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Lack of nationwide evidence on awareness, treatment, and control (ATC) of hypertension among older adults in India impeded targeted management of this condition. We aimed to estimate rates of hypertension ATC in the older population and to assess differences in these rates across sociodemographic groups and states in India. We used a nationally representative survey of individuals aged 45 years and over and their spouses in all Indian states (except one) in 2017 to 2018. We identified hypertension by blood pressure (BP) measurement [greater than or equal to]140/90 mm Hg or self-reported diagnosis if also taking medication or observing salt/diet restriction to control BP. We distinguished those who (i) reported diagnosis (\"aware\"); (ii) reported taking medication or being under salt/diet restriction to control BP (\"treated\"); and (iii) had measured systolic BP <140 and diastolic BP <90 (\"controlled\"). We estimated age-sex adjusted hypertension prevalence and rates of ATC by consumption quintile, education, age, sex, urban-rural, caste, religion, marital status, living arrangement, employment status, health insurance, and state. We used concentration indices to measure socioeconomic inequalities and multivariable logistic regression to estimate fully adjusted differences in these outcomes. Study limitations included reliance on BP measurement on a single occasion, missing measurements of BP for some participants, and lack of data on nonadherence to medication. Hypertension prevalence was high, and ATC of the condition were low among older adults in India. Inequalities in these indicators pointed to opportunities to target hypertension management more effectively and equitably on socially disadvantaged groups.

Estimate associations between the health-related quality of life (HRQoL) and adiposity in a low-income population. In a cluster random sample of 3796 Filipinos aged 40-70 years in Nueva Ecija province, we measured body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), and six dimensions of HRQoL using the 20-item Short Form Health Survey. We stratified by sex and used nonparametric regression to graph mean HRQoL in each dimension by BMI, WC, and WHR. We used ordinary least squares regression to estimate differences in each HRQoL dimension by categories of BMI, WC, and WHR adjusted for sociodemographic characteristics and smoking. Mean HRQoL was lowest for health perception (Males: 67.5 (SD = 15.9); Females: 66.7 (15.8)) and highest for role functioning (Males: 97.5 (12.9); Females: 97.4 (13.3)). Mean (SD) values of BMI, WC, and WHR were 22.1 (3.6), 84.8 cm (9.5), and 0.9 (0.1), respectively for males, and 23.7 (4.2), 86.5 cm (10.2), and 0.9 (0.1), respectively, for females. There was no evidence that higher BMI was associated with lower HRQoL. Adjusted mean social functioning was 4.92 (p = 0.076) higher for males with high BMI risk (8.6% prevalence) compared with acceptable BMI risk (50.3%). Mean social functioning was 3.61 (p = 0.012) and 5.48 (p = 0.017) lower for females with high WC (44.7%) and WHR (83.1%), respectively, compared with those with low WC (23.8%) and WHR (3.6%). Mean physical functioning was lower by 2.70 (p = 0.204) and 1.07 (p = 0.198) for males and females, respectively, with high compared with low WC. Mean physical functioning was 3.93 (p = 0.037) lower for males with high (7.6%) compared with low (38.8%) WHR. Mean role functioning was 1.09 (p = 0.124) and 2.46 (p = 0.158) lower for males with borderline and high WHR, respectively. There is discordance between future adiposity-related health risk and current experience of HRQoL.

HIV prevention through pre-exposure prophylaxis (PrEP) may encourage riskier sexual behaviours that undermine the protection afforded by PrEP and generate negative spillovers through sexually transmitted infections (STIs). Tests for such risk compensatory behaviour in high-risk populations, such as female sex workers (FSWs), are lacking. This study aims to assess whether risk compensatory behaviours were observed among FSWs in Senegal after the rollout of PrEP. In a randomised controlled trial with a Zelen design, we stratified FSWs in Dakar (Senegal) by self-reported sexual risk-taking and prior PrEP experience and randomly assigned them to immediate referral for oral PrEP (Treatment) from 7 September 2021 to end January 2022 or delayed PrEP referral (Control). We compared outcomes 3-8 months after the referral of the treatment group and before the referral of the control group. Primary outcomes were self-reported condom use with clients and perceived HIV/STI risks from sex with clients with and without a condom. The analysis is a modified intention-to-treat analysis. We estimated effects of PrEP referral as well as effects of oral PrEP use induced by randomised assignment to active PrEP referral. Out of 500 individuals randomised, 308 (61.6%) were included in the analysis (Treatment: 182/300 = 60.7%; Control: 126/200 = 63%). PrEP referral increased the probability of using oral PrEP by 34.5 percentage points (pp) (95% CI [25.4, 43.6]; p < 0.001). Estimated effects of PrEP referral and PrEP use on condom use with the last client were positive but not statistically significantly different from zero. PrEP referral was estimated to increase the probability of condom use with all of the last three clients by 11.0 pp (95% CI [0.8, 21.2]; p = 0.034). PrEP use was estimated to increase this probability by 25.8 pp (95% CI [5.2, 46.4]; p = 0.014). Main limitations were low power, high attrition, self-reported outcomes and a limited follow-up period. This study, conducted in one location, did not find evidence that PrEP referral or oral PrEP use increased self-reported risky sex behaviours of FSWs within 3-8 months. The robustness of this finding needs to be tested with larger cohorts followed for longer periods in other settings, and using survey instruments that allow further examination of whether PrEP users are more likely to overreport condom use. ISRCTN-The UK's Clinical Study Registry, ISRCTN16445862 https://www.isrctn.com/ISRCTN16445862.

Background While screening for cardiovascular disease (CVD) risk can help low-resource health systems deliver low-cost, effective prevention, evidence is needed to adapt international screening guidelines for maximal impact in local settings. We aimed to establish how the cost-effectiveness of CVD risk screening in Sri Lanka varies with who is screened, how risk is assessed, and what thresholds are used for prescription of medicines. Methods We used data for people aged 35 years and over from a 2018/19 nationally representative survey in Sri Lanka. We modelled the costs and quality adjusted life years (QALYs) for 128 screening program scenarios distinguished by a) age group screened, b) risk tool used, c) definition of high CVD risk, d) blood pressure threshold for treatment of high-risks, and e) prescription of statins to all diabetics. We used the current program as the base case. We used a Markov model of a one-year screening program with a lifetime horizon and a public health system perspective. Results Scenarios that included the WHO-2019 office-based risk tool dominated most others. Switching to this tool and raising the age threshold for screening from 35 to 40 years gave an incremental cost-effectiveness ratio (ICER) of $113/QALY. Lowering the CVD high-risk threshold from 20 to 10% and prescribing antihypertensives at a lower threshold to diabetics and people at high risk of CVD gave an ICER of $1,159/QALY. The findings were sensitive to allowing for disutility of daily medication. Conclusions In Sri Lanka, CVD risk screening scenarios that used the WHO-2019 office-based risk tool, screened people above the age of 40, and lowered risk and blood pressure thresholds would likely be cost-effective, generating an additional QALY at less than half a GDP per capita.

Background Primary prevention of cardiovascular diseases (CVD) increasingly relies on monitoring global CVD risk scores. Lack of evidence on socioeconomic inequality in these scores and the contributions that specific risk factors make to this inequality impedes effective targeting of CVD prevention. We aimed to address this evidence gap by measuring and decomposing socioeconomic inequality in CVD risk in the Philippines. Methods We used data on 8462 individuals aged 40–74 years from the Philippines National Nutrition Survey and the laboratory-based Globorisk equation to predict 10-year risk of a CVD event from sex, age, systolic blood pressure, total cholesterol, high blood glucose, and smoking. We used a household wealth index to proxy socioeconomic status and measured socioeconomic inequality with a concentration index that we decomposed into contributions of the risk factors used to predict CVD risk. We measured socioeconomic inequalities in these risk factors and decomposed them into contributions of more distal risk factors: body mass index, fat share of energy intake, low physical activity, and drinking alcohol. We stratified by sex. Results Wealthier individuals, particularly males, had greater exposure to all risk factors, with the exception of smoking, and had higher CVD risks. Total cholesterol and high blood glucose accounted for 58% and 34%, respectively, of the socioeconomic inequality in CVD risk among males. For females, the respective estimates were 63% and 69%. Systolic blood pressure accounted for 26% of the higher CVD risk of wealthier males but did not contribute to inequality among females. If smoking prevalence had not been higher among poorer individuals, then the inequality in CVD risk would have been 35% higher for males and 75% higher for females. Among distal risk factors, body mass index and fat intake contributed most to inequalities in total cholesterol, high blood sugar, and, for males, systolic blood pressure. Conclusions Wealthier Filipinos have higher predicted CVD risks and greater exposure to all risk factors, except smoking. There is need for a nuanced approach to CVD prevention that targets anti-smoking programmes on the poorer population while targeting diet and exercise interventions on the wealthier. Key message • Evidence on risk factor contributions to socioeconomic inequalities in cardiovascular disease (CVD) risk is needed to target prevention programmes and meet the SDG target of a one third reduction in premature non-communicable disease mortality by 2030. • In the Philippines, wealthier individuals have higher predicted CVD risks and greater exposure to all risk factors, except smoking. • Total Cholesterol (TC) and High Blood Glucose (HBG) contribute most to the higher CVD risks of wealthier Filipinos. • Wealth inequalities in TC and HBG, and (for males) in systolic blood pressure, are mostly explained by differences in body mass index and fat share of energy intake, and not by differences in physical exercise. • To maximise impact, CVD prevention in the Philippines should target diet programmes on wealthier groups and smoking programmes on poorer groups.

We use matching combined with difference-in-differences to identify the causal effects of sudden illness, represented by acute hospitalizations, on employment and income up to six years after the health shock using linked Dutch hospital and tax register data. An acute hospital admission lowers the employment probability by seven percentage points and results in a 5 percent loss of personal income two years after the shock. There is no subsequent recovery in either employment or income. There are large spillover effects: Household income falls by 50 percent more than the income of the disabled person.

Context Expeditious diagnosis and treatment of chronic conditions are critical to control the burden of non-communicable disease in low- and middle-income countries. We aimed to estimate sociodemographic and geographic inequalities in diagnosis and treatment of chronic conditions among adults aged 45 + in India. Methods We used 2017–18 nationally representative data to estimate prevalence of chronic conditions (hypertension, diabetes, lung disease, heart disease, stroke, arthritis, cholesterol, and neurological) reported as diagnosed and percentages of diagnosed conditions that were untreated by sociodemographic characteristics and state. We used concentration indices to measure socioeconomic inequalities in diagnosis and lack of treatment. Fully adjusted inequalities were estimated with multivariable probit and fractional regression models. Findings About 46.1% (95% CI: 44.9 to 47.3) of adults aged 45 + reported a diagnosis of at least one chronic condition and 27.5% (95% CI: 26.2 to 28.7) of the reported conditions were untreated. The percentage untreated was highest for neurological conditions (53.2%; 95% CI: 50.1 to 59.6) and lowest for diabetes (10.1%; 95% CI: 8.4 to 11.5). Age- and sex-adjusted prevalence of any diagnosed condition was highest in the richest quartile (55.3%; 95% CI: 53.3 to 57.3) and lowest in the poorest (37.7%: 95% CI: 36.1 to 39.3). Conditional on reported diagnosis, the percentage of conditions untreated was highest in the poorest quartile (34.4%: 95% CI: 32.3 to 36.5) and lowest in the richest (21.1%: 95% CI: 19.2 to 23.1). Concentration indices confirmed these patterns. Multivariable models showed that the percentage of untreated conditions was 6.0 points higher (95% CI: 3.3 to 8.6) in the poorest quartile than in the richest. Between state variations in the prevalence of diagnosed conditions and their treatment were large. Conclusions Ensuring more equitable treatment of chronic conditions in India requires improved access for poorer, less educated, and rural older people who often remain untreated even once diagnosed. Highlights • Little is known about sociodemographic and geographic inequalities in the diagnosis and treatment of chronic illness among middle-aged and older adults in India. • Self-reported diagnosed chronic conditions are more prevalent among socially advantaged groups but the disadvantaged are more likely to be untreated. • To ensure more equitable treatment of chronic conditions, efforts to improve access should be directed towards poorer, less educated, and ruralolder people.

Despite widespread exposure to substantial medical expenditure risk in low-income populations, health insurance enrollment is typically low. This is puzzling from the perspective of expected utility theory. To help explain it, this paper introduces a decomposition of the stated willingness to pay (WTP) for insurance into its fair price and three behavioral deviations from that price due to risk perception and risk attitude consistent with prospect theory, plus a residual. To apply this approach, we elicit WTP, subjective distributions of medical expenditures and risk attitude (utility curvature and probability weighting) from Filipino households in a nationwide survey. We find that the mean stated WTP of the uninsured is less than both the actuarially fair price and the subsidized price at which public insurance is offered. This is not explained by downwardly biased beliefs: both the mean and the median subjective expectation are greater than the subsidized price. Convex utility in the domain of losses pushes mean WTP below the fair price and the subsidized price, and the transformation of probabilities into decision weights depresses the mean further, at least using one of two specific decompositions. WTP is reduced further by factors other than risk perception and attitude.

To assess missed opportunities for hypertension screening at health facilities in India and describe systematic differences in these missed opportunities across states and sociodemographic groups. We used nationally representative survey data from the 2017-2018 Longitudinal Ageing Study in India to estimate the proportion of adults aged 45 years or older identified with hypertension and who had not been diagnosed with hypertension despite having visited a health facility during the previous 12 months. We estimated age-sex adjusted proportions of missed opportunities to diagnose hypertension, as well as actual and potential proportions of diagnosis, by sociodemographic characteristics and for each state. Among those identified as having hypertension, 22.6% (95% confidence interval, CI: 21.3 to 23.8) had not been diagnosed despite having recently visited a health facility. If these opportunities had been realized, the prevalence of diagnosed hypertension would have increased from 54.8% (95% CI: 53.5 to 56.1) to 77.3% (95% CI: 76.2 to 78.5). Missed opportunities for diagnosis were more common among individuals who were poorer (  = 0.001), less educated (  < 0.001), male (  < 0.001), rural (  < 0.001), Hindu (  = 0.001), living alone (  = 0.028) and working (  < 0.001). Missed opportunities for diagnosis were more common at private than at public health facilities (  < 0.001) and varied widely across states (  < 0.001). Opportunistic screening for hypertension has the potential to significantly increase detection of the condition and reduce sociodemographic and geographic inequalities in its diagnosis. Such screening could be a first step towards more effective and equitable hypertension treatment and control.