Child marriage and risky health behaviors: an analysis of tobacco use among early adult and early middle-aged women in India.

BACKGROUND: Though the harmful impacts of child marriage have been evaluated across several domains, evidence on the relationship between child marriage and health behaviors over the life course is limited. In this paper, we examined whether getting married as a child is associated with one of the most common risky health behaviors, tobacco use, in adulthood. METHODS: Using nationally representative data from India, we compared the odds in favor of tobacco use among early adult (age 22-34) and early middle-aged (age 35-44) women who were married before age 18 with that of those who were married as youths (age 18-21). We estimated univariate and multivariable logistic regressions to obtain odds ratios in favor of any tobacco-use and relative risk ratios in favor of mutually exclusive types of tobacco use (smoking-only, smokeless-only, and dual-use). We also explored the intensive margin of the relationship by assessing if the odds of tobacco use in adulthood were affected by how early (13 or less, 14-15, or 16-17) a child bride was married. RESULTS: We find that the adjusted odds of tobacco use for those who were married as a child were 1.3 and 1.2 times that of those who were married as a youth among early adult and early middle-aged women, respectively. The younger was the child bride when married, the higher were the odds of tobacco use as an adult. The relative risks of different types of tobacco use were also higher for child brides than their peers. CONCLUSIONS: These results are the first evidence of the association between child marriage and a major risky health behavior, tobacco use, over the life course. These findings will inform policies to strengthen child marriage prevention efforts and targeted tobacco control initiatives in the low-and-middle income countries.

An analytical model of population level chronic conditions and COVID-19 related hospitalization in the United States.

BACKGROUND: The surge in the COVID-19 related hospitalization has been straining the US health system. COVID-19 patients with underlying chronic conditions have a disproportionately higher risk of hospitalization and intensive care unit (ICU) admission. We developed a retrospective analytical model of COVID-19 related hospitalizations and ICU admissions linked to each of the three major chronic conditions - hypertension, diabetes, and cardiovascular diseases (CVD). METHODS: Based on the differential probability of hospitalization of the COVID-19 patients with and without a chronic condition, we estimate a baseline cumulative hospitalization rate and ICU admission rate using the population level chronic condition prevalence from the 2019 Behavioral Risk Factor Surveillance System survey. Next, we estimate the hospitalization and ICU admission rates under an alternative scenario of a lower prevalence of the same chronic condition, aligned with the World Health Organization target of 25% relative reduction of prevalence by 2025. We then compare the outcomes of the baseline and the alternative scenarios. RESULTS: We estimate that the lower prevalence of hypertension would have lowered the cumulative hospitalization and ICU admission rates by more than 2.5%. The lower prevalence of diabetes and CVD would lower the cumulative hospitalization rate by 0.6% and 1.4% respectively. The decrease in the rates would have been relatively higher among Black and elderly (age 55+). CONCLUSIONS: Our model, thus, provides evidence on the importance of prevention, control, and management of chronic conditions to lessen the overwhelming financial and public health burden on the health system during a pandemic like the COVID-19.

Role of Subsidized Coverage Eligibility in Medication Adherence Among Patients With Hypertension and Diabetes: Evidence From the NHIS 2011-2018.

Introduction: The subsidized insurance provision under the Affordable Care Act is an important instrument for health insurance coverage among middle-income nonelderly individuals. However, unlike the health impacts of the Medicaid expansion under the Affordable Care Act, the impact of subsidized insurance is relatively less explored in extant literature. This study aims to assess the role of subsidized coverage eligibility in medication adherence among nonelderly patients with hypertension and diabetes in the U.S. Methods: Using pooled data from 8 rounds (2011-2018) of the National Health Interview Survey, we estimated a difference-in-differences model to examine the change in medication adherence among study participants with a household income of 150%-399% of the Federal Poverty Line compared with that among their counterparts with a household income of ≥400% of the Federal Poverty Line during pre‒ and post‒Affordable Care Act periods. We also performed event study analysis and falsification tests to check the validity of our quasi-experimental design. Analyses were conducted in 2022. Results: Medication adherence in the treatment group increased by 4.5 percentage points (95% CI=2.8, 6.2) during the post‒Affordable Care Act periods, whereas the increase was only 1.8 percentage points (95% CI=0.6, 3.0) in the control group. Results of the difference-in-differences model suggest that because of the subsidized insurance under the Affordable Care Act, medication adherence in the treatment group increased by 3.1 percentage points (95% CI=1.0, 5.2) during the post‒Affordable Care Act periods, compared with that in the control group. This increase was attributable to the improved insurance coverage, which increased by 6.8 percentage points (95% CI=5.3, 8.4) in the treatment during the post‒Affordable Care Act periods. Conclusions: Our analyses generate evidence that middle-income individuals with hypertensive or diabetic conditions, who were eligible for the subsidized coverage, benefited from this provision of the Affordable Care Act.

Hypertension in women: the role of adolescent childbearing.

BACKGROUND: Adolescent childbearing is associated with various health risks to the mother and child, and potentially with adverse socioeconomic outcomes. However, little is known about the role of adolescent childbearing in maternal health outcomes in adulthood. This study investigates the link between childbirth in adolescence and later-life risk of hypertension among women in India. METHODS: We obtained nationally representative data on demographic and health outcomes for 442,845 women aged 25 to 49 from the India National Family Health Survey (NFHS) 2015-16. We assessed the difference in hypertension prevalence between women who gave birth in adolescence (age 10 to 19) and those who did not, for the full sample and various sub-samples, using linear probability models with controls for individual characteristics, hypertension risk factors, and geographic fixed effects. RESULTS: Nearly 40% of the women in the sample gave birth in adolescence. The adjusted probability of being hypertensive in adulthood was 2.3 percentage points higher for this group compared to women who did not give childbirth in adolescence. This added probability was larger for women who gave birth earlier in adolescence (4.8 percentage points) and for women who gave birth more than once in adolescence (3.4 percentage points). CONCLUSIONS: Adolescent childbearing was strongly associated with a higher probability of adult female hypertension in India. This finding illustrates the intertemporal relationship between health risk factors during the life cycle, informing the importance of addressing adverse early life events (e.g. child marriage and adolescent childbirth) for hypertension outcomes among women in India.

Uncontrolled hypertension among tobacco-users: women of prime childbearing age at risk in India.

BACKGROUND: Uncontrolled hypertension and tobacco use are two major public health issues that have implications for reproductive outcomes. This paper examines the association between tobacco-use status and uncontrolled hypertension among prime childbearing age (20-35) women in India. METHODS: We used the India National Family Health Survey (NFHS-4) 2015-2016 to obtain data on hypertension status and tobacco use for 356,853 women aged 20-35. We estimated multivariate logistic regressions to obtain the adjusted odds ratio for tobacco users in favor of having uncontrolled hypertension. We examined the adjusted odds at different wealth index quintiles, at different educational attainment, and at different level of nutritional status measured by body mass index. RESULTS: We found that the odds of having uncontrolled hypertension for the tobacco user women in India was 1.1 (95% CI: 1.01-1.19) times that of tobacco non-users at prime childbearing age. The odds were higher for tobacco-users at the poorest quintile (1.27, 95% CI: 1.14-1.42) and with no education (1.22, 95% CI: 1.10-1.34). The odds were also higher for tobacco-users who were overweight (1.88, 95% CI: 1.57-2.29) or obese (2.82, 95% CI: 1.88-4.24). CONCLUSIONS: Our findings highlight the disproportionate dual risk of uncontrolled hypertension and tobacco use among lower-income women of prime childbearing age, identifying an opportunity for coordinated tobacco control and hypertension prevention initiatives to ensure better health of reproductive-age women in India.

Carbonating the household diet: a Pakistani tale.

OBJECTIVE: Carbonated beverage consumption is associated with various adverse health conditions such as obesity, type 2 diabetes and CVD. Pakistan has a high burden of these health conditions. At the same time, the carbonated beverage industry is rapidly growing in Pakistan. In this context, we analyse the trends and socioeconomic factors associated with carbonated beverage consumption in Pakistan. DESIGN: We use six waves of the cross-sectional household surveys from 2005-2006 to 2015-2016 to analyse carbonated beverage consumption. We examine the trends in carbonated beverage consumption-prevalence for different economic groups categorised by per capita household consumption quintiles. We estimate the expenditure elasticity of carbonated beverages for these groups using a two-stage budgeting system framework. We also construct concentration curves of carbonated beverage expenditure share to analyse the burden of expenditure across households of different economic status. SETTING: Pakistan. PARTICIPANTS: Nationally representative sample of households in respective survey waves. RESULTS: We find that the wealthier the household, the higher is the prevalence of carbonated beverage consumption, and the prevalence has increased for all household groups over time. From the expenditure elasticity analysis, we observe that carbonated beverages are becoming an essential part of food consumption particularly for wealthier households. And, lastly, poorer households are bearing a larger share of carbonated beverage expenditure in 2014-2016 than that in 2006-2008. CONCLUSION: Carbonated beverages are becoming an increasingly essential part of household food consumption in Pakistan. Concerns about added sugar intake can prompt consideration of public health approaches to reduce dietary causes of the disease burden in Pakistan.

The crowding out effect of out-of-pocket medication expenses of two major non-communicable diseases in Pakistan.

BACKGROUND: Elevated blood pressure (i.e. hypertension) and diabetes (BPD) are the two major noncommunicable diseases that expose households to high out-of-pocket treatment costs in low- and middle-income countries. Medication is the biggest share of BPD treatment expenses, and households with someone suffering from BPD may need to adjust consumption of other commodities to pay for essential BPD medicines. We assess how BPD medication expenditures are associated with crowding out of other household commodities in Pakistan. METHODS: We analyze self-reported household consumption data from the nationally representative Pakistan Household Income and Expenditure Survey 2015-16. We estimate conditional Engel curves under the Quadratic Almost Ideal Demand System framework to examine the differences in average consumption shares between BPD medication-consuming and not-consuming households. RESULTS: We find that BPD medication expenditures are associated with crowding out of food and crowding in of other medical expenditures for all households, but the magnitudes of crowding out and crowding in are larger for the poorer households. BPD medication spending is also associated with crowding out of education and personal care for middle-class and wealthier households. CONCLUSIONS: Our results indicate that allocations for essential commodities, like food and education, are lower for BPD medication-consuming households and inform policies for preventive health promotions and affordable treatment for hypertension and diabetes.