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Some studies, mainly from high-income countries (HICs), report that women receive less care (investigations and treatments) for cardiovascular disease than do men and might have a higher risk of death. However, very few studies systematically report risk factors, use of primary or secondary prevention medications, incidence of cardiovascular disease, or death in populations drawn from the community. Given that most cardiovascular disease occurs in low-income and middle-income countries (LMICs), there is a need for comprehensive information comparing treatments and outcomes between women and men in HICs, middle-income countries, and low-income countries from community-based population studies. In the Prospective Urban Rural Epidemiological study (PURE), individuals aged 35–70 years from urban and rural communities in 27 countries were considered for inclusion. We recorded information on participants' sociodemographic characteristics, risk factors, medication use, cardiac investigations, and interventions. 168 490 participants who enrolled in the first two of the three phases of PURE were followed up prospectively for incident cardiovascular disease and death. From Jan 6, 2005 to May 6, 2019, 202 072 individuals were recruited to the study. The mean age of women included in the study was 50·8 (SD 9·9) years compared with 51·7 (10) years for men. Participants were followed up for a median of 9·5 (IQR 8·5–10·9) years. Women had a lower cardiovascular disease risk factor burden using two different risk scores (INTERHEART and Framingham). Primary prevention strategies, such as adoption of several healthy lifestyle behaviours and use of proven medicines, were more frequent in women than men. Incidence of cardiovascular disease (4·1 [95% CI 4·0–4·2] for women vs 6·4 [6·2–6·6] for men per 1000 person-years; adjusted hazard ratio [aHR] 0·75 [95% CI 0·72–0·79]) and all-cause death (4·5 [95% CI 4·4–4·7] for women vs 7·4 [7·2–7·7] for men per 1000 person-years; aHR 0·62 [95% CI 0·60–0·65]) were also lower in women. By contrast, secondary prevention treatments, cardiac investigations, and coronary revascularisation were less frequent in women than men with coronary artery disease in all groups of countries. Despite this, women had lower risk of recurrent cardiovascular disease events (20·0 [95% CI 18·2–21·7] versus 27·7 [95% CI 25·6–29·8] per 1000 person-years in men, adjusted hazard ratio 0·73 [95% CI 0·64-0·83]) and women had lower 30-day mortality after a new cardiovascular disease event compared with men (22% in women versus 28% in men; p<0·0001). Differences between women and men in treatments and outcomes were more marked in LMICs with little differences in HICs in those with or without previous cardiovascular disease. Treatments for cardiovascular disease are more common in women than men in primary prevention, but the reverse is seen in secondary prevention. However, consistently better outcomes are observed in women than in men, both in those with and without previous cardiovascular disease. Improving cardiovascular disease prevention and treatment, especially in LMICs, should be vigorously pursued in both women and men. Full funding sources are listed at the end of the paper (see Acknowledgments).

In high-income countries, only 50% of patients treated for chronic diseases adhere to the prescribed treatment. This issue is even more pronounced in resource-limited countries. Medication adherence scales are simple, low-cost approaches to identify nonadherence in clinical practice. In India, nonadherence to medication varies from 18.7% to 74%, assessed using scales validated in the Western population, as there is no validated medication adherence tool contextualized to the Indian setting. The phrasing of questions in scales validated elsewhere and its interpretations may vary when applied in Indian patients unless accounting for the unique cultural, social, and economic factors influencing medication adherence in India. This could result in inaccurate reports of adherence behavior. This study aims to develop and validate a novel medication adherence tool for select noncommunicable diseases (diabetes mellitus, hypertension, chronic obstructive pulmonary disease, bronchial asthma, and coronary artery disease) in the Indian population. An exploratory sequential mixed methods design will be used, beginning with a qualitative phase where the construct of the scale is defined and preliminary items are generated through a scoping review, focus group discussions, and in-depth interviews. This will be followed by the tool's development phase, including an expert panel review and item revision. Finally, a quantitative phase in 4 zones in India (North, South, East, and West) will be conducted to confirm and validate the newly developed scale. In the first phase, we will frame the construct definition and develop an inventory of potential items for the proposed medication adherence tool. In the second phase, item-level and scale-level content validity indices, along with content validity ratio, will be estimated. In the third phase, we will conduct an item reduction analysis and determine the scoring matrix and item weightage after expert review. We will assess the tool's psychometric properties, plot the receiver operating characteristic (ROC) curve to set an adherence cut-off score, and compute the construct validity and test-retest reliability from the quantitative survey. A medication adherence tool for noncommunicable diseases, developed after ensuring it is ethnically, culturally, and linguistically appropriate incorporating stakeholder perspectives and validated in community settings, would offer a real-world perspective of adherence. The tool will have 2 versions for clinical practice and research, aiding policy makers in adopting tailored adherence policies. PRR1-10.2196/60805.

Background Family caregivers are vital for long-term care for persons with serious health-related suffering in Kerala. Long-term caregiving and ageing may become burdensome and detrimental to patients and caregivers. We compared the caregiver burden and quality-of-life of ageing caregivers with younger caregivers. We also explored the palliative care nurses’ perceptions of the family caregivers’ issues. Methods We did a mixed method study focusing on two groups: (i) three in-depth interviews and a cross-sectional survey among 221 caregivers of palliative care patients in five randomly selected panchayats (most peripheral tier of three-tier local self-government system in India concerned with governance of a village or small town) of Kollam district, Kerala, as part of development and validation of the Achutha Menon Centre Caregiver Burden Inventory; (ii) five in-depth interviews with purposively selected primary palliative care nurses as part of a study on local governments and palliative care. We used a structured interview schedule to collect cross-sectional data on sociodemographic and caregiving-related characteristics, caregiver burden, and health-related quality of life using the EuroQol EQ5D5L and interview guidelines on caregiver issues tailored based on participant type for qualitative interviews. Results Older caregivers comprised 28.1% of the sample and had significantly poorer health and quality-of-life attributes. More senior caregivers experiencing caregiver burden had the lowest mean scores of 0.877 (Standard deviation (SD 0.066, 95% confidence intervals (CI) 0.854–0.899) followed by younger caregivers with high burden (0.926, SD 0.090, 95% CI 0.907–0.945), older caregivers with low burden (0.935, SD 0.058, 95% CI 0.912–0.958) and younger caregivers with low burden (0.980, SD 0.041, 95% CI 0.970–0.990). Caregivers faced physical, psychological, social, and financial issues, leading to a caregiver burden. The relationships between the palliative care nurses and family caregivers were complex, and nurses perceived caregiver burden, but there were no specific interventions to address this. Conclusion In our study from Kollam, Kerala, three out of ten caregivers of palliative care patients were 60 years of age or older. They had significantly lower health-related quality of life, particularly if they perceived caregiver burden. Despite being recognized by palliative care nurses, caregiver issues were not systematically addressed. Further research and suitable interventions must be developed to target such problems in the palliative care programme in Kerala.

AbstractObjectiveTo evaluate the relation between intake of ultra-processed food and risk of inflammatory bowel disease (IBD).DesignProspective cohort study.Setting21 low, middle, and high income countries across seven geographical regions (Europe and North America, South America, Africa, Middle East, south Asia, South East Asia, and China).Participants116 087 adults aged 35-70 years with at least one cycle of follow-up and complete baseline food frequency questionnaire (FFQ) data (country specific validated FFQs were used to document baseline dietary intake). Participants were followed prospectively at least every three years.Main outcome measuresThe main outcome was development of IBD, including Crohn’s disease or ulcerative colitis. Associations between ultra-processed food intake and risk of IBD were assessed using Cox proportional hazard multivariable models. Results are presented as hazard ratios with 95% confidence intervals.ResultsParticipants were enrolled in the study between 2003 and 2016. During the median follow-up of 9.7 years (interquartile range 8.9-11.2 years), 467 participants developed incident IBD (90 with Crohn’s disease and 377 with ulcerative colitis). After adjustment for potential confounding factors, higher intake of ultra-processed food was associated with a higher risk of incident IBD (hazard ratio 1.82, 95% confidence interval 1.22 to 2.72 for ≥5 servings/day and 1.67, 1.18 to 2.37 for 1-4 servings/day compared with <1 serving/day, P=0.006 for trend). Different subgroups of ultra-processed food, including soft drinks, refined sweetened foods, salty snacks, and processed meat, each were associated with higher hazard ratios for IBD. Results were consistent for Crohn’s disease and ulcerative colitis with low heterogeneity. Intakes of white meat, red meat, dairy, starch, and fruit, vegetables, and legumes were not associated with incident IBD.ConclusionsHigher intake of ultra-processed food was positively associated with risk of IBD. Further studies are needed to identify the contributory factors within ultra-processed foods.Study registrationClinicalTrials.gov NCT03225586.

Dietary guidelines recommend minimising consumption of whole-fat dairy products, as they are a source of saturated fats and presumed to adversely affect blood lipids and increase cardiovascular disease and mortality. Evidence for this contention is sparse and few data for the effects of dairy consumption on health are available from low-income and middle-income countries. Therefore, we aimed to assess the associations between total dairy and specific types of dairy products with mortality and major cardiovascular disease. The Prospective Urban Rural Epidemiology (PURE) study is a large multinational cohort study of individuals aged 35–70 years enrolled from 21 countries in five continents. Dietary intakes of dairy products for 136 384 individuals were recorded using country-specific validated food frequency questionnaires. Dairy products comprised milk, yoghurt, and cheese. We further grouped these foods into whole-fat and low-fat dairy. The primary outcome was the composite of mortality or major cardiovascular events (defined as death from cardiovascular causes, non-fatal myocardial infarction, stroke, or heart failure). Hazard ratios (HRs) were calculated using multivariable Cox frailty models with random intercepts to account for clustering of participants by centre. Between Jan 1, 2003, and July 14, 2018, we recorded 10 567 composite events (deaths [n=6796] or major cardiovascular events [n=5855]) during the 9·1 years of follow-up. Higher intake of total dairy (>2 servings per day compared with no intake) was associated with a lower risk of the composite outcome (HR 0·84, 95% CI 0·75–0·94; ptrend=0·0004), total mortality (0·83, 0·72–0·96; ptrend=0·0052), non-cardiovascular mortality (0·86, 0·72–1·02; ptrend=0·046), cardiovascular mortality (0·77, 0·58–1·01; ptrend=0·029), major cardiovascular disease (0·78, 0·67–0·90; ptrend=0·0001), and stroke (0·66, 0·53–0·82; ptrend=0·0003). No significant association with myocardial infarction was observed (HR 0·89, 95% CI 0·71–1·11; ptrend=0·163). Higher intake (>1 serving vs no intake) of milk (HR 0·90, 95% CI 0·82–0·99; ptrend=0·0529) and yogurt (0·86, 0·75–0·99; ptrend=0·0051) was associated with lower risk of the composite outcome, whereas cheese intake was not significantly associated with the composite outcome (0·88, 0·76–1·02; ptrend=0·1399). Butter intake was low and was not significantly associated with clinical outcomes (HR 1·09, 95% CI 0·90–1·33; ptrend=0·4113). Dairy consumption was associated with lower risk of mortality and major cardiovascular disease events in a diverse multinational cohort. Full funding sources are listed at the end of the paper (see Acknowledgments).

Background Negotiating anti-Tuberculosis treatment is a complicated process comprising daily consumption of multiple medications at stipulated times and dosages, as well as periodic follow-ups and investigations, may not be uniform for all Tuberculosis (TB) patients and some may perform better than others. In this context, we conducted a study in Thiruvananthapuram district, Kerala to ascertain the ability of those suffering from TB to follow treatment guidelines. Methods This study used an embedded mixed methods design. We collected cross-sectional data from 135 drug sensitive pulmonary TB patients aged 18 years or above in Thiruvananthapuram, Kerala using a structured questionnaire to get the proportion of patients following all treatment guidelines. We also did eight in-depth interviews (four men and four women) from within the survey sample. The in-depth interviews were inductively analysed for getting deeper insights about reasons for the choices people made regarding the treatment guidelines. Written informed consent was taken from all participants and the study was implemented after the necessary programmatic and ethical clearances. Results Of the 105 men and 30 women studied, uninterrupted daily drug consumption was reported by 80 persons (59.3%, 95% Confidence Intervals (CI) 50.8-67.2%). Overall, 38 (28.2%, 95% CI 21.3%-36.3%) persons were able to follow all seven aspects of advised guidelines. Living in an extended/ joint family (Adjusted Odds ratio (AOR) 2.6, 95% CI 1.1-6.0), approximate monthly household expenditure of over rupees 13,500 (AOR 2.9, 95% CI 1.3–6.7) and no perceived delay in seeking initial care (AOR 3.2, 95% CI 1.2–8.7) were significantly associated with following all aspects of treatment guidelines. In-depth interviews revealed reflective treatment related behaviours were influenced by bodily experiences, moral perceptions, social construct of TB, programmatic factors and substance use. Sometimes behaviours were non-reflective also. Programmatic stress was on individual agency for changing behaviour but capability and opportunity for these were influenced social aspects like stigma, gender roles and poverty. Conclusion TB patients live amidst a syndemic of biomedical and social problems. These problems influence the capabilities and opportunities of such TB patients to follow treatment guidelines. Interventions should balance focus on individual agency and social abd economic factors.

In these circumstances, we wish to reflect on the occasional statement of lack of acceptance of palliative care and the plausibility of an epistemic schism in the acknowledgement of the discipline within medicine and public health. [...]the preceding century has witnessed marked demographic and epidemiological transition and chronic medical conditions have emerged as important public health issues. The community centred approach for health and wellness proposed by Public Health England, an executive agency of the Department of Health and Social Care in the United Kingdom, makes a strong case for person and community centred ways in public health (South, 2015). The report mentions capacity building, peer roles, partnerships, and community resources, and the neighborhood network for palliative care in Kerala is an approach on par with this (Sallnow et al., 2010). [...]the discourse on welfare and development has included disability and suffering, recognizing the setback that these render to the development agenda.

Urbanization may influence physical activity (PA) levels, although little evidence is available for low- and middle- income countries where urbanization is occurring fastest. We evaluated associations between urbanization and total PA, as well as work-, leisure-, home-, and transport-specific PA, for 138,206 adults living in 698 communities across 22 countries within the Prospective Urban and Rural Epidemiology (PURE) study. The 1-week long-form International PA Questionnaire was administered at baseline (2003–2015). We used satellite-derived population density and impervious surface area estimates to quantify baseline urbanization levels for study communities, as well as change measures for 5- and 10-years prior to PA surveys. We used generalized linear mixed effects models to examine associations between urbanization measures and PA levels, controlling for individual, household and community factors. Higher community baseline levels of population density (− 12.4% per IQR, 95% CI − 16.0, − 8.7) and impervious surface area (− 29.2% per IQR, 95% CI − 37.5, − 19.7), as well as the rate of change in 5-year population density (− 17.2% per IQR, 95% CI − 25.7, − 7.7), were associated with lower total PA levels. Important differences in the associations between urbanization and PA were observed between PA domains, country-income levels, urban/rural status, and sex. These findings provide new information on the complex associations between urbanization and PA.

NCDs arise from complex interactions of modifiable factors such as unhealthy lifestyles, poor diet, and psychosocial challenges, along with non-modifiable factors like age and genetics. Notably, medication non-adherence is a widespread and growing concern, significantly contributing to disease progression and poor outcomes globally. This scoping review aims to synthesize evidence on medication adherence scales used for selected non communicable diseases. It examines their development methods, psychometric properties, and assessed domains, while identifying gaps or limitations in their design and application. The Joanna Briggs Institute methodological framework guided this scoping review and the protocol was registered prospectively to ensure methodological transparency and rigor. Electronic databases, the reference list of included articles, and grey literature were searched. Studies published in English from January 1950 to June 2024 were included. Two reviewers independently screened all articles, and a third reviewer settled any conflicts between the reviewers. Critical appraisal of the screened-in articles was done using JBI critical appraisal scales. The data was compiled into tables and a narrative summary that is consistent with the review's goal. Our study included 140 articles, identifying 57 medication adherence scales. These scales, developed using qualitative methods (10.8%), literature review (32.4%), and mixed methods (45.9%), primarily focus on behavior, often neglecting cost-related non-adherence, self-efficacy, and systemic barriers. Psychometric findings varied widely, reflecting heterogeneity in study designs and scale development approaches. Many scales lack validation in diverse settings, underscoring the need for comprehensive, context-sensitive tools. This scoping review highlights gaps in existing medication adherence scales for NCDs, particularly their limited consideration of socioeconomic and cultural factors and incomplete adherence assessment. Future research should focus on developing more holistic, contextually relevant adherence scales that integrate these dimensions. Strengthening adherence measurement methodologies can enhance patient-centered care, inform policy interventions, and improve health outcomes.

While the burden of dementia is increasing in low- and middle-income countries, there is a low rate of diagnosis and paucity of research in these regions. A major challenge to study dementia is the limited availability of standardised diagnostic tools for use in populations with linguistic and educational diversity. The objectives of the study were to develop a standardised and comprehensive neurocognitive test battery to diagnose dementia and mild cognitive impairment (MCI) due to varied etiologies, across different languages and educational levels in India, to facilitate research efforts in diverse settings. A multidisciplinary expert group formed by Indian Council of Medical Research (ICMR) collaborated towards adapting and validating a neurocognitive test battery, that is, the ICMR Neurocognitive Tool Box (ICMR-NCTB) in five Indian languages (Hindi, Bengali, Telugu, Kannada, and Malayalam), for illiterates and literates, to standardise diagnosis of dementia and MCI in India. Following a review of existing international and national efforts at standardising dementia diagnosis, the ICMR-NCTB was developed and adapted to the Indian setting of sociolinguistic diversity. The battery consisted of tests of cognition, behaviour, and functional activities. A uniform protocol for diagnosis of normal cognition, MCI, and dementia due to neurodegenerative diseases and stroke was followed in six centres. A systematic plan for validating the ICMR-NCTB and establishing cut-off values in a diverse multicentric cohort was developed. A key outcome was the development of a comprehensive diagnostic tool for diagnosis of dementia and MCI due to varied etiologies, in the diverse socio-demographic setting of India.