices was a key enabler for telehealth use. Most rural areas had intermittent, unreliable internet connectivity. Having easy access to user support was another key enabler. Trust in the health system focused on waiting times, lack of/delayed communication and coordination, and cost. The second theme was “choice” with three sub-themes – health service access, consultation type and telehealth deployment. Access to health services by telehealth needs to be culturally appropriate and enable access to currently limited or absent services such as mental health and specialist services. Accessing specialist care by telehealth was extremely popular but some participants would rather be seen in person. A major enabler for telehealth was deploying telehealth by a fixed community ‘hub’ or on a mobile bus, with support available, and especially when combined with non-health related services such as online banking. CONCLUSIONS Overall, participants were keen on the idea of telehealth. Several barriers and enablers were identified. The term ‘telehealth’ is not well understood. The unreliable and expensive connectivity options available to the rural communities has limited the telehealth experience to phone or patient portal use, for those who have connectivity. Having the opportunity to try telehealth, especially using video, would increase understanding and acceptance of telehealth. The study highlights that local rural communities need to be involved in the design of telehealth services within their community.