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In Nepal, the proportion of annual deaths from cardiovascular disease (CVD) increased from 12% in 1990 to 22% in 2021. Although CVD manifests in adulthood, exposure to risk factors begins early in life. In Nepal, a high prevalence of risk factors combined with limited knowledge about cardiovascular health warrants a life course approach. One strategy could be a digitalized health education targeted at adolescents to prevent future CVDs. We conducted a cross-sectional survey to assess adolescents' knowledge, attitude and practice (KAP) regarding cardiovascular health and explored possibilities for digital education. In total, 649 adolescents in grades 8-10 from two public and seven private schools in a semi-urban community of Nepal were surveyed. A self-administered questionnaire assessed KAP, digital prerequisites such as mobile phone use and internet availability at home, and gaming behaviors. Quantile regression was performed to assess the relationship among the variables. The median scores were 69.1% (Interquartile range/IQR 63.1%-74.4%) for knowledge about cardiovascular health, 77.9% (73.3%-82.3%) for attitude and 76.7% (72.2%-81.1%) for practice. Quantile regression showed that the knowledge score for grade 9 adolescents was 4.2 percentage point (pp) higher (p < 0.001) and grade 10 adolescents was 4.0pp higher (p < 0.001) than those in grade 8. Knowledge was 4.9pp higher (p < 0.001) for private than for public school adolescents. Attitude scores were 2.0pp higher (p = 0.001) for girls than for boys and 1.7pp higher (p = 0.008) for private than for public school adolescents. For practice, boys scored 2.2pp higher (p < 0.001) than girls and private school adolescents scored 2.5pp higher (p < 0.001) than public. Furthermore, 98.6% of adolescents had smartphone access, 91.5% had internet access and 68.0% played mobile games. Adolescents have lower knowledge than attitude and practice regarding cardiovascular health. This combined with high digital access provides opportunities for digital health education, especially in public schools.

Hand, foot, and mouth disease (HFMD) outbreaks leading to clinical and fatal complications have increased since late 1990s; especially in the Asia Pacific Region. Outbreaks of HFMD peaks in the warmer season of the year, but the underlying factors for this annual pattern and the reasons to the recent upsurge trend have not yet been established. This study analyzed the effect of short-term changes in weather on the incidence of HFMD in Singapore. The relative risks between weekly HFMD cases and temperature and rainfall were estimated for the period 2001-2008 using time series Poisson regression models allowing for over-dispersion. Smoothing was used to allow non-linear relationship between weather and weekly HFMD cases, and to adjust for seasonality and long-term time trend. Additionally, autocorrelation was controlled and weather was allowed to have a lagged effect on HFMD incidence up to 2 weeks. Weekly temperature and rainfall showed statistically significant association with HFMD incidence at time lag of 1-2 weeks. Every 1°C increases in maximum temperature above 32°C elevated the risk of HFMD incidence by 36% (95% CI = 1.341-1.389). Simultaneously, one mm increase of weekly cumulative rainfall below 75 mm increased the risk of HFMD by 0.3% (CI = 1.002-1.003). While above 75 mm the effect was opposite and each mm increases of rainfall decreased the incidence by 0.5% (CI = 0.995-0.996). We also found that a difference between minimum and maximum temperature greater than 7°C elevated the risk of HFMD by 41% (CI = 1.388-1.439). Our findings suggest a strong association between HFMD and weather. However, the exact reason for the association is yet to be studied. Information on maximum temperature above 32°C and moderate rainfall precede HFMD incidence could help to control and curb the up-surging trend of HFMD.

Southeast Asia faces an epidemic of chronic non-communicable diseases, now responsible for 60% of deaths in the region. The problem stems from environmental factors that promote tobacco use, unhealthy diet, and inadequate physical activity. Disadvantaged populations are the hardest hit, with death rates inversely proportional to a country's gross national income. Families shoulder the financial burden, but entire economies suffer as well. Although attempts to control non-communicable diseases are increasing, more needs to be done. Health-care systems need to be redesigned to deliver chronic care that is founded on existing primary health-care facilities, but supported by good referral systems. Surveillance of key modifiable risk factors is needed to monitor the magnitude of the problem and to study the effects of interventions. All branches of government and all sectors of society have to get involved in establishing environments that are conducive to healthy living. The Association of Southeast Asian Nations is in a unique position to make a united stand against chronic non-communicable diseases in the region. Inaction will affect millions of lives—often, the lives of those who have the least.

An accurate early warning system to predict impending epidemics enhances the effectiveness of preventive measures against dengue fever. The aim of this study was to develop and validate a forecasting model that could predict dengue cases and provide timely early warning in Singapore. We developed a time series Poisson multivariate regression model using weekly mean temperature and cumulative rainfall over the period 2000-2010. Weather data were modeled using piecewise linear spline functions. We analyzed various lag times between dengue and weather variables to identify the optimal dengue forecasting period. Autoregression, seasonality and trend were considered in the model. We validated the model by forecasting dengue cases for week 1 of 2011 up to week 16 of 2012 using weather data alone. Model selection and validation were based on Akaike's Information Criterion, standardized Root Mean Square Error, and residuals diagnoses. A Receiver Operating Characteristics curve was used to analyze the sensitivity of the forecast of epidemics. The optimal period for dengue forecast was 16 weeks. Our model forecasted correctly with errors of 0.3 and 0.32 of the standard deviation of reported cases during the model training and validation periods, respectively. It was sensitive enough to distinguish between outbreak and non-outbreak to a 96% (CI = 93-98%) in 2004-2010 and 98% (CI = 95%-100%) in 2011. The model predicted the outbreak in 2011 accurately with less than 3% possibility of false alarm. We have developed a weather-based dengue forecasting model that allows warning 16 weeks in advance of dengue epidemics with high sensitivity and specificity. We demonstrate that models using temperature and rainfall could be simple, precise, and low cost tools for dengue forecasting which could be used to enhance decision making on the timing, scale of vector control operations, and utilization of limited resources.

Back pain is a common disabling chronic condition that burdens individuals, families and societies. Epidemiological evidence, mainly from high-income countries, shows positive association between back pain prevalence and older age. There is an urgent need for accurate epidemiological data on back pain in adult populations in low- and middle-income countries (LMICs) where populations are ageing rapidly. The objectives of this study are to: measure the prevalence of back pain; identify risk factors and determinants associated with back pain, and describe association between back pain and disability in adults aged 50 years and older, in six LMICs from different regions of the world. The findings provide insights into country-level differences in self-reported back pain and disability in a group of socially, culturally, economically and geographically diverse LMICs. Standardized national survey data collected from adults (50 years and older) participating in the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) were analysed. The weighted sample (n = 30, 146) comprised respondents in China, Ghana, India, Mexico, South Africa and the Russian Federation. Multivariable regressions describe factors associated with back pain prevalence and intensity, and back pain as a determinant of disability. Prevalence was highest in the Russian Federation (56%) and lowest in China (22%). In the pooled multi-country analyses, female sex, lower education, lower wealth and multiple chronic morbidities were significant in association with past-month back pain (p<0.01). About 8% of respondents reported that they experienced intense back pain in the previous month. Evidence on back pain and its impact on disability is needed in developing countries so that governments can invest in cost-effective education and rehabilitation to reduce the growing social and economic burden imposed by this disabling condition.

People living with HIV (PLWH) who smoke face significant health risks from tobacco use, which dual use of cigarettes and waterpipes may exacerbate due to increased nicotine exposure and dependency. This study examined the sociodemographic, behavioral, psychosocial and health-related factors associated with dual smoking among PLWH receiving care at HIV clinics in Hanoi, Vietnam. This cross-sectional study used baseline survey data from the VQUIT study, an RCT of smoking cessation interventions involving 662 PLWH from 13 outpatient clinics in Vietnam. Eligible participants were current tobacco smokers; dual smokers were those using both cigarettes and waterpipes. Multivariable logistic regression was used to identify factors associated with cigarette-only and dual use among PLWH. Over half of the study participants were dual smokers. Dual smoking was associated with a lower annual income (aOR: 1.91, 95%CI: 1.08-3.38) and higher nicotine dependence (aOR: 2.31, 95%CI: 1.62-3.31). They were less likely to report a prior quit attempt (aOR: 0.47, 95% CI: 0.33-0.68), more likely to perceive cigarettes as more harmful (aOR 1.44, 95% CI: 1.01-2.09), and more likely to report recent illicit drug use (aOR: 2.32, 95% CI: 1.26-4.24) and longer antiretroviral treatment duration (aOR: 1.06, 95% CI: 1.03-1.10). Social support for quitting lowered the odds of dual smoking (aOR: 0.62, 95% CI: 0.39-0.97). Dual smoking was prevalent among PLWH receiving HIV care in VQUIT study and was shaped by complex sociodemographic, behavioral, and social factors. These findings emphasize the need for integrated cessation interventions in Vietnam, where dual smoking is prevalent, particularly among PLWH. Socioeconomic status and barriers to quitting, including drug use, nicotine dependence, and tobacco-related misconceptions, should be considered. Future research should examine the long-term health impacts of dual smoking and evaluate cessation strategies for PLWH in similar settings.

Hypertension remains a problem of public health across various socioeconomic groups, despite its high prevalence. However, few studies account for geographical variation in examining socioeconomic inequalities and hypertension in Indonesia. To investigate the burden of hypertension in Indonesia based on prevalence, awareness, treatment, and control of hypertension among adults; and assess whether or not the burdens vary according to geographical variation and socioeconomic status In Wave 5 of the Indonesian Family Life Survey in 2015, 32,034 individuals aged 15 and over participated in the study. Concentration Curves (CC) and Concentration Indexes (CI) were used to analyse socioeconomic inequality. We used multilevel logistic regression to assess biological, geographical variation, and socioeconomic factors associated with the burden of hypertension, adjusting for potential covariates. The prevalence of hypertension in Indonesia was 26.1%, and only 26.9% of those with hypertension were aware of their condition. Approximately 22.5% of hypertensive patients received treatment, but only 28.2% had controlled blood pressure and reached the therapeutic goal. Low socioeconomic groups were more prone to hypertension (CI = −0.047 in urban and CI = −0.075 in rural). In contrast, awareness, treatment, and control of hypertension were more concentrated in higher socioeconomic groups. The high prevalence of hypertension, low awareness of the condition, poor compliance with treatment, and poor control of the condition, as well as the existing socioeconomic inequality, make this a significant determinant of public health issue in Indonesia. There is a need for effective programs for the prevention of hypertension and better management of hypertensive patients.

Background The COVID-19 pandemic has disrupted healthcare utilization globally, but little is known about the effects among patients with cardiovascular diseases (CVDs) and other multimorbidities. This study analyzed the impacts of COVID-19 on healthcare utilization for patients aged 30 years and older with cardiovascular diseases (CVDs) with or without other chronic disease comorbidities in Indonesia. Methods We designed a retrospective cohort study based on the Indonesian National Health Insurance (NHI) sample data from 2016–2020. We defined healthcare utilization as monthly outpatient and inpatient visits related to chronic diseases at the hospital and primary healthcare levels per 10,000 NHI members. We used interrupted time series analysis to evaluate how the healthcare utilization patterns had changed due to the COVID-19 pandemic. Results Overall, hospital outpatient visits decreased by 39% when the pandemic occurred (95% Confidence Interval (CI): 0.48,0.76), inpatient visits by 28% (95% CI: 0.62,0.83), and primary healthcare visits by 34% (95% CI:0.55, 0.81). For patients with CVDs and multimorbidity, hospital outpatient and inpatient visit rates were reduced by 36% and 38%, respectively and primary healthcare visits by 32%. Some insignificant differences in the reduction of out-and inpatient visits were observed across diagnosis groups and regions. Conclusion Healthcare utilization among patients with chronic diseases decreased significantly during COVID-19 and consistently across different chronic diseases and regions. To cope with the unmet needs of healthcare utilization in the context of the pandemic, the healthcare system needs to be strengthened to cater to the needs of the population-at-risk, especially for patients with CVDs and multimorbidity.

ObjectiveTo explore health professionals’ perspectives on the barriers and enablers of healthcare access for older adults in Cambodia.DesignA qualitative study based on semi-structured interviews conducted in Khmer, recorded, transcribed, translated into English and analysed using an abductive thematic analysis approach.SettingPhnom Penh, Cambodia.ParticipantsA purposive sample of 11 health professionals serving in diverse roles and sectors participated in the study.ResultsThree key barriers emerged: (1) institutional barriers, (2) patient-specific access barriers and (3) communication barriers. However, four key enablers were also identified: (1) supportive healthcare environment, (2) reaching out to improve access to health services, (3) peer and community engagement and (4) government direct support to access healthcare. Despite previous policy efforts, gaps in the implementation of healthcare services for older adults persist across all health facilities. Health professionals identified that improving healthcare access for older adults in Cambodia requires a multifaceted strategy involving proactive outreach, health promotion, financial assistance and stronger community and family support.ConclusionEffective policy implementation requires collaboration among stakeholders and the active involvement of older adults in programme design to enhance dignity and well-being in Cambodia’s ageing population.

Background Cardiovascular diseases (CVDs) are the leading cause of death in Indonesia, accounting for 38% of the total mortality in 2019. Moreover, healthcare spending on CVDs has been at the top of the spending under the National Health Insurance (NHI) implementation. This study analyzed the association between the presence of CVDs with or without other chronic disease comorbidities and healthcare costs among adults (> 30 years old) and if the association differed between NHI members in the subsidized group (poorer) and non-subsidized households group (better-off) in Indonesia. Methods This retrospective cohort study analyzed the NHI database from 2016–2018 for individuals with chronic diseases ( n  = 271,065) ascertained based on ICD-10 codes. The outcome was measured as healthcare costs in USD value for 2018. We employed a three-level multilevel linear regression, with individuals at the first level, households at the second level, and districts at the third level. The outcome of healthcare costs was transformed with an inverse hyperbolic sine to account for observations with zero costs and skewed data. We conducted a cross-level interaction analysis to analyze if the association between individuals with different diagnosis groups and healthcare costs differed between those who lived in subsidized and non-subsidized households. Results The mean healthcare out- and inpatient costs were higher among patients diagnosed with CVDs and multimorbidity than patients with other diagnosis groups. The predicted mean outpatient costs for patients with CVDs and multimorbidity were more than double compared to those with CVDs but no comorbidity (USD 119.5 vs USD 49.1, respectively for non-subsidized households and USD 79.9 vs USD 36.7, respectively for subsidized households). The NHI household subsidy status modified relationship between group of diagnosis and healthcare costs which indicated a weaker effect in the subsidized household group (β = -0.24, 95% CI -0.29, -0.19 for outpatient costs in patients with CVDs and multimorbidity). At the household level, higher out- and inpatient costs were associated with the number of household members with multimorbidity. At the district level, higher healthcare costs was associated with the availability of primary healthcare centres. Conclusions CVDs and multimorbidity are associated with higher healthcare costs, and the association is stronger in non-subsidized NHI households. Households' subsidy status can be construed as indirect socioeconomic inequality that hampers access to healthcare facilities. Efforts to combat cardiovascular diseases (CVDs) and multimorbidity should consider their distinct impacts on subsidized households. The effort includes affirmative action on non-communicable disease (NCD) management programs that target subsidized households from the early stage of the disease.