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Objectives Subjective social status is a known antecedent for many health outcomes, but little research has examined the association between subjective status and frailty among older people. Using longitudinal data, the goal of this study was, first, to identify latent trajectories of frailty over time, and second, to investigate the relationship between subjective social status and frailty trajectory.Methods Data were drawn from the 2002–2019 surveys of the English Longitudinal Study of Ageing, involving 9484 individuals aged 50+ years at baseline. Group-based trajectory models were used to identify frailty trajectories over the 18-year period, and multinomial regression models were used to investigate the relationship between subjective social status and frailty trajectory membership. Controls were included for confounding factors, including a range of socioeconomic indicators and health behaviours.Results Four trajectories of the frailty index were retained: low frailty (53% of participants), progressive mild frailty (25%), progressive moderate frailty (15%) and high frailty (6%). Higher subjective social status is associated with higher probabilities of being in the low-frailty group and lower probabilities of being in one of the progressive or high-frailty groups.Conclusions Subjective social status is significantly associated with being in a milder frailty trajectory after controlling for age, health behaviours and a wide range of objective socioeconomic status markers.

Objectives Exposures in utero and during infancy may impact the development of diseases later in life. They may be linked with development of frailty, although the mechanism is unclear. This study aims to determine the associations between early life risk factors and development of frailty among middle-aged and older adults as well as potential pathways via education, for any observed association.Design A cross-sectional study.Settings This study used data from UK Biobank, a large population-based cohort.Participants 502 489 individuals aged 37–73 years were included in the analysis.Primary and secondary outcome measures Early life factors in this study included being breast fed as a baby, maternal smoking, birth weight, the presence of perinatal diseases, birth month and birth place (in or outside the UK). We developed a frailty index comprising 49 deficits. We used generalised structural equation modelling to examine the associations between early life factors and development of frailty and whether any observed association was mediated via educational attainment.Results A history of breast feeding and normal birth weight were associated with a lower frailty index while maternal smoking, the occurrence of perinatal diseases and birth month with a longer day length were associated with a higher frailty index. Educational level mediated the relationship between these early life factors and frailty index.Conclusions This study highlights that biological and social risk occurring at different stages of life are related to the variations in frailty index in later life and suggests opportunities for prevention across the life course.

Background The WHO has warned that substandard and falsified medicines threaten health, especially in low and middle-income countries (LMICs). However, the magnitude of that threat for many medicines in different regions is not well described, and high-quality studies remain rare. Recent reviews of studies of cardiovascular and diabetes medicine quality recorded that 15.4% of cardiovascular and 6.8% of diabetes samples failed at least one quality test. Review authors warn that study quality was mixed. Because they did not record medicine volume, no study reflected the risk posed to patients.Methods and findings We investigated the quality of five medicines for cardiovascular disease and diabetes in Malang district, East Java, Indonesia. Our sample frame, based on dispensing volumes by outlet and price category, included sampling from public and private providers and pharmacies and reflected the potential risk posed to patients. The content of active ingredient was determined by high-performance liquid chromatography and compared with the labelled content. Dissolution testing was also performed.We collected a total of 204 samples: amlodipine (88); captopril (22); furosemide (21); glibenclamide (21) and simvastatin (52), comprising 83 different brands/products. All were manufactured in Indonesia, and all samples met specifications for both assay and dissolution. None was suspected of being falsified.Conclusions While we cannot conclude that the prevalence of poor-quality medicines in Malang district is zero, our sampling method, which reflects likely exposure to specific brands and outlets, suggests that the risk to patients is very low; certainly nothing like the rates found in recent reviews of surveys in LMICs. Our study demonstrates the feasibility of sampling medicines based on likely exposure to specific products and underlines the dangers of extrapolating results across countries.

Background Community health workers (CHWs) play a critical role in supporting health systems, and in improving accessibility to primary healthcare. In many settings CHW programmes do not have formalised employment models and face issues of high attrition and poor performance. This study aims to determine the employment preferences of CHWs in Malang district, Indonesia, to inform policy interventions.Methods A discrete choice experiment was conducted with 471 CHWs across 28 villages. Attributes relevant to CHW employment were identified through a multistage process including literature review, focus group discussions and expert consultation. Respondents’ choices were analysed with a mixed multinomial logit model and latent class analyses.Results Five attributes were identified: (1) supervision; (2) training; (3) monthly financial benefit; (4) recognition; and (5) employment structure. The most important influence on choice of job was a low monthly financial benefit (US$~2) (β=0.53, 95% CI=0.43 to 0.63), followed by recognition in the form of a performance feedback report (β=0.13, 95% CI=0.07 to 0.20). A large monthly financial benefit (US$~20) was most unappealing to respondents (β=−0.13, 95% CI=−0.23 to −0.03). Latent class analysis identified two groups of CHWs who differed in their willingness to accept either job presented and preferences over specific attributes. Preferences diverged based on respondent characteristics including experience, hours’ worked per week and income.Conclusion CHWs in Malang district, Indonesia, favour a small monthly financial benefit which likely reflects the unique cultural values underpinning the programme and a desire for remuneration that is commensurate with the limited number of hours worked. CHWs also desire enhanced methods of performance feedback and greater structure around training and their rights and responsibilities. Fulfilling these conditions may become increasingly important should CHWs work longer hours.

Objectives This study aims to examine sociodemographic characteristics and health access associated with COVID-19 infection and death in Malang District, Indonesia.Design A non-random cross-sectional study.Setting Population in 390 villages in Malang District, East Java Province, Indonesia.Participants We used Malang District government COVID-19 contact tracing data from 14 264 individuals, spanning from 1 March 2020 to 29 July 2020.Primary outcome measures The outcome variables in this study are COVID-19 infections and COVID-19 deaths. The associations between sociodemographic characteristics and health access of COVID-19 infection and death were analysed using multilevel logistic regression.Results Among the 14 264 samples, 551 individuals were confirmed as being infected with COVID-19; 62 individuals died of COVID-19. Women, individuals with direct contact with confirmed COVID-19 cases and individuals with hypertension constituted the groups most vulnerable to COVID-19 infection. Among respondents with confirmed COVID-19 cases, men, individuals aged 61 years and older, individuals with hypertension, and those diagnosed with pneumonia and respiratory failure were at higher risk of death. The number of community-based healthcare interventions was significantly associated with lower COVID-19 infection and COVID-19 mortality. Greater distance to a COVID-19 referral hospital increased risk of COVID-19 mortality.Conclusions COVID-19 infection and death were related not only to sociodemographic characteristics of individuals but also to the presence of community-based healthcare interventions and access to hospital care. Strategies in public health, including improving healthcare access, are required to reduce COVID-19 infections among the most susceptible groups in Indonesia.