Cardiovascular health through a sex and gender lens in six South Asian countries: Findings from the WHO STEPS surveillance

Abstract

Background Sex and gender-based differences in cardiovascular health (CVH) has been explored in the context of high-income countries. However, these relationships have not been examined in low- and middle-income countries. The main aim of this study was to examine how sex and gender-related factors are associated with cardiovascular risk factors of people in South Asian countries. Methods We conducted a retrospective analysis of the World Health Organization’s “STEPwise approach to surveillance of risk factors for non-communicable disease” or “STEPS” from six South Asian countries, surveys conducted between 2014-2019. The main outcomes were CVH as measured by a composite measure of STEPS-HEART health index (smoking, physical activity, fruit and vegetable consumption, overweight/obesity, diabetes and hypertension), values ranging from 0 (worst) to 6 (best or ideal) and self-reported occurrence of cardiovascular disease (ie, heart attack and stroke). Multivariate linear and logistic regression models were performed. Multiple imputation with chained equations was performed. Results The final analytic sample consisted of 33 106 participants (57.5% females). The mean STEPS-HEART index score in the South Asian population was 3.43 [SD: 0.92]. Female sex (β: 0.05, 95% confidence interval (CI) = 0.01-0.08, P < 0.05) was significantly associated with better CVH compared to males. Being married (β male = -0.30, 95% CI = -0.37, -0.23 vs β female = -0.23, 95% CI = -0.29, -0.17; P < 0.001) and having a household size ≥5 (β male = -0.15, 95% CI = -0.24, -0.06 vs β female = -0.11, 95% CI = -0.16, -0.04; P < 0.01) were associated with poorer CVH, more so in males. Being married was also associated with high risk of CVD (OR male = 2.54, 95% CI = 1.68-3.86, P < 0.001 vs OR female = 1.19, 95% CI = 0.84-1.68, P = 0.31), significant in males. Conclusions Among the South Asian population, being female may be advantageous in having an ideal CVH. However, gender-related factors such as marital status and large household size were associated with poorer CVH and greater risk of CVD, regardless of sex.

The SIMI Gender ‘5 Ws’ Rule for the integration of sex and gender-related variables in clinical studies towards internal medicine equitable research

“…Depending on the availability of data it might be worthy to test the effect of gender using a composite measure as was performed by GENESIS-PRAXY Investigators [9,10]. The methodology of constructing the gender score has been validated since the inception in cohorts from retrospective and prospective studies [11][12][13][14][15][16][17][18][19]. Furthermore, international scientists have been supporting the assessment of even one domain or few individual gender-related factors depending on the availability of data [20][21][22].…”

“…The applicability of the GENESIS-PRAXY methodology using retrospective cohorts have been tested in other contexts [11,12] and systematically incorporated as a potential tool in the application of the 'Gender Outcomes International Group: to Further Well-being Development' (GOING-FWD framework [13][14][15][16][17][18][19]. The GOING-FWD methodology has led to understand more clearly the effect of gender on outcomes also in population-based health surveys and in diverse clinical scenarios.…”

“…The GOING-FWD methodology has led to understand more clearly the effect of gender on outcomes also in population-based health surveys and in diverse clinical scenarios. The most intriguing finding is that the genderrelated factors included in the gender score measure vary by countries underlying the cultural and country-specific nature of gender [15][16][17][18][19].…”