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To investigate trends in out-of-pocket health-care payments and catastrophic health expenditure in India by household age composition. We obtained data from four national consumer expenditure surveys and three health-care utilization surveys conducted between 1993 and 2014. Households were divided into five groups by age composition. We defined catastrophic health expenditure as out-of-pocket payments equalling or exceeding 10% of household expenditure. Factors associated with catastrophic expenditure were identified by multivariable analysis. Overall, the proportion of catastrophic health expenditure increased 1.47-fold between the 1993-1994 expenditure survey (12.4%) and the 2011-2012 expenditure survey (18.2%) and 2.24-fold between the 1995-1996 utilization survey (11.1%) and the 2014 utilization survey (24.9%). The proportion increased more in the poorest than the richest quintile: 3.00-fold versus 1.74-fold, respectively, across the utilization surveys. Catastrophic expenditure was commonest among households comprising only people aged 60 years or older: the adjusted odds ratio (aOR) was 3.26 (95% confidence interval, CI: 2.76-3.84) compared with households with no older people or children younger than 5 years. The risk was also increased among households with both older people and children (aOR: 2.58; 95% CI: 2.31-2.89), with a female head (aOR: 1.32; 95% CI: 1.19-1.47) and with a rural location (aOR: 1.27; 95% CI: 1.20-1.35). The proportion of households experiencing catastrophic health expenditure in India increased over the past two decades. Such expenditure was highest among households with older people. Financial protection mechanisms are needed for population groups at risk for catastrophic health expenditure.

In India, the prevalence of overweight and obesity has increased rapidly in recent decades. Given the association between overweight and obesity with many non-communicable diseases, forecasts of the future prevalence of overweight and obesity can help inform policy in a country where around one sixth of the world's population resides. We used a system of multi-state life tables to forecast overweight and obesity prevalence among Indians aged 20-69 years by age, sex and urban/rural residence to 2040. We estimated the incidence and initial prevalence of overweight using nationally representative data from the National Family Health Surveys 3 and 4, and the Study on global AGEing and adult health, waves 0 and 1. We forecasted future mortality, using the Lee-Carter model fitted life tables reported by the Sample Registration System, and adjusted the mortality rates for Body Mass Index using relative risks from the literature. The prevalence of overweight will more than double among Indian adults aged 20-69 years between 2010 and 2040, while the prevalence of obesity will triple. Specifically, the prevalence of overweight and obesity will reach 30.5% (27.4%-34.4%) and 9.5% (5.4%-13.3%) among men, and 27.4% (24.5%-30.6%) and 13.9% (10.1%-16.9%) among women, respectively, by 2040. The largest increases in the prevalence of overweight and obesity between 2010 and 2040 is expected to be in older ages, and we found a larger relative increase in overweight and obesity in rural areas compared to urban areas. The largest relative increase in overweight and obesity prevalence was forecast to occur at older age groups. The overall prevalence of overweight and obesity is expected to increase considerably in India by 2040, with substantial increases particularly among rural residents and older Indians. Detailed predictions of excess weight are crucial in estimating future non-communicable disease burdens and their economic impact.

ObjectivesWe aimed to examine trends in prevalence of overweight/obesity among adults in India by socioeconomic position (SEP) between 1998 and 2016.DesignRepeated cross-sectional study using nationally representative data from India collected in 1998/1999, 2005/2006 and 2015/2016. Multilevel regressions were used to assess trends in prevalence of overweight/obesity by SEP.Setting26, 29 and 36 Indian states or union territories, in 1998/99, 2005/2006 and 2015/2016, respectively.Participants628 795 ever-married women aged 15–49 years and 93 618 men aged 15–54 years.Primary outcome measureOverweight/obesity defined by body mass index >24.99 kg/m2.ResultsBetween 1998 and 2016, overweight/obesity prevalence increased among men and women in both urban and rural areas. In all periods, overweight/obesity prevalence was consistently highest among higher SEP individuals. In urban areas, overweight/obesity prevalence increased considerably over the study period among lower SEP adults. For instance, between 1998 and 2016, overweight/obesity prevalence increased from approximately 15%–32% among urban women with no education. Whereas the prevalence among urban men with higher education increased from 26% to 34% between 2005 and 2016, we did not observe any notable changes among high SEP urban women between 1998 and 2016. In rural areas, more similar increases in overweight/obesity prevalence were found among all individuals across the study period, irrespective of SEP. Among rural women with higher education, overweight/obesity increased from 16% to 25% between 1998 and 2016, while the prevalence among rural women with no education increased from 4% to 14%.ConclusionsWe identified some convergence of overweight/obesity prevalence across SEP in urban areas among both men and women, with fewer signs of convergence across SEP groups in rural areas. Efforts are therefore needed to slow the increasing trend of overweight/obesity among all Indians, as we found evidence suggesting it may no longer be considered a ‘diseases of affluence’.

Aims/hypothesisWe aimed to estimate the lifetime risk of diabetes and diabetes-free life expectancy in metropolitan cities in India among the population aged 20 years or more, and their variation by sex, age and BMI.MethodsA Markov simulation model was adopted to estimate age-, sex- and BMI-specific lifetime risk of developing diabetes and diabetes-free life expectancy. The main data inputs used were as follows: age-, sex- and BMI-specific incidence rates of diabetes in urban India taken from the Centre for Cardiometabolic Risk Reduction in South Asia (2010–2018); age-, sex- and urban-specific rates of mortality from period lifetables reported by the Government of India (2014); and prevalence of diabetes from the Indian Council for Medical Research INdia DIABetes study (2008–2015).ResultsLifetime risk (95% CI) of diabetes in 20-year-old men and women was 55.5 (51.6, 59.7)% and 64.6 (60.0, 69.5)%, respectively. Women generally had a higher lifetime risk across the lifespan. Remaining lifetime risk (95% CI) declined with age to 37.7 (30.1, 46.7)% at age 60 years among women and 27.5 (23.1, 32.4)% in men. Lifetime risk (95% CI) was highest among obese Indians: 86.0 (76.6, 91.5)% among 20-year-old women and 86.9 (75.4, 93.8)% among men. We identified considerably higher diabetes-free life expectancy at lower levels of BMI.Conclusions/interpretationLifetime risk of diabetes in metropolitan cities in India is alarming across the spectrum of weight and rises dramatically with higher BMI. Prevention of diabetes among metropolitan Indians of all ages is an urgent national priority, particularly given the rapid increase in urban obesogenic environments across the country.

Background India’s economic development and urbanisation in recent decades has varied considerably between states. Attempts to assess how overweight (including obesity) varies by socioeconomic position at the national level may mask considerable sub-national heterogeneity. We examined the socioeconomic patterning of overweight among adults in India’s most and least economically developed states between 1998 and 2016. Methods We used state representative data from the National Family Health Surveys from 1998 to 99, 2005–06 and 2015–16. We estimated the prevalence of overweight by socioeconomic position in men (15–54 years) and women (15–49 years) from India’s most and least economically developed states using multilevel logistic regressions. Results We observed an increasing trend of overweight prevalence among low socioeconomic position women. Amongst high socioeconomic position women, overweight prevalence either increased to a smaller extent, remained the same or even declined between 1998 and 2016. This was particularly the case in urban areas of the most developed states, where in the main analysis, the prevalence of overweight increased from 19 to 33% among women from the lowest socioeconomic group between 1998 and 2016 compared to no change among women from the highest socioeconomic group. Between 2005 and 2016, the prevalence of overweight increased to similar extents among high and low socioeconomic status men, irrespective of residence. Conclusions The converging prevalence of overweight by socioeconomic position in India’s most developed states, particularly amongst urban women, implies that this subpopulation may be the first to exhibit a negative association between socioeconomic position and overweight in India. Programs aiming to reduce the increasing overweight trends may wish to focus on poorer women in India’s most developed states, amongst whom the increasing trend in prevalence has been considerable.

Background Disability does not only depend on individuals’ health conditions but also the contextual factors in which individuals live. Therefore, disability measurement scales need to be developed or adapted to the context. Bangladesh lacks any locally developed or validated scales to measure disabilities in adults with mobility impairment. We developed a new Locomotor Disability Scale (LDS) in a previous qualitative study. The present study developed a shorter version of the scale and explored its factorial structure. Methods We administered the LDS to 316 adults with mobility impairments, selected from outpatient and community-based settings of a rehabilitation centre in Bangladesh. We did exploratory factor analysis (EFA) to determine a shorter version of the LDS and explore its factorial structure. Results We retained 19 items from the original LDS following evaluation of response rate, floor/ceiling effects, inter-item correlations, and factor loadings in EFA. The Eigenvalues greater than one rule and the Scree test suggested a two-factor model of measuring locomotor disability (LD) in adults with mobility impairment. These two factors are ‘mobility activity limitations’ and ‘functional activity limitations’. We named the higher order factor as ‘locomotor disability’. This two-factor model explained over 68% of the total variance among the LD indicators. The reproduced correlation matrix indicated a good model fit with 14% non-redundant residuals with absolute values > 0.05. However, the Chi-square test indicated poor model fit ( p  < .001). The Bartlett’s test of Sphericity confirmed patterned relationships amongst the LD indicators ( p  < .001). The Kaiser-Meyer-Olkin Measure (KMO) of sampling adequacy was .94 and the individual diagonal elements in the anti-correlation matrix were > .91. Among the retained 19 items, there was no correlation coefficient > .9 or a large number of correlation coefficients < .3. The communalities were high: between .495 and .882 with a mean of 0.684. As an evidence of convergent validity, we had all loadings above .5, except one. As an evidence of discriminant validity, we had no strong (> .3) cross loadings and the correlation between the two factors was .657. The ‘mobility activity limitations’ and ‘functional activity limitations’ sub-scales demonstrated excellent internal consistency (Cronbach’s alpha were .954 and .937, respectively). Conclusions The 19-item LDS was found to be a reliable and valid scale to measure the latent constructs mobility activity limitations and functional activity limitations among adults with mobility impairments in outpatient and community-based settings in Bangladesh.

Few youth-friendly health services worldwide have been scaled up or evaluated from young people's perspectives. South Africa's Youth Friendly Services (YFS) programme is one of the few to have been scaled up. This study investigated young people's experiences of using sexual and reproductive health services at clinics providing the YFS programme, compared to those that did not, using the simulated client method. Fifteen primary healthcare clinics in Soweto were randomly sampled: seven provided the YFS programme. Simulated clients conducted 58 visits; young men requested information on condom reliability and young women on contraceptive methods. There were two outcome measures: a single measure of the overall clinic experience (clinic visit score) and whether or not simulated clients would recommend a clinic to their peers. The clinic visit score was based on variables relating to the simulated clients' interactions with staff, details of their consultation, privacy, confidentiality, the healthcare workers' characteristics, and the clinic environment. A larger score corresponds to a worse experience than a smaller one. Multilevel regression models and framework analysis were used to investigate young people's experiences. Health facilities providing the YFS programme did not deliver a more positive experience to young people than those not providing the programme (mean difference in clinic visit score: −0.18, 95% CI: −0.95, 0.60, p=0.656). They were also no more likely to be recommended by simulated clients to their peers (odds ratio: 0.48, 95% CI: 0.11, 2.10, p=0.331). More positive experiences were characterised by young people as those where healthcare workers were friendly, respectful, knew how to talk to young people, and appeared to value them seeking health information. Less positive experiences were characterised by having to show soiled sanitary products to obtain contraceptives, healthcare workers expressing negative opinions about young people seeking information, lack of privacy, and inadequate information. The provision and impact of the YFS programme are limited. Future research should explore implementation. Regular training and monitoring could enable healthcare workers to address young people's needs.

Background Socio-demographic variables are widely known to have an association with the presence of any disability. However, the association between the severity of locomotor disability and socio-demographic variables has never been investigated in Bangladesh. Methods A cross sectional survey of adults with locomotor disabilities was conducted between December 2010 and February 2011 at the Centre for the Rehabilitation of the Paralysed (CRP), Dhaka, Bangladesh. During the study period 328 adults with locomotor disabilities met our selection criteria, but 316 consented and participated in the study. The 55-item Locomotor Disability Scale was used to measure disability. This study investigated the socio-demographic determinants of the severity of locomotor disability: age, gender, marital status, educational attainment, occupation, income status, type of house, living in own/rented house, household monthly income, household population and area of residence. Results Participants’ age was positively associated with the severity of their locomotor disability (β = 0.01; 95% CI: 0.004 to 0.02), adjusting for diagnosis and other socio-demographic variables studied. Individuals who had an income experienced 0.35 (95% CI: -0.63 to −0.07) points decrease in the severity of disability than those did not have an income, adjusting for diagnosis and rest of the socio-demographic variables studied. In comparison to the unemployed individuals, students, homemakers, and individuals in elementary occupation respectively experienced 0.75 (95% CI: -1.08 to −0.43), 0.51 (95% CI: -0.82 to −0.19) and 0.37 (95% CI: -0.66 to −0.08) points decrease in the severity of locomotor disability, adjusting for diagnosis and rest of the socio-demographic variables studied. Conclusions The severity of locomotor disability has an association with individuals’ age, income status and occupation of the adults with such disability in Bangladesh. No such association was evident with other socioeconomic position and demographic variables. This finding suggests that people with locomotor disabilities in Bangladesh experience similar disabling built and attitudinal environments irrespective of their socioeconomic positions and demographic characteristics. Further community-based studies are needed to confirm such conclusions.

This study examines the social context of men’s health and health behaviors in rural KwaZulu-Natal, South Africa, particularly in relationship to fathering and fatherhood. Individual interviews and focus groups were conducted with 51 Zulu-speaking men. Three themes related to men’s health emerged from the analysis of transcripts: (a) the interweaving of health status and health behaviors in descriptions of “good” and “bad” fathers, (b) the dominance of positive accounts of health and health status in men’s own accounts, and (c) fathers’ narratives of transformations and positive reinforcement in health behaviors. The study reveals the pervasiveness of an ideal of healthy fathers, one in which the health of men has practical and symbolic importance not only for men themselves but also for others in the family and community. The study also suggests that men hold in esteem fathers who manage to be involved with their biological children who are not coresident or who are playing a fathering role for nonbiological children (social fathers). In South Africa, men’s health interventions have predominantly focused on issues related to HIV and sexual health. The new insights obtained from the perspective of men indicate that there is likely to be a positive response to health interventions that incorporate acknowledgment of, and support for, men’s aspirations and lived experiences of social and biological fatherhood. Furthermore, the findings indicate the value of data on men’s involvement in families for men’s health research in sub-Saharan Africa.

Equity in healthcare has been a long-term guiding principle of health policy in India. We estimate the change in horizontal inequities in healthcare use over two decades comparing the older population (60 years or more) with the younger population (under 60 years). We used data from the nationwide healthcare surveys conducted in India by the National Sample Survey Organization in 1995–96 and 2014 with sample sizes 633 405 and 335 499, respectively. Bivariate and multivariate logit regression analyses were used to study the socioeconomic differentials in self-reported morbidity (SRM), outpatient care and untreated morbidity. Deviations in the degree to which healthcare was distributed according to need were measured by horizontal inequity index (HI). In each consumption quintile the older population had four times higher SRM and outpatient care rate than the younger population in 2014. In 1995–96, the pro-rich inequity in outpatient care was higher for the older (HI: 0.085; 95 % CI: 0.066, 0.103) than the younger population (0.039; 0.034, 0.043), but by 2014 this inequity became similar. Untreated morbidity was concentrated among the poor; more so for the older (-0.320; -0.391, -0.249) than the younger (-0.176; -0.211, -0.141) population in 2014. The use of public facilities increased most in the poorest and poor quintiles; the increase was higher for the older than the younger population in the poorest (1.19 times) and poor (1.71 times) quintiles. The use of public facilities was disproportionately higher for the poor in 2014 than in 1995–96 for the older (-0.189; -0.234, -0.145 vs - 0.065; -0.129, -0.001) and the younger (-0.145; -0.175, -0.115 vs - 0.056; -0.086, -0.026) population. The older population has much higher morbidity and is often more disadvantaged in obtaining treatment. Health policy in India should pay special attention to equity in access to healthcare for the older population. L’équité dans les soins de santé a toujours été l’un des principes directeurs de la politique de santé à long terme en Inde. Nous estimons la variation des iniquités horizontales dans l’utilisation des soins de santé au cours de deux décennies en comparant la population vieillissante (60 ans ou plus) avec la population plus jeune (moins de 60 ans). Nous nous basons sur les données des enquêtes nationales sur les soins de santé menées en Inde par la National Sample Survey Organization en 1995-1996 et 2014 avec des échantillons de 633 405 et 335 499, respectivement. On a eu recours à des analyses de régression logitale bivariées et multivariées pour étudier les différentiels socioéconomiques dans la morbidité auto-déclarée (SRM), les soins ambulatoires et la morbidité non traitée. Les écarts observés dans la dispensation des soins selon les besoins ont été mesurés par l’indice d’iniquité horizontale (HI). Dans chaque quintile de consommation en 2014, le taux de SRM et des soins ambulatoires était quatre fois plus élevé au sein de la population vieillissante que parmi les plus jeunes. En 1995- 1996, le taux d’iniquité en faveur des riches dans le cadre des soins ambulatoires était plus élevé chez les personnes âgées (HI: 0,085; 95% IC: 0,066, 0,103) qu’au sein de la population plus jeune (0,039; 0,034, 0,043), mais, avant 2014, ce taux d’iniquité est devenu identique. En 2014, la morbidité non traitée était concentrée sur les pauvres; pesant davantage sur la population vieillissante (-0.320; -0.391, -0.249) que sur la population plus jeune (-0.176; -0.211, -0.141). Le recours aux formations sanitaires publiques a connu une croissance plus élevée au sein des quintiles des plus pauvres et des démunis; cette croissance a été plus élevée parmi les personnes âgées que chez les plus jeunes dans les quintiles des plus pauvres (1,19 fois) et des démunis (1,71 fois). Par rapport à 1995-1996, le recours aux formations sanitaires publiques a été disproportionnellement plus élevé en 2014 chez les pauvres en comparaison aux personnes plus âgées (-0.189; -0.234, -0.145 vs -0.065; -0.129, -0.001) et aux plus jeunes (-0.145; -0.175, -0.115 vs -0.056; -0.086, -0.026). La population vieillissante souffre d’un taux de morbidité beaucoup plus élevé et est souvent confrontée à davantage de difficultés pour l’accès au traitement. La politique sanitaire de l’Inde devrait accorder une attention particulière à l’équité envers la population vieillissante en matière d’accès aux soins de santé. 医疗公平性是印度卫生政策的长期指导原则。我们通过比较 老年人群 （≥60岁） 和较年轻人群 （<60岁）, 估计20年来医 疗横向公平性的变化。数据来源为国家抽样调查组织与1995-1996年和2014年在印度进行的全国医疗调查, 样本量分别为 633405和335499。应用双因素和多因素Logit回归分析研究自 报疾病 （SRM）、门诊服务和未处理疾病的社会经济差异。 以横向不公平指数 （HI） 衡量医疗根据需求分布的差异程 度。在各个消费五分组, 2014年老年人群的SRM和门诊使用 是较年轻人群的4倍。1995-1996年, 门诊服务中偏向富人的不 公平性在老年人群中 （HI： 0.085； 95% CI： 0.066, 0.103） 高于较年轻人群 （0.03； 0.034, 0.043）, 但到2014年, 两组人 群的不公平性相近。未处理疾病主要集中在贫困人群, 在2014 年的老年人中尤其如此 （-0.320； -0.391, -0.249）, 同年较年 轻人群为 （-0.176； -0.211, -0.141） 。公立机构的使用在最 贫困和贫困的五分组中增长最快, 其中老年人增加较快, 在最 贫困无分组为<0岁以下人群的1.19倍, 在贫困无分组为1.71 倍。贫困人群的公立机构使用率更高, 且2014年高于1995-1996年, 在老年人群中为-0.189 （-0.234, -0.145） 比-0.065 （-0.129, -0.001）, 较年轻人群为-0.145 （-0.175, -0.115） 比- 0.056 （-0.086, -0.026） 。 老年人患病率更好, 通常在寻求治 疗时更加处于弱势。印度的卫生政策应特别关注老年人就医 的公平性。 La equidad en la atención de la salud ha sido un principio orientador a largo plazo de la política de salud en la India. Estimamos el cambio en las inequidades horizontales en el uso de la atención de la salud durante dos décadas comparando la población mayor (60 años o más) con la población más joven (menos de 60 años). Usamos los datos de las encuestas nacionales de salud llevadas a cabo en India por la Organización Nacional de Encuestas de Muestras en 1995-96 y 2014 con tamaños de muestra de 633405 y 335499, respectivamente. Se usaron análisis de regresión logística bivariante y multivariante para estudiar los diferenciales socioeconómicos en morbilidad auto-informada (MAI), atención ambulatoria y morbilidad no tratada. Las desviaciones en el grado en cual la atención de salud se distribuyó según la necesidad se midieron por índice de inequidad horizontal (IH). En cada quintil de consumo, la población mayor tuvo una tasa de MAI y de atención ambulatoria cuatro veces más alta que la población más joven en 2014. En 1995-96, la inequidad pro-ricos en la atención ambulatoria fue mayor para los mayores (IH:0.085; 95% IC:0.066, 0.103) que para la población más joven (0.039; 0.034, 0.043), pero para 2014 esta inequidad se volvió similar. La morbilidad no tratada se concentró entre los pobres; más para los mayores (-0.320; -0.391, -0.249) respecto a la población más joven (-0.176; -0.211, -0.141) en 2014. El uso de las instalaciones públicas aumentó más en los quintiles más pobres y pobres; el aumento fue mayor para la población mayor que para la más joven en los quintiles más pobres (1.19 veces) y pobres (1.71 veces). El uso de instalaciones públicas fue desproporcionadamente más alto para los pobres en 2014 que en 1995-96 para los más viejos (-0.189; -0.234, -0.145 vs -0.065; -0.129, -0.001) y en la población más joven (-0.145; -0.175, -0.115 vs -0.056; - 0.086, -0.026). La población mayor tiene una morbilidad mucho más alta y a menudo se encuentra en desventaja en la obtención de tratamiento. La política de salud en la India debería prestar especial atención a la equidad en el acceso a la atención de la salud para la población mayor