Prevalence and risk factors of non-communicable diseases in indigenous populations of South Asia: a systematic review protocol

doi:10.21203/rs.3.rs-3329706/v1

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Systematic Review

Prevalence and risk factors of non-communicable diseases in indigenous populations of South Asia: a systematic review protocol

https://doi.org/10.21203/rs.3.rs-3329706/v1

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Objective: Theobjective of this review is to estimate the prevalence and risk factors of non-communicable diseases among the adult indigenous populations of South Asia.

Introduction: Indigenous communities in South Asia have undergone a rapid epidemiologic transformation with non-communicable Diseases (NCDs) currently accounting for around 60% of all deaths with ischemic heart disease, stroke and diabetes being the leading causes. Studies have also reported an increase in the prevalence of NCD in indigenous populations.

Inclusion criteria: Conditions included in this review are hypertension, stroke, oral diseases, mental health, cardiovascular disease, diabetes, cancers (Head and neck cancers, Lung Cancer, Liver Cancer, Stomach Cancer, Colorectal Cancer, Esophageal Cancer, Breast Cancer), eye diseases, Chronic Kidney Disease, Leukemia, Chronic Obstructive Pulmonary Disease, Liver Cirrhosis, Ischemic Heart Disease, Hypertensive Heart Disease, Cerebrovascular disease, Alzheimer’s disease, neoplasms and skin diseases in adults (above 18 year)s from the indigenous populations in South Asian countries (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka). Outcomes will include studies estimating the prevalence and incidence of the conditions mentioned above. Risk factors will include conditions that maybe be associated with pre-existing condition and outcomes as defined by guidelines from Conducting Systematic Reviews and Meta-Analyses of Observational Studies of Etiology (COSMOS-E).

Methods: PubMed (MEDLINE), Embase, Scopus, Web of Science, Google Scholar, Shodhganga, and gray literature will be searched for relevant studies published, since inception. Two reviewers will independently screen the titles/abstracts and full texts using JBI SUMARI software, and any disagreements will be managed in discussion with a third reviewer. Included studies will be critically appraised for quality and eligibility and data extracted accordingly. If possible, pooled prevalence for prevalence and pooled OR/RR for determinants will be conducted, and heterogeneity will be tested. Subgroup analyses for country, age, sex and NCD type will be conducted based on available data. The characteristics and results of included studies will be summarized using tables, supplemented by a narrative summary.

Registration No: PROSPERO CRD42022331898

Epidemiology

Prevalence

Indigenous

NCDs

Systematic review

South Asia

Noncommunicable diseases (NCDs) are long-term illnesses caused by genetic, physiological, environmental, and behavioral factors¹. By 2030, the worldwide average age-standardized NCD mortality rate would be 510.54 (per 100,000 population), and 75.26% of all deaths would be attributable to NCDs². More than 15 million individuals aged 30 to 69 dies from an NCD every year; 85% of these "premature" deaths occur in low- and middle-income nations. Cardiovascular disease is the most prevalent NCD, killing 17.9 million people annually, followed by cancer (9.3 million), respiratory conditions (4.1 million), and diabetes (1.5 million)³. Risk factors refers to pre-existing conditions that may increase a person/populations chances of contracting NCDs. It may be modifiable behavioral risk factors such as tobacco use, physical inactivity, poor diet, and alcohol abuse or metabolic risk factors like elevated blood pressure, obesity, hyperglycemia (high blood glucose levels), and hyperlipidemia (high blood fat levels)¹. Unplanned urbanization, unhealthy lifestyles, and an aging population contribute to the global pandemic of NCDs. Micronutrient deficiencies pose a significant public health issue, since they have the potential to elevate the susceptibility to noncommunicable diseases (NCDs) such as cardiovascular diseases, some types of malignancies, and diabetes⁴.

Hypertension, stroke, oral diseases, mental health, cardiovascular disease, diabetes, cancers (Head and neck cancers, Lung Cancer, Liver Cancer, Stomach Cancer, Colorectal Cancer, Esophageal Cancer, Breast Cancer), eye diseases, Chronic Kidney Disease, Leukemia, Chronic Obstructive Pulmonary Disease, Liver Cirrhosis, Ischemic Heart Disease, Hypertensive Heart Disease, Cerebrovascular disease, Alzheimer’s disease, neoplasms and skin diseases are NCDs that are prevalent in South Asian region^5–14 which will be considered in this review. These NCDs were selected on the literature search^5–15, WHO South-East Asian Region website¹⁶ , Global Burden of Diseases (GBD)¹⁷ and in consultation with two clinicians who are co-authors in the review (JM, CJ).

South Asia comprises of eight countries; Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka¹⁸. This region is characterized by a significant degree of ethnic diversity, encompassing over 2,000 distinct ethnic entities that vary in size from small indigenous groups to populations numbering in the hundreds of millions¹⁸. South Asia has experienced numerous invasions and settlements by diverse ethnic groups throughout history, including Dravidian, Indo-Aryan, and Iranian groups. This has resulted in the amalgamation of Dravidian culture with other cultural influences¹⁹.

South Asia is currently home to one-fourth of the world's population. With the increase in population, the health burden is also increasing at a rapid rate, making it a high priority region with significant public health concerns. In contrast to the population's gradual development in communicable and nutritional diseases, noncommunicable diseases are on the rise rapidly in South Asia. Globalization and urbanization is contributing to the NCDs becoming the primary cause of mortality in South Asian countries²⁰. According to GBD (2016) South Asian countries have recorded a disproportionate number of deaths due to noncommunicable diseases (NCDs) such as Ischemic Heart Disease (IHD), Stroke, Chronic Obstructive Pulmonary Disease (COPD), Chronic Kidney Disease (CKD), and Diabetes²¹.

Indigenous populations in South Asia face a quadruple burden of malnutrition, infectious morbidity, inherited disorders (sickle cell anemia), and noncommunicable diseases, in addition to avoidable mortality and social vulnerabilities²². Inadequate access to adequate and culturally appropriate health care services is one of the primary issues indigenous people in Asia face and a primary cause of the indigenous health deficit²³. There is evidence of an early epidemiological change in indigenous communities and a corresponding rise in NCD incidence^23–25. There is a notable global trend indicating a heightened incidence of hypertension and diabetes within indigenous populations. The indigenous population is at risk of non-communicable diseases due to their frequent exposure to urban lifestyle, including dietary habits. Numerous research endeavors conducted in Bangladesh have examined the health status of indigenous populations, revealing a heightened incidence of diabetes²⁶. In addition, rates of depression and diabetes co-occurrence were found to be high: 7.4% and 61.9%, respectively. The prevalence of hypertension is 23.7% greater in indigenous populations in India²⁷. Several recent studies indicate a substantial increase in the prevalence of hypertension between 1980 and 2008, with rates rising from 17% to 35%. In 2010, it was determined that the Pakistani population was at a greater risk for chronic respiratory diseases, malignancies, and cardiovascular diseases²⁸. According to the Afghanistan Mortality Survey of 2010, the primary causes of death are cardiovascular disease (women 17.9%, men 14%), respiratory disease (2.3%, men 1.7%), cancer (8.3%, men 7.3%), and diabetes mellitus (2.7%, males 3.7%). According to 2016 WHO statistics, 8.4% of Afghans are affected by diabetes²⁹. Most South Asians suffer from Type 2 diabetes. From 2000 to 2030, the incidence of type 2 diabetes is expected to increase by 151%, 4.5%, 4.3% (1999-2000), 8.7% (1995), and 10.3% (2005-2006 of adults in India, Maldives, Pakistan and Sri Lanka have type 2 diabetes. India's marginalized populations have a mortality rate that is disproportionately greater for NCDs³⁰.

Indigenous healthcare has mostly been restricted to rural areas and the long-standing evidence is that indigenous people have poor health and considerable unmet needs. The national rural healthcare model was predicted to apply to indigenous people as well, albeit with slight variances in the population-to-provider ratio as they share comparable health issues and requirements. The fact that they live in difficult terrain and environments, have different social systems, and have different cultures, and hence have diverse healthcare needs, has been ignored. Health and healthcare in indigenous people, predictably, remain an unaddressed issue³¹. NCDs and poverty are inextricably related. With the rapid increase in NCDs, poverty reduction efforts in low-income countries is expected to be thwarted.

A search on PROSPERO, ProQuest, Cochrane and JBI Database of Systematic Reviews did not identify any systematic reviews on the topic. This review is solely concentrated on South Asian studies as the region is home to a largely diversified groups of indigenous population¹⁹. In fact, India has the largest indigenous population in the world³². This review will give a general overview of prevalence and risk factors associated with NCDs among the South Asian indigenous populations, and will also have a significant ramification for global public health, since South Asian nations make up nearly a quarter of the world's population³³, and contribute to a disproportionate amount of diabetes and cardiovascular disorders compared to other parts of the world.

This proposed systematic review aims to provide detailed evidence on prevalence and the risk factors of NCDs in the indigenous populations. The NCDs include hypertension, stroke, oral diseases, mental health, cardiovascular disease, diabetes, cancers (head and neck, lung cancer, liver cancer, stomach, colorectal, esophageal and breast), eye diseases, chronic kidney disease, leukemia, chronic obstructive pulmonary disease, liver cirrhosis, ischemic heart disease, hypertension, cerebrovascular disease, Alzheimer’s disease, neoplasms and skin diseases. These findings will be useful for policymakers for planning and implementation of preventive programs on NCDs among indigenous populations in the region.

Review questions

What is the prevalence/incidence and associated risk factors of NCDs among indigenous populations in South Asia?

Inclusion criteria- Prevalence

Condition

The conditions that will include for this review are NCDs such as Hypertension, Stroke, Oral Diseases, Mental Health, Cardiovascular Disease, Diabetes, Cancers (Head and Neck, Lung, Liver, Stomach, Colorectal, Esophageal, And Breast), Eye Diseases, Chronic Kidney Disease, Leukemia, Chronic Obstructive Pulmonary Disease, Liver Cirrhosis, Ischemic Heart Disease, Hypertensive Heart Disease, Cerebrovascular Disease, Alzheimer’s Disease, Neoplasms And Skin Diseases. The conditions will be defined in accordance with the 7th US JNC recommendations i.e.., those with blood pressure ≥ 140/90 mmHg or under antihypertensive medication will be considered as hypertensive. For cancer and stroke, conditions will be defined either through screening or diagnostic investigation. For CVD, participant’s condition will be defined through routine investigation, BMI, lifestyle habits, etc. For Diabetes mellitus, participants condition will be defined through Blood sugar levels.

Where data is available;

Stages for the severity for hypertension will include categories of Type 1 and Type 2 with systolic ranging from 130-139mmHg and 140mmHg or higher and diastolic between 80-89mmHg and diastolic 90mmHg or higher respectively.
For cancer, stages of severity would be classified into 3 stages; stage 1 whereby the cancer is small and hasn’t spread, stage 2- the cancer has grown but hasn’t spread and stage 3 the cancer has grown and may have spread to surrounding tissues and/or lymph nodes.
Severity stages for stroke to be classified as very severe stroke (0–14 points), severe stroke (15–29 points), moderate stroke (30–44 points), and mild stroke (45–58 points).
CVD stages of severity will be categorized as no severity (score=0); low severity (score=1–2); moderate severity (score=3–4); and high severity (score ≥5)²⁹. Classification for severity of diabetes will be assessed as good-HbA1c < 7%; intermediate-7% ≤ HbA1c < 8%; and poor-8% ≤ HbA1c.

Context

This review will consider community-based research, hospital studies, and studies that were solely conducted among indigenous populations in South Asian countries.

Population

Adults above the age group of 18 years, irrespective of gender and those living in South Asian countries (Afghanistan, Bangladesh, India, Maldives, Pakistan, and Sri Lanka) and belonging to an indigenous community. In this review, adults with condition of any NCDs, i.e. Hypertension, Stroke, Oral Diseases, Mental Health, Cardiovascular Disease, Diabetes, Cancers (Head And Neck, Lung, Liver, Stomach, Colorectal, Esophageal, And Breast), Eye Diseases, Chronic Kidney Disease, Leukemia, Chronic Obstructive Pulmonary Disease, Liver Cirrhosis, Ischemic Heart Disease, Hypertensive Heart Disease, Cerebrovascular Disease, Alzheimer’s Disease, Neoplasms And Skin Diseases, will be considered.

Types of outcomes

Studies documenting estimation of incidence, prevalence and mortality of any NCDs (listed above) will be considered.

Types of studies

Studies on any epidemiological design reporting incidence, prevalence and mortality of above mentioned NCDs will be included. These will include cohort, cross-sectional, and case control study designs.

Inclusion criteria- Risk

Population

Adults above the age group of 18 years, irrespective of gender and those living in South Asia, belonging to an indigenous community with NCDs.

Exposure

This review will consider studies that evaluate exposure to risk factors (e.g. age, gender, tobacco and alcohol use, obesity, literacy, income status, etc.) of the above listed NCDs.

Outcomes

Studies documenting estimation of risk factors of the above listed NCDs calculated by odds ratio/relative risk, as defined by guidelines from Conducting Systematic Reviews and Meta-Analyses of Observational Studies of Etiology (COSMOS-E) ³⁴.

Types of studies

Studies on any epidemiological design reporting incidence, prevalence and factors of the listed NCDs as in the previous section will be included. These will include cohort, cross-sectional, and case control studies that report characteristics of the diseases or with multi-morbidity at baseline.

Exclusion criteria

Studies that include case studies, case reports literature reviews, letters, qualitative study, children, and persons below the age of 18 years will be excluded for this review and other diseases apart from those listed above and from countries other than India, Bangladesh, Maldives, Pakistan, and Sri Lanka and Afghanistan will be excluded.

The proposed systematic review has been registered with the International Prospective Registry of Systematic reviews (PROSPERO CRD42022331898) and will be conducted in accordance with JBI methodology for systematic review³⁵.

Search strategy

A three-step search process will be used to try to find published as well as unpublished studies. A preliminary PubMed (MEDLINE) search was done to discover relevant studies (Annexure 1). This search strategy will be validated using CADTH PRESS 2015 guidelines and a revised search strategy will be developed³⁷. Further, this search strategy will be customized for each relevant database using the text words found in the titles, abstracts, and index terms of pertinent publications. All research that has been published in English will be considered. The search will not be restricted for any date limits.

The following search terms will be included:

Information sources

PubMed (MEDLINE), Embase, Web of Science, Scopus and Google Scholar databases will be searched. Grey literature such as the Ministry of Health and Family Welfare technical reports, master's and doctoral theses, and literature from NGOs, along with websites of WHO, World Bank, Asian Development Bank, and Gates Foundation will also be included. We will search and examine administrative information such as the Integrated Disease Surveillance Program (IDSP), the Health Management Information System (HMIS), and the Central Bureau of Health Intelligence (CBHI). We shall cross-reference relevant studies along with forward and backward screening of including studies, using Citation Chaser³⁶.

Search strategy developed in PubMed (MEDLINE) is provided in Appendix I.

Study selection

All citations found by the search will be compiled, imported, and separated from duplicates in Zotero v5.0.60 afterward³⁷. Two independent reviewers (SK and PB) will conduct screening of the titles and abstracts to determine if they meet the review's inclusion requirements. Studies that are relevant will be fully retrieved, and their citation information will be imported into the JBI System for the Unified Management, Assessment and Review of Information³⁶. The full text of the selected citations will be carefully examined by two independent reviewers (SK and PD) in accordance with the inclusion criteria (SK and PD). The final systematic review will include an appendix with the justifications for excluding full-text papers. Any discrepancies between the reviewers at each level of the screening selection procedure will be settled by consensus or with the advice of a third reviewer (DJ). The complete report of the search findings will be included in the final systematic review and presented as a flow diagram in accordance with PRISMA-2020³⁸.

Assessment of methodological quality

Prior to being included in the review, papers chosen for retrieval will be evaluated by two independent reviewers (SK and PD) for methodological validity using standardized critical evaluation tools. For all prevalence-based studies (irrespective of study designs) JBI Checklist for Prevalence/Incidence studies will be used⁴¹. Critical appraisal of studies reporting risk factors will be conducted using AXIS checklist for cross-sectional, and JBI checklists for case control and cohort^42,43. The reviewers will address any differences through consensus or through the help of a third reviewer (DJ).

Data extraction

Using the JBI SUMARI standardized data extraction tools, two independent reviewers (SK and PD) will perform data extraction from the publications that are included in the review. The data extracted will include study design, characteristics of the study participants, risk factors, exposures and outcomes, study period, study location, laboratory investigations, characteristics of study participants, gender, age distribution of cases, number of cases, year of publication and bibliographic information consisting of journal or preprint, year of publication, volume and page numbers, and the digital object identifier. Study participant and outcome characteristics are collected individually for cases and controls in case control studies or exposed and unexposed in cohort studies. Advice from a third reviewer (DJ) will be sought in case of any difference of opinion between the two reviewers. Authors of the articles will be approached as needed to obtain any missing data or additional information. Data will be taken from any publications authored by the reviewers' independent authors.

Appendix II provides the data extraction tool.

Data synthesis

The characteristics and results of included studies will be summarized using tables, supplemented by a narrative summary around; study ID, country of publication, type of micronutrient deficiency, study design, sample size, and other methodological features, suing a ‘characteristics of included studies’ table.

For prevalence outcomes, where feasible, following Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines, using logit and inverse logit transformations for proportion variance stabilization, the pooled proportion of each population sub-group related to incidence/prevalence will be shown, along with the 95% confidence intervals⁴⁴. Binomial-normal mixed effects regression model will be used to estimate the pooled proportion of prevalence and will be displayed using forest plots. P <0.05 will be considered as statistically significant. Sensitivity analysis will be carried by leaving out one study at a time in the order of publication to check for consistency of pooled estimates. This will be accomplished by examining the effects of including or removing large studies and its effects on pooled prevalence.

Wherever feasible, the following plausible subcategories will be examined: gender, age ranges, socioeconomic status and country for subgroup analysis. Study quality, pertinent exposures, and study design will all be considered when determining potential risk/etiology subgroups. The 'metafor' package of the statistical computer language R will be used for the analysis^45,46.

For primary outcomes related to risk or etiology, effect sizes will be expressed as odds ratios or risk ratios, and their 95% confidence intervals. Heterogeneity will be assessed statistically by using the standard χ² and I² tests and will be explored using subgroup analyses based on any systematic difference between the studies. Potential subgroups will be based on the study quality, exposures of interest, micronutrient deficiency outcomes, and study designs. Due to the nature of the observational and descriptive studies, a random effects model is most likely to be appropriate for meta-analysis. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.

The principles of meta-regression will be applied to measure the effect of different aspects of determinants (e.g., education) on micronutrient deficiencies. A two-stage meta-analysis method through application of a random effect regression model to multiple dose-response studies will be used as described in Berlin et al. (1998)⁴⁷. The “dosresmeta" package of R software (The R Foundation, Vienna, Austria) will be used for conducting dose-response meta-analysis if a sufficient number of studies are identified for such analysis⁴⁸.

Publication bias will be assessed using Egger's test and funnel plots if ≥ 10 studies are available.

Where statistical pooling is not possible due to heterogeneity, tables and figures will be used to present the results in a narrative synthesis. The final report will outline the sources of heterogeneity and the justification for pooling of data being undesirable will be reported.

Conflicts of interest

There is no conflict of interest.

Funding

No funding was sought for this study.

Acknowledgements

The authors express their gratitude to the Trustees of MANT for their generous support in facilitating the extension of their assistance for this review protocol.

Author Contributions

DJ identified the topic and is guarantor of the review. DJ, SK, PB and PD designed the search strategy and conducted searches. JM, CJ validated the list of diseases to be included. SK and DJ prepared the protocol draft and all others reviewed and edited the draft. All authors agreed to the final manuscript.

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Prevalence and risk factors of non-communicable diseases in indigenous populations of South Asia: a systematic review protocol

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Abstract

Introduction

Population

Types of outcomes

Inclusion criteria- Risk

Population

Exposure

Outcomes

Types of studies

Exclusion criteria

Methods

Assessment of methodological quality

Data extraction

Declarations

References

Supplementary Files

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