Monika Arora

Global burden of diseases, injuries, and risk factors for young people's health during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

BACKGROUND Young peoples health has emerged as a neglected yet pressing issue in global development. Changing patterns of young peoples health have the potential to undermine future population health as well as global economic development unless timely and effective strategies are put into place. We report the past, present, and anticipated burden of disease in young people aged 10-24 years from 1990 to 2013 using data on mortality, disability, injuries, and health risk factors. METHODS The Global Burden of Disease Study 2013 (GBD 2013) includes annual assessments for 188 countries from 1990 to 2013, covering 306 diseases and injuries, 1233 sequelae, and 79 risk factors. We used the comparative risk assessment approach to assess how much of the burden of disease reported in a given year can be attributed to past exposure to a risk. We estimated attributable burden by comparing observed health outcomes with those that would have been observed if an alternative or counterfactual level of exposure had occurred in the past. We applied the same method to previous years to allow comparisons from 1990 to 2013. We cross-tabulated the quantiles of disability-adjusted life-years (DALYs) by quintiles of DALYs annual increase from 1990 to 2013 to show rates of DALYs increase by burden. We used the GBD 2013 hierarchy of causes that organises 306 diseases and injuries into four levels of classification. Level one distinguishes three broad categories: first, communicable, maternal, neonatal, and nutritional disorders; second, non-communicable diseases; and third, injuries. Level two has 21 mutually exclusive and collectively exhaustive categories, level three has 163 categories, and level four has 254 categories. FINDINGS The leading causes of death in 2013 for young people aged 10-14 years were HIV/AIDS, road injuries, and drowning (25·2%), whereas transport injuries were the leading cause of death for ages 15-19 years (14·2%) and 20-24 years (15·6%). Maternal disorders were the highest cause of death for young women aged 20-24 years (17·1%) and the fourth highest for girls aged 15-19 years (11·5%) in 2013. Unsafe sex as a risk factor for DALYs increased from the 13th rank to the second for both sexes aged 15-19 years from 1990 to 2013. Alcohol misuse was the highest risk factor for DALYs (7·0% overall, 10·5% for males, and 2·7% for females) for young people aged 20-24 years, whereas drug use accounted for 2·7% (3·3% for males and 2·0% for females). The contribution of risk factors varied between and within countries. For example, for ages 20-24 years, drug use was highest in Qatar and accounted for 4·9% of DALYs, followed by 4·8% in the United Arab Emirates, whereas alcohol use was highest in Russia and accounted for 21·4%, followed by 21·0% in Belarus. Alcohol accounted for 9·0% (ranging from 4·2% in Hong Kong to 11·3% in Shandong) in China and 11·6% (ranging from 10·1% in Aguascalientes to 14·9% in Chihuahua) of DALYs in Mexico for young people aged 20-24 years. Alcohol and drug use in those aged 10-24 years had an annual rate of change of >1·0% from 1990 to 2013 and accounted for more than 3·1% of DALYs. INTERPRETATION Our findings call for increased efforts to improve health and reduce the burden of disease and risks for diseases in later life in young people. Moreover, because of the large variations between countries in risks and burden, a global approach to improve health during this important period of life will fail unless the particularities of each country are taken into account. Finally, our results call for a strategy to overcome the financial and technical barriers to adequately capture young peoples health risk factors and their determinants in health information systems. FUNDING Bill & Melinda Gates Foundation.

Preventing Tobacco Use Among Young People in India: Project MYTRI

OBJECTIVES We assessed the effectiveness of a 2-year multicomponent, school-based intervention designed to reduce tobacco use rates among adolescents in an urban area of India. METHODS Students from 32 schools in Delhi and Chennai, India, were recruited and randomly assigned to an intervention or control group. Baseline, intermediate, and outcome data were collected from 2 cohorts of 6th- and 8th-grade students in 2004; 14,063 students took part in the study and completed a survey in 2004, 2005, or 2006. The intervention consisted of behavioral classroom curricula, school posters, a parental involvement component, and peer-led activism. The main outcome measures were self-reported use of cigarettes, bidis (small hand-rolled, often flavored, cigarettes), and chewing tobacco and future intentions to smoke or use chewing tobacco. RESULTS Findings showed that students in the intervention group were significantly less likely than were students in the control group to exhibit increases in cigarette smoking or bidi smoking over the 2-year study period. They were also less likely to intend to smoke or chew tobacco in the future. CONCLUSIONS School-based programs similar to the intervention examined here should be considered as part of a multistrategy approach to reducing tobacco use among young people in India.

Differences in tobacco use among young people in urban India by sex, socioeconomic status, age, and school grade: assessment of baseline survey data

BACKGROUND The epidemic of tobacco use is shifting from developed to developing countries, including India, where increased use is expected to result in a large disease burden in the future. Changes in prevalence of tobacco use in adolescents are important to monitor, since increased use by young people might be a precursor to increased rates in the population. METHODS 11 642 students in the sixth and eighth grades in 32 schools in Delhi and Chennai, India, were surveyed about their tobacco use and psychosocial factors related to onset of tobacco use. Schools were representative of the range of types of school in these cities. RESULTS Students who were in government schools, male, older, and in sixth grade were more likely to use tobacco than students who were in private schools, female, younger, and in eighth grade. Students in sixth grade were, overall, two to four times more likely to use tobacco than those in eighth grade. 24.8% (1529 of 6165) of sixth-grade students and 9.3% (509 of 5477) of eighth-grade students had ever used tobacco; 6.7% (413 of 6165) and 2.9% (159 of 5477), respectively, were current users. Psychosocial risk factors were greater in sixth-grade than in eighth-grade students. The increase in tobacco use by age within each grade was larger in sixth grade than in eighth grade in government schools, with older sixth-grade students at especially high risk. DISCUSSION The finding that sixth-grade students use significantly more tobacco than eighth-grade students is unusual, and might indicate a new wave of increased tobacco use in urban India that warrants confirmation and early intervention.

Tobacco and alcohol use outcomes of a school-based intervention in New Delhi.

OBJECTIVE To reduce tobacco use among adolescents. METHODS Thirty schools in New Delhi, India, were randomly assigned to 3 conditions: school-based and family-based intervention, school-based intervention only, or control group. Students were in the seventh grade at pretest (N = 4,776). The smoking intervention included posters, booklets, classroom activities, debates, and a signature campaign. The family intervention involved home activities. The survey measured tobacco knowledge, attitudes, offers, use, and intentions. RESULTS Intervention students were significantly less likely than controls to have been offered, received, experimented with, or have intentions to use tobacco. CONCLUSION The project had a significant impact on tobacco use.

Indian Youth Speak About Tobacco: Results of Focus Group Discussions With School Students

This article discusses the findings of Focus Group Discussions (FGDs) that were conducted as a formative assessment for Project MYTRI (Mobilizing Youth for Tobacco Related Initiatives in India), a randomized, multicomponent, school-based trial to prevent and control tobacco use among youth in India. Forty-eight FGDs were conducted with students (N = 435) in sixth and eighth grades in six schools in Delhi, India. Key findings include: (a) students in government schools reported as “consumers” of tobacco, whereas students in private schools reported as “commentators”; (b) parents and peers have a strong influence on youth tobacco use; (c) chewing gutkha is considered less harmful and more accessible than smoking cigarettes; (d) schools are not promoting tobacco control activities; and (e) students were enthusiastic about the role government should play in tobacco control. These findings are being used to develop a comprehensive intervention program to prevent and control tobacco use among Indian youth.

Differences in prevalence of tobacco use among Indian urban youth : The role of socioeconomic status

This study examined whether the distribution of tobacco use and related psychosocial risk factors among youth in urban India vary by socioeconomic status (SES). Data were derived from a cross-sectional survey of students enrolled in the 6th and 8th grades in 32 schools in Delhi and Chennai (N = 11,642). The survey was conducted in 2004, before the implementation of a program designed to prevent and reduce tobacco use (MYTRI). Mixed-effect regression models were used (a) to determine the prevalence of tobacco use among private (higher SES) and government (lower SES) school students, (b) to investigate whether certain psychosocial factors were associated with increased tobacco use, and (c) to determine how these factors varied by school type. Ever-use of multiple forms of tobacco (e.g., gutkha, bidis, and cigarettes) was more prevalent among government school students than private school students. After adjusting for city, gender, grade, and age, we found the prevalence rate for ever-use of any tobacco product to be 18.9% for government school students, compared with 12.2% for private school students (p<.01). Students in government schools scored lower than private school students on most psychosocial risk factors for tobacco use studied here, indicating higher risk. Government school students scored the lowest for refusal skills, self-efficacy, and reasons not to use tobacco. Social susceptibility to chewing tobacco and social susceptibility to smoking were strong correlates of current tobacco use among government school students. Exposure to tobacco advertising was also a strong correlate of current tobacco use for government school students but not private school students. In two large cities of India, students attending government schools are using many forms of tobacco at higher rates than private school students. The psychosocial risk profile of government school students suggests they are more vulnerable to initiation and use and to outside influences that encourage use.

Why are urban Indian 6th graders using more tobacco than 8th graders? Findings from Project MYTRI

Objective: To investigate why urban Indian 6th graders may be using more tobacco than urban Indian 8th graders. Design: Cross-sectional survey of students conducted in the summer of 2004, as the baseline evaluation tool for a group-randomised tobacco prevention intervention trial (Project MYTRI). Mixed-effects regression models were used to (1) examine the relationship between 15 psychosocial risk factors and current use of any tobacco, by grade; and (2) examine differences in psychosocial risk factors, by grade. Setting: Thirty-two private (high socioeconomic status (SES)) and government (low-mid SES) schools in two large cities in India (Delhi and Chennai). Subjects: Students in the 6th and 8th grade in these schools (n  =  11642). Among these, 50.6% resided in Delhi (v Chennai), 61.4% attended a government school (v a private school), 52.9% were enrolled in 6th grade (v 8th), and 54.9% were male (v female). Main outcome measure: Current (past 30 day) use of any tobacco, including chewing tobacco (for example, gutkha), bidis, or cigarettes. Result: Almost all psychosocial factors were significantly related to tobacco use, for students in both grades. Some of the strongest correlates included social susceptibility to and social norms about use. Exposure to tobacco advertising was a strong correlate of tobacco use for 6th graders, but not for 8th graders. Sixth graders scored lower than 8th graders on almost all factors, indicating higher risk. Conclusions: The “risk profile” of 6th graders suggests they would be vulnerable to use and to begin using tobacco, as well as to outside influences that may encourage use.

Association of breakfast intake with obesity, dietary and physical activity behavior among urban school-aged adolescents in Delhi, India: results of a cross-sectional study.

BackgroundIn developed countries, regular breakfast consumption is inversely associated with excess weight and directly associated with better dietary and improved physical activity behaviors. Our objective was to describe the frequency of breakfast consumption among school-going adolescents in Delhi and evaluate its association with overweight and obesity as well as other dietary, physical activity, and sedentary behaviors.MethodsDesign: Cross-sectional study. Setting: Eight schools (Private and Government) of Delhi in the year 2006. Participants: 1814 students from 8th and 10th grades; response rate was 87.2%; 55% were 8th graders, 60% were boys and 52% attended Private schools. Main outcome measures: Body mass index, self-reported breakfast consumption, diet and physical activity related behaviors, and psychosocial factors. Data analysis: Mixed effects regression models were employed, adjusting for age, gender, grade level and school type (SES).ResultsSignificantly more Government school (lower SES) students consumed breakfast daily as compared to Private school (higher SES) students (73.8% vs. 66.3%; p<0.01). More 8th graders consumed breakfast daily vs.10th graders (72.3% vs. 67.0%; p<0.05). A dose–response relationship was observed such that overall prevalence of overweight and obesity among adolescents who consumed breakfast daily (14.6%) was significantly lower vs. those who only sometimes (15.2%) or never (22.9%) consumed breakfast (p<0.05 for trend). This relationship was statistically significant for boys (15.4 % vs. 16.5% vs. 26.0; p<0.05 for trend) but not for girls. Intake of dairy products, fruits and vegetables was 5.5 (95% CI 2.4-12.5), 1.7 (95% CI 1.1-2.5) and 2.2 (95% CI 1.3-3.5) times higher among those who consumed breakfast daily vs. those who never consumed breakfast. Breakfast consumption was associated with greater physical activity vs. those who never consumed breakfast. Positive values and beliefs about healthy eating; body image satisfaction; and positive peer and parental influence were positively associated with daily breakfast consumption, while depression was negatively associated.ConclusionDaily breakfast consumption is associated with less overweight and obesity and with healthier dietary- and physical activity-related behaviors among urban Indian students. Although prospective studies should confirm the present results, intervention programs to prevent or treat childhood obesity in India should consider emphasizing regular breakfast consumption.

Tobacco use in Bollywood movies, tobacco promotional activities and their association with tobacco use among Indian adolescents.

Background Smoking in Hollywood movies is a known risk factor for teen smoking in the USA and Europe, but little is known about the association between exposure to tobacco use in Bollywood movies and teen tobacco use in India. Methods A cross-sectional sample of 3956 adolescents (eighth and ninth grades, ages 12–16 years) from 12 randomly selected New Delhi schools was surveyed in 2009, assessing tobacco use status, receptivity to tobacco promotions (based on owning or being willing to wear tobacco-branded merchandise) and exposure to tobacco use in movies. Quartiles of exposure to tobacco use in popular Bollywood movies released from 2006 to 2008 (n=59) were determined by content coding them for tobacco use and querying the adolescents whether they had seen each one. Logistic regression was used to control for covariates including age, gender, parent education, school performance, sensation-seeking propensity, family and peer tobacco use, and authoritative parenting. Results Altogether, the 59 movies contained 412 tobacco use occurrences. The prevalence of ever tobacco use among adolescents was 5.3%. Compared with low-exposure adolescents (quartile 1), the adjusted odds of ever tobacco use among high-exposure adolescents (quartile 4) was 2.3 (95% CI 1.3 to 3.9). Being receptive to tobacco promotions was also associated with higher adjusted odds of ever tobacco use, 2.0 (95% CI 1.4 to 3.0). Conclusion Watching tobacco use in Bollywood movies and receptivity to tobacco promotional activities were both independently associated with ever tobacco use among adolescents in India, with ORs being similar to the studies of adolescents elsewhere.

Prevention in translation: tobacco use prevention in India.

Mobilising Youth for Tobacco-Related Initiatives in India (Project MYTRI) is a randomized community trial to prevent tobacco use among students in Grades 6 through 9 in 32 private and government schools in Delhi and Chennai, India (N = 12,484). The project is a partnership between researchers and practitioners in the United States and India. This article describes the steps that were carried out to ensure that prior effective programs are appropriate and applicable to India. These steps involve (a) developing a conceptual behavioral intervention model, (b) ensuring the appropriateness of the model for urban India, (c) developing intervention strategies that modify factors in the model, (d) implementing the MYTRI program with more than 5,000 students, and (e) evaluating the process and outcomes of the intervention. Data to date suggest that this process has been successful, including high participation rates, teacher perceptions of appropriateness, and agreements for further implementation.