Pascal Geldsetzer is an Assistant Professor of Medicine in the Division of Primary Care and Population Health and, by courtesy, in the Department of Epidemiology and Population Health. He is also affiliated with the Department of Biomedical Data Science, Department of Health Policy, King Center for Global Development, and the Stanford Centers for Population Health Sciences, Innovation in Global Health, and Artificial Intelligence in Medicine & Imaging.

His research focuses on identifying and evaluating the most effective interventions for improving health at older ages. In addition to leading several randomized trials, his methodological emphasis lies on the use of quasi-experimental approaches to ascertain causal effects in large observational datasets, particularly in electronic health record data. He has won an NIH New Innovator Award (in 2022), a Chan Zuckerberg Biohub investigatorship (in 2022), and two NIH R01 grants as Principal Investigator (both in 2023).

Academic Appointments

Honors & Awards

  • NIH New Innovator Award, NIAID (2022 – 2027)
  • Chan Zuckerberg Biohub investigator, Chan Zuckerberg Biohub (2022 – 2027)
  • Young Investigator Award, American Diabetes Association (2023)

Boards, Advisory Committees, Professional Organizations

  • Faculty Fellow, Center for Innovation in Global Health, Stanford University (2020 - Present)
  • Faculty Affiliate, King Center for Global Development, Stanford University (2020 - Present)

Professional Education

  • PhD, Harvard University (2018)
  • MPH, Harvard University (2012)
  • MD, University of Edinburgh (2011)

Clinical Trials

  • A Community Health Worker-Led LSSS Intervention in Bangladesh Recruiting

    The sodium found in salt is a powerful cause of high blood pressure, and most sodium ingested by humans is from their diet. High blood pressure is known to cause heart attacks and strokes, so various public health programs have attempted to find ways for people to reduce their salt intake to avoid these complications. These programs, however, have proven challenging, as asking people to alter their food preparation practices is often met with resistance. As such, we wish to test the blood pressure-lowering effects of low sodium salt substitute (LSSS), a salt substance in which a third of the compound by weight is composed of potassium (which does not increase blood pressure) rather than sodium. Additionally, the best way of supplying LSSS to people is yet unknown. We thus propose to study the effectiveness of an LSSS product by directly providing it via community health workers in 309 households in rural Bangladesh.

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  • Strengthening Primary Healthcare Delivery for Diabetes and Hypertension in Eswatini Recruiting

    The WHO-PEN@Scale project is a three-arm cluster-randomized trial that is investigating the population-level effects of a healthcare reform in Eswatini, which aims to strengthen primary care for diabetes and hypertension. Prior to the reform, healthcare for diabetes and hypertension was mostly provided through physician-led teams in hospital outpatient departments. The healthcare reform aims to strengthen the provision of nurse-led care for diabetes and hypertension in primary healthcare facilities and community health worker-led care for these conditions in the facilities' catchment areas. The reform will broadly be guided by the World Health Organization's "Package of Essential Noncommunicable Disease Interventions for Primary Health Care in Low-Resource Settings" (WHO-PEN). The trial will take place at 84 clusters (a primary healthcare facility and its catchment area) across the country.

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  • The Impact of Home Delivery of Antiretroviral Therapy on Virological Suppression Not Recruiting

    Home delivery of antiretroviral therapy (ART) by community health workers (CHWs) has the potential to reduce key barriers to ART care retention. The aim of this study is to determine whether CHW-led home delivery of ART for patients who are stable on ART combined with facility-based care for those not stable on ART is non-inferior to the standard of care (facility-based care for all ART patients) in achieving and maintaining virological suppression. The primary endpoint of this trial is the proportion of ART patients (regardless of whether they were clinically stable on ART at enrollment) who are in viral failure at the end of the study period. The non-inferiority design applies only to this primary endpoint. The margin of non-inferiority was set at a Risk Ratio (comparing intervention to control) of 1.45. This is a cluster-randomized controlled trial set in Dar es Salaam. The unit of randomization is a healthcare facility with its surrounding neighborhoods (the 'catchment area'). We matched all 48 healthcare facilities offering ART services and having affiliated public-sector CHWs in Dar es Salaam into pairs (stratified by district) based on having a similar number of patients currently on ART. In each pair, one cluster was randomized to the intervention and one to the control arm. The intervention consists of home visits by CHWs to provide counseling and deliver ART to patients who are stable on ART, while the control is the standard of care (facility-based ART care and CHW home visits at least every three months without ART home delivery). In addition, within each study arm, half of the healthcare facilities were randomized to enhanced CHW-led nutrition counseling and half to standard counseling.

    Stanford is currently not accepting patients for this trial.

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Stanford Advisees

All Publications

  • Disparities in air pollution attributable mortality in the US population by race/ethnicity and sociodemographic factors. Nature medicine Geldsetzer, P., Fridljand, D., Kiang, M. V., Bendavid, E., Heft-Neal, S., Burke, M., Thieme, A. H., Benmarhnia, T. 2024


    There are large differences in premature mortality in the USA by race/ethnicity, education, rurality and social vulnerability index groups. Using existing concentration-response functions, published particulate matter (PM2.5) air pollution estimates, population estimates at the census tract level and county-level mortality data from the US National Vital Statistics System, we estimated the degree to which these mortality discrepancies can be attributed to differences in exposure and susceptibility to PM2.5. We show that differences in PM2.5-attributable mortality were consistently more pronounced by race/ethnicity than by education, rurality or social vulnerability index, with the Black American population having the highest proportion of deaths attributable to PM2.5 in all years from 1990 to 2016. Our model estimates that over half of the difference in age-adjusted all-cause mortality between the Black American and non-Hispanic white population was attributable to PM2.5 in the years 2000 to 2011. This difference decreased only marginally between 2000 and 2015, from 53.4% (95% confidence interval 51.2-55.9%) to 49.9% (95% confidence interval 47.8-52.2%), respectively. Our findings underscore the need for targeted air quality interventions to address environmental health disparities.

    View details for DOI 10.1038/s41591-024-03117-0

    View details for PubMedID 38951636

    View details for PubMedCentralID 7439614

  • The prevalence of cardiovascular disease risk factors among adults living in extreme poverty. Nature human behaviour Geldsetzer, P., Tisdale, R. L., Stehr, L., Michalik, F., Lemp, J., Aryal, K. K., Damasceno, A., Houehanou, C., Jorgensen, J. M., Lunet, N., Mayige, M., Saeedi Moghaddam, S., Mwangi, K. J., Bommer, C., Marcus, M., Theilmann, M., Ebert, C., Atun, R., Davies, J. I., Flood, D., Manne-Goehler, J., Seiglie, J., Barnighausen, T., Vollmer, S. 2024


    Evidence on cardiovascular disease (CVD) risk factor prevalence among adults living below the World Bank's international line for extreme poverty (those with income <$1.90 per day) globally is sparse. Here we pooled individual-level data from 105 nationally representative household surveys across 78 countries, representing 85% of people living in extreme poverty globally, and sorted individuals by country-specific measures of household income or wealth to identify those in extreme poverty. CVD risk factors (hypertension, diabetes, smoking, obesity and dyslipidaemia) were present among 17.5% (95% confidence interval (CI) 16.7-18.3%), 4.0% (95% CI 3.6-4.5%), 10.6% (95% CI 9.0-12.3%), 3.1% (95% CI 2.8-3.3%) and 1.4% (95% CI 0.9-1.9%) of adults in extreme poverty, respectively. Most were not treated for CVD-related conditions (for example, among those with hypertension earning <$1.90 per day, 15.2% (95% CI 13.3-17.1%) reported taking blood pressure-lowering medication). The main limitation of the study is likely measurement error of poverty level and CVD risk factors that could have led to an overestimation of CVD risk factor prevalence among adults in extreme poverty. Nonetheless, our results could inform equity discussions for resource allocation and design of effective interventions.

    View details for DOI 10.1038/s41562-024-01840-9

    View details for PubMedID 38480824

  • Quasi-experimental evaluation of a nationwide diabetes prevention programme. Nature Lemp, J. M., Bommer, C., Xie, M., Michalik, F., Jani, A., Davies, J. I., Bärnighausen, T., Vollmer, S., Geldsetzer, P. 2023


    Diabetes is a leading cause of morbidity, mortality and cost of illness1,2. Health behaviours, particularly those related to nutrition and physical activity, play a key role in the development of type 2 diabetes mellitus3. Whereas behaviour change programmes (also known as lifestyle interventions or similar) have been found efficacious in controlled clinical trials4,5, there remains controversy about whether targeting health behaviours at the individual level is an effective preventive strategy for type 2 diabetes mellitus6 and doubt among clinicians that lifestyle advice and counselling provided in the routine health system can achieve improvements in health7-9. Here we show that being referred to the largest behaviour change programme for prediabetes globally (the English Diabetes Prevention Programme) is effective in improving key cardiovascular risk factors, including glycated haemoglobin (HbA1c), excess body weight and serum lipid levels. We do so by using a regression discontinuity design10, which uses the eligibility threshold in HbA1c for referral to the behaviour change programme, in electronic health data from about one-fifth of all primary care practices in England. We confirm our main finding, the improvement of HbA1c, using two other quasi-experimental approaches: difference-in-differences analysis exploiting the phased roll-out of the programme and instrumental variable estimation exploiting regional variation in programme coverage. This analysis provides causal, rather than associational, evidence that lifestyle advice and counselling implemented at scale in a national health system can achieve important health improvements.

    View details for DOI 10.1038/s41586-023-06756-4

    View details for PubMedID 37968391

    View details for PubMedCentralID 7478957

  • Patterns of tobacco use in low and middle income countries by tobacco product and sociodemographic characteristics: nationally representative survey data from 82 countries. BMJ (Clinical research ed.) Theilmann, M., Lemp, J. M., Winkler, V., Manne-Goehler, J., Marcus, M. E., Probst, C., Lopez-Arboleda, W. A., Ebert, C., Bommer, C., Mathur, M., Andall-Brereton, G., Bahendeka, S. K., Bovet, P., Farzadfar, F., Ghasemi, E., Mayige, M. T., Saeedi Moghaddam, S., Mwangi, K. J., Naderimagham, S., Sturua, L., Atun, R., Davies, J. I., Bärnighausen, T., Vollmer, S., Geldsetzer, P. 2022; 378: e067582


    To determine the prevalence and frequency of using any tobacco product and each of a detailed set of tobacco products, how tobacco use and frequency of use vary across countries, world regions, and World Bank country income groups, and the socioeconomic and demographic gradients of tobacco use and frequency of use within countries.Secondary analysis of nationally representative, cross-sectional, household survey data from 82 low and middle income countries collected between 1 January 2015 and 31 December 2020.Population based survey data.1 231 068 individuals aged 15 years and older.Self-reported current smoking, current daily smoking, current smokeless tobacco use, current daily smokeless tobacco use, pack years, and current use and use frequencies of each tobacco product. Products were any type of cigarette, manufactured cigarette, hand rolled cigarette, water pipe, cigar, oral snuff, nasal snuff, chewing tobacco, and betel nut (with and without tobacco).The smoking prevalence in the study sample was 16.5% (95% confidence interval 16.1% to 16.9%) and ranged from 1.1% (0.9% to 1.3%) in Ghana to 50.6% (45.2% to 56.1%) in Kiribati. The user prevalence of smokeless tobacco was 7.7% (7.5% to 8.0%) and prevalence was highest in Papua New Guinea (daily user prevalence of 65.4% (63.3% to 67.5%)). Although variation was wide between countries and by tobacco product, for many low and middle income countries, the highest prevalence and cigarette smoking frequency was reported in men, those with lower education, less household wealth, living in rural areas, and higher age.Both smoked and smokeless tobacco use and frequency of use vary widely across tobacco products in low and middle income countries. This study can inform the design and targeting of efforts to reduce tobacco use in low and middle income countries and serve as a benchmark for monitoring progress towards national and international goals.

    View details for DOI 10.1136/bmj-2021-067582

    View details for PubMedID 36041745

  • The Association of Socioeconomic Status With Hypertension in 76 Low- and Middle-Income Countries. Journal of the American College of Cardiology Kirschbaum, T. K., Sudharsanan, N., Manne-Goehler, J., De Neve, J. W., Lemp, J. M., Theilmann, M., Marcus, M. E., Ebert, C., Chen, S., Yoosefi, M., Sibai, A. M., Rouhifard, M., Moghaddam, S. S., Mayige, M. T., Martins, J. S., Lunet, N., Jorgensen, J. M., Houehanou, C., Farzadfar, F., Damasceno, A., Bovet, P., Bahendeka, S. K., Aryal, K. K., Andall-Brereton, G., Davies, J. I., Atun, R., Vollmer, S., Bärnighausen, T., Jaacks, L. M., Geldsetzer, P. 2022; 80 (8): 804-817


    Effective equity-focused health policy for hypertension in low- and middle-income countries (LMICs) requires an understanding of the condition's current socioeconomic gradients and how these are likely to change in the future as countries develop economically.This cross-sectional study aimed to determine how hypertension prevalence in LMICs varies by individuals' education and household wealth, and how these socioeconomic gradients in hypertension prevalence are associated with a country's gross domestic product (GDP) per capita.We pooled nationally representative household survey data from 76 LMICs. We disaggregated hypertension prevalence by education and household wealth quintile, and used regression analyses to adjust for age and sex.We included 1,211,386 participants in the analysis. Pooling across all countries, hypertension prevalence tended to be similar between education groups and household wealth quintiles. The only world region with a clear positive association of hypertension with education or household wealth quintile was Southeast Asia. Countries with a lower GDP per capita had, on average, a more positive association of hypertension with education and household wealth quintile than countries with a higher GDP per capita, especially in rural areas and among men.Differences in hypertension prevalence between socioeconomic groups were generally small, with even the least educated and least wealthy groups having a substantial hypertension prevalence. Our cross-sectional interaction analyses of GDP per capita with the socioeconomic gradients of hypertension suggest that hypertension may increasingly affect adults in the lowest socioeconomic groups as LMICs develop economically.

    View details for DOI 10.1016/j.jacc.2022.05.044

    View details for PubMedID 35981824

  • Variation in the Proportion of Adults in Need of BP-Lowering Medications by Hypertension Care Guideline in Low- and Middle-Income Countries: A Cross-Sectional Study of 1,037,215 Individuals from 50 Nationally Representative Surveys. Circulation Sudharsanan, N., Theilmann, M., Kirschbaum, T. K., Manne-Goehler, J., Azadnajafabad, S., Bovet, P., Chen, S., Damasceno, A., De Neve, J., Dorobantu, M., Ebert, C., Farzadfar, F., Gathecha, G., Gurung, M. S., Jamshidi, K., Jorgensen, J. M., Labadarios, D., Lemp, J., Lunet, N., Mwangi, J. K., Saeedi Moghaddam, S., Bahendeka, S. K., Zhumadilov, Z., Barnighausen, T., Vollmer, S., Atun, R., Davies, J. I., Geldsetzer, P. 2021


    Background: Current hypertension guidelines vary substantially in their definition of who should be offered blood-pressure-lowering medications. Understanding the impact of guideline choice on the proportion of adults who require treatment will be crucial for planning and scaling up hypertension care in low- and middle-income countries (LMICs). Methods: We extracted cross-sectional data on age, sex, blood pressure, hypertension treatment and diagnosis status, smoking, and body mass index for adults ages 30-70 from nationally representative surveys in 50 LMICs (N = 1,037,215). Our main objective was to determine the impact of hypertension guideline choice on the proportion of adults in need of blood-pressure-lowering medications. We considered four hypertension guidelines: the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline, the commonly used 140/90 mmHg threshold, the 2016 World Health Organization HEARTS guideline (WHO), and the 2019 United Kingdom National Institute for Health and Care Excellence (NICE) guideline. Results: The proportion of adults in need of blood-pressure-lowering medications was highest under the ACC/AHA followed by the 140/90, NICE, and WHO guidelines (ACC/AHA: women, 27.7% [95% CI: 27.2%, 28.2%], men, 35.0% [34.4%, 35.7%]; 140/90: women: 26.1% [25.5%, 26.6%], men, 31.2% [30.6%, 31.9%]; NICE: women, 11.8% [11.4%, 12.1%]; men, 15.7% [15.3%, 16.2%]; WHO: women, 9.2% [8.9%, 9.5%], men, 11.0% [10.6%,11.4%]). Individuals who were unaware that they have hypertension were the primary contributor to differences in the proportion needing treatment under different guideline criteria. Differences in the proportion needing blood-pressure-lowering medications were largest in the oldest, 65-69, age group (ACC/AHA: women, 60.2% [58.8%, 61.6%], men, 70.1% [68.8%, 71.3%]; WHO: women, 20.1% [18.8%, 21.3%], men, 24.1.0% [22.3%, 25.9%]). For both women and men and across all guidelines, countries in the European and Eastern Mediterranean regions had the highest proportion of adults in need of blood-pressure-lowering medicines while the South and Central Americas had the lowest. Conclusions: There was substantial variation in the proportion of adults in need of blood-pressure-lowering medications depending on which hypertension guideline was used. Given the great implications of this choice for health system capacity, policymakers will need to carefully consider which guideline they should adopt when scaling up hypertension care in their country.

    View details for DOI 10.1161/CIRCULATIONAHA.120.051620

    View details for PubMedID 33554610

  • Lifetime Prevalence of Cervical Cancer Screening in 55 Low- and Middle-Income Countries. JAMA Lemp, J. M., De Neve, J., Bussmann, H., Chen, S., Manne-Goehler, J., Theilmann, M., Marcus, M., Ebert, C., Probst, C., Tsabedze-Sibanyoni, L., Sturua, L., Kibachio, J. M., Moghaddam, S. S., Martins, J. S., Houinato, D., Houehanou, C., Gurung, M. S., Gathecha, G., Farzadfar, F., Dryden-Peterson, S., Davies, J. I., Atun, R., Vollmer, S., Barnighausen, T., Geldsetzer, P. 2020; 324 (15): 1532–42


    Importance: The World Health Organization is developing a global strategy to eliminate cervical cancer, with goals for screening prevalence among women aged 30 through 49 years. However, evidence on prevalence levels of cervical cancer screening in low- and middle-income countries (LMICs) is sparse.Objective: To determine lifetime cervical cancer screening prevalence in LMICs and its variation across and within world regions and countries.Design, Setting, and Participants: Analysis of cross-sectional nationally representative household surveys carried out in 55 LMICs from 2005 through 2018. The median response rate across surveys was 93.8% (range, 64.0%-99.3%). The population-based sample consisted of 1 136 289 women aged 15 years or older, of whom 6885 (0.6%) had missing information for the survey question on cervical cancer screening.Exposures: World region, country; countries' economic, social, and health system characteristics; and individuals' sociodemographic characteristics.Main Outcomes and Measures: Self-report of having ever had a screening test for cervical cancer.Results: Of the 1 129 404 women included in the analysis, 542 475 were aged 30 through 49 years. A country-level median of 43.6% (interquartile range [IQR], 13.9%-77.3%; range, 0.3%-97.4%) of women aged 30 through 49 years self-reported to have ever been screened, with countries in Latin America and the Caribbean having the highest prevalence (country-level median, 84.6%; IQR, 65.7%-91.1%; range, 11.7%-97.4%) and those in sub-Saharan Africa the lowest prevalence (country-level median, 16.9%; IQR, 3.7%-31.0%; range, 0.9%-50.8%). There was large variation in the self-reported lifetime prevalence of cervical cancer screening among countries within regions and among countries with similar levels of per capita gross domestic product and total health expenditure. Within countries, women who lived in rural areas, had low educational attainment, or had low household wealth were generally least likely to self-report ever having been screened.Conclusions and Relevance: In this cross-sectional study of data collected in 55 low- and middle-income countries from 2005 through 2018, there was wide variation between countries in the self-reported lifetime prevalence of cervical cancer screening. However, the median prevalence was only 44%, supporting the need to increase the rate of screening.

    View details for DOI 10.1001/jama.2020.16244

    View details for PubMedID 33079153

  • Mapping physical access to health care for older adults in sub-Saharan Africa and implications for the COVID-19 response: a cross-sectional analysis LANCET HEALTHY LONGEVITY Geldsetzer, P., Reinmuth, M., Ouma, P. O., Lautenbach, S., Okiro, E. A., Baernighausen, T., Zipf, A. 2020; 1 (1): E32-E42


    Severe acute respiratory syndrome coronavirus 2, the virus causing COVID-19, is rapidly spreading across sub-Saharan Africa. Hospital-based care for COVID-19 is often needed, particularly among older adults. However, a key barrier to accessing hospital care in sub-Saharan Africa is travel time to the nearest health-care facility. To inform the geographical targeting of additional health-care resources, we aimed to estimate travel time at a 1 km × 1 km resolution to the nearest hospital and to the nearest health-care facility of any type for adults aged 60 years and older in sub-Saharan Africa.We assembled a dataset on the geolocation of health-care facilities, separately for hospitals and any type of health-care facility and including both private-sector and public-sector facilities, using data from the OpenStreetMap project and the Kenya Medical Research Institute-Wellcome Trust Programme. Population data at a 1 km × 1 km resolution were obtained from WorldPop. We estimated travel time to the nearest health-care facility for each 1 km × 1 km grid using a cost-distance algorithm.9·6% (95% CI 5·2-16·9) of adults aged 60 years or older across sub-Saharan Africa had an estimated travel time to the nearest hospital of 6 h or longer, varying from 0·0% (0·0-3·7) in Burundi and The Gambia to 40·9% (31·8-50·7) in Sudan. For the nearest health-care facility of any type (whether primary, secondary, or tertiary care), 15·9% (95% CI 10·1-24·4) of adults aged 60 years or older across sub-Saharan Africa had an estimated travel time of 2 h or longer, ranging from 0·4% (0·0-4·4) in Burundi to 59·4% (50·1-69·0) in Sudan. Most countries in sub-Saharan Africa contained populated areas in which adults aged 60 years and older had a travel time to the nearest hospital of 12 h or longer and to the nearest health-care facility of any type of 6 h or longer. The median travel time to the nearest hospital for the fifth of adults aged 60 years or older with the longest travel times was 348 min (IQR 240-576; equal to 5·8 h) for the entire population of sub-Saharan Africa, ranging from 41 min (34-54) in Burundi to 1655 min (1065-2440; equal to 27·6 h) in Gabon.Our high-resolution maps of estimated travel times to both hospitals and health-care facilities of any type can be used by policy makers and non-governmental organisations to help target additional health-care resources, such as makeshift hospitals or transport programmes to existing health-care facilities, to older adults with the least physical access to care. In addition, this analysis shows the locations of population groups most likely to under-report COVID-19 symptoms because of low physical access to health-care facilities. Beyond the COVID-19 response, this study can inform the efforts of countries to improve physical access to care for conditions that are common among older adults in the region, such as chronic non-communicable diseases.Bill & Melinda Gates Foundation.

    View details for Web of Science ID 000659222500010

    View details for PubMedID 34173615

    View details for PubMedCentralID PMC7574846

  • A stepped-wedge randomized trial and qualitative survey of HIV pre-exposure prophylaxis uptake in the Eswatini population. Science translational medicine Geldsetzer, P., Barnighausen, K., Hettema, A., McMahon, S. A., Dalal, S., Chase, R. P., Oldenburg, C. E., Kohler, S., Chen, S., Dlamini, P., Mavuso, M., Hughey, A. B., Matse, S., Barnighausen, T. 2020; 12 (562)


    Clinical trials have shown that antiretroviral drugs used as pre-exposure prophylaxis (PrEP) are highly effective for preventing HIV acquisition. PrEP efforts, including in sub-Saharan Africa, have almost exclusively focused on certain priority groups, particularly female sex workers, men having sex with men, pregnant women, serodiscordant couples, and young women. As part of a PrEP demonstration project involving the general population at six primary health care facilities in Eswatini (formerly Swaziland), we conducted a randomized trial of a health care facility-based PrEP promotion package designed to increase PrEP uptake. Over the 18-month study duration, 33.6% (517 of 1538) of adults identified by health care workers as being at risk of acquiring HIV took up PrEP, and 30.0% of these individuals attended all scheduled appointments during the first 6 months after initiation of PrEP. The PrEP promotion package was associated with a 55% (95% confidence interval, 15 to 110%; P = 0.036) relative increase in the number of individuals taking up PrEP, with an absolute increase of 2.2 individuals per month per health care facility. When asked how PrEP uptake could be improved in 217 accompanying in-depth qualitative interviews, interviewees recommended an expansion of PrEP promotion activities beyond health care facilities to communities. Although a health care facility-based promotion package improved PrEP uptake, both uptake and retention remained low. Expanding promotion activities to the community is needed to achieve greater PrEP coverage among adults at risk of HIV infection in Eswatini and similar settings.

    View details for DOI 10.1126/scitranslmed.aba4487

    View details for PubMedID 32967974

  • The Contribution of the Age Distribution of Cases to COVID-19 Case Fatality Across Countries: A 9-Country Demographic Study. Annals of internal medicine Sudharsanan, N., Didzun, O., Barnighausen, T., Geldsetzer, P. 2020


    BACKGROUND: There is wide variation in coronavirus disease 2019 (COVID-19) case-fatality rates (CFRs) across countries, leading to uncertainty about the true lethality of the disease. A large part of this variation may be due to the ages of individuals who are tested and identified.OBJECTIVE: To measure the contribution of distortions from the age distributions of confirmed cases to CFRs within and across populations.DESIGN: Cross-sectional demographic study using aggregate data on COVID-19 cases and deaths by age.SETTING: Population-based data from China, France, Germany, Italy, the Netherlands, South Korea, Spain, Switzerland, and the United States.PARTICIPANTS: All individuals with confirmed COVID-19, as reported by each country as of 19 April 2020 (N= 1223261).MEASUREMENTS: Age-specific COVID-19 CFRs and age-specific population shares by country.RESULTS: The overall observed CFR varies widely, with the highest rates in Italy (9.3%) and the Netherlands (7.4%) and the lowest rates in South Korea (1.6%) and Germany (0.7%). Adjustment for the age distribution of cases explains 66% of the variation of across countries, with a resulting age-standardized median CFR of 1.9%. Among a larger sample of 95 countries, the observed variation in COVID-19 CFRs is 13 times larger than what would be expected on the basis of just differences in the age-composition of countries.LIMITATION: The age-adjusted rates assume that, conditional on age, COVID-19 mortality among diagnosed cases is the same as that among undiagnosed cases and that individuals of all ages are equally susceptible to severe acute respiratory syndrome coronavirus 2 infection.CONCLUSION: Selective testing and identifying of older cases considerably warps estimates of the lethality of COVID-19 within populations and comparisons across countries. Removing age distortions and focusing on differences in age-adjusted case fatality will be essential for accurately comparing countries' performance in caring for patients with COVID-19 and for monitoring the epidemic over time.PRIMARY FUNDING SOURCE: Alexander von Humboldt Foundation.

    View details for DOI 10.7326/M20-2973

    View details for PubMedID 32698605

  • Knowledge and Perceptions of COVID-19 Among the General Public in the United States and the United Kingdom: A Cross-sectional Online Survey. Annals of internal medicine Geldsetzer, P. n. 2020

    View details for DOI 10.7326/M20-0912

    View details for PubMedID 32196071

  • The Effect Of Home-Based Hypertension Screening On Blood Pressure Change Over Time In South Africa. Health affairs (Project Hope) Sudharsanan, N., Chen, S., Garber, M., Barnighausen, T., Geldsetzer, P. 2020; 39 (1): 124–32


    There is considerable policy interest in home-based screening campaigns for hypertension in many low- and middle-income countries. However, it is unclear whether such efforts will result in long-term population-level blood pressure improvements without more comprehensive interventions that strengthen the entire hypertension care continuum. Using multiple waves of the South African National Income Dynamics Study and the regression discontinuity design, we evaluated the impact of home-based hypertension screening on two-year change in blood pressure. We found that the home-based screening intervention resulted in important reductions in systolic blood pressure for women and younger men. We did not find evidence of an effect on systolic blood pressure for older men or on diastolic blood pressure for either sex. Our results suggest that home-based hypertension screening may be a promising strategy for reducing high blood pressure in low- and middle-income countries, but additional research and policy efforts are needed to ensure that such strategies have maximum reach and impact.

    View details for DOI 10.1377/hlthaff.2019.00585

    View details for PubMedID 31905068

  • Anaemia among men in India: a nationally representative cross-sectional study LANCET GLOBAL HEALTH Didzun, O., De Neve, J., Awasthi, A., Dubey, M., Theilmann, M., Barnighausen, T., Vollmer, S., Geldsetzer, P. 2019; 7 (12): E1685–E1694


    Population-based studies on anaemia in India have mostly focused on women and children, with men with anaemia receiving much less attention despite anaemia's adverse effect on health, wellbeing, and economic productivity. This study aimed to determine the national prevalence of anaemia among men in India; how the prevalence of anaemia in men varies across India among states and districts and by sociodemographic characteristics; and whether the geographical and sociodemographic variation in the prevalence of anaemia among men is similar to that among women to inform whether anaemia reduction efforts for men should be coupled with existing efforts for women.In this cross-sectional study, we analysed data from a nationally representative household survey carried out from January, 2015, to December, 2016, among men aged 15-54 years and women aged 15-49 years in all 29 states and seven Union Territories of India. Haemoglobin concentration was measured using the portable HemoCue Hb 201+ (HemoCue AB, Ängelholm, Sweden) and a capillary blood sample. In addition to disaggregating anaemia prevalence (separately in men and women) by state and age group, we used mixed-effects Poisson regression to determine individual-level and district-level predictors of anaemia.106 298 men and 633 305 women were included in our analysis. In men, the prevalence of any anaemia was 23·2% (95% CI 22·7-23·7), moderate or severe anaemia was 5·1% (4·9-5·4), and severe anaemia was 0·5% (0·5-0·6). An estimated 21·7% (20·9-22·5) of men with any degree of anaemia had moderate or severe anaemia compared with 53·2% (52·9-53·5) of women with any anaemia. Men aged 20-34 years had the lowest probability of having anaemia whereas anaemia prevalence among women was similar across age groups. State-level prevalence of any anaemia in men varied from 9·2% (7·7-10·9) in Manipur to 32·9% (31·0-34·7) in Bihar. The individual-level predictors of less household wealth, lower education, living in a rural area, smoking, consuming smokeless tobacco, and being underweight and the district-level predictors of living in a district with a lower rate of primary school completion, level of urbanisation, and household wealth were all associated with a higher probability of anaemia in men. Although some important exceptions were noted, district-level and state-level prevalence of anaemia among men correlated strongly with that among women.Anaemia among men in India is an important public health problem. Because of the similarities in the patterns of geographical and sociodemographic variation of anaemia between men and women, future efforts to reduce anaemia among men could target similar population groups as those targeted in existing efforts to reduce anaemia among women.Alexander von Humboldt Foundation.

    View details for DOI 10.1016/S2214-109X(19)30440-1

    View details for Web of Science ID 000496201100030

    View details for PubMedID 31708149

  • The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1.1 million adults LANCET Geldsetzer, P., Manne-Goehler, J., Marcus, M., Ebert, C., Zhumadilov, Z., Wesseh, C. S., Tsabedze, L., Supiyev, A., Sturua, L., Bahendeka, S. K., Sibai, A. M., Quesnel-Crooks, S., Norov, B., Mwangi, K. J., Mwalim, O., Wong-McClure, R., Mayige, M. T., Martins, J. S., Lunet, N., Labadarios, D., Karki, K. B., Kagaruki, G. B., Jorgensen, J. A., Hwalla, N. C., Houinato, D., Houehanou, C., Msaidie, M., Guwatudde, D., Gurung, M. S., Gathecha, G., Dorobantu, M., Damasceno, A., Bovet, P., Bicaba, B. W., Aryal, K. K., Andall-Brereton, G., Agoudavi, K., Stokes, A., Davies, J. I., Baernighausen, T., Atun, R., Vollmer, S., Jaacks, L. M. 2019; 394 (10199): 652–62


    Evidence from nationally representative studies in low-income and middle-income countries (LMICs) on where in the hypertension care continuum patients are lost to care is sparse. This information, however, is essential for effective targeting of interventions by health services and monitoring progress in improving hypertension care. We aimed to determine the cascade of hypertension care in 44 LMICs-and its variation between countries and population groups-by dividing the progression in the care process, from need of care to successful treatment, into discrete stages and measuring the losses at each stage.In this cross-sectional study, we pooled individual-level population-based data from 44 LMICs. We first searched for nationally representative datasets from the WHO Stepwise Approach to Surveillance (STEPS) from 2005 or later. If a STEPS dataset was not available for a LMIC (or we could not gain access to it), we conducted a systematic search for survey datasets; the inclusion criteria in these searches were that the survey was done in 2005 or later, was nationally representative for at least three 10-year age groups older than 15 years, included measured blood pressure data, and contained data on at least two hypertension care cascade steps. Hypertension was defined as a systolic blood pressure of at least 140 mm Hg, diastolic blood pressure of at least 90 mm Hg, or reported use of medication for hypertension. Among those with hypertension, we calculated the proportion of individuals who had ever had their blood pressure measured; had been diagnosed with hypertension; had been treated for hypertension; and had achieved control of their hypertension. We weighted countries proportionally to their population size when determining this hypertension care cascade at the global and regional level. We disaggregated the hypertension care cascade by age, sex, education, household wealth quintile, body-mass index, smoking status, country, and region. We used linear regression to predict, separately for each cascade step, a country's performance based on gross domestic product (GDP) per capita, allowing us to identify countries whose performance fell outside of the 95% prediction interval.Our pooled dataset included 1 100 507 participants, of whom 192 441 (17·5%) had hypertension. Among those with hypertension, 73·6% of participants (95% CI 72·9-74·3) had ever had their blood pressure measured, 39·2% of participants (38·2-40·3) had been diagnosed with hypertension, 29·9% of participants (28·6-31·3) received treatment, and 10·3% of participants (9·6-11·0) achieved control of their hypertension. Countries in Latin America and the Caribbean generally achieved the best performance relative to their predicted performance based on GDP per capita, whereas countries in sub-Saharan Africa performed worst. Bangladesh, Brazil, Costa Rica, Ecuador, Kyrgyzstan, and Peru performed significantly better on all care cascade steps than predicted based on GDP per capita. Being a woman, older, more educated, wealthier, and not being a current smoker were all positively associated with attaining each of the four steps of the care cascade.Our study provides important evidence for the design and targeting of health policies and service interventions for hypertension in LMICs. We show at what steps and for whom there are gaps in the hypertension care process in each of the 44 countries in our study. We also identified countries in each world region that perform better than expected from their economic development, which can direct policy makers to important policy lessons. Given the high disease burden caused by hypertension in LMICs, nationally representative hypertension care cascades, as constructed in this study, are an important measure of progress towards achieving universal health coverage.Harvard McLennan Family Fund, Alexander von Humboldt Foundation.

    View details for DOI 10.1016/S0140-6736(19)30955-9

    View details for Web of Science ID 000483011200029

    View details for PubMedID 31327566

  • Hypertension screening, awareness, treatment, and control in India: A nationally representative cross-sectional study among individuals aged 15 to 49 years PLOS MEDICINE Prenissl, J., Manne-Goehler, J., Jaacks, L. M., Prabhakaran, D., Awasthi, A., Bischops, A., Atun, R., Baernighausen, T., Davies, J. I., Vollmer, S., Geldsetzer, P. 2019; 16 (5): e1002801


    Evidence on where in the hypertension care process individuals are lost to care, and how this varies among states and population groups in a country as large as India, is essential for the design of targeted interventions and to monitor progress. Yet, to our knowledge, there has not yet been a nationally representative analysis of the proportion of adults who reach each step of the hypertension care process in India. This study aimed to determine (i) the proportion of adults with hypertension who have been screened, are aware of their diagnosis, take antihypertensive treatment, and have achieved control and (ii) the variation of these care indicators among states and sociodemographic groups.We used data from a nationally representative household survey carried out from 20 January 2015 to 4 December 2016 among individuals aged 15-49 years in all states and union territories (hereafter "states") of the country. The stages of the care process-computed among those with hypertension at the time of the survey-were (i) having ever had one's blood pressure (BP) measured before the survey ("screened"), (ii) having been diagnosed ("aware"), (iii) currently taking BP-lowering medication ("treated"), and (iv) reporting being treated and not having a raised BP ("controlled"). We disaggregated these stages by state, rural-urban residence, sex, age group, body mass index, tobacco consumption, household wealth quintile, education, and marital status. In total, 731,864 participants were included in the analysis. Hypertension prevalence was 18.1% (95% CI 17.8%-18.4%). Among those with hypertension, 76.1% (95% CI 75.3%-76.8%) had ever received a BP measurement, 44.7% (95% CI 43.6%-45.8%) were aware of their diagnosis, 13.3% (95% CI 12.9%-13.8%) were treated, and 7.9% (95% CI 7.6%-8.3%) had achieved control. Male sex, rural location, lower household wealth, and not being married were associated with greater losses at each step of the care process. Between states, control among individuals with hypertension varied from 2.4% (95% CI 1.7%-3.3%) in Nagaland to 21.0% (95% CI 9.8%-39.6%) in Daman and Diu. At 38.0% (95% CI 36.3%-39.0%), 28.8% (95% CI 28.5%-29.2%), 28.4% (95% CI 27.7%-29.0%), and 28.4% (95% CI 27.8%-29.0%), respectively, Puducherry, Tamil Nadu, Sikkim, and Haryana had the highest proportion of all adults (irrespective of hypertension status) in the sampled age range who had hypertension but did not achieve control. The main limitation of this study is that its results cannot be generalized to adults aged 50 years and older-the population group in which hypertension is most common.Hypertension prevalence in India is high, but the proportion of adults with hypertension who are aware of their diagnosis, are treated, and achieve control is low. Even after adjusting for states' economic development, there is large variation among states in health system performance in the management of hypertension. Improvements in access to hypertension diagnosis and treatment are especially important among men, in rural areas, and in populations with lower household wealth.

    View details for DOI 10.1371/journal.pmed.1002801

    View details for Web of Science ID 000470187500006

    View details for PubMedID 31050680

    View details for PubMedCentralID PMC6499417

  • Impact of Coming Demographic Changes on the Number of Adults in Need of Care for Hypertension in Brazil, China, India, Indonesia, Mexico, and South Africa A Modeling Study HYPERTENSION Sudharsanan, N., Geldsetzer, P. 2019; 73 (4): 770–76


    Over the coming decades, middle-income countries are expected to undergo substantial demographic changes. We estimated the consequences of these changes on the number of adults in need of hypertension care between 2015 and 2050 using nationally representative household-survey data collected in Brazil, China, India, Indonesia, Mexico, and South Africa (N=770 121). To reflect unmet need for healthcare, we defined hypertension as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg regardless of treatment status. Using a mathematical disease projection equation, we calculated the change in the number of individuals in need of hypertension care in each country that was due to changes in population size, age composition, and age-specific prevalence under various epidemiological scenarios. If the current age-specific prevalence schedule of hypertension remains unchanged until 2050, demographic changes alone will increase the number of adults in need of hypertension care by 319.7 million individuals, ranging from a relative growth of 55% in China to 151% in Mexico. Even if the age-specific prevalence of hypertension is reduced by 25% by 2050 among adults aged ≥40 years, the number of individuals in need of hypertension care will still increase by 145.9 million individuals, with relative increases ranging from 16% in China to 88% in Mexico. Overall, our results suggest that coming demographic changes in middle-income countries will overpower even ideal prevention efforts. Middle-income countries will need to massively expand healthcare services for aging-related diseases, such as hypertension, if they are to meet the virtually inevitable future increase in care needs for these conditions.

    View details for DOI 10.1161/HYPERTENSIONAHA.118.12337

    View details for Web of Science ID 000469351200004

    View details for PubMedID 30739534

  • Community health workers to improve uptake of maternal healthcare services: A cluster-randomized pragmatic trial in Dar es Salaam, Tanzania PLOS MEDICINE Geldsetzer, P., Mboggo, E., Larson, E., Lema, I., Magesa, L., Machumi, L., Ulenga, N., Sando, D., Mwanyika-Sando, M., Spiegelman, D., Mungure, E., Li, N., Siril, H., Mujinja, P., Naburi, H., Chalamilla, G., Kilewo, C., Ekstrom, A., Foster, D., Fawzi, W., Baernighausen, T. 2019; 16 (3): e1002768


    Home delivery and late and infrequent attendance at antenatal care (ANC) are responsible for substantial avoidable maternal and pediatric morbidity and mortality in sub-Saharan Africa. This cluster-randomized trial aimed to determine the impact of a community health worker (CHW) intervention on the proportion of women who (i) visit ANC fewer than 4 times during their pregnancy and (ii) deliver at home.As part of a 2-by-2 factorial design, we conducted a cluster-randomized trial of a home-based CHW intervention in 2 of 3 districts of Dar es Salaam from 18 June 2012 to 15 January 2014. Thirty-six wards (geographical areas) in the 2 districts were randomized to the CHW intervention, and 24 wards to the standard of care. In the standard-of-care arm, CHWs visited women enrolled in prevention of mother-to-child HIV transmission (PMTCT) care and provided information and counseling. The intervention arm included additional CHW supervision and the following additional CHW tasks, which were targeted at all pregnant women regardless of HIV status: (i) conducting home visits to identify pregnant women and refer them to ANC, (ii) counseling pregnant women on maternal health, and (iii) providing home visits to women who missed an ANC or PMTCT appointment. The primary endpoints of this trial were the proportion of pregnant women (i) not making at least 4 ANC visits and (ii) delivering at home. The outcomes were assessed through a population-based household survey at the end of the trial period. We did not collect data on adverse events. A random sample of 2,329 pregnant women and new mothers living in the study area were interviewed during home visits. At the time of the survey, the mean age of participants was 27.3 years, and 34.5% (804/2,329) were pregnant. The proportion of women who reported having attended fewer than 4 ANC visits did not differ significantly between the intervention and standard-of-care arms (59.1% versus 60.7%, respectively; risk ratio [RR]: 0.97; 95% CI: 0.82-1.15; p = 0.754). Similarly, the proportion reporting that they had attended ANC in the first trimester did not differ significantly between study arms. However, women in intervention wards were significantly less likely to report having delivered at home (3.9% versus 7.3%; RR: 0.54; 95% CI: 0.30-0.95; p = 0.034). Mixed-methods analyses of additional data collected as part of this trial suggest that an important reason for the lack of effect on ANC outcomes was the perceived high economic burden and inconvenience of attending ANC. The main limitations of this trial were that (i) the outcomes were ascertained through self-report, (ii) the study was stopped 4 months early due to a change in the standard of care in the other trial that was part of the 2-by-2 factorial design, and (iii) the sample size of the household survey was not prespecified.A home-based CHW intervention in urban Tanzania significantly reduced the proportion of women who reported having delivered at home, in an area that already has very high uptake of facility-based delivery. The intervention did not affect self-reported ANC attendance. Policy makers should consider piloting, evaluating, and scaling interventions to lessen the economic burden and inconvenience of NCT01932138.

    View details for DOI 10.1371/journal.pmed.1002768

    View details for Web of Science ID 000462996000012

    View details for PubMedID 30925181

    View details for PubMedCentralID PMC6440613

  • Community delivery of antiretroviral drugs: A non-inferiority cluster-randomized pragmatic trial in Dar es Salaam, Tanzania PLOS MEDICINE Geldsetzer, P., Francis, J. M., Sando, D., Asmus, G., Lema, I. A., Mboggo, E., Koda, H., Lwezaula, S., Ambikapathi, R., Fawzi, W., Ulenga, N., Baernighausen, T. 2018; 15 (9): e1002659


    With the increase in people living with HIV in sub-Saharan Africa and expanding eligibility criteria for antiretroviral therapy (ART), there is intense interest in the use of novel delivery models that allow understaffed health systems to successfully deal with an increasing demand for antiretroviral drugs (ARVs). This pragmatic randomized controlled trial in Dar es Salaam, Tanzania, evaluated a novel model of ARV community delivery: lay health workers (home-based carers [HBCs]) deliver ARVs to the homes of patients who are clinically stable on ART, while nurses and physicians deliver standard facility-based care for patients who are clinically unstable. Specifically, the trial aimed to assess whether the ARV community delivery model performed at least equally well in averting virological failure as the standard of care (facility-based care for all ART patients).The study took place from March 1, 2016, to October 27, 2017. All (48) healthcare facilities in Dar es Salaam that provided ART and had an affiliated team of public-sector HBCs were randomized 1:1 to either (i) ARV community delivery (intervention) or (ii) the standard of care (control). Our prespecified primary endpoint was the proportion of adult non-pregnant ART patients with virological failure at the end of the study period. The prespecified margin of non-inferiority was a risk ratio (RR) of 1.45. The mean follow-up period was 326 days. We obtained intent-to-treat (ITT) RRs using a log-binomial model adjusting standard errors for clustering at the level of the healthcare facility. A total of 2,172 patients were enrolled at intervention (1,163 patients) and control (1,009 patients) facilities. Of the 1,163 patients in the intervention arm, 516 (44.4%) were both clinically stable on ART and opted to receive ARVs in their homes or at another meeting point of their choosing in the community. At the end of the study period, 10.9% (95/872) of patients in the control arm and 9.7% (91/943) in the intervention arm were failing virologically. The ITT RR for virological failure demonstrated non-inferiority of the ARV community delivery model (RR 0.89 [1-sided 95% CI 0.00-1.18]). We observed no significant difference between study arms in self-reported patient healthcare expenditures over the last 6 months before study exit. Of those who received ARVs in the community, 97.2% (95% CI 94.7%-98.7%) reported being either "satisfied" or "very satisfied" with the program. Other than loss to follow-up (18.9% in the intervention and 13.6% in the control arm), the main limitation of this trial was that substantial decongestion of healthcare facilities was not achieved, thus making the logic for our preregistered ITT approach (which includes those ineligible to receive ARVs at home in the intervention sample) less compelling.In this study, an ARV community delivery model performed at least as well as the standard of care regarding the critical health indicator of virological failure. The intervention did not significantly reduce patient healthcare expenditures, but satisfaction with the program was high and it is likely to save patients time. Policy-makers should consider piloting, evaluating, and scaling more ambitious ARV community delivery programs that can reach higher proportions of ART NCT02711293.

    View details for DOI 10.1371/journal.pmed.1002659

    View details for Web of Science ID 000445914900011

    View details for PubMedID 30231024

    View details for PubMedCentralID PMC6145501

  • Geographic and sociodemographic variation of cardiovascular disease risk in India: A cross-sectional study of 797,540 adults PLOS MEDICINE Geldsetzer, P., Manne-Goehler, J., Theilmann, M., Davies, J., Awasthi, A., Danaei, G., Gaziano, T. A., Vollmer, S., Jaacks, L. M., Baernighausen, T., Atun, R. 2018; 15 (6): e1002581


    Cardiovascular disease (CVD) is the leading cause of mortality in India. Yet, evidence on the CVD risk of India's population is limited. To inform health system planning and effective targeting of interventions, this study aimed to determine how CVD risk-and the factors that determine risk-varies among states in India, by rural-urban location, and by individual-level sociodemographic characteristics.We used 2 large household surveys carried out between 2012 and 2014, which included a sample of 797,540 adults aged 30 to 74 years across India. The main outcome variable was the predicted 10-year risk of a CVD event as calculated with the Framingham risk score. The Harvard-NHANES, Globorisk, and WHO-ISH scores were used in secondary analyses. CVD risk and the prevalence of CVD risk factors were examined by state, rural-urban residence, age, sex, household wealth, and education. Mean CVD risk varied from 13.2% (95% CI: 12.7%-13.6%) in Jharkhand to 19.5% (95% CI: 19.1%-19.9%) in Kerala. CVD risk tended to be highest in North, Northeast, and South India. District-level wealth quintile (based on median household wealth in a district) and urbanization were both positively associated with CVD risk. Similarly, household wealth quintile and living in an urban area were positively associated with CVD risk among both sexes, but the associations were stronger among women than men. Smoking was more prevalent in poorer household wealth quintiles and in rural areas, whereas body mass index, high blood glucose, and systolic blood pressure were positively associated with household wealth and urban location. Men had a substantially higher (age-standardized) smoking prevalence (26.2% [95% CI: 25.7%-26.7%] versus 1.8% [95% CI: 1.7%-1.9%]) and mean systolic blood pressure (126.9 mm Hg [95% CI: 126.7-127.1] versus 124.3 mm Hg [95% CI: 124.1-124.5]) than women. Important limitations of this analysis are the high proportion of missing values (27.1%) in the main outcome variable, assessment of diabetes through a 1-time capillary blood glucose measurement, and the inability to exclude participants with a current or previous CVD event.This study identified substantial variation in CVD risk among states and sociodemographic groups in India-findings that can facilitate effective targeting of CVD programs to those most at risk and most in need. While the CVD risk scores used have not been validated in South Asian populations, the patterns of variation in CVD risk among the Indian population were similar across all 4 risk scoring systems.

    View details for DOI 10.1371/journal.pmed.1002581

    View details for Web of Science ID 000437409600012

    View details for PubMedID 29920517

    View details for PubMedCentralID PMC6007838

  • Diabetes and Hypertension in India A Nationally Representative Study of 1.3 Million Adults JAMA INTERNAL MEDICINE Geldsetzer, P., Manne-Goehler, J., Theilmann, M., Davies, J. I., Awasthi, A., Vollmer, S., Jaacks, L. M., Baernighausen, T., Atun, R. 2018; 178 (3): 363–72


    Understanding how diabetes and hypertension prevalence varies within a country as large as India is essential for targeting of prevention, screening, and treatment services. However, to our knowledge there has been no prior nationally representative study of these conditions to guide the design of effective policies.To determine the prevalence of diabetes and hypertension in India, and its variation by state, rural vs urban location, and individual-level sociodemographic characteristics.This was a cross-sectional, nationally representative, population-based study carried out between 2012 and 2014. A total of 1 320 555 adults 18 years or older with plasma glucose (PG) and blood pressure (BP) measurements were included in the analysis.State, rural vs urban location, age, sex, household wealth quintile, education, and marital status.Diabetes (PG level ≥126 mg/dL if the participant had fasted or ≥200 mg/dL if the participant had not fasted) and hypertension (systolic BP≥140 mm Hg or diastolic BP≥90 mm Hg).Of the 1 320 555 adults, 701 408 (53.1%) were women. The crude prevalence of diabetes and hypertension was 7.5% (95% CI, 7.3%-7.7%) and 25.3% (95% CI, 25.0%-25.6%), respectively. Notably, hypertension was common even among younger age groups (eg, 18-25 years: 12.1%; 95% CI, 11.8%-12.5%). Being in the richest household wealth quintile compared with being in the poorest quintile was associated with only a modestly higher probability of diabetes (rural: 2.81 percentage points; 95% CI, 2.53-3.08 and urban: 3.47 percentage points; 95% CI, 3.03-3.91) and hypertension (rural: 4.15 percentage points; 95% CI, 3.68-4.61 and urban: 3.01 percentage points; 95% CI, 2.38-3.65). The differences in the probability of both conditions by educational category were generally small (≤2 percentage points). Among states, the crude prevalence of diabetes and hypertension varied from 3.2% (95% CI, 2.7%-3.7%) to 19.9% (95% CI, 17.6%-22.3%), and 18.0% (95% CI, 16.6%-19.5%) to 41.6% (95% CI, 37.8%-45.5%), respectively.Diabetes and hypertension prevalence is high in middle and old age across all geographical areas and sociodemographic groups in India, and hypertension prevalence among young adults is higher than previously thought. Evidence on the variations in prevalence by state, age group, and rural vs urban location is critical to effectively target diabetes and hypertension prevention, screening, and treatment programs to those most in need.

    View details for DOI 10.1001/jamainternmed.2017.8094

    View details for Web of Science ID 000427030000010

    View details for PubMedID 29379964

    View details for PubMedCentralID PMC5885928

  • Preferences regarding COVID-19 vaccination among 12,000 adults in China: A cross-sectional discrete choice experiment. PLOS global public health Yu, F., Jiao, L., Chen, Q., Wang, Q., De Allegri, M., Cao, Z., Chen, W., Ma, X., Wang, C., Wachinger, J., Jin, Z., Bunker, A., Geldsetzer, P., Yang, J., Xue, L., Bärnighausen, T., Chen, S. 2024; 4 (7): e0003387


    Understanding public preferences concerning vaccination is critical to inform pandemic response strategies. To investigate Chinese adults' preferences regarding COVID-19 vaccine attributes, we conducted a cross-sectional online survey in 12,000 Chinese adults in June-July, 2021. Participants were requested to answer a series of discrete choice questions related to hypothetical COVID-19 vaccines. Using mixed logit models, our analysis revealed that participants had a higher preference for COVID-19 vaccines with longer duration of protection (coefficient: 1.272, 95% confidence interval [1.016 to 1.529]) and higher efficacy (coefficient: 1.063, [0.840, 1.287]). Conversely, participants demonstrated a lower preference associated with higher risk of rare but serious side-effects (coefficient: -1.158, [-1.359, -0.958]), oral administration (coefficient: -0.211, [-0.377, -0.046]), more doses (coefficient: -0.148, [-0.296, 0.000]) and imported origin (coefficient: -0.653, [-0.864, -0.443]). Moreover, preferences were heterogeneous by individual factors: highly educated participants were more sensitive to the negative vaccine attributes including price (coefficient -0.312, [-0.370, -0.253]) and imported vaccine (coefficient -0.941, [-1.186, -0.697]); there was also substantial heterogeneity in vaccine preferences with respect to age group, marital status, work status, income, chronic diagnosis history, COVID-19 vaccination history and geographic regions. As the first study of examining the public preferences for COVID-19 vaccine in China with a large nationwide sample of 12,000 adults, our results indicate that future vaccine should pose lower risk, possess longer protection period, have higher efficacy, be domestically produced, and have lower costs to increase the COVID-19 vaccination coverage. Our current study findings from this study provide insights and recommendations for not only COVID-19 vaccine design but also vaccine attribute preferences to increase vaccine uptake in potential future pandemics.

    View details for DOI 10.1371/journal.pgph.0003387

    View details for PubMedID 38990924

    View details for PubMedCentralID PMC11239003

  • Portable spirometer-based pulmonary function test willingness in China: A nationwide cross-sectional study from the "Happy Breathing Program". Chinese medical journal Qi, W., Huang, K., Chen, Q., Jiao, L., Yu, F., Yu, Y., Niu, H., Li, W., Fang, F., Lei, J., Chu, X., Li, Z., Geldsetzer, P., Barnighausen, T., Chen, S., Yang, T., Wang, C. 2024


    BACKGROUND: Understanding willingness to undergo pulmonary function tests (PFTs) and the factors associated with poor uptake of PFTs is crucial for improving early detection and treatment of chronic obstructive pulmonary disease (COPD). This study aimed to understand willingness to undergo PFTs among high-risk populations and identify any barriers that may contribute to low uptake of PFTs.METHODS: We collected data from participants in the "Happy Breathing Program" in China. Participants who did not follow physicians' recommendations to undergo PFTs were invited to complete a survey regarding their willingness to undergo PFTs and their reasons for not undergoing PFTs. We estimated the proportion of participants who were willing to undergo PFTs and examined the various reasons for participants to not undergo PFTs. We conducted univariable and multivariable logistic regressions to analyze the impact of individual-level factors on willingness to undergo PFTs.RESULTS: A total of 8475 participants who had completed the survey on willingness to undergo PFTs were included in this study. Out of these participants, 7660 (90.4%) were willing to undergo PFTs. Among those who were willing to undergo PFTs but actually did not, the main reasons for not doing so were geographical inaccessibility (n=3304, 43.1%) and a lack of trust in primary healthcare institutions (n=2809, 36.7%). Among the 815 participants who were unwilling to undergo PFTs, over half (n= 447, 54.8%) believed that they did not have health problems and would only consider PFTs when they felt unwell. In the multivariable regression, individuals who were ≤54 years old, residing in rural townships, with a secondary educational level, with medical reimbursement, still working, with occupational exposure to dust, and aware of the abbreviation "COPD" were more willing to undergo PFTs.CONCLUSIONS: Willingness to undergo PFTs was high among high-risk populations. Policymakers may consider implementing strategies such as providing financial incentives, promoting education, and establishing community-based programs to enhance the utilization of PFTs.

    View details for DOI 10.1097/CM9.0000000000003121

    View details for PubMedID 38955430

  • Frailty progression in adults aged 40 years and older in rural Burkina Faso: a longitudinal, population-based study. The lancet. Healthy longevity Goodman-Palmer, D., Greig, C., Agyapong-Badu, S., Witham, M. D., Payne, C. F., Bountogo, M., Coulibaly, B., Geldsetzer, P., Harling, G., Inghels, M., Manne-Goehler, J., Ouermi, L., Sie, A., Davies, J. I. 2024; 5 (7): e493-e502


    Little is known about ageing and frailty progression in low-income settings. We aimed to describe frailty changes over time in individuals living in rural Burkina Faso and to assess which sociodemographic, disability, and multimorbidity factors are associated with frailty progression and mortality.This longitudinal, population-based study was conducted at the Nouna Health and Demographic Surveillance Systems (HDSS) site in northwestern Burkina Faso. Eligible participants were aged 40 years or older and had been primarily resident in a household within the HDSS area for at least the past 6 months before the baseline survey and were selected from the 2015 HDSS household census using a stratified random sample of adults living in unique households within the area. Participants were interviewed in their homes in 2018 (baseline), 2021 (follow-up), or both. We derived the Fried frailty score for each participant at each timepoint using data on grip strength, gait speed, self-reported weight loss, self-reported exhaustion, and physical activity, and described changes in frailty status (no frailty, pre-frailty, or frailty) between 2018 and 2021. We used multivariate regression models to assess factors (ie, sex, age, marital status, educational attainment, wealth quintile, WHO Disability Assessment Schedule (WHODAS) score, and multimorbidity) associated with frailty progression (either worsening frailty status or dying, compared with frailty status remaining the same or improving) and with mortality, and developed sequential models: unadjusted, adjusting for sociodemographic factors (sex, age, marital status, educational attainment, and wealth quintile), and adjusting for sociodemographic factors, disability, and multimorbidity.Between May 25 and July 19, 2018, and between July 1 and Aug 22, 2021, 5952 individuals were invited to participate: 1709 (28·7%) did not consent, 1054 (17·8%) participated in 2018 only and were lost to follow-up, 1214 (20·4%) participated in 2021 only, and 1975 (33·2%) were included in both years or died between years. Of 1967 participants followed up with complete demographic data, 190 (9·7%) were frail or unable to complete the frailty assessment in 2018, compared with 77 (3·9%) in 2021. Between 2018 and 2021, frailty status improved in 567 (28·8%) participants and worsened in 327 (16·6%), and 101 (5·1%) participants died. The relative risk of frailty status worsening or of dying (compared with frailty impRoving or no change) increased with age and WHODAS score, whereas female sex appeared protective. After controlling for all sociodemographic factors, multimorbidity, and WHODAS score, odds of mortality were 1·07 (odds ratio 2·07, 95% CI 1·05-4·09) times higher among pre-frail individuals and 1·1 (2·21, 0·90-5·41) times higher among frail individuals than among non-frail individuals.Frailty status was highly dynamic in this low-income setting and appears to be modifiable. Given the rapid increase in the numbers of older adults in low-income or middle-income countries, understanding the behaviour of frailty in these settings is of high importance for the development of policies and health systems to ensure the maintenance of health and wellbeing in ageing populations. Future work should focus on designing context-appropriate interventions to improve frailty status.Alexander Von Humboldt Foundation, Institute for Global Innovation, University of Birmingham, and Wellcome Trust.

    View details for DOI 10.1016/S2666-7568(24)00096-5

    View details for PubMedID 38945131

  • The Association Between Depressive Symptoms, Access to Diabetes Care, and Glycemic Control in Five Middle-Income Countries. Diabetes care Merkel, L., Teufel, F., Malta, D. C., Theilmann, M., Marcus, M. E., Flood, D., Geldsetzer, P., Manne-Goehler, J., Petrak, F., Vollmer, S., Davies, J. 2024


    The relationship between depression, diabetes, and access to diabetes care is established in high-income countries (HICs) but not in middle-income countries (MICs), where contexts and health systems differ and may impact this relationship. In this study, we investigate access to diabetes care for individuals with and without depressive symptoms in MICs.We analyzed pooled data from nationally representative household surveys across Brazil, Chile, China, Indonesia, and Mexico. Validated survey tools Center for Epidemiologic Studies Depression Scale Revised, Composite International Diagnostic Interview, Short Form, and Patient Health Questionnaire identified participants with depressive symptoms. Diabetes, defined per World Health Organization Package of Essential Noncommunicable Disease Interventions guidelines, included self-reported medication use and biochemical data. The primary focus was on tracking diabetes care progression through the stages of diagnosis, treatment, and glycemic control. Descriptive and multivariable logistic regression analyses, accounting for gender, age, education, and BMI, examined diabetes prevalence and care continuum progression.The pooled sample included 18,301 individuals aged 50 years and above; 3,309 (18.1%) had diabetes, and 3,934 (21.5%) exhibited depressive symptoms. Diabetes prevalence was insignificantly higher among those with depressive symptoms (28.9%) compared with those without (23.8%, P = 0.071). Co-occurrence of diabetes and depression was associated with increased odds of diabetes detection (odds ratio [OR] 1.398, P < 0.001) and treatment (OR 1.344, P < 0.001), but not with higher odds of glycemic control (OR 0.913, P = 0.377).In MICs, individuals aged 50 years and older with diabetes and depression showed heightened diabetes identification and treatment probabilities, unlike patterns seen in HICs. This underscores the unique interplay of these conditions in different income settings.

    View details for DOI 10.2337/dc23-1507

    View details for PubMedID 38917276

  • Global Prevalence of Aspirin Use for Primary Prevention of Cardiovascular Disease: A Cross-Sectional Study of Nationally Representative, Individual-Level Data. Global heart Yoo, S. G., Chung, G. S., Bahendeka, S. K., Sibai, A. M., Damasceno, A., Farzadfar, F., Rohloff, P., Houehanou, C., Norov, B., Karki, K. B., Azangou-Khyavy, M., Marcus, M. E., Aryal, K. K., Brant, L. C., Theilmann, M., Cífková, R., Lunet, N., Gurung, M. S., Mwangi, J. K., Martins, J., Haghshenas, R., Sturua, L., Vollmer, S., Bärnighausen, T., Atun, R., Sussman, J. B., Singh, K., Moghaddam, S. S., Guwatudde, D., Geldsetzer, P., Manne-Goehler, J., Huffman, M. D., Davies, J. I., Flood, D. 2024; 19 (1): 44

    View details for DOI 10.5334/gh.1323

    View details for PubMedID 38708405

    View details for PubMedCentralID PMC11067965

  • Association between concurrence of multiple risk factors and under-5 mortality: a pooled analysis of data from Demographic and Health Survey in 61 low-and-middle-income countries. EClinicalMedicine Kong, Y., Chen, S., Ma, N., Chen, Z., Karoli, P., Niyi, J. L., Fan, P., Fink, G., Kwete, X. J., Wehrmeister, F. C., Cheng, F., Wang, D., Zemene, M. A., Gatimu, S. M., Khan, N., Rahman, A., Fekadu, L., Shibre, G., Rahmartani, L. D., Aheto, J. M., Geldsetzer, P., Li, Z. 2024; 71: 102583


    Exposure to multiple risk factors is prevalent in low-and middle-income countries (LMICs), challenging one-directional strategies to address preventable under-5 mortality (U5M). This study aims to assess the associations between concurrence of multiple risk factors and U5M in LMICs.We extracted data from the Demographic and Health Surveys conducted between 2010 and 2021 across 61 LMICs. Our primary outcome was U5M, defined as deaths from birth to 59 months. Binary logistic regression model was applied to ascertain the association between U5M and a total of 20 critical risk factors. Upon identifying the risk factors demonstrating the strongest associations, we investigated the simultaneous presence of multiple risk factors in each individual and assessed their combined effects on U5M with logistic regression models.Of the 604,372 under-5 children, 18,166 (3.0%) died at the time of the survey. Unsatisfied family planning needs was the strongest risk factor for U5M (odds ratio [OR]: 2.0, 95% confidence interval [CI]: 1.9-2.1), followed by short birth interval (<18 months; OR: 2.0, 95% CI: 1.9-2.1), small birth size (OR: 2.0, 95% CI: 1.8-2.1), never breastfed or delayed breastfeeding (OR: 2.0, 95% CI: 1.9-2.0), and low maternal education (OR: 1.6, 95% CI: 1.4-1.8). 66.7% (66.6%-66.8%) of the children had 2 or more leading risk factors simultaneously. Simultaneous presence of multiple leading risk factors was significantly associated with elevated risk of U5M and children presenting with all 5 leading risk factors exhibited an exceedingly high risk of U5M (OR: 5.2, 95% CI: 4.3-6.3); a dose-response relationship between the number of risk factors and U5M was also observed-with the increment of numbers of leading risk factors, the U5M showed an increasing trend (p-trend < 0.001).Exposure to multiple risk factors is very common in LMICs and underscores the necessity of developing multisectoral and integrated approaches to accelerate progress in reducing U5M in line with the SDG 3.2.This research is funded by Research Fund, Vanke School of Public Health, Tsinghua University.

    View details for DOI 10.1016/j.eclinm.2024.102583

    View details for PubMedID 38618201

    View details for PubMedCentralID PMC11015335

  • Cost-effectiveness of population-based screening for chronic obstructive pulmonary disease in China: a simulation modeling study. The Lancet regional health. Western Pacific Chen, Q., Fan, Y., Huang, K., Li, W., Geldsetzer, P., Bärnighausen, T., Yang, T., Wang, C., Chen, S. 2024; 46: 101065


    China has the highest disease burden of chronic obstructive pulmonary disease (COPD) in the world; however, the diagnosis rate remains low. Screening for COPD in the population may improve early diagnosis and long-term health outcomes for patients with COPD. In this study, we aimed to evaluate the cost-effectiveness of population-based COPD screening policies in China.We developed a microsimulation model that simulated incidence, natural history, and clinical management of COPD over a lifetime horizon among the general population aged 35-80 years in China. We evaluated population-based screening policies with different screening methods (one-step with COPD Screening Questionnaire or two-step with additional portable spirometer test) and frequencies (one-time or every 1-10 years). We calculated the incremental cost-effectiveness ratio (ICER) of the screening policies compared with the status quo (without screening) and identified the most cost-effective screening policy. Scenario and sensitivity analyses were performed to assess the impact of key parameters and the robustness of model results.Compared with the status quo, all population-based COPD screening policies were cost-effective with estimated ICERs ranging between $8034 and $13,209 per quality-adjusted-life-year (QALY), all under the willingness-to-pay value of $38,441/QALY (three times China's gross domestic product per capita). A total of 0.39%-8.10% of COPD-related deaths and 0.58%-2.70% of COPD exacerbations were projected to be averted by COPD screening. Among all screening policies, annual two-step screening was the most cost-effective. Improving the linkage from screening to diagnosis and treatment could further increase population health benefits and the cost-effectiveness of COPD screening.Population-based screening for COPD could be cost-effective in China. Offering public programs for COPD screening similar to existing preventive health services for other chronic diseases could be a promising strategy to improve population health outcomes and mitigate the disease burden of COPD in China.Alexander von Humboldt Foundation, National Natural Science Foundation of China, CAMS Innovation Fund for Medical Science, Chinese Academy of Engineering project, and Horizon Europe.

    View details for DOI 10.1016/j.lanwpc.2024.101065

    View details for PubMedID 38721063

    View details for PubMedCentralID PMC11077022

  • Prevalence and Associated Factors of E-Cigarette Use and Susceptibility Among Adolescents in China. American journal of respiratory and critical care medicine Min, K., Wang, M., Wang, C., Geldsetzer, P., Barnighausen, T., Wang, C., Liu, J., Chen, S., Yang, J. 2024

    View details for DOI 10.1164/rccm.202402-0421LE

    View details for PubMedID 38564414

  • Multiple cardiovascular risk factor care in 55 low- and middle-income countries: A cross-sectional analysis of nationally-representative, individual-level data from 280,783 adults. PLOS global public health Diallo, A. O., Marcus, M. E., Flood, D., Theilmann, M., Rahim, N. E., Kinlaw, A., Franceschini, N., Stürmer, T., Tien, D. V., Abbasi-Kangevari, M., Agoudavi, K., Andall-Brereton, G., Aryal, K., Bahendeka, S., Bicaba, B., Bovet, P., Dorobantu, M., Farzadfar, F., Ghamari, S. H., Gathecha, G., Guwatudde, D., Gurung, M., Houehanou, C., Houinato, D., Hwalla, N., Jorgensen, J., Kagaruki, G., Karki, K., Martins, J., Mayige, M., McClure, R. W., Moghaddam, S. S., Mwalim, O., Mwangi, K. J., Norov, B., Quesnel-Crooks, S., Sibai, A., Sturua, L., Tsabedze, L., Wesseh, C., Geldsetzer, P., Atun, R., Vollmer, S., Bärnighausen, T., Davies, J., Ali, M. K., Seiglie, J. A., Gower, E. W., Manne-Goehler, J. 2024; 4 (3): e0003019


    The prevalence of multiple age-related cardiovascular disease (CVD) risk factors is high among individuals living in low- and middle-income countries. We described receipt of healthcare services for and management of hypertension and diabetes among individuals living with these conditions using individual-level data from 55 nationally representative population-based surveys (2009-2019) with measured blood pressure (BP) and diabetes biomarker. We restricted our analysis to non-pregnant individuals aged 40-69 years and defined three mutually exclusive groups (i.e., hypertension only, diabetes only, and both hypertension-diabetes) to compare individuals living with concurrent hypertension and diabetes to individuals with each condition separately. We included 90,086 individuals who lived with hypertension only, 11,975 with diabetes only, and 16,228 with hypertension-diabetes. We estimated the percentage of individuals who were aware of their diagnosis, used pharmacological therapy, or achieved appropriate hypertension and diabetes management. A greater percentage of individuals with hypertension-diabetes were fully diagnosed (64.1% [95% CI: 61.8-66.4]) than those with hypertension only (47.4% [45.3-49.6]) or diabetes only (46.7% [44.1-49.2]). Among the hypertension-diabetes group, pharmacological treatment was higher for individual conditions (38.3% [95% CI: 34.8-41.8] using antihypertensive and 42.3% [95% CI: 39.4-45.2] using glucose-lowering medications) than for both conditions jointly (24.6% [95% CI: 22.1-27.2]).The percentage of individuals achieving appropriate management was highest in the hypertension group (17.6% [16.4-18.8]), followed by diabetes (13.3% [10.7-15.8]) and hypertension-diabetes (6.6% [5.4-7.8]) groups. Although health systems in LMICs are reaching a larger share of individuals living with both hypertension and diabetes than those living with just one of these conditions, only seven percent achieved both BP and blood glucose treatment targets. Implementation of cost-effective population-level interventions that shift clinical care paradigm from disease-specific to comprehensive CVD care are urgently needed for all three groups, especially for those with multiple CVD risk factors.

    View details for DOI 10.1371/journal.pgph.0003019

    View details for PubMedID 38536787

    View details for PubMedCentralID PMC10971750

  • Effectiveness of an Artificial Intelligence-Enabled Intervention for Detecting Clinical Deterioration. JAMA internal medicine Gallo, R. J., Shieh, L., Smith, M., Marafino, B. J., Geldsetzer, P., Asch, S. M., Shum, K., Lin, S., Westphal, J., Hong, G., Li, R. C. 2024


    Inpatient clinical deterioration is associated with substantial morbidity and mortality but may be easily missed by clinicians. Early warning scores have been developed to alert clinicians to patients at high risk of clinical deterioration, but there is limited evidence for their effectiveness.To evaluate the effectiveness of an artificial intelligence deterioration model-enabled intervention to reduce the risk of escalations in care among hospitalized patients using a study design that facilitates stronger causal inference.This cohort study used a regression discontinuity design that controlled for confounding and was based on Epic Deterioration Index (EDI; Epic Systems Corporation) prediction model scores. Compared with other observational research, the regression discontinuity design facilitates causal analysis. Hospitalized adults were included from 4 general internal medicine units in 1 academic hospital from January 17, 2021, through November 16, 2022.An artificial intelligence deterioration model-enabled intervention, consisting of alerts based on an EDI score threshold with an associated collaborative workflow among nurses and physicians.The primary outcome was escalations in care, including rapid response team activation, transfer to the intensive care unit, or cardiopulmonary arrest during hospitalization.During the study, 9938 patients were admitted to 1 of the 4 units, with 963 patients (median [IQR] age, 76.1 [64.2-86.2] years; 498 males [52.3%]) included within the primary regression discontinuity analysis. The median (IQR) Elixhauser Comorbidity Index score in the primary analysis cohort was 10 (0-24). The intervention was associated with a -10.4-percentage point (95% CI, -20.1 to -0.8 percentage points; P = .03) absolute risk reduction in the primary outcome for patients at the EDI score threshold. There was no evidence of a discontinuity in measured confounders at the EDI score threshold.Using a regression discontinuity design, this cohort study found that the implementation of an artificial intelligence deterioration model-enabled intervention was associated with a significantly decreased risk of escalations in care among inpatients. These results provide evidence for the effectiveness of this intervention and support its further expansion and testing in other care settings.

    View details for DOI 10.1001/jamainternmed.2024.0084

    View details for PubMedID 38526472

  • Interviewer biases in medical survey data: The example of blood pressure measurements. PNAS nexus Geldsetzer, P., Chang, A. Y., Meijer, E., Sudharsanan, N., Charu, V., Kramlinger, P., Haarburger, R. 2024; 3 (3): pgae109


    Health agencies rely upon survey-based physical measures to estimate the prevalence of key global health indicators such as hypertension. Such measures are usually collected by nonhealthcare worker personnel and are potentially subject to measurement error due to variations in interviewer technique and setting, termed "interviewer effects." In the context of physical measurements, particularly in low- and middle-income countries, interviewer-induced biases have not yet been examined. Using blood pressure as a case study, we aimed to determine the relative contribution of interviewer effects on the total variance of blood pressure measurements in three large nationally representative health surveys from the Global South. We utilized 169,681 observations between 2008 and 2019 from three health surveys (Indonesia Family Life Survey, National Income Dynamics Study of South Africa, and Longitudinal Aging Study in India). In a linear mixed model, we modeled systolic blood pressure as a continuous dependent variable and interviewer effects as random effects alongside individual factors as covariates. To quantify the interviewer effect-induced uncertainty in hypertension prevalence, we utilized a bootstrap approach comparing subsamples of observed blood pressure measurements to their adjusted counterparts. Our analysis revealed that the proportion of variation contributed by interviewers to blood pressure measurements was statistically significant but small: ∼0.24--2.2% depending on the cohort. Thus, hypertension prevalence estimates were not substantially impacted at national scales. However, individual extreme interviewers could account for measurement divergences as high as 12%. Thus, highly biased interviewers could have important impacts on hypertension estimates at the subdistrict level.

    View details for DOI 10.1093/pnasnexus/pgae109

    View details for PubMedID 38525305

    View details for PubMedCentralID PMC10959064

  • Subnational estimates of vitamin A supplementation coverage in children: a geospatial analysis of 45 low- and middle-income countries. Public health Seufert, J., Krishnan, N., Darmstadt, G. L., Wang, G., Bärnighausen, T., Geldsetzer, P. 2024; 228: 194-199


    Vitamin A supplementation (VAS) can protect children from the adverse health consequences of vitamin A deficiency. Granular data on VAS coverage can guide global and national efforts to achieve universal VAS coverage. To provide geographically precise targeting of VAS programs and to monitor progress in reducing geographic disparities, we aimed to create high-resolution (5 × 5 km2) maps of VAS coverage in children under 5 years across VAS priority countries.We used cross-sectional data from the Demographic and Health Surveys (DHS) program.We used data from the DHS program for United Nations Children's Fund -designated VAS priority countries between 2000 and 2017 with data available from 2005 or later. The outcome variable was the proportion of children under 5 years who received a vitamin A dose in each sampled cluster. We applied a Bayesian geostatistical approach incorporating geographic, climatic, and nutritional covariates to estimate VAS coverage for each cell. We estimated and mapped absolute VAS coverage, Bayesian uncertainty intervals, and exceedance probabilities.Our sample included countries from Latin America and the Caribbean, Asia, and Africa. Most countries had estimated VAS coverage levels <70%, and our exceedance probabilities indicated high certainty that our estimates fell below this threshold in most grid cells. International variations were most notable in the Latin America and the Caribbean region and Africa. Intranational variations were greatest in some South Asian and West and Central African countries.These prevalence and exceedance maps, especially used with data on indicators of VAS need, could help to improve equity.

    View details for DOI 10.1016/j.puhe.2024.01.018

    View details for PubMedID 38394746

  • Hypertension care cascades and reducing inequities in cardiovascular disease in low- and middle-income countries. Nature medicine Stein, D. T., Reitsma, M. B., Geldsetzer, P., Agoudavi, K., Aryal, K. K., Bahendeka, S., Brant, L. C., Farzadfar, F., Gurung, M. S., Guwatudde, D., Houehanou, Y. C., Malta, D. C., Martins, J. S., Saeedi Moghaddam, S., Mwangi, K. J., Norov, B., Sturua, L., Zhumadilov, Z., Bärnighausen, T., Davies, J. I., Flood, D., Marcus, M. E., Theilmann, M., Vollmer, S., Manne-Goehler, J., Atun, R., Sudharsanan, N., Verguet, S. 2024


    Improving hypertension control in low- and middle-income countries has uncertain implications across socioeconomic groups. In this study, we simulated improvements in the hypertension care cascade and evaluated the distributional benefits across wealth quintiles in 44 low- and middle-income countries using individual-level data from nationally representative, cross-sectional surveys. We raised diagnosis (diagnosis scenario) and treatment (treatment scenario) levels for all wealth quintiles to match the best-performing country quintile and estimated the change in 10-year cardiovascular disease (CVD) risk of individuals initiated on treatment. We observed greater health benefits among bottom wealth quintiles in middle-income countries and in countries with larger baseline disparities in hypertension management. Lower-middle-income countries would see the greatest absolute benefits among the bottom quintiles under the treatment scenario (29.1 CVD cases averted per 1,000 people living with hypertension in the bottom quintile (Q1) versus 17.2 in the top quintile (Q5)), and the proportion of total CVD cases averted would be largest among the lowest quintiles in upper-middle-income countries under both diagnosis (32.0% of averted cases in Q1 versus 11.9% in Q5) and treatment (29.7% of averted cases in Q1 versus 14.0% in Q5) scenarios. Targeted improvements in hypertension diagnosis and treatment could substantially reduce socioeconomic-based inequalities in CVD burden in low- and middle-income countries.

    View details for DOI 10.1038/s41591-023-02769-8

    View details for PubMedID 38278990

    View details for PubMedCentralID 7755038

  • Individual characteristics associated with road traffic collisions and healthcare seeking in low- and middle-income countries and territories. PLOS global public health Ghalichi, L., Goodman-Palmer, D., Whitaker, J., Abio, A., Wilson, M. L., Wallis, L., Norov, B., Aryal, K. K., Malta, D. C., Bärnighausen, T., Geldsetzer, P., Flood, D., Vollmer, S., Theilmann, M., Davies, J. 2024; 4 (1): e0002768


    Incidence of road traffic collisions (RTCs), types of users involved, and healthcare requirement afterwards are essential information for efficient policy making. We analysed individual-level data from nationally representative surveys conducted in low- or middle-income countries (LMICs) between 2008-2019. We describe the weighted incidence of non-fatal RTC in the past 12 months, type of road user involved, and incidence of traffic injuries requiring medical attention. Multivariable logistic regressions were done to evaluate associated sociodemographic and economic characteristics, and alcohol use. Data were included from 90,790 individuals from 15 countries or territories. The non-fatal RTC incidence in participants aged 24-65 years was 5.2% (95% CI: 4.6-5.9), with significant differences dependent on country income status. Drivers, passengers, pedestrians and cyclists composed 37.2%, 40.3%, 11.3% and 11.2% of RTCs, respectively. The distribution of road user type varied with country income status, with divers increasing and cyclists decreasing with increasing country income status. Type of road users involved in RTCs also varied by the age and sex of the person involved, with a greater proportion of males than females involved as drivers, and a reverse pattern for pedestrians. In multivariable analysis, RTC incidence was associated with younger age, male sex, being single, and having achieved higher levels of education; there was no association with alcohol use. In a sensitivity analysis including respondents aged 18-64 years, results were similar, however, there was an association of RTC incidence with alcohol use. The incidence of injuries requiring medical attention was 1.8% (1.6-2.1). In multivariable analyses, requiring medical attention was associated with younger age, male sex, and higher wealth quintile. We found remarkable heterogeneity in RTC incidence, the type of road users involved, and the requirement for medical attention after injuries depending on country income status and socio-demographic characteristics. Targeted data-informed approaches are needed to prevent and manage RTCs.

    View details for DOI 10.1371/journal.pgph.0002768

    View details for PubMedID 38241424

    View details for PubMedCentralID PMC10798533

  • Stakeholder-Informed Solutions To Address Barriers for Alcohol Screening and Brief Intervention in Thai Hypertension Care. Journal of prevention (2022) Lemp, J. M., Pengpid, S., Buntup, D., Sornpaisarn, B., Peltzer, K., Geldsetzer, P., Probst, C. 2023


    Premature deaths from NCDs disproportionately affect people in low- and middle-income countries. Since alcohol use is one of the most common causes of reversible hypertension, interventions targeting alcohol use may be a feasible and effective low-cost approach to synergistically reduce the prevalence of harmful drinking and high blood pressure. This study sought to identify key factors in successfully implementing alcohol use screening and brief intervention in hypertension care in Thailand. For this purpose, we surveyed participants (NRound 1 = 91, NRound 2 = 27) from three different groups of Thai stakeholders (policy- and decisionmakers, primary healthcare practitioners, and patients diagnosed with hypertension) in a two-round stakeholder elicitation. In round 1, we identified limited resources, lack of clear guidelines for lifestyle intervention, stigmatization, and inconsistent monitoring of patients' alcohol use as important barriers. In round 2, we sought to elicit solutions for the barriers identified in round 1. While stakeholders emphasized the need for adaptability to existing realities in Thai primary healthcare such as a high workload and limited digitization, they favorably evaluated a digital alcohol assessment tool with integrated, tailored advice for brief intervention as a potential scalable solution. Findings suggest that as one possible route to reduce the NCD burden caused by hypertension in Thailand, primary healthcare services may be enhanced by digital tools that support resource-effective, intuitive, and seamless delivery of alcohol screening and brief intervention.

    View details for DOI 10.1007/s10935-023-00763-x

    View details for PubMedID 38148463

  • Heterogeneous Treatment Effects of Intensive Glycemic Control on Kidney Microvascular Outcomes and Mortality in ACCORD. Journal of the American Society of Nephrology : JASN Charu, V., Liang, J. W., Chertow, G. M., Li, J., Montez-Rath, M. E., Geldsetzer, P., de Boer, I. H., Tian, L., Tamura, M. K. 2023


    Clear criteria to individualize glycemic targets in patients with type II diabetes are lacking. In this post-hoc analysis of the Action to Control Cardiovascular Risk in Diabetes trial (ACCORD), we evaluate whether the kidney failure risk equation (KFRE) can identify patients for whom intensive glycemic control confers more benefit in preventing kidney microvascular outcomes.We divided the ACCORD trial population into quartiles based on 5-year kidney failure risk using the KFRE. We estimated conditional treatment effects within each quartile and compared them to the average treatment effect in the trial. The treatment effects of interest were the 7-year restricted-mean-survival-time (RMST) differences between intensive and standard glycemic control arms on (1) time-to-first development of severely elevated albuminuria or kidney failure and (2) all-cause mortality.We found evidence that the effect of intensive glycemic control on kidney microvascular outcomes and all-cause mortality varies with baseline risk of kidney failure. Patients with elevated baseline risk of kidney failure derived the most from intensive glycemic control in reducing kidney microvascular outcomes (7-year RMST difference of 114.8 (95% CI 58.1, 176.4)v. 48.4 (25.3, 69.6) days in the entire trial population) However, this same patient group also experienced a shorter time to death (7-year RMST difference of -56.7 (-100.2, -17.5) v. -23.6 (-42.2, -6.6)days).We found evidence of heterogenous treatment effects of intensive glycemic control on kidney microvascular outcomes in ACCORD as a function of predicted baseline risk of kidney failure. Patients with higher kidney failure risk experienced the most pronounced reduction in kidney microvascular outcomes but also experienced the highest risk of all-cause mortality.

    View details for DOI 10.1681/ASN.0000000000000272

    View details for PubMedID 38073026

  • Prevalence and changes of intimate partner violence against women aged 15 to 49 years in 53 low-income and middle-income countries from 2000 to 2021: a secondary analysis of population-based surveys. The Lancet. Global health Ma, N., Chen, S., Kong, Y., Chen, Z., Geldsetzer, P., Zeng, H., Wu, L., Wehrmeister, F. C., Lu, C., Subramanian, S. V., Song, Y., Li, Z. 2023; 11 (12): e1863-e1873


    In low-income and middle-income countries (LMICs), intimate partner violence poses a substantial barrier to accomplishing target 5.2 of the Sustainable Development Goals: to eliminate all forms of violence against women and girls. Our study aimed to assess the prevalence and changes of intimate partner violence against women in LMICs. We also explored the association between women's empowerment and intimate partner violence.In this secondary analysis of population-based surveys, we obtained data from the nationally representative Demographic and Health Surveys conducted in LMICs between 2000 and 2021. We selected countries with available data on the domestic violence module, and women aged 15 to 49 years who currently or formerly had a husband or partner, and who had provided information about intimate partner violence, were included in the analysis. We first estimated the weighted prevalence of intimate partner violence in LMICs with available data, and then we assessed the average annual rate of change using Poisson regression with robust error variance in a subset of countries with at least two surveys. We used multilevel analysis to investigate the association between intimate partner violence and women's empowerment measured at both the country and individual levels. Country-level empowerment was measured by gender inequality index, while individual-level empowerment considered social independence, decision making, and attitude to violence.A total of 359 479 women aged 15 to 49 years were included from 53 LMICs. 336 811 women from 21 countries with two surveys provided data for assessing the trends of intimate partner violence. The weighted prevalence of any type of intimate partner violence was 37·2% (95% CI 36·6 to 37·8). A significant overall decline in the prevalence of any type of intimate partner violence was observed with an average annual rate of change of -0·2% (95% CI -0·4 to -0·03); however six countries showed significant increasing trends, with average annual rates of change ranging from 1·2% (95% CI 0·7 to 1·7) in Nigeria to 6·6% (5·3 to 7·8) in Sierra Leone. Notably, the prevalence of psychological intimate partner violence has risen (average annual rate of change, 2·3% [95% CI 2·1 to 2·6]), reflected in increased rates across eight countries. Higher levels of country-level women's empowerment were associated with a lower risk of intimate partner violence: women from countries with the highest tertile of gender inequality index had an increased odds of any type of intimate partner violence (odds ratio 1·58 [95% CI 1·12 to 2·23]). Similarly, better individual-level women's empowerment also showed significant associations with a lower risk of intimate partner violence.The prevalence of intimate partner violence remains high, and some countries have shown an increasing trend. The strong relationship between both country-level and individual-level women's empowerment and the prevalence of intimate partner violence suggests that accelerating women's empowerment could be one strategy to further reduce intimate partner violence against women.National Natural Science Foundation; Vanke School of Public Health, Tsinghua University; and Sanming Project of Medicine in Shenzhen.

    View details for DOI 10.1016/S2214-109X(23)00417-5

    View details for PubMedID 37973337

  • Prevalence of Short Peer Reviews in 3 Leading General Medical Journals. JAMA network open Geldsetzer, P., Heemann, M., Tikka, P., Wang, G., Cusick, M. M., Lenjani, A., Krishnan, N. 2023; 6 (12): e2347607


    Importance: High-quality peer reviews are often thought to be essential to ensuring the integrity of the scientific publication process, but measuring peer review quality is challenging. Although imperfect, review word count could potentially serve as a simple, objective metric of review quality.Objective: To determine the prevalence of very short peer reviews and how often they inform editorial decisions on research articles in 3 leading general medical journals.Design, Setting, and Participants: This cross-sectional study compiled a data set of peer reviews from published, full-length original research articles from 3 general medical journals (The BMJ, PLOS Medicine, and BMC Medicine) between 2003 and 2022. Eligible articles were those with peer review data; all peer reviews used to make the first editorial decision (ie, accept vs revise and resubmit) were included.Main Outcomes and Measures: Prevalence of very short reviews was the primary outcome, which was defined as a review of fewer than 200 words. In secondary analyses, thresholds of fewer than 100 words and fewer than 300 words were used. Results were disaggregated by journal and year. The proportion of articles for which the first editorial decision was made based on a set of peer reviews in which very short reviews constituted 100%, 50% or more, 33% or more, and 20% or more of the reviews was calculated.Results: In this sample of 11 466 reviews (including 6086 in BMC Medicine, 3816 in The BMJ, and 1564 in PLOS Medicine) corresponding to 4038 published articles, the median (IQR) word count per review was 425 (253-575) words, and the mean (SD) word count was 520.0 (401.0) words. The overall prevalence of very short (<200 words) peer reviews was 1958 of 11 466 reviews (17.1%). Across the 3 journals, 843 of 4038 initial editorial decisions (20.9%) were based on review sets containing 50% or more very short reviews. The prevalence of very short reviews and share of editorial decisions based on review sets containing 50% or more very short reviews was highest for BMC Medicine (693 of 2585 editorial decisions [26.8%]) and lowest for The BMJ (76 of 1040 editorial decisions [7.3%]).Conclusion and Relevance: In this study of 3 leading general medical journals, one-fifth of initial editorial decisions for published articles were likely based at least partially on reviews of such short length that they were unlikely to be of high quality. Future research could determine whether monitoring peer review length improves the quality of peer reviews and which interventions, such as incentives and norm-based interventions, may elicit more detailed reviews.

    View details for DOI 10.1001/jamanetworkopen.2023.47607

    View details for PubMedID 38095896

  • Diabetes risk and provision of diabetes prevention activities in 44 low-income and middle-income countries: a cross-sectional analysis of nationally representative, individual-level survey data. The Lancet. Global health Rahim, N. E., Flood, D., Marcus, M. E., Theilmann, M., Aung, T. N., Agoudavi, K., Aryal, K. K., Bahendeka, S., Bicaba, B., Bovet, P., Diallo, A. O., Farzadfar, F., Guwatudde, D., Houehanou, C., Houinato, D., Hwalla, N., Jorgensen, J., Kagaruki, G. B., Mayige, M., Wong-McClure, R., Larijani, B., Saeedi Moghaddam, S., Mwalim, O., Mwangi, K. J., Sarkar, S., Sibai, A. M., Sturua, L., Wesseh, C., Geldsetzer, P., Atun, R., Vollmer, S., Bärnighausen, T., Davies, J., Ali, M. K., Seiglie, J. A., Manne-Goehler, J. 2023; 11 (10): e1576-e1586


    The global burden of diabetes is rising rapidly, yet there is little evidence on individual-level diabetes prevention activities undertaken by health systems in low-income and middle-income countries (LMICs). Here we describe the population at high risk of developing diabetes, estimate diabetes prevention activities, and explore sociodemographic variation in these activities across LMICs.We performed a pooled, cross-sectional analysis of individual-level data from nationally representative, population-based surveys conducted in 44 LMICs between October, 2009, and May, 2019. Our sample included all participants older than 25 years who did not have diabetes and were not pregnant. We defined the population at high risk of diabetes on the basis of either the presence of impaired fasting glucose (or prediabetes in countries with a haemoglobin A1c available) or overweight or obesity, consistent with the WHO Package of Essential Noncommunicable Disease Guidelines for type 2 diabetes management. We estimated the proportion of survey participants that were at high risk of developing diabetes based on this definition. We also estimated the proportion of the population at high risk that reported each of four fundamental diabetes prevention activities: physical activity counselling, weight loss counselling, dietary counselling, and blood glucose screening, overall and stratified by World Bank income group. Finally, we used multivariable Poisson regression models to evaluate associations between sociodemographic characteristics and these activities.The final pooled sample included 145 739 adults (86 269 [59·2%] of whom were female and 59 468 [40·4%] of whom were male) across 44 LMICs, of whom 59 308 (40·6% [95% CI 38·5-42·8]) were considered at high risk of diabetes (20·6% [19·8-21·5] in low-income countries, 38·0% [37·2-38·9] in lower-middle-income countries, and 57·5% [54·3-60·6] in upper-middle-income countries). Overall, the reach of diabetes prevention activities was low at 40·0% (38·6-41·4) for physical activity counselling, 37·1% (35·9-38·4) for weight loss counselling, 42·7% (41·6-43·7) for dietary counselling, and 37·1% (34·7-39·6) for blood glucose screening. Diabetes prevention varied widely by national-level wealth: 68·1% (64·6-71·4) of people at high risk of diabetes in low-income countries reported none of these activities, whereas 49·0% (47·4-50·7) at high risk in upper-middle-income countries reported at least three activities. Educational attainment was associated with diabetes prevention, with estimated increases in the predicted probability of receipt ranging between 6·5 (3·6-9·4) percentage points for dietary fruit and vegetable counselling and 21·3 (19·5-23·2) percentage points for blood glucose screening, among people with some secondary schooling compared with people with no formal education.A large proportion of individuals across LMICs are at high risk of diabetes but less than half reported receiving fundamental prevention activities overall, with the lowest receipt of these activities among people in low-income countries and with no formal education. These findings offer foundational evidence to inform future global targets for diabetes prevention and to strengthen policies and programmes to prevent continued increases in diabetes worldwide.Harvard T H Chan School of Public Health McLennan Fund: Dean's Challenge Grant Program and the EU's Research and Innovation programme Horizon 2020.

    View details for DOI 10.1016/S2214-109X(23)00348-0

    View details for PubMedID 37734801

  • Healthcare provider-targeted mobile applications to diagnose, screen, or monitor communicable diseases of public health importance in low- and middle-income countries: A systematic review. PLOS digital health Geldsetzer, P., Flores, S., Flores, B., Rogers, A. B., Chang, A. Y. 2023; 2 (10): e0000156


    Communicable diseases remain a leading cause of death and disability in low- and middle-income countries (LMICs). mHealth technologies carry considerable promise for managing these disorders within resource-poor settings, but many existing applications exclusively represent digital versions of existing guidelines or clinical calculators, communication facilitators, or patient self-management tools. We thus systematically searched PubMed, Web of Science, and Cochrane Central for studies published between January 2007 and October 2019 involving technologies that were mobile phone- or tablet-based; able to screen for, diagnose, or monitor a communicable disease of importance in LMICs; and targeted health professionals as primary users. We excluded technologies that digitized existing paper-based tools or facilitated communication (i.e., knowledge-based algorithms). Extracted data included disease category, pathogen type, diagnostic method, intervention purpose, study/target population, sample size, study methodology, development stage, accessory requirement, country of development, operating system, and cost. Given the search timeline, studies involving COVID-19 were not included in the analysis. Of 13,262 studies identified by the screen, 33 met inclusion criteria. 12% were randomized clinical trials (RCTs), with 58% of publications representing technical descriptions. 62% of studies had 100 or fewer subjects. All studied technologies involved diagnosis or screening steps; none addressed the monitoring of infections. 52% focused on priority diseases (HIV, malaria, tuberculosis), but only 12% addressed a neglected tropical disease. Although most reported studies were priced under 20USD at time of publication, two thirds of the records did not yet specify a cost for the study technology. We conclude that there are only a small number of mHealth technologies focusing on innovative methods of screening and diagnosing communicable diseases potentially of use in LMICs. Rigorous RCTs, analyses with large sample size, and technologies assisting in the monitoring of diseases are needed.

    View details for DOI 10.1371/journal.pdig.0000156

    View details for PubMedID 37801442

  • Stakeholder perspectives on interventions to improve HIV pre-exposure prophylaxis uptake and continuation in Lesotho: A participant-ranked preferences study. PLOS global public health Chebet, J. J., McMahon, S. A., Chase, R. P., Tarumbiswa, T., Maponga, C., Mandara, E., Bärnighausen, T., Geldsetzer, P. 2023; 3 (9): e0001423


    Low uptake and high discontinuation remain major obstacles to realizing the potential of Pre-Exposure Prophylaxis (PrEP) in changing the trajectory of the HIV epidemic. We conducted a card sorting and ranking exercise with 155 local stakeholders to determine their views on the most important barriers and most promising interventions to achieving high PrEP coverage. Stakeholders were a purposive sample of PrEP policymakers and implementing partners (n = 7), healthcare providers (n = 51), and end-users (n = 97). End-users included adults who were currently using PrEP (n = 55), formerly using PrEP (n = 36), and those who were offered PrEP but declined (n = 6). Participants sorted pre-selected interventions and barriers to PrEP coverage into three piles-most, somewhat, and least important. Participants then ranked interventions and barriers in the "most important" piles in ascending order of significance. Ranked preferences were analyzed as voting data to identify the smallest set of candidates for which each candidate in the set would win in a two-candidate election against any candidate outside the set. Participants viewed a lack of PrEP awareness as the most important barrier to PrEP uptake for women, and a fear of HIV testing for men. Community-based HIV testing was ranked as the most promising intervention to improve PrEP uptake for both men and women. Perceived or experienced stigma was seen as an important barrier for PrEP continuation for both men and women, with an additional important barrier for men being daily activities that compete with the time needed to take a daily pill. Adherence counseling and multi-month PrEP prescriptions were seen as the most promising interventions to improve PrEP continuation. Our findings suggest community-based activities that generate PrEP demand (community-based HIV testing and mass media campaigns), reinforced with facility-based follow-up (counseling and multi-month prescription) could be promising interventions for PrEP programs that are aimed at the general adult population.

    View details for DOI 10.1371/journal.pgph.0001423

    View details for PubMedID 37756319

    View details for PubMedCentralID PMC10529554

  • Does Early Childhood BCG Vaccination Improve Survival to Midlife in a Population With a Low Tuberculosis Prevalence? Quasi-experimental Evidence on Nonspecific Effects From 32 Swedish Birth Cohorts. Demography Theilmann, M., Geldsetzer, P., Bärnighausen, T., Sudharsanan, N. 2023


    The Bacillus Calmette-Guérin (BCG) vaccine for tuberculosis (TB) is widely used globally. Many high-income countries discontinued nationwide vaccination policies starting in the 1980s as the TB prevalence decreased. However, there is continued scientific interest in whether the general childhood immunity boost conferred by the BCG vaccination impacts adult health and mortality in low-TB contexts (known as nonspecific effects). While recent studies have found evidence of an association between BCG vaccination and survival to ages 34-45, it is unclear whether these associations are causal or driven by the unobserved characteristics of those who chose to voluntarily vaccinate. We use the abrupt discontinuation of mandatory BCG vaccination in Sweden in 1975 as a natural experiment to estimate the causal nonspecific effect of the BCG vaccine on cohort survival to midlife. Applying two complementary study designs, we find no evidence that survival to age 40 was affected by the discontinuation of childhood BCG vaccination. The results are consistent among both males and females and are robust to several sensitivity tests. Overall, despite prior correlational studies suggesting large nonspecific effects, we do not find any population-level evidence for a nonspecific effect of the BCG vaccine discontinuation on survival to age 40 in Sweden.

    View details for DOI 10.1215/00703370-10970757

    View details for PubMedID 37732832

  • Diagnostic testing for hypertension, diabetes, and hypercholesterolaemia in low-income and middle-income countries: a cross-sectional study of data for 994 185 individuals from 57 nationally representative surveys. The Lancet. Global health Ochmann, S., von Polenz, I., Marcus, M., Theilmann, M., Flood, D., Agoudavi, K., Aryal, K. K., Bahendeka, S., Bicaba, B., Bovet, P., Campos Caldeira Brant, L., Carvalho Malta, D., Damasceno, A., Farzadfar, F., Gathecha, G., Ghanbari, A., Gurung, M., Guwatudde, D., Houehanou, C., Houinato, D., Hwalla, N., Jorgensen, J. A., Karki, K. B., Lunet, N., Martins, J., Mayige, M., Moghaddam, S. S., Mwalim, O., Mwangi, K. J., Norov, B., Quesnel-Crooks, S., Rezaei, N., Sibai, A. M., Sturua, L., Tsabedze, L., Wong-McClure, R., Davies, J., Geldsetzer, P., Barnighausen, T., Atun, R., Manne-Goehler, J., Vollmer, S. 2023; 11 (9): e1363-e1371


    BACKGROUND: Testing for the risk factors of cardiovascular disease, which include hypertension, diabetes, and hypercholesterolaemia, is important for timely and effective risk management. Yet few studies have quantified and analysed testing of cardiovascular risk factors in low-income and middle-income countries (LMICs) with respect to sociodemographic inequalities. We aimed to address this knowledge gap.METHODS: In this cross-sectional analysis, we pooled individual-level data for non-pregnant adults aged 18 years or older from nationally representative surveys done between Jan 1, 2010, and Dec 31, 2019 in LMICs that included a question about whether respondents had ever had their blood pressure, glucose, or cholesterol measured. We analysed diagnostic testing performance by quantifying the overall proportion of people who had ever been tested for these cardiovascular risk factors and the proportion of individuals who met the diagnostic testing criteria in the WHO package of essential noncommunicable disease interventions for primary care (PEN) guidelines (ie, a BMI >30 kg/m2 or a BMI >25 kg/m2 among people aged 40 years or older). We disaggregated and compared diagnostic testing performance by sex, wealth quintile, and education using two-sided t tests and multivariable logistic regression models.FINDINGS: Our sample included data for 994 185 people from 57 surveys. 19·1% (95% CI 18·5-19·8) of the 943 259 people in the hypertension sample met the WHO PEN criteria for diagnostic testing, of whom 78·6% (77·8-79·2) were tested. 23·8% (23·4-24·3) of the 225 707 people in the diabetes sample met the WHO PEN criteria for diagnostic testing, of whom 44·9% (43·7-46·2) were tested. Finally, 27·4% (26·3-28·6) of the 250 573 people in the hypercholesterolaemia sample met the WHO PEN criteria for diagnostic testing, of whom 39·7% (37·1-2·4) were tested. Women were more likely than men to be tested for hypertension and diabetes, and people in higher wealth quintiles compared with those in the lowest wealth quintile were more likely to be tested for all three risk factors, as were people with at least secondary education compared with those with less than primary education.INTERPRETATION: Our study shows opportunities for health systems in LMICs to improve the targeting of diagnostic testing for cardiovascular risk factors and adherence to diagnostic testing guidelines. Risk-factor-based testing recommendations rather than sociodemographic characteristics should determine which individuals are tested.FUNDING: Harvard McLennan Family Fund, the Alexander von Humboldt Foundation, and the National Heart, Lung, and Blood Institute of the US National Institutes of Health.

    View details for DOI 10.1016/S2214-109X(23)00280-2

    View details for PubMedID 37591584

  • Aspirin for Secondary Prevention of Cardiovascular Disease in 51 Low-, Middle-, and High-Income Countries. JAMA Yoo, S. G., Chung, G. S., Bahendeka, S. K., Sibai, A. M., Damasceno, A., Farzadfar, F., Rohloff, P., Houehanou, C., Norov, B., Karki, K. B., Azangou-Khyavy, M., Marcus, M. E., Aryal, K. K., Brant, L. C., Theilmann, M., Cifkova, R., Lunet, N., Gurung, M. S., Mwangi, J. K., Martins, J., Haghshenas, R., Sturua, L., Vollmer, S., Barnighausen, T., Atun, R., Sussman, J. B., Singh, K., Saeedi Moghaddam, S., Guwatudde, D., Geldsetzer, P., Manne-Goehler, J., Huffman, M. D., Davies, J. I., Flood, D. 2023; 330 (8): 715-724


    Importance: Aspirin is an effective and low-cost option for reducing atherosclerotic cardiovascular disease (CVD) events and improving mortality rates among individuals with established CVD. To guide efforts to mitigate the global CVD burden, there is a need to understand current levels of aspirin use for secondary prevention of CVD.Objective: To report and evaluate aspirin use for secondary prevention of CVD across low-, middle-, and high-income countries.Design, Setting, and Participants: Cross-sectional analysis using pooled, individual participant data from nationally representative health surveys conducted between 2013 and 2020 in 51 low-, middle-, and high-income countries. Included surveys contained data on self-reported history of CVD and aspirin use. The sample of participants included nonpregnant adults aged 40 to 69 years.Exposures: Countries' per capita income levels and world region; individuals' socioeconomic demographics.Main Outcomes and Measures: Self-reported use of aspirin for secondary prevention of CVD.Results: The overall pooled sample included 124 505 individuals. The median age was 52 (IQR, 45-59) years, and 50.5% (95% CI, 49.9%-51.1%) were women. A total of 10 589 individuals had a self-reported history of CVD (8.1% [95% CI, 7.6%-8.6%]). Among individuals with a history of CVD, aspirin use for secondary prevention in the overall pooled sample was 40.3% (95% CI, 37.6%-43.0%). By income group, estimates were 16.6% (95% CI, 12.4%-21.9%) in low-income countries, 24.5% (95% CI, 20.8%-28.6%) in lower-middle-income countries, 51.1% (95% CI, 48.2%-54.0%) in upper-middle-income countries, and 65.0% (95% CI, 59.1%-70.4%) in high-income countries.Conclusion and Relevance: Worldwide, aspirin is underused in secondary prevention, particularly in low-income countries. National health policies and health systems must develop, implement, and evaluate strategies to promote aspirin therapy.

    View details for DOI 10.1001/jama.2023.12905

    View details for PubMedID 37606674

  • National Estimates of the Adult Diabetes Care Continuum in India, 2019-2021. JAMA internal medicine Varghese, J. S., Anjana, R. M., Geldsetzer, P., Sudharsanan, N., Manne-Goehler, J., Thirumurthy, H., Bhattacharyya, S., Narayan, K. M., Mohan, V., Tandon, N., Ali, M. K. 2023


    Diabetes is widespread and treatable, but little is known about the diabetes care continuum (diagnosis, treatment, and control) in India and how it varies at the national, state, and district levels.To estimate the adult population levels of diabetes diagnosis, treatment, and control in India at national, state, and district levels and by sociodemographic characteristics.In this cross-sectional, nationally representative survey study from 2019 to 2021, adults in India from 28 states, 8 union territories, and 707 districts were surveyed for India's Fifth National Family Health Survey (NFHS-5). The survey team collected data on blood glucose among all adults (18-98 years) who were living in the same household as eligible participants (pregnant or nonpregnant female individuals aged 15-49 years and male individuals aged 15-54 years). The overall sample consisted of 1 895 287 adults. The analytic sample was restricted to those who either self-reported having diabetes or who had a valid measurement of blood glucose.The exposures in this survey study were district and state residence; urban vs rural residence; age (18-39 years, 40-64 years, or ≥65 years); sex; and household wealth quintile.Diabetes was defined by self-report or high capillary blood glucose (fasting: ≥126 mg/dL [to convert to mmol/L, multiply by 0.0555]; nonfasting: ≥220 mg/dL). Among respondents who had previously been diagnosed with diabetes, the main outcome was the proportion treated based on self-reported medication use and the proportion controlled (fasting: blood glucose <126 mg/dL; nonfasting: ≤180 mg/dL). The findings were benchmarked against the World Health Organization (WHO) Global Diabetes Compact targets (80% diagnosis; 80% control among those diagnosed). The variance in indicators between and within states was partitioned using variance partition coefficients (VPCs).Among 1 651 176 adult respondents (mean [SD] age, 41.6 [16.4] years; 867 896 [52.6%] female) with blood glucose measures, the proportion of individuals with diabetes was 6.5% (95% CI, 6.4%-6.6%). Among adults with diabetes, 74.2% (95% CI, 73.3%-75.0%) were diagnosed. Among those diagnosed, 59.4% (95% CI, 58.1%-60.6%) reported taking medication, and 65.5% (95% CI, 64.5%-66.4%) achieved control. Diagnosis and treatment were higher in urban areas, older age groups, and wealthier households. Among those diagnosed in the 707 districts surveyed, 246 (34.8%) districts met the WHO diagnosis target, while 76 (10.7%) districts met the WHO control target. Most of the variability in diabetes diagnosis (VPC, 89.1%), treatment (VPC, 85.9%), and control (VPC, 95.6%) were within states, not between states.In this survey study, the diabetes care continuum in India is represented by considerable district-level variation, age-related disparities, and rural-urban differences. Surveillance at the district level can guide state health administrators to prioritize interventions and monitor achievement of global targets.

    View details for DOI 10.1001/jamainternmed.2023.3070

    View details for PubMedID 37523192

  • Effectiveness of a community health worker-led low-sodium salt intervention to reduce blood pressure in rural Bangladesh: protocol for a cluster randomized controlled trial. Trials Chang, A. Y., Rahman, M., Talukder, A., Shah, H., Mridha, M. K., Hasan, M., Sarker, M., Geldsetzer, P. 2023; 24 (1): 480


    High blood pressure is a major public health problem in low- and middle-income countries. Low-sodium salt substitute (LSSS) is a promising population-level blood pressure-lowering intervention requiring minimal behavioral change. The optimal method of delivering LSSS to individuals, however, is currently unknown. Community health workers (CHWs) have successfully been used to implement health interventions in Bangladesh and may provide a venue for the dissemination of LSSS.We aim to conduct a cluster-randomized controlled trial involving 309 households in rural Bangladesh previously identified and characterized by the BRAC James P Grant School of Public Health, BRAC University (BRAC JPGSPH). These households will be randomly assigned to three arms: (1) control, i.e., no intervention; (2) information only, i.e., community health workers will provide basic information on high blood pressure, the health consequences of excessive salt consumption, and feedback to the participant on the likely quantity of salt s/he consumes (estimated using a questionnaire); (3) free LSSS arm: the same information as in arm 2 will be provided, but participants will receive 6 months of free low-sodium salt along with education on the benefits of LSSS. One male and one female adult (age ≥ 18 years) in each household will be invited to participate, the exclusion criteria being households with members known to have high serum potassium levels, are taking medications known to elevate potassium levels (e.g., ACE inhibitors, ARBs, potassium-sparing diuretics), are already taking potassium supplements, or those who have known kidney disease or abnormal serum creatinine at baseline. The primary endpoint will be blood pressure at 6 months post-intervention.Recent large clinical trials of LSSS in China and India have shown not only blood pressure improvements, but also stroke, major cardiac event, and all-cause mortality reductions. Nevertheless, how to best translate this intervention to population-level effectiveness remains unclear. Our study would test whether a community health worker-based program could be effectively used to disseminate LSSS and achieve measurable blood pressure NCT05425030. Registered on June 21, 2022.

    View details for DOI 10.1186/s13063-023-07518-3

    View details for PubMedID 37501102

    View details for PubMedCentralID PMC10375753

  • Motivations for pre-exposure prophylaxis uptake and decline in an HIV-hyperendemic setting: findings from a qualitative implementation study in Lesotho. AIDS research and therapy Chebet, J. J., McMahon, S. A., Tarumbiswa, T., Hlalele, H., Maponga, C., Mandara, E., Ernst, K., Alaofe, H., Baernighausen, T., Ehiri, J. E., Geldsetzer, P., Nichter, M. 2023; 20 (1): 43


    BACKGROUND: Pre-Exposure Prophylaxis (PrEP) has demonstrated clinical efficacy in preventing HIV infection, yet its uptake remains low. This study, conducted in five PrEP implementing districts in Lesotho, examined factors motivating persons at risk of HIV infection to adopt or reject PrEP when offered freely.METHODS: In-depth interviews were undertaken with stakeholders directly engaged with PrEP policy (n=5), program implementation (n=4), and use (current PrEP users=55, former PrEP users=36, and PrEP decliners (n=6)). Focus group discussions (n=11, 105 total participants) were conducted with health staff directly providing HIV and PrEP services.RESULTS: Demand for PrEP was reported highest among those at greatest risk for HIV acquisition: those in serodiscordant relationships and/or engaged in sex work. Culturally sensitive PrEP counseling was described as an opportunity to transfer knowledge, build trust, and address user concerns. Conversely, top-down counseling resulted in PrEP distrust and confusion about HIV status. Key motivations for PrEP uptake revolved around sustaining core social relationships,desire forsafer conception, and caring for ailingrelatives. The decline of PrEPinitiation was driven by a combination of individual-level factors(risk perception, perceived side effects, disbelief of the drug's efficacy and PrEP's daily pill regimen), societal factors(lack of social support and HIV-related stigma),and structural factorsrelated to PrEP access.CONCLUSIONS: Ourfindings suggest strategies for effective national PrEP rollout and implementation include: (1) demand creation campaigns which highlight positive aspects of PrEP, while simultaneously addressing apprehensions for uptake; (2) strengthening health provider counseling capacity; and (3) addressing societal and structural HIV-related stigma.

    View details for DOI 10.1186/s12981-023-00535-x

    View details for PubMedID 37415180

  • Changing socioeconomic and geographic gradients in cardiovascular disease risk factors among Indians aged 15-49 years - evidence from nationally representative household surveys. The Lancet regional health. Southeast Asia Wetzel, S., Geldsetzer, P., Mani, S. S., Gupta, A., Singh, K., Ali, M. K., Prabhakaran, D., Tandon, N., Sudharsanan, N. 2023; 12: 100188


    Cardiovascular diseases (CVDs) are the leading cause of death in most low- and middle-income countries (LMICs). CVDs and their metabolic risk factors have historically been concentrated among urban residents with higher socioeconomic status (SES) in LMICs such as India. However, as India develops, it is unclear whether these socioeconomic and geographic gradients will persist or change. Understanding these social dynamics in CVD risk is essential for mitigating the rising burden of CVDs and to reach those with the greatest needs.Using nationally representative data with biomarker measurements from the fourth (2015-16) and fifth (2019-21) Indian National Family and Health Surveys, we investigated trends in the prevalence of four CVD risk factors: smoking (self-reported), unhealthy weight (BMI ≥25 kgm2), diabetes (random plasma glucose concentration ≥200 mg/dL or self-reported diabetes), and hypertension (one of: average systolic blood pressure ≥140 mmHg, average diastolic blood pressure ≥90 mmHg, self-reported past diagnosis, or self-reported current antihypertensive medication use) among adults aged 15-49 years. We first described changes at the national level and then trends stratified by place of residence (urban versus rural), geographic region (northern, northeastern, central, eastern, western, southern), regional level of development (Empowered Action Group member state or not), and two measures of socioeconomic status: level of education (no education, primary incomplete, primary complete, secondary incomplete, secondary complete, higher) and wealth (quintiles).Unhealthy weight increased among all social and geographic groups but both the absolute and the relative changes were substantially higher among people with low SES (as measured by education or wealth) and in rural areas. For diabetes and hypertension, the prevalence increased for those from disadvantaged groups while staying constant or even decreasing among the wealthier and more educated. In contrast, smoking consumption declined for all social and geographic groups.In 2015-16, CVD risk factors were higher among more advantaged subpopulations in India. However, between 2015-16 and 2019-21, the prevalence of these risk factors grew more rapidly for less wealthy and less educated subpopulations and those living in rural areas. These trends have resulted in CVD risk becoming far more widespread throughout the population; CVD can no longer be characterized as a wealthy urban phenomenon.This work was supported by the Alexander von Humboldt Foundation (grant received by NS); the Stanford Diabetes Research Center [grant received by PG] and the Chan Zuckerberg Biohub [grant received by PG].

    View details for DOI 10.1016/j.lansea.2023.100188

    View details for PubMedID 37384058

    View details for PubMedCentralID PMC10305936

  • Early-stage predictors of deterioration among 3145 nonsevere SARS-CoV-2-infected people community-isolated in Wuhan, China: A combination of machine learning algorithms and competing risk survival analyses. Journal of evidence-based medicine Min, K., Cheng, Z., Liu, J., Fang, Y., Wang, W., Yang, Y., Geldsetzer, P., Bärnighausen, T., Yang, J., Liu, D., Chen, S., Wang, C. 2023


    To determine which early-stage variables best predicted the deterioration of coronavirus disease 2019 (COVID-19) among community-isolated people infected with severe acute respiratory syndrome coronavirus 2 and to test the performance of prediction using only inexpensive-to-measure variables.Medical records of 3145 people isolated in two Fangcang shelter hospitals (large-scale community isolation centers) from February to March 2020 were accessed. Two complementary methods-machine learning algorithms and competing risk survival analyses-were used to test potential predictors, including age, gender, severity upon admission, symptoms (general symptoms, respiratory symptoms, and gastrointestinal symptoms), computed tomography (CT) signs, and comorbid chronic diseases. All variables were measured upon (or shortly after) admission. The outcome was deterioration versus recovery of COVID-19.More than a quarter of the 3145 people did not present any symptoms, while one-third ended isolation due to deterioration. Machine learning models identified moderate severity upon admission, old age, and CT ground-glass opacity as the most important predictors of deterioration. Removing CT signs did not degrade the performance of models. Competing risk models identified age ≥ 35 years, male gender, moderate severity upon admission, cough, expectoration, CT patchy opacity, CT consolidation, comorbid diabetes, and comorbid cardiovascular or cerebrovascular diseases as significant predictors of deterioration, while a stuffy or runny nose as a predictor of recovery.Early-stage prediction of COVID-19 deterioration can be made with inexpensive-to-measure variables, such as demographic characteristics, severity upon admission, observable symptoms, and self-reported comorbid diseases, among asymptomatic people and mildly to moderately symptomatic patients.

    View details for DOI 10.1111/jebm.12529

    View details for PubMedID 37186434

  • Rapidly rising diabetes and increasing body weight: A counterfactual analysis in repeated cross-sectional nationally representative data from Bangladesh. Epidemiology (Cambridge, Mass.) Wetzel, S., Sarker, M., Hasan, M., Talukder, A., Sudharsanan, N., Geldsetzer, P. 2023


    Diabetes is a growing concern in South Asia but few nationally representative studies identify factors behind this rising disease burden. We studied the nationwide change in diabetes prevalence in Bangladesh, subpopulations disproportionately affected, and the contribution of rising unhealthy weight to the change in diabetes prevalence.Based on a sample of 13,959 adults aged 35 years and older with biomarker measurements from the 2011 and 2017/2018 Bangladesh Demographic and Health Surveys, we estimated how the prevalence of diabetes changed nationally and across socioeconomic/geographic groups. Using counterfactual decomposition, we assessed how much the prevalence of diabetes would have grown if BMI had not changed between 2011 and 2017.Diabetes prevalence increased from 12.1 (11.1, 13.1) to 14.4% (13.3, 15.5) between 2011 and 2017/2018. Diabetes grew disproportionately quickly among population groups with higher household wealth, more education, and in three regions. Over this same period, mean BMI increased from 20.9 (20.8, 21.1) to 22.5 kg/m2 (22.4, 22.7) and overweight from 25.8 (24.4, 27.3) to 42.1% (40.4, 43.7). Under the counterfactual scenario of constant BMI, diabetes would have risen by only 1.0 (-0.4, 2.4) instead of 2.3 percentage points (0.8, 3.7) nationally, corresponding to a contribution of 58% (-106.3, 221.7). Similarly, group-specific trends were largely attributable to increasing BMI.Diabetes prevalence in Bangladesh has increased rapidly between 2011 and 2017/2018. Decomposition analysis estimates have wide confidence intervals but are consistent with the hypothesis that this change was driven by the dramatic rise in body weights.

    View details for DOI 10.1097/EDE.0000000000001622

    View details for PubMedID 37042958

  • Strengthening primary care for diabetes and hypertension in Eswatini: study protocol for a nationwide cluster-randomized controlled trial. Trials Theilmann, M., Ginindza, N., Myeni, J., Dlamini, S., Cindzi, B. T., Dlamini, D., Dlamini, T. L., Greve, M., Harkare, H. V., Hleta, M., Khumalo, P., Kolbe, L. M., Lewin, S., Marowa, L., Masuku, S., Mavuso, D., Molemans, M., Ntshalintshali, N., Nxumalo, N., Osetinsky, B., Pell, C., Reis, R., Shabalala, F., Simelane, B. R., Stehr, L., Tediosi, F., van Leth, F., De Neve, J., Barnighausen, T., Geldsetzer, P. 2023; 24 (1): 210


    BACKGROUND: Diabetes and hypertension are increasingly important population health challenges in Eswatini. Prior to this project, healthcare for these conditions was primarily provided through physician-led teams at tertiary care facilities and accessed by only a small fraction of people living with diabetes or hypertension. This trial tests and evaluates two community-based healthcare service models implemented at the national level, which involve health care personnel at primary care facilities and utilize the country's public sector community health worker cadre (the rural health motivators [RHMs]) to help generate demand for care.METHODS: This study is a cluster-randomized controlled trial with two treatment arms and one control arm. The unit of randomization is a primary healthcare facility along with all RHMs (and their corresponding service areas) assigned to the facility. A total of 84 primary healthcare facilities were randomized in a 1:1:1 ratio to the three study arms. The first treatment arm implements differentiated service delivery (DSD) models at the clinic and community levels with the objective of improving treatment uptake and adherence among clients with diabetes or hypertension. In the second treatment arm, community distribution points (CDPs), which previously targeted clients living with human immunodeficiency virus, extend their services to clients with diabetes or hypertension by allowing them to pick up medications and obtain routine nurse-led follow-up visits in their community rather than at the healthcare facility. In both treatment arms, RHMs visit households regularly, screen clients at risk, provide personalized counseling, and refer clients to either primary care clinics or the nearest CDP. In the control arm, primary care clinics provide diabetes and hypertension care services but without the involvement of RHMs and the implementation of DSD models or CDPs. The primary endpoints are mean glycated hemoglobin (HbA1c) and systolic blood pressure among adults aged 40years and older living with diabetes or hypertension, respectively. These endpoints will be assessed through a household survey in the RHM service areas. In addition to the health impact evaluation, we will conduct studies on cost-effectiveness, syndemics, and the intervention's implementation processes.DISCUSSION: This study has the ambition to assist the Eswatini government in selecting the most effective delivery model for diabetes and hypertension care. The evidence generated with this national-level cluster-randomized controlled trial may also prove useful to policy makers in the wider Sub-Saharan African region.TRIAL REGISTRATION: NCT04183413.Trial registration date:December 3, 2019.

    View details for DOI 10.1186/s13063-023-07096-4

    View details for PubMedID 36949485

  • Improving health outcomes of people with diabetes: target setting for the WHO Global Diabetes Compact. Lancet (London, England) Gregg, E. W., Buckley, J., Ali, M. K., Davies, J., Flood, D., Mehta, R., Griffiths, B., Lim, L., Manne-Goehler, J., Pearson-Stuttard, J., Tandon, N., Roglic, G., Slama, S., Shaw, J. E., Global Health and Population Project on Access to Care for Cardiometabolic Diseases, Agoudavi, K., Aryal, K. K., Atun, R., Bahendeka, S., Bicaba, B. W., Bovet, P., Brian, G., Damasceno, A., Davies, J. I., Dorobantu, M., Farzadfar, F., Flood, D., Geldsetzer, P., Gurung, M. S., Guwatudde, D., Houehanou, C., Houinato, D., Hwalla, N., Jaacks, L., Karki, B. K., Labadarios, D., Lunet, N., Manne-Goehler, J., Marcus, M. E., Martins, J., Mayige, T. M., Norov, B., Saeedi Moghaddam, S., Quesnel-Crooks, S., Sibai, A. M., Sturua, L., Theilmann, M., Tsabedze, L., Vollmer, S., Zhumadilov, Z. 2023


    The Global Diabetes Compact is a WHO-driven initiative uniting stakeholders around goals of reducing diabetes risk and ensuring that people with diabetes have equitable access to comprehensive, affordable care and prevention. In this report we describe the development and scientific basis for key health metrics, coverage, and treatment targets accompanying the Compact. We considered metrics across four domains: factors at a structural, system, or policy level; processes of care; behaviours and biomarkers such as glycated haemoglobin (HbA1c); and health events and outcomes; and three risk tiers (diagnosed diabetes, high risk, or whole population), and reviewed and prioritised them according to their health importance, modifiability, data availability, and global inequality. We reviewed the global distribution of each metric to set targets for future attainment. This process led to five core national metrics and target levels for UN member states: (1) of all people with diabetes, at least 80% have been clinically diagnosed; and, for people with diagnosed diabetes, (2) 80% have HbA1c concentrations below 8·0% (63·9 mmol/mol); (3) 80% have blood pressure lower than 140/90 mm Hg; (4) at least 60% of people 40 years or older are receiving therapy with statins; and (5) each person with type 1 diabetes has continuous access to insulin, blood glucose meters, and test strips. We also propose several complementary metrics that currently have limited global coverage, but warrant scale-up in population-based surveillance systems. These include estimation of cause-specific mortality, and incidence of end-stage kidney disease, lower-extremity amputations, and incidence of diabetes. Primary prevention of diabetes and integrated care to prevent long-term complications remain important areas for the development of new metrics and targets. These metrics and targets are intended to drive multisectoral action applied to individuals, health systems, policies, and national health-care access to achieve the goals of the Global Diabetes Compact. Although ambitious, their achievement can result in broad health benefits for people with diabetes.

    View details for DOI 10.1016/S0140-6736(23)00001-6

    View details for PubMedID 36931289

  • A deep-learning algorithm to classify skin lesions from mpox virus infection. Nature medicine Thieme, A. H., Zheng, Y., Machiraju, G., Sadee, C., Mittermaier, M., Gertler, M., Salinas, J. L., Srinivasan, K., Gyawali, P., Carrillo-Perez, F., Capodici, A., Uhlig, M., Habenicht, D., Loser, A., Kohler, M., Schuessler, M., Kaul, D., Gollrad, J., Ma, J., Lippert, C., Billick, K., Bogoch, I., Hernandez-Boussard, T., Geldsetzer, P., Gevaert, O. 2023


    Undetected infection and delayed isolation of infected individuals are key factors driving the monkeypox virus (now termed mpox virus or MPXV) outbreak. To enable earlier detection of MPXV infection, we developed an image-based deep convolutional neural network (named MPXV-CNN) for the identification of the characteristic skin lesions caused by MPXV. We assembled a dataset of 139,198 skin lesion images, split into training/validation and testing cohorts, comprising non-MPXV images (n=138,522) from eight dermatological repositories and MPXV images (n=676) from the scientific literature, news articles, social media and a prospective cohort of the Stanford University Medical Center (n=63 images from 12 patients, all male). In the validation and testing cohorts, the sensitivity of the MPXV-CNN was 0.83 and 0.91, the specificity was 0.965 and 0.898 and the area under the curve was 0.967 and 0.966, respectively. In the prospective cohort, the sensitivity was 0.89. The classification performance of the MPXV-CNN was robust across various skin tones and body regions. To facilitate the usage of the algorithm, we developed a web-based app by which the MPXV-CNN can be accessed for patient guidance. The capability of the MPXV-CNN for identifying MPXV lesions has the potential to aid in MPXV outbreak mitigation.

    View details for DOI 10.1038/s41591-023-02225-7

    View details for PubMedID 36864252

  • Estimates and Projections of the Global Economic Cost of 29 Cancers in 204 Countries and Territories From 2020 to 2050. JAMA oncology Chen, S., Cao, Z., Prettner, K., Kuhn, M., Yang, J., Jiao, L., Wang, Z., Li, W., Geldsetzer, P., Barnighausen, T., Bloom, D. E., Wang, C. 2023


    Importance: Cancers are a leading cause of mortality, accounting for nearly 10 million annual deaths worldwide, or 1 in 6 deaths. Cancers also negatively affect countries' economic growth. However, the global economic cost of cancers and its worldwide distribution have yet to be studied.Objective: To estimate and project the economic cost of 29 cancers in 204 countries and territories.Design, Setting, and Participants: A decision analytical model that incorporates economic feedback in assessing health outcomes associated with the labor force and investment. A macroeconomic model was used to account for (1) the association of cancer-related mortality and morbidity with labor supply; (2) age-sex-specific differences in education, experience, and labor market participation of those who are affected by cancers; and (3) the diversion of cancer treatment expenses from savings and investments. Data were collected on April 25, 2022.Main Outcomes and Measures: Economic cost of 29 cancers across countries and territories. Costs are presented in international dollars at constant 2017 prices.Results: The estimated global economic cost of cancers from 2020 to 2050 is $25.2 trillion in international dollars (at constant 2017 prices), equivalent to an annual tax of 0.55% on global gross domestic product. The 5 cancers with the highest economic costs are tracheal, bronchus, and lung cancer (15.4%); colon and rectum cancer (10.9%); breast cancer (7.7%); liver cancer (6.5%); and leukemia (6.3%). China and the US face the largest economic costs of cancers in absolute terms, accounting for 24.1% and 20.8% of the total global burden, respectively. Although 75.1% of cancer deaths occur in low- and middle-income countries, their share of the economic cost of cancers is lower at 49.5%. The relative contribution of treatment costs to the total economic cost of cancers is greater in high-income countries than in low-income countries.Conclusions and Relevance: In this decision analytical modeling study, the macroeconomic cost of cancers was found to be substantial and distributed heterogeneously across cancer types, countries, and world regions. The findings suggest that global efforts to curb the ongoing burden of cancers are warranted.

    View details for DOI 10.1001/jamaoncol.2022.7826

    View details for PubMedID 36821107

  • Medication Use for Cardiovascular Disease Prevention in 40 Low- and Middle-Income Countries. Journal of the American College of Cardiology Zhu, J. Z., Manne-Goehler, J., Agarwal, A., Bahendeka, S. K., Damasceno, A., Marcus, M. E., Saeedi Moghaddam, S., Vollmer, S., Huffman, M. D., Flood, D. 2023; 81 (6): 620-622

    View details for DOI 10.1016/j.jacc.2022.12.003

    View details for PubMedID 36754520

  • Spatial, temporal and demographic patterns in asthma mortality in China: A systematic analysis from 2014 to 2020. The World Allergy Organization journal Tong, X., Yin, P., Liu, W., Chen, S., Geldsetzer, P., Long, Z., Cheng, A., Zhou, M., Li, Y. 2023; 16 (1): 100735


    Background: Asthma is an important contributor to the burden of non-communicable diseases in China. Understanding spatial, temporal, and demographic patterns in asthma mortality is relevant to the design and implementation of targeted interventions.Methods: This study collected information on asthma deaths occurring across 605 disease surveillance points (DSPs) as recorded in the population-based national mortality surveillance system (NMSS) of China. Asthma was defined according to the International Classification of Diseases, 10th Revision code J45-J46. Estimates of age-standardized mortality rates and total national asthma deaths were calculated based on yearly population data. Statistical analysis was performed to investigate the influence of various factors on asthma mortality.Results: Between 2014 and 2020, a total of 40 116 asthma deaths occurred in DSPs. Standardized asthma mortality per 100 000 people decreased from 1.79 (95% CI: 1.74-1.83) in 2014 to 1.07 (95% CI: 1.03-1.10) in 2020 in China. In 2020, the overall asthma mortality rate was higher for male patients than for female patients, and asthma mortality rates increased substantially with age. Age-standardized asthma mortality per 100,000 people exhibited significant geographic variation, ranging from 0.93 (95% CI: 0.89-0.98) in Eastern China to 1.04 (95% CI: 0.98-1.10) in Central China and 1.37 (95% CI: 1.29-1.45) in Western China in 2020. Asthma mortality in urban areas appeared to be higher than in rural areas. Socioeconomic factors, including gross domestic product per capita and density of hospital beds per 10,000 population, may be related to asthma mortality. Male asthma patients who lived in rural areas and were aged 65 years and above were generally at high risk of asthma-related mortality.Conclusions: This study found a spatial and temporal trend for a reduction in asthma deaths over seven years in China; however, there remain important sociodemographic groups that have not secured the same decrease in mortality rates.Trial registration: This was a purely observational study and thus registration was not required.

    View details for DOI 10.1016/j.waojou.2022.100735

    View details for PubMedID 36789097

  • Health service readiness to provide care for HIV and cardiovascular disease risk factors in low- and middle-income countries. PLOS global public health Cockburn, N., Flood, D., Seiglie, J. A., Manne-Goehler, J., Aryal, K., Karki, K., Damasceno, A., Atun, R., Vollmer, S., Barnighausen, T., Geldsetzer, P., Mayige, M., Hirschhorn, L., Davies, J. 2023; 3 (9): e0002373


    Cardiovascular disease risk factors (CVDRF), in particular diabetes and hypertension, are chronic conditions which carry a substantial disease burden in Low- and Middle-Income Countries. Unlike HIV, they were neglected in the Millenium Development Goals along with the health services required to manage them. To inform the level of health service readiness that could be achieved with increased attention, we compared readiness for CVDRF with that for HIV. Using data from national Service Provision Assessments, we describe facility-reported readiness to provide services for CVDRF and HIV, and derive a facility readiness score of observed essential components to manage them. We compared HIV vs CVDRF coverage scores by country, rural or urban location, and facility type, and by whether or not facilities reported readiness to provide care. We assessed the factors associated with coverage scores for CVDRF and HIV in a multivariable analysis. In our results, we include 7522 facilities in 8 countries; 86% of all facilities reported readiness to provide services for CVDRF, ranging from 77-98% in individual countries. For HIV, 30% reported of facilities readiness to provide services, ranging from 3-63%. Median derived facility readiness score for CVDRF was 0.28 (IQR 0.16-0.50), and for HIV was 0.43 (0.32-0.60). Among facilities which reported readiness, this rose to 0.34 (IQR 0.18-0.52) for CVD and 0.68 (0.56-0.76) for HIV. Derived readiness scores were generally significantly lower for CVDRF than for HIV, except in private facilities. In multivariable analysis, odds of a higher readiness score in both CVDRF or HIV care were higher in urban vs rural and secondary vs primary care; facilities with higher CVDRF scores were significantly associated with higher HIV scores. Derived readiness scores for HIV are higher than for CVDRF, and coverage for CVDRF is significantly higher in facilities with higher HIV readiness scores. This suggests possible benefits from leveraging HIV services to provide care for CVDRF, but poor coverage in rural and primary care facilities threatens Sustainable Development Goal 3.8 to provide high quality universal healthcare for all.

    View details for DOI 10.1371/journal.pgph.0002373

    View details for PubMedID 37738224

  • Addressing the diagnostic gap in hypertension through possible interventions and scale-up: A microsimulation study. PLoS medicine Koeppel, L., Dittrich, S., Brenner Miguel, S., Carmona, S., Ongarello, S., Vetter, B., Cohn, J. E., Baernighausen, T., Geldsetzer, P., Denkinger, C. M., HPACC Consortium 2022; 19 (12): e1004111


    BACKGROUND: Cardiovascular diseases (CVDs) are the leading cause of mortality globally with almost a third of all annual deaths worldwide. Low- and middle-income countries (LMICs) are disproportionately highly affected covering 80% of these deaths. For CVD, hypertension (HTN) is the leading modifiable risk factor. The comparative impact of diagnostic interventions that improve either the accuracy, the reach, or the completion of HTN screening in comparison to the current standard of care has not been estimated.METHODS AND FINDINGS: This microsimulation study estimated the impact on HTN-induced morbidity and mortality in LMICs for four different scenarios: (S1) lower HTN diagnostic accuracy; (S2) improved HTN diagnostic accuracy; (S3) better implementation strategies to reach more persons with existing tools; and, lastly, (S4) the wider use of easy-to-use tools, such as validated, automated digital blood pressure measurement devices to enhance screening completion, in comparison to the current standard of care (S0). Our hypothetical population was parametrized using nationally representative, individual-level HPACC data and the global burden of disease data. The prevalence of HTN in the population was 31% out of which 60% remained undiagnosed. We investigated how the alteration of a yearly blood pressure screening event impacts morbidity and mortality in the population over a period of 10 years. The study showed that while improving test accuracy avoids 0.6% of HTN-induced deaths over 10 years (13,856,507 [9,382,742; 17,395,833]), almost 40 million (39,650,363 [31,34,233, 49,298,921], i.e., 12.7% [9.9, 15.8]) of the HTN-induced deaths could be prevented by increasing coverage and completion of a screening event in the same time frame. Doubling the coverage only would still prevent 3,304,212 million ([2,274,664; 4,164,180], 12.1% [8.3, 15.2]) CVD events 10 years after the rollout of the program. Our study is limited by the scarce data available on HTN and CVD from LMICs. We had to pool some parameters across stratification groups, and additional information, such as dietary habits, lifestyle choice, or the blood pressure evolution, could not be considered. Nevertheless, the microsimulation enabled us to include substantial heterogeneity and stochasticity toward the different income groups and personal CVD risk scores in the model.CONCLUSIONS: While it is important to consider investing in newer diagnostics for blood pressure testing to continuously improve ease of use and accuracy, more emphasis should be placed on screening completion.

    View details for DOI 10.1371/journal.pmed.1004111

    View details for PubMedID 36472973

  • The impact of a community health worker intervention on uptake of antenatal care: a cluster-randomized pragmatic trial in Dar es Salaam. Health policy and planning Regan, M., Cheng, C., Mboggo, E., Larson, E., Lema, I. A., Magesa, L., Machumi, L., Ulenga, N., Sando, D., Mwanyika-Sando, M., Barnhart, D. A., Hong, B., Mungure, E., Li, N., Siril, H., Mujinja, P., Naburi, H., Kilewo, C., Ekstrom, A. M., Geldsetzer, P., Fawzi, W., Barnighausen, T., Sudfeld, C. R., Spiegelman, D. 2022


    The provision of high-quality antenatal care (ANC) is important for preventing maternal and newborn mortality and morbidity, but only around half of pregnant women in Tanzania attended four or more ANC visits in 2019. Although there is emerging evidence on the benefit of community health worker (CHW) interventions on ANC uptake, few large-scale pragmatic trials have been conducted. This pragmatic cluster-randomized trial, implemented directly through the public sector health system, assessed the impact of an intervention that trained public sector CHWs to promote uptake of ANC. We randomized 60 administrative wards in Dar es Salaam to either a targeted CHW intervention or standard of care. The impact of the intervention was assessed using generalized estimating equations (GEE) with an independent working correlation matrix to account for clustering within wards. A total of 243,908 women were included in the analysis of our primary outcome of four or more ANC visits. The intervention significantly increased the likelihood of attending four or more ANC visits (RR 1.42; 95% CI: 1.05, 1.92), and had a modest beneficial effect on the total number of ANC visits (percent change: 7.7%; 95% CI: 0.2%, 15.5%). While slightly more women in the intervention arm attended ANC in their first trimester compared to the standard-of-care arm (19% vs 18.7%) the difference was not significant (RR:1.02; 95% CI: 0.84, 1.22). Our findings suggest that trained CHWs can increase attendance of ANC visits in Dar es Salaam and similar settings. However, additional interventions appear necessary to promote early initiation of ANC. This study demonstrates that routine health systems data can be leveraged for outcome assessment in trials and program evaluation, and that the results are likely superior, both in terms of bias and precision, to data that is collected specifically for science.

    View details for DOI 10.1093/heapol/czac100

    View details for PubMedID 36377764

  • Data Resource Profile: The Global School-based Student Health Survey-behavioural risk and protective factors among adolescents. International journal of epidemiology Bischops, A. C., Radev, S. T., Kothe, U., Chen, S., Geldsetzer, P., Sarker, M., Su, T. T., Mohamed, F. A., Darwish, N., Ahmad, N. A., Ould Baba, S. A., Barnighausen, T., Barteit, S. 2022

    View details for DOI 10.1093/ije/dyac208

    View details for PubMedID 36350584

  • Knowledge and attitudes about HIV pre-exposure prophylaxis: Evidence from in-depth interviews and focus group discussions with policy makers, healthcare providers, and end-users in Lesotho. PLOS global public health Geldsetzer, P., Chebet, J. J., Tarumbiswa, T., Phate-Lesihla, R., Maponga, C., Mandara, E., Bärnighausen, T., McMahon, S. A. 2022; 2 (10): e0000762


    Studies on knowledge and attitudes about HIV pre-exposure prophylaxis (PrEP) have mostly focused on key populations in North America and Europe. To inform Lesotho's national rollout of PrEP to the general population, this study aimed to characterize knowledge and attitudes about PrEP among policy makers, implementing partners, healthcare providers, and PrEP end-users in Lesotho. Respondents were purposively selected to participate based on personal experience in the development and implementation of Lesotho's PrEP program, or the personal use of PrEP. We conducted 106 in-depth interviews with policy makers (n = 5), implementing partners (n = 4), and end-users (current PrEP users = 55; former PrEP users = 36; and PrEP "decliners" = 6). In addition, we held 11 focus group discussions (FGDs) with a total of 105 healthcare providers. Interview and FGD transcripts were analyzed following the tenets of Grounded Theory. Respondents expressed positive attitudes toward PrEP, owing to experienced and perceived personal, familial, and societal benefits. PrEP was viewed as i) an opportunity for serodiscordant couples to remain together, ii) a means of conceiving children with minimized risk of HIV infection, iii) providing a sense of agency and control, and iv) an avenue for addressing the HIV epidemic in Lesotho. Respondents demonstrated understanding of PrEP's intended use, eligibility requirements, and modality of use. However, respondents also reported that several important misconceptions of PrEP were common among adults in Lesotho, including a belief that PrEP protects against sexually transmitted infections other than HIV, promotes promiscuity, prevents pregnancy, causes seroconversion, and provides lifelong protection from taking the pill just once. In addition to building on the perceived advantages of PrEP to shape a positive message, Lesotho's national rollout of PrEP will likely benefit from a communication strategy that specifically addresses the common misconceptions of PrEP identified in this study.

    View details for DOI 10.1371/journal.pgph.0000762

    View details for PubMedID 36962565

    View details for PubMedCentralID PMC10021845

  • Addressing alcohol use among blood pressure patients in Thai primary care: Lessons from a survey-based stakeholder consultation. Preventive medicine reports Lemp, J. M., Pengpid, S., Buntup, D., Bärnighausen, T. W., Geldsetzer, P., Peltzer, K., Rehm, J., Sornpaisarn, B., Probst, C. 2022; 29: 101954


    Alcohol use is a major risk factor for noncommunicable diseases in Thailand, and one of its pathways is high blood pressure. Given that brief intervention can effectively reduce hazardous alcohol consumption, this study aimed to investigate how hypertensive patients with concomitant alcohol use are identified and treated in Thai primary care settings and what this may mean for screening and lifestyle intervention strategies. In a cross-sectional, mixed-method design, we surveyed 91 participants from three different groups of Thai stakeholders: policy- and decisionmakers; healthcare practitioners; and patients diagnosed with hypertension. Data was collected between December 2020 and May 2021. Responses were analyzed descriptively and using open coding tools to identify current practices, barriers, facilitators, and implications for interventions. All stakeholder groups regarded alcohol use as an important driver of hypertension. While lifestyle interventions among hypertensive patients were perceived as beneficial, current lifestyle support was limited. Barriers included limited resources in primary healthcare facilities, lack of continuous monitoring or follow-up, missing tools or procedures for risk assessment and lifestyle intervention, and stigmatization of alcohol use. Our results suggest that although screening for lifestyle risk factors (including alcohol use) and lifestyle interventions are not yet sufficiently established, a wide range of stakeholders still recognize the potential of interventions targeted at hazardous alcohol use among hypertensive patients. Future interventions may establish standardized assessment tools, be tailored to high-risk groups, and include electronic or remote elements.

    View details for DOI 10.1016/j.pmedr.2022.101954

    View details for PubMedID 36161118

    View details for PubMedCentralID PMC9502666

  • Hypertension care in demographic surveillance sites: a cross-sectional study in Bangladesh, India, Indonesia, Malaysia, Viet Nam. Bulletin of the World Health Organization Geldsetzer, P., Tan, M. M., Dewi, F. S., Quyen, B. T., Juvekar, S., Hanifi, S. M., Roy, S., Asgari-Jirhandeh, N., Reidpath, D., Su, T. T. 2022; 100 (10): 601-609


    Objective: To determine the proportion of adults with hypertension who reported: (i)having been previously diagnosed with hypertension; (ii)taking blood pressure-lowering medication; and (iii) having achieved hypertension control, in five health and demographic surveillance system sites across five countries in Asia.Methods: Data were collected during household surveys conducted between 2016 and 2020 in the five surveillance sites in Bangladesh, India, Indonesia, Malaysia and Viet Nam. We defined hypertension as systolic blood pressure ≥140mmHg, diastolic blood pressure ≥90mmHg or taking blood pressure-lowering medication. We defined hypertension control as systolic blood pressure <140mmHg and diastolic blood pressure <90mmHg. We disaggregated hypertension awareness, treatment and control by surveillance site, and within each site by sex, age group, education, body mass index and smoking status.Findings: Of 22142 participants, 11137 had hypertension (Bangladesh: 211; India: 487; Indonesia: 1641; Malaysia: 8164; and Viet Nam: 634). The mean age of participants with hypertension was 60 years (range: 19-101 years). Only in the Malaysian site were more than half of individuals with hypertension aware of their condition. Hypertension treatment ranged from 20.8% (341/1641; 95% CI: 18.8-22.8%) in the Indonesian site to 44.7% (3649/8164; 95% CI: 43.6-45.8%) in the Malaysian site. Less than one in four participants with hypertension had achieved hypertension control in any site. Hypertension awareness, treatment and control were generally higher among women and older adults.Conclusion: While hypertension awareness and treatment varied widely across surveillance sites, hypertension control was low in all sites.

    View details for DOI 10.2471/BLT.22.287807

    View details for PubMedID 36188011

  • Perceptions of and obstacles to SARS-CoV-2 vaccination among adults in Lebanon: a cross-sectional online survey. JMIR formative research Abou-Arraj, N. E., Maddah, D., Buhamdan, V., Abbas, R., Jawad, N. K., Karaki, F., Alami, N. H., Geldsetzer, P. 2022


    BACKGROUND: The COVID-19 pandemic is an additional burden on Lebanon's stressed population, fragmented healthcare system, and political, economic, and refugee crises. Vaccination is an important means to overcoming the pandemic.OBJECTIVE: Our study's aims were to 1) assess rates of intention to vaccinate and vaccine hesitancy in Lebanon; 2) determine how vaccine hesitancy in Lebanon varies by sociodemographic, economic, and geographic characteristics; and 3) understand individuals' motivations for vaccinating and concerns and obstacles to vaccination.METHODS: We performed a cross-sectional study from 29 Jan 2021 to 11 Mar 2021 using an online questionnaire of open- and closed-ended questions in Arabic via convenience "snowball" sampling to assess the perceptions of adults residing in Lebanon.RESULTS: 1,185 adults participated in the survey. 46.1% [95% CI: 43.2%-49.0%] of survey participants intended to take the SARS-CoV-2 vaccine when available to them, 19.0% [16.8%-21.4%] indicated that they would not, and 34.0% [31.3%-36.8%] were unsure. The most common reasons for hesitancy were concerns about safety, limited testing, side effects, and efficacy. Top motivations for vaccinating were to protect oneself, to protect one's family and the public, and to end the pandemic. Despite financial hardships in Lebanon, barriers to vaccine access were not frequently described as concerns. Established healthcare facilities, rather than new temporary vaccination centers, were most frequently selected as preferred vaccination sites.CONCLUSIONS: Vaccine hesitancy appears to be high in Lebanon. Disseminating clear, consistent, evidence-based safety and efficacy information on vaccines may help reduce vaccine hesitancy, especially among the large proportion of adults who appear to be unsure about (rather than opposed to) vaccination.CLINICALTRIAL:

    View details for DOI 10.2196/36827

    View details for PubMedID 36383635

  • The impact of face-mask mandates on all-cause mortality in Switzerland: a quasi-experimental study. European journal of public health De Giorgi, G., Geldsetzer, P., Michalik, F., Speziali, M. M. 2022


    BACKGROUND: Whereas there is strong evidence that wearing a face mask is effective in reducing the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), evidence on the impact of mandating the wearing of face masks on deaths from coronavirus disease 2019 (COVID-19) and all-cause mortality is more sparse and likely to vary by context. Focusing on a quasi-experimental setting in Switzerland, we aimed to determine (i) the effect of face-mask mandates for indoor public spaces on all-cause mortality; and (ii) how the effect has varied over time, and by age and sex.METHODS: Our analysis exploited the fact that between July and October 2020, nine cantons in Switzerland extended a face-mask mandate at different time points from being restricted to public transportation only to applying to all public indoor places. We used both a Difference-in-Differences approach with fixed-effects for canton and week and an event-study approach.RESULTS: In our main Difference-in-Differences model, the face-mask mandate was associated with a 0.3% reduction in all-cause mortality [95% confidence interval (CI): -3.4% to 2.7%; P=0.818]. This null effect was confirmed in the event-study approach and a variety of robustness checks. Combining the face-mask mandate with social distancing rules led to an estimated 5.1% (95% CI: -7.9% to -2.4%; P=0.001) reduction in all-cause mortality.CONCLUSIONS: Mandating face-mask use in public indoor spaces in Switzerland in mid-to-late 2020 does not appear to have resulted in large reductions in all-cause mortality in the short term. There is some suggestion that combining face-mask mandates with social distancing rules reduced all-cause mortality.

    View details for DOI 10.1093/eurpub/ckac123

    View details for PubMedID 36087339

  • The socioeconomic gradient of alcohol use: an analysis of nationally representative survey data from 55 low-income and middle-income countries. The Lancet. Global health Xu, Y., Geldsetzer, P., Manne-Goehler, J., Theilmann, M., Marcus, M. E., Zhumadilov, Z., Quesnel-Crooks, S., Mwalim, O., Moghaddam, S. S., Koolaji, S., Karki, K. B., Farzadfar, F., Ebrahimi, N., Damasceno, A., Aryal, K. K., Agoudavi, K., Atun, R., Bärnighausen, T., Davies, J., Jaacks, L. M., Vollmer, S., Probst, C. 2022; 10 (9): e1268-e1280


    Alcohol is a leading risk factor for over 200 conditions and an important contributor to socioeconomic health inequalities. However, little is known about the associations between individuals' socioeconomic circumstances and alcohol consumption, especially heavy episodic drinking (HED; ≥5 drinks on one occasion) in low-income or middle-income countries. We investigated the association between individual and household level socioeconomic status, and alcohol drinking habits in these settings.In this pooled analysis of individual-level data, we used available nationally representative surveys-mainly WHO Stepwise Approach to Surveillance surveys-conducted in 55 low-income and middle-income countries between 2005 and 2017 reporting on alcohol use. Surveys from participants aged 15 years or older were included. Logistic regression models controlling for age, country, and survey year stratified by sex and country income groups were used to investigate associations between two indicators of socioeconomic status (individual educational attainment and household wealth) and alcohol use (current drinking and HED amongst current drinkers).Surveys from 336 287 participants were included in the analysis. Among males, the highest prevalence of both current drinking and HED was found in lower-middle-income countries (L-MICs; current drinking 49·9% [95% CI 48·7-51·2] and HED 63·3% [61·0-65·7]). Among females, the prevalence of current drinking was highest in upper-middle-income countries (U-MIC; 29·5% [26·1-33·2]), and the prevalence of HED was highest in low-income countries (LICs; 36·8% [33·6-40·2]). Clear gradients in the prevalence of current drinking were observed across all country income groups, with a higher prevalence among participants with high socioeconomic status. However, in U-MICs, current drinkers with low socioeconomic status were more likely to engage in HED than participants with high socioeconomic status; the opposite was observed in LICs, and no association between socioeconomic status and HED was found in L-MICs.The findings call for urgent alcohol control policies and interventions in LICs and L-MICs to reduce harmful HED. Moreover, alcohol control policies need to be targeted at socially disadvantaged groups in U-MICs.Deutsche Forschungsgemeinschaft and the National Center for Advancing Translational Sciences of the US National Institutes of Health.

    View details for DOI 10.1016/S2214-109X(22)00273-X

    View details for PubMedID 35961350

  • Patterns of multimorbidity in India: A nationally representative cross-sectional study of individuals aged 15 to 49 years. PLOS global public health Prenissl, J., De Neve, J. W., Sudharsanan, N., Manne-Goehler, J., Mohan, V., Awasthi, A., Prabhakaran, D., Roy, A., Tandon, N., Davies, J. I., Atun, R., Bärnighausen, T., Jaacks, L. M., Vollmer, S., Geldsetzer, P. 2022; 2 (8): e0000587


    There is a dearth of evidence on the epidemiology of multimorbidity in low- and middle-income countries. This study aimed to determine the prevalence of multimorbidity in India and its variation among states and population groups. We analyzed data from a nationally representative household survey conducted in 2015-2016 among individuals aged 15 to 49 years. Multimorbidity was defined as having two or more conditions out of five common chronic morbidities in India: anemia, asthma, diabetes, hypertension, and obesity. We disaggregated multimorbidity prevalence by condition, state, rural versus urban areas, district-level wealth, and individual-level sociodemographic characteristics. 712,822 individuals were included in the analysis. The prevalence of multimorbidity was 7·2% (95% CI, 7·1% - 7·4%), and was higher in urban (9·7% [95% CI, 9·4% - 10·1%]) than in rural (5·8% [95% CI, 5·7% - 6·0%]) areas. The three most prevalent morbidity combinations were hypertension with obesity (2·9% [95% CI, 2·8% - 3·1%]), hypertension with anemia (2·2% [95% CI, 2·1%- 2·3%]), and obesity with anemia (1·2% [95% CI, 1·1%- 1·2%]). The age-standardized multimorbidity prevalence varied from 3·4% (95% CI: 3·0% - 3·8%) in Chhattisgarh to 16·9% (95% CI: 13·2% - 21·5%) in Puducherry. Being a woman, being married, not currently smoking, greater household wealth, and living in urban areas were all associated with a higher risk of multimorbidity. Multimorbidity is common among young and middle-aged adults in India. This study can inform screening guidelines for chronic conditions and the targeting of relevant policies and interventions to those most in need.

    View details for DOI 10.1371/journal.pgph.0000587

    View details for PubMedID 36962723

    View details for PubMedCentralID PMC10021201

  • The Effect of Particulate Matter Exposure During Pregnancy on Pregnancy and Child Health Outcomes in South Asia: Protocol for an Instrumental Variable Analysis. JMIR research protocols Reitzug, F., Luby, S. P., Pullabhotla, H. K., Geldsetzer, P. 2022; 11 (8): e35249


    BACKGROUND: Determining the longer-term health effects of air pollution has been difficult owing to the multitude of potential confounding variables in the relationship between air pollution and health. Air pollution in many areas of South Asia is seasonal, with large spikes in particulate matter (PM) concentration occurring in the winter months. This study exploits this seasonal variation in PM concentration through a natural experiment.OBJECTIVE: This project aims to determine the causal effect of PM exposure during pregnancy on pregnancy and child health outcomes.METHODS: We will use an instrumental variable (IV) design whereby the estimated month of conception is our instrument for exposure to PM with a diameter less than 2.5 mum (PM2.5) during pregnancy. We will assess the plausibility of our assumption that timing of conception is exogenous with regard to our outcomes of interest and will adjust for date of monsoon onset to control for confounding variables related to harvest timing. Our outcomes are 1) birth weight, 2) pregnancy termination resulting in miscarriage, abortion, or still birth, 3) neonatal death, 4) infant death, and 5) child death. We will use data from the Demographic and Health Surveys (DHS) conducted in relevant regions of Bangladesh, India, Nepal, and Pakistan, along with monthly gridded data on PM2.5 concentration (0.1°*0.1° spatial resolution), precipitation data (0.5°*0.5° resolution), temperature data (0.5°*0.5°), and agricultural land use data (0.1°*0.1° resolution).RESULTS: Data access to relevant DHSs was granted on June 6, 2021 for India, Nepal, Bangladesh, August 24, 2021 for Pakistan, and June 19 2022 for the latest DHS from India.CONCLUSIONS: If the assumptions for a causal interpretation of our instrumental variable analysis are met, this analysis will provide important causal evidence on the maternal and child health effects of PM2.5 exposure during pregnancy. This evidence is important to inform personal behavior and interventions, such as the adoption of indoor air filtration during pregnancy as well as environmental and health policy.INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/35249.

    View details for DOI 10.2196/35249

    View details for PubMedID 35947440

  • Health Insurance Coverage In Low- And Middle-Income Countries Remains Far From The Goal Of Universal Coverage. Health affairs (Project Hope) Chen, S., Geldsetzer, P., Chen, Q., Moshabela, M., Jiao, L., Ogbuoji, O., Sie, A., Atun, R., Barnighausen, T. 2022; 41 (8): 1142-1152


    This study aimed to determine levels of health insurance coverage in low- and middle-income countries and how coverage varies by people's sociodemographic characteristics. We conducted a population size-weighted, one-stage individual participant data meta-analysis of health insurance coverage, using a population-based sample of 2,035,401 participants ages 15-59 from nationally representative household surveys in fifty-six countries during the period 2006-18. One in five people (20.3percent) across the fifty-six countries in our study had health insurance. Health insurance coverage exceeded 50percent in only seven countries and 70percent in only three countries. Substantially more people had public health insurance than private health insurance (71.4percent versus 28.6percent). We found that men and older, more educated, and wealthier people were more likely to have health insurance; these sociodemographic gradients in health insurance coverage were strongest in sub-Saharan Africa and followed traditional lines of privilege. Low- and middle-income countries need to massively expand health insurance coverage if they intend to use insurance to achieve universal health coverage.

    View details for DOI 10.1377/hlthaff.2021.00951

    View details for PubMedID 35914199

  • A systematic review of healthcare provider-targeted mobile applications for non-communicable diseases in low- and middle-income countries. NPJ digital medicine Geldsetzer, P., Flores, S., Wang, G., Flores, B., Rogers, A. B., Bunker, A., Chang, A. Y., Tisdale, R. 2022; 5 (1): 99


    Mobile health (mHealth) interventions hold promise for addressing the epidemic of noncommunicable diseases (NCDs) in low- and middle-income countries (LMICs) by assisting healthcare providers managing these disorders in low-resource settings. We aimed to systematically identify and assess provider-facing mHealth applications used to screen for, diagnose, or monitor NCDs in LMICs. In this systematic review, we searched the indexing databases of PubMed, Web of Science, and Cochrane Central for studies published between January 2007 and October 2019. We included studies of technologies that were: (i) mobile phone- or tablet-based, (ii) able to screen for, diagnose, or monitor an NCD of public health importance in LMICs, and (iii) targeting health professionals as users. We extracted disease type, intervention purpose, target population, study population, sample size, study methodology, technology stage, country of development, operating system, and cost. Our initial search retrieved 13,262 studies, 315 of which met inclusion criteria and were analyzed. Cardiology was the most common clinical domain of the technologies evaluated, with 89 publications. mHealth innovations were predominantly developed using Apple's iOS operating system. Cost data were provided in only 50 studies, but most technologies for which this information was available cost less than 20 USD. Only 24 innovations targeted the ten NCDs responsible for the greatest number of disability-adjusted life years lost globally. Most publications evaluated products created in high-income countries. Reported mHealth technologies are well-developed, but their implementation in LMICs faces operating system incompatibility and a relative neglect of NCDs causing the greatest disease burden.

    View details for DOI 10.1038/s41746-022-00644-3

    View details for PubMedID 35853936

  • Longitudinal evidence on treatment discontinuation, adherence, and loss of hypertension control in four middle-income countries. Science translational medicine Mauer, N., Geldsetzer, P., Manne-Goehler, J., Davies, J. I., Stokes, A. C., McConnell, M., Ali, M. K., Winkler, V., Sudharsanan, N. 2022; 14 (652): eabi9522


    Managing hypertension is a highly dynamic process, yet current evidence on hypertension control in middle-income countries (MICs) is largely based on cross-sectional data. Using multiple waves of population-based cohort data from four MICs (China, Indonesia, Mexico, and South Africa), we undertook a longitudinal investigation into how individuals with hypertension move through care over time. We classified adults aged 40 years and over (N = 8527) into care stages at both baseline and follow-up waves and estimated the probability of transitioning between stages using Poisson regression models. Over a 5- to 9-year follow-up period, only around 30% of undiagnosed individuals became diagnosed [Mexico, 27% (95% confidence interval: 23%, 31%); China, 30% (26%, 33%); Indonesia, 30% (28%, 32%); and South Africa, 36% (31%, 41%)], and one in four untreated individuals became treated [Indonesia, 11% (10%, 12%); Mexico, 24% (20%, 28%); China, 26% (23%, 29%); and South Africa, 33% (29%, 38%)]. The probability of reaching blood pressure (BP) control was lower [Indonesia, 2% (1%, 2%); China, 9% (7%, 11%); Mexico, 12% (9%, 14%); and South Africa, 24% (20%, 28%)] regardless of treatment status. A substantial proportion of individuals discontinued treatment [Indonesia, 70% (67%, 73%); China, 36% (32%, 40%); Mexico, 34% (29%, 39%); and South Africa, 20% (15%, 25%)], and most individuals lost BP control by follow-up [Indonesia, 92% (89%, 96%); Mexico, 77% (71%, 83%); China, 76% (69%, 83%); and South Africa 45% (36%, 54%)]. Our results highlight that policies solely aimed at improving diagnosis or initiating treatment may not lead to long-term hypertension control improvements in MICs.

    View details for DOI 10.1126/scitranslmed.abi9522

    View details for PubMedID 35857627

  • Rural-Urban Differences in Diabetes Care and Control in 42 Low- and Middle-Income Countries: A Cross-sectional Study of Nationally Representative Individual-Level Data. Diabetes care Flood, D., Geldsetzer, P., Agoudavi, K., Aryal, K. K., Brant, L. C., Brian, G., Dorobantu, M., Farzadfar, F., Gheorghe-Fronea, O., Gurung, M. S., Guwatudde, D., Houehanou, C., Jorgensen, J. M., Kondal, D., Labadarios, D., Marcus, M. E., Mayige, M., Moghimi, M., Norov, B., Perman, G., Quesnel-Crooks, S., Rashidi, M. M., Moghaddam, S. S., Seiglie, J. A., Karaireho, S. K., Steinbrook, E., Theilmann, M., Ware, L. J., Vollmer, S., Atun, R., Davies, J. I., Ali, M. K., Rohloff, P., Manne-Goehler, J. 2022


    Diabetes prevalence is increasing rapidly in rural areas of low- and middle-income countries (LMICs), but there are limited data on the performance of health systems in delivering equitable and effective care to rural populations. We therefore assessed rural-urban differences in diabetes care and control in LMICs.We pooled individual-level data from nationally representative health surveys in 42 countries. We used Poisson regression models to estimate age-adjusted differences in the proportion of individuals with diabetes in rural versus urban areas achieving performance measures for the diagnosis, treatment, and control of diabetes and associated cardiovascular risk factors. We examined differences across the pooled sample, by sex, and by country.The pooled sample from 42 countries included 840,110 individuals (35,404 with diabetes). Compared with urban populations with diabetes, rural populations had ∼15-30% lower relative risk of achieving performance measures for diabetes diagnosis and treatment. Rural populations with diagnosed diabetes had a 14% (95% CI 5-22%) lower relative risk of glycemic control, 6% (95% CI -5 to 16%) lower relative risk of blood pressure control, and 23% (95% CI 2-39%) lower relative risk of cholesterol control. Rural women with diabetes had lower achievement of performance measures relating to control than urban women, whereas among men, differences were small.Rural populations with diabetes experience substantial inequities in the achievement of diabetes performance measures in LMICs. Programs and policies aiming to strengthen global diabetes care must consider the unique challenges experienced by rural populations.

    View details for DOI 10.2337/dc21-2342

    View details for PubMedID 35771765

  • Data Resource Profile: The Global Health and Population Project on Access to Care for Cardiometabolic Diseases (HPACC). International journal of epidemiology Manne-Goehler, J., Theilmann, M., Flood, D., Marcus, M. E., Andall-Brereton, G., Agoudavi, K., Arboleda, W. A., Aryal, K. K., Bicaba, B., Bovet, P., Brant, L. C., Brian, G., Chamberlin, G., Chen, G., Damasceno, A., Dorobantu, M., Dunn, M., Ebert, C., Farzadfar, F., Gurung, M. S., Guwatudde, D., Houehanou, C., Houinato, D., Hwalla, N., Jorgensen, J. M., Karki, K. B., Labadarios, D., Lunet, N., Malta, D. C., Martins, J. S., Mayige, M. T., McClure, R. W., Saeedi Moghaddam, S., Mwangi, K. J., Mwalim, O., Norov, B., Quesnel-Crooks, S., Rhode, S., Seiglie, J. A., Sibai, A., Silver, B. K., Sturua, L., Stokes, A., Supiyev, A., Tsabedze, L., Zhumadilov, Z., Jaacks, L. M., Atun, R., Davies, J. I., Geldsetzer, P., Vollmer, S., Bärnighausen, T. W. 2022

    View details for DOI 10.1093/ije/dyac125

    View details for PubMedID 35762972

  • Sex differences in the mortality rate for coronavirus disease 2019 compared to other causes of death: an analysis of population-wide data from 63 countries. European journal of epidemiology Geldsetzer, P., Mukama, T., Jawad, N. K., Riffe, T., Rogers, A., Sudharsanan, N. 2022


    Men are more likely than women to die due to coronavirus disease 2019 (COVID-19). An open question is whether these sex differences reflect men's generally poorer health and lower life expectancy compared to women of similar ages or if men face a unique COVID-19 disadvantage. Using age-specific data on COVID-19 mortalityas well as cause-specific and all-cause mortality for 63 countries, we compared the sex difference in COVID-19 mortality to sexdifferences in all-causemortality and mortality fromother common causes of death to determine the magnitude of theexcess male mortalitydisadvantage for COVID-19. We found that sex differences in the age-standardized COVID-19 mortality rate were substantially larger than for the age-standardized all-cause mortality rate and mortality rate formost other common causes of death. Theexcess male mortality disadvantage for COVID-19 was especially large in the oldest age groups. Our findings suggest that the causal pathways that link male sex to a higher mortality from a SARS-CoV-2 infection may be specific to SARS-CoV-2, rather than shared with the pathways responsible for the shorter life expectancy among men or sex differences for other common causes of death. Understanding these causal chains could assist in the development of therapeutics and preventive measures for COVID-19 and, possibly, other coronavirus diseases.

    View details for DOI 10.1007/s10654-022-00866-5

    View details for PubMedID 35737205

  • The provision of COVID-19 vaccines developed in China to other countries: A cross-sectional online survey on the views of the Chinese public. JMIR public health and surveillance Yu, H., Du, R., Wang, M., Yu, F., Yang, J., Jiao, L., Wang, Z., Liu, H., Wu, P., Bärnighausen, T., Xue, L., Wang, C., McMahon, S., Geldsetzer, P., Chen, S. 2022


    COVID-19 vaccines are in short supply globally. China was among the first countries to pledge supplies of the COVID-19 vaccine as a global public product, and to date the country has provided more than 600 million vaccines to more than 200 countries and regions with low COVID-19 vaccination rates. Understanding the public's attitude in China towards the global distribution of COVID-19 vaccines could inform global and national decisions, policies and debates.The aim of this study was to determine the attitudes of adults living in China regarding the global allocation of COVID-19 vaccines developed in China, and how these attitudes vary across provinces and by sociodemographic characteristics.We conducted a cross-sectional online survey among adults registered with the survey company KuRunData. The survey asked participants 31 questions on their attitudes regarding the global allocation of COVID-19 vaccines developed in China. We disaggregated responses by province and sociodemographic characteristics. All analyses used survey sampling weights.A total of 10,000 participants completed the questionnaire. Participants generally favored providing COVID-19 vaccines to foreign countries before fully fulfilling domestic needs (75.6%, 95% CI: 74.6% - 76.5%). Women (76.8%, OR = 1.18, 95% CI: 1.07 - 1.32, P = .002) and those living in rural areas (76.8%, OR = 1.13, 95% CI: 1.01 - 1.27, P = .03) were especially likely to hold this opinion. Most respondents preferred providing financial support through international platforms rather than directly offering support to individual countries (72.1%, 95% CI: 71.0% - 73.1%), while for vaccine products they preferred direct provision to relevant countries instead of via a delivery platform such as COVAX (77.3%, 95% CI: 76.3% - 78.2%).Among our survey sample, we find that adults are generally supportive of the international distribution of COVID-19 vaccines, which may encourage policy makers to support and implement the distribution of COVID-19 vaccines developed in China globally. Conducting similar surveys in other countries could help align policymakers' actions on COVID-19 vaccine distribution with the preferences of their constituencies.

    View details for DOI 10.2196/33484

    View details for PubMedID 35483084

  • Applying systems thinking to identify enablers and challenges to scale-up interventions for hypertension and diabetes in low-income and middle-income countries: protocol for a longitudinal mixed-methods study. BMJ open Ramani-Chander, A., Joshi, R., van Olmen, J., Wouters, E., Delobelle, P., Vedanthan, R., Miranda, J. J., Oldenburg, B., Sherwood, S., Rawal, L. B., Mash, R. J., Irazola, V. E., Martens, M., Lazo-Porras, M., Liu, H., Agarwal, G., Waqa, G., Marcolino, M. S., Esandi, M. E., Ribeiro, A. L., Probandari, A., Gonzalez-Salazar, F., Shrestha, A., Sujarwoto, S., Levitt, N., Paredes, M., Sugishita, T., Batal, M., Li, Y., Haghparast-Bidgoli, H., Naanyu, V., He, F. J., Zhang, P., Mfinanga, S. G., De Neve, J., Daivadanam, M., Siddiqi, K., Geldsetzer, P., Klipstein-Grobusch, K., Huffman, M. D., Webster, J., Ojji, D., Beratarrechea, A., Tian, M., Postma, M., Owolabi, M. O., Birungi, J., Antonietti, L., Ortiz, Z., Patel, A., Peiris, D., Schouw, D., Koot, J., Nakamura, K., Tampubolon, G., Thrift, A. G., Global Alliance for Chronic Diseases Upscaling Working Group Collaborators.,, 2022; 12 (4): e053122


    INTRODUCTION: There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions.METHODS AND ANALYSIS: We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (TP), initiation of implementation (T0) and 1-year postinitiation (T1). We will extract project-related data from secondary documents at TP and conduct multistakeholder qualitative interviews to gather data at T0 and T1. We will undertake descriptive statistical analysis of TP data and analyse T0 and T1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks.ETHICS AND DISSEMINATION: The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network.

    View details for DOI 10.1136/bmjopen-2021-053122

    View details for PubMedID 35437244

  • PrEP uptake and delivery setting preferences among clients visiting six healthcare facilities in Eswatini. AIDS and behavior Inghels, M., Kim, H., Tanser, F., Hettema, A., McMahon, S. A., Oldenburg, C. E., Matse, S., Kohler, S., Geldsetzer, P., Barnighausen, T. 2022


    Due to the high HIV incidence among the general population of Eswatini, pre-exposure prophylaxis (PrEP) for HIV-exposed individuals is recommended. However, little is known about PrEP uptake and preferences in PrEP delivery healthcare setting among the general population. We conducted a secondary analysis of a randomized trial that aimed to increase PrEP uptake. All clients eligible for PrEP in one of six public-sector healthcare facilities in Eswatini were included. PrEP uptake was stratified by initial reason for visit (e.g. outpatient). Preferences in PrEP delivery setting were collected among those clients who initiated PrEP. A total of 1782 clients had their HIV acquisition risk assessed. Of these, 72% (1277/1782) were considered at risk by healthcare providers and, among them, 40% (517/1277) initiated PrEP. Uptake was higher among clients visiting specifically to initiate PrEP (93%), followed by HIV testing visits (45.8%) and outpatient visits (40%). Among those who initiated PrEP, preferred delivery settings were outpatient services (31%), HIV testing services (26%), family planning (21%) and antenatal services (14%). Men or those at high risk of HIV acquisition were more likely to prefer HIV testing and outpatient services, while young women were more likely to visit and express a preference for antenatal and family planning services. Outpatient services and HIV testing services could be preferable choices for PrEP delivery integration, due to the high PrEP uptake and delivery setting preferences of the populations who use these services. Antenatal and family planning could also be considered with a view to targeting the youngest women.

    View details for DOI 10.1007/s10461-022-03646-0

    View details for PubMedID 35429309

  • Use of statins for the prevention of cardiovascular disease in 41 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data. The Lancet. Global health Marcus, M. E., Manne-Goehler, J., Theilmann, M., Farzadfar, F., Moghaddam, S. S., Keykhaei, M., Hajebi, A., Tschida, S., Lemp, J. M., Aryal, K. K., Dunn, M., Houehanou, C., Bahendeka, S., Rohloff, P., Atun, R., Barnighausen, T. W., Geldsetzer, P., Ramirez-Zea, M., Chopra, V., Heisler, M., Davies, J. I., Huffman, M. D., Vollmer, S., Flood, D. 2022; 10 (3): e369-e379


    BACKGROUND: In the prevention of cardiovascular disease, a WHO target is that at least 50% of eligible people use statins. Robust evidence is needed to monitor progress towards this target in low-income and middle-income countries (LMICs), where most cardiovascular disease deaths occur. The objectives of this study were to benchmark statin use in LMICs and to investigate country-level and individual-level characteristics associated with statin use.METHODS: We did a cross-sectional analysis of pooled, individual-level data from nationally representative health surveys done in 41 LMICs between 2013 and 2019. Our sample consisted of non-pregnant adults aged 40-69 years. We prioritised WHO Stepwise Approach to Surveillance (STEPS) surveys because these are WHO's recommended method for population monitoring of non-communicable disease targets. For countries in which no STEPS survey was available, a systematic search was done to identify other surveys. We included surveys that were done in an LMIC as classified by the World Bank in the survey year; were done in 2013 or later; were nationally representative; had individual-level data available; and asked questions on statin use and previous history of cardiovascular disease. Primary outcomes were the proportion of eligible individuals self-reporting use of statins for the primary and secondary prevention of cardiovascular disease. Eligibility for statin therapy for primary prevention was defined among individuals with a history of diagnosed diabetes or a 10-year cardiovascular disease risk of at least 20%. Eligibility for statin therapy for secondary prevention was defined among individuals with a history of self-reported cardiovascular disease. At the country level, we estimated statin use by per-capita health spending, per-capita income, burden of cardiovascular diseases, and commitment to non-communicable disease policy. At the individual level, we used modified Poisson regression models to assess statin use alongside individual-level characteristics of age, sex, education, and rural versus urban residence. Countries were weighted in proportion to their population size in pooled analyses.FINDINGS: The final pooled sample included 116 449 non-pregnant individuals. 9229 individuals reported a previous history of cardiovascular disease (7·9% [95% CI 7·4-8·3] of the population-weighted sample). Among those without a previous history of cardiovascular disease, 8453 were eligible for a statin for primary prevention of cardiovascular disease (9·7% [95% CI 9·3-10·1] of the population-weighted sample). For primary prevention of cardiovascular disease, statin use was 8·0% (95% CI 6·9-9·3) and for secondary prevention statin use was 21·9% (20·0-24·0). The WHO target that at least 50% of eligible individuals receive statin therapy to prevent cardiovascular disease was achieved by no region or income group. Statin use was less common in countries with lower health spending. At the individual level, there was generally higher statin use among women (primary prevention only, risk ratio [RR] 1·83 [95% CI 1·22-2·76), and individuals who were older (primary prevention, 60-69 years, RR 1·86 [1·04-3·33]; secondary prevention, 50-59 years RR 1·71 [1·35-2·18]; and 60-69 years RR 2·09 [1·65-2·65]), more educated (primary prevention, RR 1·61 [1·09-2·37]; secondary prevention, RR 1·28 [0·97-1·69]), and lived in urban areas (secondary prevention only, RR 0·82 [0·66-1·00]).INTERPRETATION: In a diverse sample of LMICs, statins are used by about one in ten eligible people for the primary prevention of cardiovascular diseases and one in five eligible people for secondary prevention. There is an urgent need to scale up statin use in LMICs to achieve WHO targets. Policies and programmes that facilitate implementation of statins into primary health systems in these settings should be investigated for the future.FUNDING: National Clinician Scholars Program at the University of Michigan Institute for Healthcare Policy and Innovation, and National Institute of Diabetes and Digestive and Kidney Diseases.TRANSLATION: For the Spanish translation of the abstract see Supplementary Materials section.

    View details for DOI 10.1016/S2214-109X(21)00551-9

    View details for PubMedID 35180420

  • Animated, video entertainment-education to improve vaccine confidence globally during the COVID-19 pandemic: an online randomized controlled experiment with 24,000 participants. Trials Chen, S., Forster, S., Yang, J., Yu, F., Jiao, L., Gates, J., Wang, Z., Liu, H., Chen, Q., Geldsetzer, P., Wu, P., Wang, C., McMahon, S., Barnighausen, T., Adam, M. 2022; 23 (1): 161


    BACKGROUND: Science-driven storytelling and entertainment-education (E-E) media demonstrate potential for promoting improved attitudes and behavioral intent towards health-related practices. Months after the outbreak of coronavirus disease 2019 (COVID-19), emerging research highlights the essential role of interventions to improve public confidence in the COVID-19 vaccine. To improve vaccine confidence, we designed three short, animated videos employing three research-informed pedagogical strategies. These can be distributed globally through social media platforms, because of their wordless and culturally accessible design. However, the effectiveness of short, animated storytelling videos, deploying various pedagogic strategies, needs to be explored across different global regions.METHODS/DESIGN: The present study is a multi-site, parallel group, randomized controlled trial (RCT) comparing the effectiveness of (i) a storytelling-instructional-humor approach, (ii) a storytelling-analogy approach, (iii) a storytelling-emotion-focused approach, and (iv) no video. For our primary outcomes, we will measure vaccine hesitancy, and for secondary outcomes, we will measure behavioral intent to seek vaccination and hope. Using online platforms, we will recruit 12,000 participants (aged 18-59years) from the USA and China, respectively, yielding a total sample size of 24,000.DISCUSSION: This trial uses innovative online technology, reliable randomization algorithms, validated survey instruments, and list experiments to establish the effectiveness of three short, animated videos employing various research-informed pedagogical strategies. Results will be used to scientifically support the broader distribution of these short, animated video as well as informing the design of future videos for rapid, global public health communication.TRIAL REGISTRATION: German Clinical Trials Register DRKS #00023650 . Date of registration: 2021/02/09.

    View details for DOI 10.1186/s13063-022-06067-5

    View details for PubMedID 35183238

  • Use of lifestyle interventions in primary care for individuals with newly diagnosed hypertension, hyperlipidaemia or obesity: a retrospective cohort study. Journal of the Royal Society of Medicine Lemp, J. M., Nuthanapati, M. P., Barnighausen, T. W., Vollmer, S., Geldsetzer, P., Jani, A. 2022: 1410768221077381


    OBJECTIVE: Lifestyle interventions can be efficacious in reducing cardiovascular disease risk factors and are recommended as first-line interventions in England. However, recent information on the use of these interventions in primary care is lacking. We investigated for how many patients with newly diagnosed hypertension, hyperlipidaemia or obesity, lifestyle interventions were recorded in their primary care electronic health record.DESIGN: A retrospective cohort study.SETTING: English primary care, using UK Clinical Practice Research Datalink.PARTICIPANTS: A total of 770,711 patients who were aged 18 years or older and received a new diagnosis of hypertension, hyperlipidaemia or obesity between 2010 and 2019.MAIN OUTCOME MEASURES: Record of lifestyle intervention and/or medication in 12 months before to 12 months after initial diagnosis (2-year timeframe).RESULTS: Analyses show varying results across conditions: While 55.6% (95% CI 54.9-56.4) of individuals with an initial diagnosis of hypertension were recorded as having lifestyle support (lifestyle intervention or signposting) within the 2-year timeframe, this number was reduced to 45.2% (95% CI 43.8-46.6) for hyperlipidaemia and 52.6% (95% CI 51.1-54.1) for obesity. For substantial proportions of individuals neither lifestyle support nor medication (hypertension: 12.2%, 95% CI 11.9-12.5; hyperlipidaemia: 32.2%, 95% CI 31.2-33.3; obesity: 43.9%, 95% CI 42.3-45.4) were recorded. Sensitivity analyses confirm that limited proportions of patients had lifestyle support recorded in their electronic health record before they were first prescribed medication (diagnosed and undiagnosed), ranging from 12.1% for hypertension to 19.7% for hyperlipidaemia, and 19.5% for obesity (23.4% if restricted to Orlistat).CONCLUSIONS: Limited evidence of lifestyle support for individuals with cardiovascular risk factors (hypertension, hyperlipidaemia, obesity) recommended by national guidelines in England may stem from poor recording in electronic health records but may also represent missed opportunities. Given the link between progression to cardiovascular disease and modifiable lifestyle factors, early support for patients to manage their conditions through non-pharmaceutical interventions by establishing lifestyle modification as first-line treatment is crucial.

    View details for DOI 10.1177/01410768221077381

    View details for PubMedID 35176215

  • Maximising use of population data on cardiometabolic diseases. The lancet. Diabetes & endocrinology Flood, D., Guwatudde, D., Damasceno, A., Manne-Goehler, J., Davies, J. I. 2022

    View details for DOI 10.1016/S2213-8587(21)00328-4

    View details for PubMedID 35026159

  • Health System Performance for Multimorbid Cardiometabolic Disease in India: A Population-Based Cross-Sectional Study Global Heart Geldsetzer, P., De Neve, J., Mohan, V., Prabhakaran, D., Roy, A., Tandon, N., Davies, J. I., Vollmer, S., Bärnighausen, T., Prenissl, J. 2022; 17 (1)

    View details for DOI 10.5334/gh.1056

  • Prevalence of depression in China during the early stage of the COVID-19 pandemic: a cross-sectional study in an online survey sample. BMJ open Liu, W., Yu, F., Geldsetzer, P., Yang, J., Wang, Z., Golden, T., Jiao, L., Chen, Q., Liu, H., Wu, P., Wang, C., Barnighausen, T., Chen, S. 2022; 12 (3): e056667


    OBJECTIVES: We aimed to determine (1) the prevalence of depression during the COVID-19 pandemic among Chinese adults and (2) how depression prevalence varied by province and sociodemographic characteristics.DESIGN: Cross-sectional study.SETTING: National online survey in China.PARTICIPANTS: We conducted a cross-sectional online survey among adults registered with the survey company KuRunData from 8 May 2020 to 8 June 2020. We aimed to recruit 300-360 adults per province (n=14 493), with a similar distribution by sex and rural-urban residency as the general population within each of these provinces.PRIMARY OUTCOME: Participants completed the Patient Health Questionaire-9 (PHQ-9). We calculated the prevalence of depression (defined as a PHQ-9 score ≥10) nationally and separately for each province.ANALYSIS: Covariate-unadjusted and covariate-adjusted logistic regression models were used to examine how the prevalence of depression varied by adults' sociodemographic characteristics. All analyses used survey sampling weights.RESULTS: The survey was initiated by 14 493 participants, with 10 000 completing all survey questions and included in the analysis. The prevalence of depression in the national sample was 6.3% (95% CI 5.7% to 6.8%). A higher odds of depression was associated with living in an urban area (OR 1.50; 95% CI 1.18 to 1.90) and working as a nurse (OR 3.06; 95% CI 1.41 to 6.66). A lower odds of depression was associated with participants who had accurate knowledge of COVID-19 transmission prevention actions (OR 0.71; 95% CI 0.51 to 0.98), the knowledge that saliva is a main transmission route (OR 0.80; 95% CI 0.64 to 0.99) and awareness of COVID-19 symptoms (OR, 0.82; 95% CI 0.68 to 1.00).CONCLUSION: Around one in 20 adults in our online survey sample had a PHQ-9 score suggestive of depression. Interventions and policies to prevent and treat depression during the COVID-19 pandemic in China may be particularly needed for nurses and those living in urban areas.

    View details for DOI 10.1136/bmjopen-2021-056667

    View details for PubMedID 35264364

  • Public health impacts of an imminent Red Sea oil spill. Nature sustainability Huynh, B. Q., Kwong, L. H., Kiang, M. V., Chin, E. T., Mohareb, A. M., Jumaan, A. O., Basu, S., Geldsetzer, P., Karaki, F. M., Rehkopf, D. H. 2021; 4 (12): 1084-1091


    The possibility of a massive oil spill in the Red Sea is increasingly likely. The Safer, a deteriorating oil tanker containing 1.1 million barrels of oil, has been deserted near the coast of Yemen since 2015 and threatens environmental catastrophe to a country presently in a humanitarian crisis. Here, we model the immediate public health impacts of a simulated spill. We estimate that all of Yemen's imported fuel through its key Red Sea ports would be disrupted and that the anticipated spill could disrupt clean-water supply equivalent to the daily use of 9.0-9.9 million people, food supply for 5.7-8.4 million people and 93-100% of Yemen's Red Sea fisheries. We also estimate an increased risk of cardiovascular hospitalization from pollution ranging from 5.8 to 42.0% over the duration of the spill. The spill and its potentially disastrous impacts remain entirely preventable through offloading the oil. Our results stress the need for urgent action to avert this looming disaster.

    View details for DOI 10.1038/s41893-021-00774-8

    View details for PubMedID 34926834

    View details for PubMedCentralID PMC8682806

  • Maternal Iron-and-Folic-Acid Supplementation and its Association with Low-birthweight and Neonatal Mortality in India. Public health nutrition Rai, R. K., De Neve, J., Geldsetzer, P., Vollmer, S. 2021: 1-29


    OBJECTIVE: This study assessed intake of iron-and-folic-acid (IFA) tablet/syrup (grouped into none, <100 days of IFA consumption or <100 IFA, and ≥100 days of IFA consumption or ≥100 IFA) among prospective mothers and its association with various stages of low-birthweight (ELBW: extremely low-birthweight, VLBW: very low-birthweight, and LBW: low-birthweight) and neonatal mortality (death during day 0-1, 2-6, 7-27, and 0-27) in India.DESIGN: The cross-sectional, nationally representative, 2015-2016 National Family Health Survey (NFHS-4) data were used. Weighted descriptive analysis, and multiple binary logistic regression modelling were used.SETTING: NFHS-4 covered 640 districts from 37 states/ union territories of India.PARTICIPANTS: A total of 120,374 and 143,675 index children aged 0-59 months were included to analyse LBW and neonatal mortality, respectively.RESULTS: Overall, 30.7% mothers consumed ≥100 IFA in 2015-2016, and this estimate ranged from 0.0% in Zunheboto district of Nagaland state to 89.5% in Mahe district of Puducherry of India. Multiple regression analysis revealed that children of mothers who consumed ≥100 IFA had lower odds of ELBW, VLBW, LBW, and neonatal mortality during day 0-1, as compared to mothers who did not buy/receive any IFA. Consumption of IFA (<100 IFA and ≥100 IFA) had protective association with neonatal death during day 7-27, and 0-27. Consumption of IFA was not associated with neonatal death during day 2-6.CONCLUSIONS: While ≥100 IFA consumption during pregnancy was found to be associated with preventing select types of LBW and neonatal mortality, a large variation in coverage of ≥100 IFA consumption across 640 districts is concerning.

    View details for DOI 10.1017/S1368980021004572

    View details for PubMedID 34743779

  • Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys. PLoS medicine Marcus, M. E., Ebert, C., Geldsetzer, P., Theilmann, M., Bicaba, B. W., Andall-Brereton, G., Bovet, P., Farzadfar, F., Singh Gurung, M., Houehanou, C., Malekpour, M., Martins, J. S., Moghaddam, S. S., Mohammadi, E., Norov, B., Quesnel-Crooks, S., Wong-McClure, R., Davies, J. I., Hlatky, M. A., Atun, R., Barnighausen, T. W., Jaacks, L. M., Manne-Goehler, J., Vollmer, S. 2021; 18 (10): e1003841


    BACKGROUND: As the prevalence of hypercholesterolemia is increasing in low- and middle-income countries (LMICs), detailed evidence is urgently needed to guide the response of health systems to this epidemic. This study sought to quantify unmet need for hypercholesterolemia care among adults in 35 LMICs.METHODS AND FINDINGS: We pooled individual-level data from 129,040 respondents aged 15 years and older from 35 nationally representative surveys conducted between 2009 and 2018. Hypercholesterolemia care was quantified using cascade of care analyses in the pooled sample and by region, country income group, and country. Hypercholesterolemia was defined as (i) total cholesterol (TC) ≥240 mg/dL or self-reported lipid-lowering medication use and, alternatively, as (ii) low-density lipoprotein cholesterol (LDL-C) ≥160 mg/dL or self-reported lipid-lowering medication use. Stages of the care cascade for hypercholesterolemia were defined as follows: screened (prior to the survey), aware of diagnosis, treated (lifestyle advice and/or medication), and controlled (TC <200 mg/dL or LDL-C <130 mg/dL). We further estimated how age, sex, education, body mass index (BMI), current smoking, having diabetes, and having hypertension are associated with cascade progression using modified Poisson regression models with survey fixed effects. High TC prevalence was 7.1% (95% CI: 6.8% to 7.4%), and high LDL-C prevalence was 7.5% (95% CI: 7.1% to 7.9%). The cascade analysis showed that 43% (95% CI: 40% to 45%) of study participants with high TC and 47% (95% CI: 44% to 50%) with high LDL-C ever had their cholesterol measured prior to the survey. About 31% (95% CI: 29% to 33%) and 36% (95% CI: 33% to 38%) were aware of their diagnosis; 29% (95% CI: 28% to 31%) and 33% (95% CI: 31% to 36%) were treated; 7% (95% CI: 6% to 9%) and 19% (95% CI: 18% to 21%) were controlled. We found substantial heterogeneity in cascade performance across countries and higher performances in upper-middle-income countries and the Eastern Mediterranean, Europe, and Americas. Lipid screening was significantly associated with older age, female sex, higher education, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Awareness of diagnosis was significantly associated with older age, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Lastly, treatment of hypercholesterolemia was significantly associated with comorbid hypertension and diabetes, and control of lipid measures with comorbid diabetes. The main limitations of this study are a potential recall bias in self-reported information on received health services as well as diminished comparability due to varying survey years and varying lipid guideline application across country and clinical settings.CONCLUSIONS: Cascade performance was poor across all stages, indicating large unmet need for hypercholesterolemia care in this sample of LMICs-calling for greater policy and research attention toward this cardiovascular disease (CVD) risk factor and highlighting opportunities for improved prevention of CVD.

    View details for DOI 10.1371/journal.pmed.1003841

    View details for PubMedID 34695124

  • Expanding access to newer medicines for people with type 2 diabetes in low-income and middle-income countries: a cost-effectiveness and price target analysis. The lancet. Diabetes & endocrinology 2021


    For patients with type 2 diabetes in low-income and middle-income countries (LMICs), access to newer antidiabetic drugs (eg, sodium-glucose co-transporter-2 [SGLT2] inhibitors, glucagon-like peptide-1 [GLP-1] receptor agonists, and insulin analogues) could reduce the incidence of diabetes-related complications. We aimed to estimate price targets to pursue in negotiations for inclusion in national formularies given the addition of these novel agents to WHO's Essential Medicines List.We incorporated individual-level, nationally representative survey data (2006-18) from 23 678 people with diabetes in 67 LMICs into a microsimulation of cardiovascular events, heart failure, end-stage renal disease, vision loss, pressure sensation loss, hypoglycaemia requiring medical attention, and drug-specific side-effects. We estimated price targets for incremental costs of switching to newer treatments to achieve cost-effectiveness (ie, <3-times gross domestic product per disability-adjusted life-year averted) or to achieve net cost-savings when including costs of averted complications. We compared switching to SGLT2 inhibitors or GLP-1 receptor agonists in place of sulfonylureas, or insulin analogues in place of human insulin, and also compared a glycaemia-agnostic pathways of adding SGLT2 inhibitors or GLP-1 receptor agonists to existing therapies for people with heart disease, heart failure, or kidney disease.To achieve cost-effectiveness, SGLT2 inhibitors would need to have a median price of $224 per person per year (a 17·4% cost reduction; IQR $138-359, population-weighted across countries; mean price $257); GLP-1 receptor agonists $208 per person per year (98·3% reduction; $129-488; $240); and glargine insulin $20 per vial (31·0% reduction; $16-42; $28). To achieve net cost-savings, price targets would need to reduce by a further $9-10 to a median cost for SGLT2 inhibitors of $214 (21·4% reduction; $148-316; $245) and for GLP-1 receptor agonists to $199 per person per year (98·4% reduction; $138-294; $228); but insulin glargine remained around $20 per vial (32·4% reduction; $15-37; $26). Using SGLT2 inhibitors or GLP-1 receptor agonists in a glycaemia-agnostic pathway produced a 92% reduction (SGLT2 inhibitors) and 72% reduction (GLP-1 receptor agonists) in incremental cost-effectiveness ratios.Among novel agents, SGLT2 inhibitors hold particular promise for reducing complications of diabetes and meeting common price targets, particularly when used among people with established cardiovascular or kidney disease. These findings are consistent with the choice to include SGLT2 inhibitors in the WHO Essential Medicines List.Clinton Health Access Initiative.

    View details for DOI 10.1016/S2213-8587(21)00240-0

    View details for PubMedID 34656210

  • Estimated effect of increased diagnosis, treatment, and control of diabetes and its associated cardiovascular risk factors among low-income and middle-income countries: a microsimulation model. The Lancet. Global health Basu, S., Flood, D., Geldsetzer, P., Theilmann, M., Marcus, M. E., Ebert, C., Mayige, M., Wong-McClure, R., Farzadfar, F., Saeedi Moghaddam, S., Agoudavi, K., Norov, B., Houehanou, C., Andall-Brereton, G., Gurung, M., Brian, G., Bovet, P., Martins, J., Atun, R., Barnighausen, T., Vollmer, S., Manne-Goehler, J., Davies, J. 2021


    BACKGROUND: Given the increasing prevalence of diabetes in low-income and middle-income countries (LMICs), we aimed to estimate the health and cost implications of achieving different targets for diagnosis, treatment, and control of diabetes and its associated cardiovascular risk factors among LMICs.METHODS: We constructed a microsimulation model to estimate disability-adjusted life-years (DALYs) lost and health-care costs of diagnosis, treatment, and control of blood pressure, dyslipidaemia, and glycaemia among people with diabetes in LMICs. We used individual participant data-specifically from the subset of people who were defined as having any type of diabetes by WHO standards-from nationally representative, cross-sectional surveys (2006-18) spanning 15 world regions to estimate the baseline 10-year risk of atherosclerotic cardiovascular disease (defined as fatal and non-fatal myocardial infarction and stroke), heart failure (ejection fraction of <40%, with New York Heart Association class III or IV functional limitations), end-stage renal disease (defined as an estimated glomerular filtration rate <15 mL/min per 1·73 m2 or needing dialysis or transplant), retinopathy with severe vision loss (<20/200 visual acuity as measured by the Snellen chart), and neuropathy with pressure sensation loss (assessed by the Semmes-Weinstein 5·07/10 g monofilament exam). We then used data from meta-analyses of randomised controlled trials to estimate the reduction in risk and the WHO OneHealth tool to estimate costs in reaching either 60% or 80% of diagnosis, treatment initiation, and control targets for blood pressure, dyslipidaemia, and glycaemia recommended by WHO guidelines. Costs were updated to 2020 International Dollars, and both costs and DALYs were computed over a 10-year policy planning time horizon at a 3% annual discount rate.FINDINGS: We obtained data from 23678 people with diabetes from 67 countries. The median estimated 10-year risk was 10·0% (IQR 4·0-18·0) for cardiovascular events, 7·8% (5·1-11·8) for neuropathy with pressure sensation loss, 7·2% (5·6-9·4) for end-stage renal disease, 6·0% (4·2-8·6) for retinopathy with severe vision loss, and 2·6% (1·2-5·3) for congestive heart failure. A target of 80% diagnosis, 80% treatment, and 80% control would be expected to reduce DALYs lost from diabetes complications from a median population-weighted loss to 1097 DALYs per 1000 population over 10 years (IQR 1051-1155), relative to a baseline of 1161 DALYs, primarily from reduced cardiovascular events (down from a median of 143 to 117 DALYs per 1000 population) due to blood pressure and statin treatment, with comparatively little effect from glycaemic control. The target of 80% diagnosis, 80% treatment, and 80% control would be expected to produce an overall incremental cost-effectiveness ratio of US$1362 per DALY averted (IQR 1304-1409), with the majority of decreased costs from reduced cardiovascular event management, counterbalanced by increased costs for blood pressure and statin treatment, producing an overall incremental cost-effectiveness ratio of $1362 per DALY averted (IQR 1304-1409).INTERPRETATION: Reducing complications from diabetes in LMICs is likely to require a focus on scaling up blood pressure and statin medication treatment initiation and blood pressure medication titration rather than focusing on increasing screening to increase diabetes diagnosis, or a glycaemic treatment and control among people with diabetes.FUNDING: None.

    View details for DOI 10.1016/S2214-109X(21)00340-5

    View details for PubMedID 34562369

  • The effect of eligibility for antiretroviral therapy on body mass index and blood pressure in KwaZulu-Natal, South Africa. Scientific reports Kuber, A., Reuter, A., Geldsetzer, P., Chimbindi, N., Moshabela, M., Tanser, F., Barnighausen, T., Vollmer, S. 2021; 11 (1): 14718


    We use a regression discontinuity design to estimate the causal effect of antiretroviral therapy (ART) eligibility according to national treatment guidelines of South Africa on two risk factors for cardiovascular disease, body mass index (BMI) and blood pressure. We combine survey data collected in 2010 in KwaZulu-Natal, South Africa, with clinical data on ART. We find that early ART eligibility significantly reduces systolic and diastolic blood pressure. We do not find any significant effects on BMI. The effect on blood pressure can be detected up to three years after becoming eligible for ART.

    View details for DOI 10.1038/s41598-021-94057-z

    View details for PubMedID 34282184

  • The effect of bearing and rearing a child on blood pressure: a nationally representative instrumental variable analysis of 444611 mothers in India. International journal of epidemiology Teufel, F., Geldsetzer, P., Sudharsanan, N., Subramanyam, M., Yapa, H. M., De Neve, J., Vollmer, S., Barnighausen, T. 2021


    BACKGROUND: At the individual level, it is well known that pregnancies have a short-term effect on a woman's cardiovascular system and blood pressure. The long-term effect of having children on maternal blood pressure, however, is unknown. We thus estimated the causal effect of having children on blood pressure among mothers in India, a country with a history of high fertility rates.METHODS: We used nationally representative cross-sectional data from the 2015-16 India National Family and Health Survey (NFHS-4). The study population comprised 444611 mothers aged 15-49years. We used the sex of the first-born child as an instrumental variable (IV) for the total number of a woman's children. We estimated the effect of an additional child on systolic and diastolic blood pressure in IV (two-stage least squares) regressions. In additional analyses, we stratified the IV regressions by time since a mother last gave birth. Furthermore, we repeated our analyses using mothers' husbands and partners as the regression sample.RESULTS: On average, mothers had 2.7 children [standard deviation (SD): 1.5], a systolic blood pressure of 116.4mmHg (SD: 14.4) and diastolic blood pressure of 78.5mmHg (SD: 9.4). One in seven mothers was hypertensive. In conventional ordinary least squares regression, each child was associated with 0.42mmHg lower systolic [95% confidence interval (CI): -0.46 to -0.39, P<0.001] and 0.13mmHg lower diastolic (95% CI: -0.15 to -0.11, P<0.001) blood pressure. In the IV regressions, each child decreased a mother's systolic blood pressure by an average of 1.00mmHg (95% CI: -1.26 to -0.74, P<0.001) and diastolic blood pressure by an average of 0.35mmHg (95% CI: -0.52 to -0.17, P<0.001). These decreases were sustained over more than a decade after childbirth, with effect sizes slightly declining as the time since last birth increased. Having children did not influence blood pressure in men.CONCLUSIONS: Bearing and rearing a child decreases blood pressure among mothers in India.

    View details for DOI 10.1093/ije/dyab058

    View details for PubMedID 34293139

  • Targeting Hypertension Screening in Low- and Middle-Income Countries: A Cross-Sectional Analysis of 1.2Million Adults in 56 Countries. Journal of the American Heart Association Kirschbaum, T. K., Theilmann, M., Sudharsanan, N., Manne-Goehler, J., Lemp, J. M., De Neve, J., Marcus, M. E., Ebert, C., Chen, S., Aryal, K. K., Bahendeka, S. K., Norov, B., Damasceno, A., Dorobantu, M., Farzadfar, F., Fattahi, N., Gurung, M. S., Guwatudde, D., Labadarios, D., Lunet, N., Rayzan, E., Saeedi Moghaddam, S., Webster, J., Davies, J. I., Atun, R., Vollmer, S., Barnighausen, T., Jaacks, L. M., Geldsetzer, P. 2021: e021063


    Background As screening programs in low- and middle-income countries (LMICs) often do not have the resources to screen the entire population, there is frequently a need to target such efforts to easily identifiable priority groups. This study aimed to determine (1) how hypertension prevalence in LMICs varies by age, sex, body mass index, and smoking status, and (2) the ability of different combinations of these variables to accurately predict hypertension. Methods and Results We analyzed individual-level, nationally representative data from 1170629 participants in 56 LMICs, of whom 220636 (18.8%) had hypertension. Hypertension was defined as systolic blood pressure ≥140mmHg, diastolic blood pressure ≥90mmHg, or reporting to be taking blood pressure-lowering medication. The shape of the positive association of hypertension with age and body mass index varied across world regions. We used logistic regression and random forest models to compute the area under the receiver operating characteristic curve in each country for different combinations of age, body mass index, sex, and smoking status. The area under the receiver operating characteristic curve for the model with all 4 predictors ranged from 0.64 to 0.85 between countries, with a country-level mean of 0.76 across LMICs globally. The mean absolute increase in the area under the receiver operating characteristic curve from the model including only age to the model including all 4 predictors was 0.05. Conclusions Adding body mass index, sex, and smoking status to age led to only a minor increase in the ability to distinguish between adults with and without hypertension compared with using age alone. Hypertension screening programs in LMICs could use age as the primary variable to target their efforts.

    View details for DOI 10.1161/JAHA.121.021063

    View details for PubMedID 34212779

  • The state of diabetes treatment coverage in 55 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data in 680 102 adults. The Lancet. Healthy longevity Flood, D., Seiglie, J. A., Dunn, M., Tschida, S., Theilmann, M., Marcus, M. E., Brian, G., Norov, B., Mayige, M. T., Singh Gurung, M., Aryal, K. K., Labadarios, D., Dorobantu, M., Silver, B. K., Bovet, P., Adelin Jorgensen, J. M., Guwatudde, D., Houehanou, C., Andall-Brereton, G., Quesnel-Crooks, S., Sturua, L., Farzadfar, F., Saeedi Moghaddam, S., Atun, R., Vollmer, S., Bärnighausen, T. W., Davies, J. I., Wexler, D. J., Geldsetzer, P., Rohloff, P., Ramírez-Zea, M., Heisler, M., Manne-Goehler, J. 2021; 2 (6): e340-e351


    Approximately 80% of the 463 million adults worldwide with diabetes live in low- and middle-income countries (LMICs). A major obstacle to designing evidence-based policies to improve diabetes outcomes in LMICs is the limited nationally representative data on the current patterns of treatment coverage. The objectives of this study are (1) to estimate the proportion of adults with diabetes in LMICs who receive coverage of recommended pharmacological and non-pharmacological diabetes treatment and (2) to describe country-level and individual-level characteristics that are associated with treatment.We conducted a cross-sectional analysis of pooled, individual data from 55 nationally representative surveys in LMICs. Our primary outcome of self-reported diabetes treatment coverage was based upon population-level monitoring indicators recommended in the 2020 World Health Organization Package of Essential Noncommunicable Disease Interventions. We assessed coverage of three pharmacological and three non-pharmacological treatments among people with diabetes. At the country level, we estimated the proportion of individuals reporting coverage by per-capita gross national income and geographic region. At the individual level, we used logistic regression models to assess coverage along several key individual characteristics including sex, age, BMI, wealth quintile, and educational attainment. In the primary analysis, we scaled sample weights such that countries were weighted equally.The final pooled sample from the 55 LMICs included 680,102 total individuals and 37,094 individuals with diabetes. Using equal weights for each country, diabetes prevalence was 9.0% (95% confidence interval [CI], 8.7-9.4), with 43.9% (95% CI, 41.9-45.9) reporting a prior diabetes diagnosis. Overall, 4.6% (95% CI, 3.9-5.4) of individuals with diabetes self-reported meeting need for all treatments recommended for them. Coverage of glucose-lowering medication was 50.5% (95% CI, 48.6-52.5); antihypertensive medication, 41.3% (95% CI, 39.3-43.3); cholesterol-lowering medication, 6.3% (95% CI, 5.5-7.2); diet counseling, 32.2% (95% CI, 30.7-33.7); exercise counseling, 28.2% (95% CI, 26.6-29.8); and weight-loss counseling, 31.5% (95% CI, 29.3-33.7). Countries at higher income levels tended to have greater coverage. Female sex and higher age, BMI, educational attainment, and household wealth were also associated with greater coverage.Fewer than one in ten people with diabetes in LMICs receive coverage of guideline-based comprehensive diabetes treatment. Scaling-up the capacity of health systems to deliver treatment not only to lower glucose but also to address cardiovascular disease risk factors such as hypertension and high cholesterol are urgent global diabetes priorities.

    View details for DOI 10.1016/s2666-7568(21)00089-1

    View details for PubMedID 35211689

    View details for PubMedCentralID PMC8865379

  • Trends in Mail-Order Pharmacy Use in the U.S. From 1996 to 2018: An Analysis of the Medical Expenditure Panel Survey. American journal of preventive medicine Do, D., Geldsetzer, P. 2021


    INTRODUCTION: The use of mail-order pharmacies is generally associated with lower healthcare costs and improved medication adherence. To promote the use of mail-order pharmacies, it is important to understand the time trends in their use and whether these trends vary by population subgroups.METHODS: This study used the 1996-2018 Medical Expenditure Panel Survey to determine the annual prevalence of mail-order pharmacy use (defined as purchasing ≥1 prescription from a mail-order or online pharmacy) among U.S. adult prescription users and its variation by population characteristics. Logistic regression was used to determine the correlates of mail-order pharmacy use. Results were presented for medications and therapeutic classes most commonly purchased by mail-order pharmacy exclusive users. Analyses were conducted in December 2020.RESULTS: The annual prevalence of mail-order pharmacy use among U.S. adult prescription users increased from 10.2% (95% CI=9.3, 11.1) in 1996 to 17.0% (95% CI=15.9, 18.1) in 2005 and then declined to 15.7% (95% CI=14.9, 16.6) by 2018. Absolute differences in the prevalence of use by race/ethnicity, education, and health insurance coverage widened over time, whereas they remained stable when stratifying by sex, age, marital status, region, limitations in daily activities, pain interference, health status, number of chronic conditions, and access to medical care. Among mail-order pharmacy exclusive users, the 3 most commonly purchased medications were atorvastatin (16.7%), levothyroxine (13.6%), and lisinopril (13.1%); the 3 most commonly purchased therapeutic classes were cardiovascular agents (57.9%), metabolic agents (52.1%), and central nervous system agents (29.6%).CONCLUSIONS: The prevalence of mail-order pharmacy use has declined in recent years and has shown significant variation across population subgroups. Future research should examine whether the declining trends and variation in use may influence the management of chronic conditions and the disparities in health and healthcare costs.

    View details for DOI 10.1016/j.amepre.2021.02.017

    View details for PubMedID 33958237

  • Questioning a South African hypertension threshold of 150 mm Hg - Authors' reply. The Lancet. Healthy longevity Sudharsanan, N., Diallo, A. O., Ali, M. K., Geldsetzer, P., Gower, E. W., Mukama, T., Wagner, R. G., Davies, J., Bijlsma, M. J. 2021; 2 (5): e248

    View details for DOI 10.1016/S2666-7568(21)00095-7

    View details for PubMedID 36098131

  • Climate and the spread of COVID-19. Scientific reports Chen, S., Prettner, K., Kuhn, M., Geldsetzer, P., Wang, C., Barnighausen, T., Bloom, D. E. 2021; 11 (1): 9042


    Visual inspection of world maps shows that coronavirus disease 2019 (COVID-19) is less prevalent in countries closer to the equator, where heat and humidity tend to be higher. Scientists disagree how to interpret this observation because the relationship between COVID-19 and climatic conditions may be confounded by many factors. We regress the logarithm of confirmed COVID-19 cases per million inhabitants in a country against the country's distance from the equator, controlling forkey confounding factors: air travel,vehicle concentration, urbanization, COVID-19testing intensity, cell phone usage, income,old-age dependency ratio, andhealth expenditure. A one-degree increase in absolute latitude is associated with a 4.3% increase in cases per million inhabitants as of January 9, 2021 (p value<0.001). Our results imply that a country, which is located 1000km closer to the equator, could expect 33% fewer cases per million inhabitants. Since the change in Earth's angle towards the sun between equinox and solstice is about 23.5°, one could expect a difference in cases per million inhabitants of 64% between two hypothetical countries whose climates differ to a similar extent as two adjacent seasons. According to our results, countries are expected to see a decline in new COVID-19 cases during summer and a resurgence during winter. However, our results do not imply that the disease will vanish during summer or will not affect countries close to the equator. Rather, the higher temperatures and more intense UV radiation in summer are likely to support public health measures to contain SARS-CoV-2.

    View details for DOI 10.1038/s41598-021-87692-z

    View details for PubMedID 33907202

  • The Impact of Immediate InitiationofAntiretroviral Therapy on Patients' Healthcare Expenditures: A Stepped-Wedge Randomized Trial in Eswatini. AIDS and behavior Steinert, J. I., Khan, S., Mafara, E., Wong, C., Mlambo, K., Hettema, A., Walsh, F. J., Lejeune, C., Mazibuko, S., Okello, V., Ogbuoji, O., De Neve, J., Vollmer, S., Barnighausen, T., Geldsetzer, P. 2021


    Immediate initiation of antiretroviral therapy (ART) for all people living with HIV has important health benefits but implications for theeconomic aspects of patients' livesare still largelyunknown. This stepped-wedge cluster-randomized controlled trial aimed to determine the causal impact of immediate ART initiation on patients' healthcare expenditures in Eswatini. Fourteen healthcare facilities were randomly assigned to transition at one of seven time points from the standard of care (ART eligibility below aCD4 countthreshold) to the immediate ART for all intervention (EAAA). 2261 patients living with HIV were interviewed over the study period to capture their past-year out-of-pocket healthcare expenditures. Inmixed-effects regression models, wefound a 49% decrease (RR 0.51, 95% CI 0.36, 0.72, p<0.001) in past-year total healthcare expenditures in the EAAA groupcompared to the standard of care, and a 98% (RR 0.02, 95% CI 0.00, 0.02, p<0.001) decrease in spending on private and traditional healthcare. Despite a higher frequency of HIV care visits for newly initiated ART patients, immediate ART initiationappears to have lowered patients' healthcare expenditures because they sought less care from alternative healthcare providers. This study adds an important economic argument to the World Health Organization's recommendation to abolish CD4-count-based eligibility thresholds for ART.

    View details for DOI 10.1007/s10461-021-03241-9

    View details for PubMedID 33834318

  • Cervical Cancer Screening in Low- and Middle-Income Countries Reply JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Geldsetzer, P., Lemp, J. M. 2021; 325 (8): 790–91
  • Cardiovascular disease risk profile and management practices in 45 low-income and middle-income countries: A cross-sectional study of nationally representative individual-level survey data. PLoS medicine Peiris, D. n., Ghosh, A. n., Manne-Goehler, J. n., Jaacks, L. M., Theilmann, M. n., Marcus, M. E., Zhumadilov, Z. n., Tsabedze, L. n., Supiyev, A. n., Silver, B. K., Sibai, A. M., Norov, B. n., Mayige, M. T., Martins, J. S., Lunet, N. n., Labadarios, D. n., Jorgensen, J. M., Houehanou, C. n., Guwatudde, D. n., Gurung, M. S., Damasceno, A. n., Aryal, K. K., Andall-Brereton, G. n., Agoudavi, K. n., McKenzie, B. n., Webster, J. n., Atun, R. n., Bärnighausen, T. n., Vollmer, S. n., Davies, J. I., Geldsetzer, P. n. 2021; 18 (3): e1003485


    Global cardiovascular disease (CVD) burden is high and rising, especially in low-income and middle-income countries (LMICs). Focussing on 45 LMICs, we aimed to determine (1) the adult population's median 10-year predicted CVD risk, including its variation within countries by socio-demographic characteristics, and (2) the prevalence of self-reported blood pressure (BP) medication use among those with and without an indication for such medication as per World Health Organization (WHO) guidelines.We conducted a cross-sectional analysis of nationally representative household surveys from 45 LMICs carried out between 2005 and 2017, with 32 surveys being WHO Stepwise Approach to Surveillance (STEPS) surveys. Country-specific median 10-year CVD risk was calculated using the 2019 WHO CVD Risk Chart Working Group non-laboratory-based equations. BP medication indications were based on the WHO Package of Essential Noncommunicable Disease Interventions guidelines. Regression models examined associations between CVD risk, BP medication use, and socio-demographic characteristics. Our complete case analysis included 600,484 adults from 45 countries. Median 10-year CVD risk (interquartile range [IQR]) for males and females was 2.7% (2.3%-4.2%) and 1.6% (1.3%-2.1%), respectively, with estimates indicating the lowest risk in sub-Saharan Africa and highest in Europe and the Eastern Mediterranean. Higher educational attainment and current employment were associated with lower CVD risk in most countries. Of those indicated for BP medication, the median (IQR) percentage taking medication was 24.2% (15.4%-37.2%) for males and 41.6% (23.9%-53.8%) for females. Conversely, a median (IQR) 47.1% (36.1%-58.6%) of all people taking a BP medication were not indicated for such based on CVD risk status. There was no association between BP medication use and socio-demographic characteristics in most of the 45 study countries. Study limitations include variation in country survey methods, most notably the sample age range and year of data collection, insufficient data to use the laboratory-based CVD risk equations, and an inability to determine past history of a CVD diagnosis.This study found underuse of guideline-indicated BP medication in people with elevated CVD risk and overuse by people with lower CVD risk. Country-specific targeted policies are needed to help improve the identification and management of those at highest CVD risk.

    View details for DOI 10.1371/journal.pmed.1003485

    View details for PubMedID 33661979

  • The impact of long-term care insurance in China on beneficiaries and caregivers: A systematic review. Journal of global health economics and policy Chen, S., Li, L., Yang, J., Jiao, L., Golden, T., Wang, Z., Liu, H., Wu, P., Bärnighausen, T., Geldsetzer, P., Wang, C. 2021; 1


    China's long-term care insurance (LTCI) policy has been minimally evaluated. This systematic review aimed to assess the impact of China's LTCI pilot on beneficiaries and their caregivers.This review is based on a search of peer-reviewed studies in English (Embase, MEDLINE, Web of Science) and Chinese (China National Knowledge Infrastructure [CNKI], VIP, Wanfang) databases from January 2016 through July 2020, with all studies published in English or Chinese included. We included quantitative analyses of beneficiary-level data that assessed the impact of LTCI on beneficiaries and their caregivers, with no restriction placed on the outcomes studied.Nine studies met our inclusion criteria. One study was a randomised trial and two used quasi-experimental approaches. Four studies examined LTCI's effect on beneficiaries' quality of life, physical pain, and health service utilisation; one study reported the effect on beneficiaries' healthcare expenditures; and one study evaluated the impact on caregivers' care tasks. These studies generally found LTCI to be associated with an improvement in patients' quality of life (including decreased physical pain), a reduction in the number of outpatient visits and hospitalisations, decreased patient-level health expenditures (e.g. one study reported a reduction in the length of stay, inpatient expenditures, and health insurance expenditures in tertiary hospitals by 41.0%, 17.7%, and 11.4%, respectively), and reduced informal care tasks for caregivers. In addition, four out of four studies that evaluated this outcome found that beneficiaries' overall satisfaction with LTCI was high.The current evidence base for the effects of LTCI in China on beneficiaries and their caregivers is sparse. Nonetheless, the existing studies suggest that LTCI has positive effects on beneficiaries and their caregivers. Further rigorous research on the impacts of LTCI in China is needed to inform the future expansion of the program.

    View details for DOI 10.52872/001c.29559

    View details for PubMedID 35083471

    View details for PubMedCentralID PMC8788994

  • Childhood vaccine uptake in Africa: threats, challenges, and opportunities Journal of Global Health Reports Mbonigaba, E., Nderu, D., Chen, S., Denkinger, C., Geldsetzer, P., McMahon, S., Bärnighausen, T. 2021; 5: e2021080

    View details for DOI 10.29392/001c.26312

  • Factors Predicting Progression to Severe COVID-19: A Competing Risk Survival Analysis of 1753 Patients in Community Isolation in Wuhan, China. Engineering (Beijing, China) Chen, S., Sun, H., Heng, M., Tong, X., Geldsetzer, P., Wang, Z., Wu, P., Yang, J., Hu, Y., Wang, C., Bärnighausen, T. 2021


    Current knowledge of the risk factors predicting the progression to severe coronavirus disease 2019 (COVID-19) among patients in community isolation who either are asymptomatic or only suffer from mild COVID-19 is very limited. Using a multivariable competing risk survival analysis, we herein identify several important predictors of progression to severe COVID-19-rather than to recovery-among patients in community isolation. A competing risk survival analysis was performed on time-to-event data from a cohort study of all COVID-19 patients (n = 1753) in the largest community isolation center in Wuhan, China, from opening to closing. The exposures were age, sex, respiratory symptoms, gastrointestinal symptoms, general symptoms, and computed tomography (CT) scan signs. The main outcomes were time to COVID-19 deterioration or recovery. The factors predicting progression to severe COVID-19 among the patients in community isolation were: male sex (hazard ratio (HR) = 1.29, 95% confidence interval (95%CI), 1.04-1.58, p = 0.018), young and old age, dyspnea (HR = 1.58, 95%CI, 1.24-2.01, p < 0.001), and CT signs of ground-glass opacity (HR = 1.39, 95%CI, 1.04-1.86, p = 0.024) and infiltrating shadows (HR= 1.84, 95%CI, 1.22-2.78, p = 0.004). The risk of progression was found to be lower among patients with nausea or vomiting (HR = 0.53, 95%CI, 0.30-0.96, p = 0.036) and headaches (HR = 0.54, 95%CI, 0.29-0.99, p = 0.046). Based on the results of this study, resource-poor settings, dyspnea, sex, and age can easily be used to identify mild COVID-19 patients who are at increased risk of progression. Looking for CT signs of ground-glass opacity and infiltrating shadows may be an affordable option to support triage decisions in resource-rich settings. Common and unspecific symptoms including headaches, nausea, and vomiting likely induced the selection for community isolation of COVID-19 patients who were relatively unlikely to deteriorate. Triage and prioritization outcomes could be boosted if strategies are incorporated to minimize the inefficient prioritization of harmless comorbidities.

    View details for DOI 10.1016/j.eng.2021.07.021

    View details for PubMedID 34721935

    View details for PubMedCentralID PMC8536486

  • Body-mass index and diabetes risk in 57 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data in 685 616 adults. Lancet (London, England) Teufel, F., Seiglie, J. A., Geldsetzer, P., Theilmann, M., Marcus, M. E., Ebert, C., Arboleda, W. A., Agoudavi, K., Andall-Brereton, G., Aryal, K. K., Bicaba, B. W., Brian, G., Bovet, P., Dorobantu, M., Gurung, M. S., Guwatudde, D., Houehanou, C., Houinato, D., Jorgensen, J. M., Kagaruki, G. B., Karki, K. B., Labadarios, D., Martins, J. S., Mayige, M. T., McClure, R. W., Mwangi, J. K., Mwalim, O., Norov, B., Crooks, S., Farzadfar, F., Moghaddam, S. S., Silver, B. K., Sturua, L., Wesseh, C. S., Stokes, A. C., Essien, U. R., De Neve, J., Atun, R., Davies, J. I., Vollmer, S., Barnighausen, T. W., Ali, M. K., Meigs, J. B., Wexler, D. J., Manne-Goehler, J. 2021; 398 (10296): 238-248


    BACKGROUND: The prevalence of overweight, obesity, and diabetes is rising rapidly in low-income and middle-income countries (LMICs), but there are scant empirical data on the association between body-mass index (BMI) and diabetes in these settings.METHODS: In this cross-sectional study, we pooled individual-level data from nationally representative surveys across 57 LMICs. We identified all countries in which a WHO Stepwise Approach to Surveillance (STEPS) survey had been done during a year in which the country fell into an eligible World Bank income group category. For LMICs that did not have a STEPS survey, did not have valid contact information, or declined our request for data, we did a systematic search for survey datasets. Eligible surveys were done during or after 2008; had individual-level data; were done in a low-income, lower-middle-income, or upper-middle-income country; were nationally representative; had a response rate of 50% or higher; contained a diabetes biomarker (either a blood glucose measurement or glycated haemoglobin [HbA1c]); and contained data on height and weight. Diabetes was defined biologically as a fasting plasma glucose concentration of 7·0 mmol/L (126·0 mg/dL) or higher; a random plasma glucose concentration of 11·1 mmol/L (200·0 mg/dL) or higher; or a HbA1c of 6·5% (48·0 mmol/mol) or higher, or by self-reported use of diabetes medication. We included individuals aged 25 years or older with complete data on diabetes status, BMI (defined as normal [18·5-22·9 kg/m2], upper-normal [23·0-24·9 kg/m2], overweight [25·0-29·9 kg/m2], or obese [≥30·0 kg/m2]), sex, and age. Countries were categorised into six geographical regions: Latin America and the Caribbean, Europe and central Asia, east, south, and southeast Asia, sub-Saharan Africa, Middle East and north Africa, and Oceania. We estimated the association between BMI and diabetes risk by multivariable Poisson regression and receiver operating curve analyses, stratified by sex and geographical region.FINDINGS: Our pooled dataset from 58 nationally representative surveys in 57 LMICs included 685 616 individuals. The overall prevalence of overweight was 27·2% (95% CI 26·6-27·8), of obesity was 21·0% (19·6-22·5), and of diabetes was 9·3% (8·4-10·2). In the pooled analysis, a higher risk of diabetes was observed at a BMI of 23 kg/m2 or higher, with a 43% greater risk of diabetes for men and a 41% greater risk for women compared with a BMI of 18·5-22·9 kg/m2. Diabetes risk also increased steeply in individuals aged 35-44 years and in men aged 25-34 years in sub-Saharan Africa. In the stratified analyses, there was considerable regional variability in this association. Optimal BMI thresholds for diabetes screening ranged from 23·8 kg/m2 among men in east, south, and southeast Asia to 28·3 kg/m2 among women in the Middle East and north Africa and in Latin America and the Caribbean.INTERPRETATION: The association between BMI and diabetes risk in LMICs is subject to substantial regional variability. Diabetes risk is greater at lower BMI thresholds and at younger ages than reflected in currently used BMI cutoffs for assessing diabetes risk. These findings offer an important insight to inform context-specific diabetes screening guidelines.FUNDING: Harvard T H Chan School of Public Health McLennan Fund: Dean's Challenge Grant Program.

    View details for DOI 10.1016/S0140-6736(21)00844-8

    View details for PubMedID 34274065

  • Knowledge about Coronavirus Disease 2019 among adults in China: A cross-sectional online survey. Journal of medical Internet research Yu, F. n., Geldsetzer, P. n., Meierkord, A. n., Yang, J. n., Chen, Q. n., Jiao, L. n., Abou-Arraj, N. E., Pan, A. n., Wang, C. n., Bärnighausen, T. n., Chen, S. n. 2021


    A detailed understanding of the public's knowledge and perceptions of coronavirus disease 2019 (COVID-19) could inform governments' public health actions in response to the pandemic.The aim of this study was to determine the knowledge and perceptions of COVID-19 among adults in China, and its variation among provinces and by sociodemographic characteristics.Between 8 May 2020 and 8 June 2020, we conducted a cross-sectional online survey among adults in China who were registered with the private survey company KuRunData. We set a target sample size of 10,000 adults, aiming to sample 300-360 adults from each province in China. Participants were asked 25 questions that tested their knowledge about COVID-19, including measures to prevent infection, common symptoms, and recommended care-seeking behavior. We disaggregated responses by age, sex, education, province, household income, rural-urban residency, and whether or not a participant had a family member, friend, or acquaintance who they know to have been infected with SARS-CoV-2. All analyses used survey sampling weights.5,079 men and 4,921 women completed the questionnaire and were included in the analysis. Out of 25 knowledge questions, participants answered a mean and median of 21.4 (95% CI: 21.3-21.4) and 22 (IQR: 20 - 23) questions correctly, respectively. 83.4% (95% CI: 82.7%-84.1%) of participants answered four-fifths or more of the questions correctly. For at least one of four ineffective prevention measures (using a hand dryer, regular nasal irrigation, gargling mouthwash, and taking antibiotics), 68.9% (95% CI: 68.0%-69.8%) of participants answered that it was an effective method to prevent a SARS-CoV-2 infection. While knowledge overall was similar across provinces, the percent of participants who answered the question on recommended care-seeking behavior correctly varied from 47.0% (95% CI: 41.4%-52.7%) in Tibet to 87.5% (95% CI: 84.1%-91.0%) in Beijing. Within provinces, participants who were male, middle-aged, residing in urban areas, and had higher household income tended to answer a higher proportion of the knowledge questions correctly.This online study of individuals across China suggests that the majority of the population has good knowledge of COVID-19. However, a significant proportion still holds misconceptions or incorrect beliefs about prevention methods and recommended healthcare-seeking behaviors, especially in rural areas and some less wealthy provinces in Western China. This study can inform the development of tailored public health policies and promotion campaigns by identifying knowledge areas for which misconceptions are comparatively common and provinces that have relatively low knowledge.

    View details for DOI 10.2196/26940

    View details for PubMedID 33844637

  • Systolic blood pressure and 6-year mortality in South Africa: a country-wide, population-based cohort study The Lancet Healthy Longevity Diallo, A. O., Ali, M. K., Geldsetzer, P., Gower, E. W., Mukama, T., Wagner, R. G., Davies, J. I., Bijlsma, M. J., Sudharsanan, N. 2021; 2 (2): E78-E86
  • Economics and Global Health [German] Global Health: An Introduction [German] Kohler, S., Roser, M., Geldsetzer, P., Bärnighausen, T. De Gruyter. 2021; 1: 523–56
  • Economic Evaluation in Global Health [German] Global Health: An Introduction [German] Kohler, S., Paul, N., Bärnighausen, T., Geldsetzer, P. De Gruyter. 2021; 1: 557–80
  • Healthcare worker attendance during the early stages of the COVID-19 pandemic: A longitudinal analysis of fingerprint-verified data from all public-sector secondary and tertiary care facilities in Bangladesh. Journal of global health Do, D., Sarker, M., Chen, S., Lenjani, A., Tikka, P., Barnighausen, T., Geldsetzer, P. 2020; 10 (2): 020509


    Background: The COVID-19 pandemic has overwhelmed hospitals in several areas in high-income countries. An effective response to this pandemic requires health care workers (HCWs) to be present at work, particularly in low- and middle-income countries (LMICs) where they are already in critically low supply. To inform whether and to what degree policymakers in Bangladesh, and LMICs more broadly, should expect a drop in HCW attendance as COVID-19 continues to spread, this study aims to determine how HCW attendance has changed during the early stages of the COVID-19 pandemic in Bangladesh.Methods: This study analyzed daily fingerprint-verified attendance data from all 527 public-sector secondary and tertiary care facilities in Bangladesh to describe HCW attendance from January 26, 2019 to March 22, 2020, by cadre, hospital type, and geographic division. We then regressed HCW attendance onto fixed effects for day-of-week, month, and hospital, as well as indicators for each of three pandemic periods: a China-focused period (January 11, 2020 (first confirmed COVID-19 death in China) until January 29, 2020), international-spread period (January 30, 2020 (World Health Organization's declaration of a global emergency) until March 6, 2020), and local-spread period (March 7, 2020 (first confirmed COVID-19 case in Bangladesh) until the end of the study period).Findings: On average between January 26, 2019 and March 22, 2020, 34.1% of doctors, 64.6% of nurses, and 70.6% of other health care staff were present for their scheduled shift. HCWs' attendance rate increased with time in 2019 among all cadres. Nurses' attendance level dropped by 2.5% points (95% confidence interval (CI)=-3.2% to -1.8%) and 3.5% points (95% CI=-4.5% to -2.5%) during the international-spread and the local-spread periods of the COVID-19 pandemic, relative to the China-focused period. Similarly, the attendance level of other health care staff declined by 0.3% points (95% CI=-0.8% to 0.2%) and 2.3% points (95% CI=-3.0% to -1.6%) during the international-spread and local-spread periods, respectively. Among doctors, however, the international-spread and local-spread periods were associated with a statistically significant increase in attendance by 3.7% points (95% CI=2.5% to 4.8%) and 4.9% points (95% CI=3.5% to 6.4%), respectively. The reduction in attendance levels across all HCWs during the local-spread period was much greater at large hospitals, where the majority of COVID-19 testing and treatment took place, than that at small hospitals.Conclusions: After a year of significant improvements, HCWs' attendance levels among nurses and other health care staff (who form the majority of Bangladesh's health care workforce) have declined during the early stages of the COVID-19 pandemic. This finding may portend an even greater decrease in attendance if COVID-19 continues to spread in Bangladesh. Policymakers in Bangladesh and similar LMICs should undertake major efforts to achieve high attendance levels among HCWs, particularly nurses, such as by providing sufficient personal protective equipment as well as monetary and non-monetary incentives.

    View details for DOI 10.7189/jogh.10.020509

    View details for PubMedID 33110592

  • Association between country preparedness indicators and quality clinical care for cardiovascular disease risk factors in 44 lower- and middle-income countries: A multicountry analysis of survey data. PLoS medicine Davies, J. I., Reddiar, S. K., Hirschhorn, L. R., Ebert, C., Marcus, M., Seiglie, J. A., Zhumadilov, Z., Supiyev, A., Sturua, L., Silver, B. K., Sibai, A. M., Quesnel-Crooks, S., Norov, B., Mwangi, J. K., Omar, O. M., Wong-McClure, R., Mayige, M. T., Martins, J. S., Lunet, N., Labadarios, D., Karki, K. B., Kagaruki, G. B., Jorgensen, J. M., Hwalla, N. C., Houinato, D., Houehanou, C., Guwatudde, D., Gurung, M. S., Bovet, P., Bicaba, B. W., Aryal, K. K., Msaidie, M., Andall-Brereton, G., Brian, G., Stokes, A., Vollmer, S., Barnighausen, T., Atun, R., Geldsetzer, P., Manne-Goehler, J., Jaacks, L. M. 2020; 17 (11): e1003268


    BACKGROUND: Cardiovascular diseases are leading causes of death, globally, and health systems that deliver quality clinical care are needed to manage an increasing number of people with risk factors for these diseases. Indicators of preparedness of countries to manage cardiovascular disease risk factors (CVDRFs) are regularly collected by ministries of health and global health agencies. We aimed to assess whether these indicators are associated with patient receipt of quality clinical care.METHODS AND FINDINGS: We did a secondary analysis of cross-sectional, nationally representative, individual-patient data from 187,552 people with hypertension (mean age 48.1 years, 53.5% female) living in 43 low- and middle-income countries (LMICs) and 40,795 people with diabetes (mean age 52.2 years, 57.7% female) living in 28 LMICs on progress through cascades of care (condition diagnosed, treated, or controlled) for diabetes or hypertension, to indicate outcomes of provision of quality clinical care. Data were extracted from national-level World Health Organization (WHO) Stepwise Approach to Surveillance (STEPS), or other similar household surveys, conducted between July 2005 and November 2016. We used mixed-effects logistic regression to estimate associations between each quality clinical care outcome and indicators of country development (gross domestic product [GDP] per capita or Human Development Index [HDI]); national capacity for the prevention and control of noncommunicable diseases ('NCD readiness indicators' from surveys done by WHO); health system finance (domestic government expenditure on health [as percentage of GDP], private, and out-of-pocket expenditure on health [both as percentage of current]); and health service readiness (number of physicians, nurses, or hospital beds per 1,000 people) and performance (neonatal mortality rate). All models were adjusted for individual-level predictors including age, sex, and education. In an exploratory analysis, we tested whether national-level data on facility preparedness for diabetes were positively associated with outcomes. Associations were inconsistent between indicators and quality clinical care outcomes. For hypertension, GDP and HDI were both positively associated with each outcome. Of the 33 relationships tested between NCD readiness indicators and outcomes, only two showed a significant positive association: presence of guidelines with being diagnosed (odds ratio [OR], 1.86 [95% CI 1.08-3.21], p = 0.03) and availability of funding with being controlled (OR, 2.26 [95% CI 1.09-4.69], p = 0.03). Hospital beds (OR, 1.14 [95% CI 1.02-1.27], p = 0.02), nurses/midwives (OR, 1.24 [95% CI 1.06-1.44], p = 0.006), and physicians (OR, 1.21 [95% CI 1.11-1.32], p < 0.001) per 1,000 people were positively associated with being diagnosed and, similarly, with being treated; and the number of physicians was additionally associated with being controlled (OR, 1.12 [95% CI 1.01-1.23], p = 0.03). For diabetes, no positive associations were seen between NCD readiness indicators and outcomes. There was no association between country development, health service finance, or health service performance and readiness indicators and any outcome, apart from GDP (OR, 1.70 [95% CI 1.12-2.59], p = 0.01), HDI (OR, 1.21 [95% CI 1.01-1.44], p = 0.04), and number of physicians per 1,000 people (OR, 1.28 [95% CI 1.09-1.51], p = 0.003), which were associated with being diagnosed. Six countries had data on cascades of care and nationwide-level data on facility preparedness. Of the 27 associations tested between facility preparedness indicators and outcomes, the only association that was significant was having metformin available, which was positively associated with treatment (OR, 1.35 [95% CI 1.01-1.81], p = 0.04). The main limitation was use of blood pressure measurement on a single occasion to diagnose hypertension and a single blood glucose measurement to diagnose diabetes.CONCLUSION: In this study, we observed that indicators of country preparedness to deal with CVDRFs are poor proxies for quality clinical care received by patients for hypertension and diabetes. The major implication is that assessments of countries' preparedness to manage CVDRFs should not rely on proxies; rather, it should involve direct assessment of quality clinical care.

    View details for DOI 10.1371/journal.pmed.1003268

    View details for PubMedID 33170842

  • Willingness to pay for community delivery of antiretroviral treatment in urban Tanzania: a cross-sectional survey. Health policy and planning Geldsetzer, P., Sauer, A., Francis, J. M., Mboggo, E., Lwezaula, S., Sando, D., Fawzi, W., Ulenga, N., Barnighausen, T. 2020


    Community health worker (CHW)-led community delivery of HIV antiretroviral therapy (ART) could increase ART coverage and decongest healthcare facilities. It is unknown how much patients would be willing to pay to receive ART at home and, thus, whether ART community delivery could be self-financing. Set in Dar es Salaam, this study aimed to determine patients' willingness to pay (WTP) for CHW-led ART community delivery. We sampled ART patients living in the neighbourhoods surrounding each of 48 public-sector healthcare facilities in Dar es Salaam. We asked participants (N=1799) whether they (1) preferred ART community delivery over standard facility-based care, (2) would be willing to pay for ART community delivery and (3) would be willing to pay each of an incrementally increasing range of prices for the service. 45.0% (810/1799; 95% CI: 42.7-47.3) of participants preferred ART community delivery over standard facility-based care and 51.5% (417/810; 95% CI: 48.1-55.0) of these respondents were willing to pay for ART community delivery. Among those willing to pay, the mean and median amount that participants were willing to pay for one ART community delivery that provides a 2-months' supply of antiretroviral drugs was 3.61 purchasing-power-parity-adjusted dollars (PPP$) (95% CI: 2.96-4.26) and 1.27 PPP$ (IQR: 1.27-2.12), respectively. An important limitation of this study is that participants all resided in neighbourhoods within the catchment area of the healthcare facility at which they were interviewed and, thus, may incur less costs to attend standard facility-based ART care than other ART patients in Dar es Salaam. While there appears to be a substantial WTP, patient payments would only constitute a minority of the costs of implementing ART community delivery. Thus, major co-financing from governments or donors would likely be required.

    View details for DOI 10.1093/heapol/czaa088

    View details for PubMedID 33083837

  • Revisiting the association between temperature and COVID-19 transmissibility across 117 countries. ERJ open research Chen, S., Prettner, K., Cao, B., Geldsetzer, P., Kuhn, M., Bloom, D. E., Barnighausen, T., Wang, C. 2020; 6 (4)


    There is a robust and significant negative association between #COVID19 transmissibility and ambient temperature at the country level. An increase of 1°C in temperature is associated with a decrease in the prevalence of COVID-19 by 5.4%.

    View details for DOI 10.1183/23120541.00550-2020

    View details for PubMedID 33263060

  • Qualitative accounts of PrEP discontinuation from the general population in Eswatini. Culture, health & sexuality Barnighausen, K., Geldsetzer, P., Matse, S., Hettema, A., Hughey, A. B., Dlamini, P., Mavuso, M., Fakudze, D., Kahn, K., Barnighausen, T., McMahon, S. A. 2020: 1–17


    People in receipt of pre-exposure prophylaxis (PrEP) for the prevention of HIV in Sub-Saharan Africa often discontinue taking the medication. We conducted 27 semi-structured interviews with men and women who had started PrEP but did not return to the clinic for a refill after a 1, 2 or 3-month period. These 'discontinuation' clients were enrolled in a PrEP demonstration project for the general population in nurse-led, public-sector, primary-care clinics in Eswatini. Reasons for discontinuation included changes to self-perceived HIV risk such as the end of pregnancy and absent partners. Others described PrEP as inaccessible when working away from home and many described difficulties relating to a daily pill regimen and managing side effects. Female clients described being prohibited from using PrEP by their partners and co-wives. From these results, we recommend that client-centred counselling stresses the prevention-effective adherence paradigm, which promotes PrEP use in risk periods that are identifiable and PrEP discontinuation when the risk period has finished. A national scale up of PrEP may mitigate problems accessing PrEP. Extended counselling and support could assist with adherence and the management of side effects. Education and support for partners and families of PrEP clients may also contribute to better PrEP continuation.

    View details for DOI 10.1080/13691058.2020.1770333

    View details for PubMedID 32633617

  • The causal effect of retirement on stress in older adults in China: Aregression discontinuity study. SSM - population health Chen, S., Geldsetzer, P., Barnighausen, T. 2020; 10: 100462


    Population aging in middle-income countries, including China, has resulted in strong economic incentives to increase the retirement age. These economic incentives should be weighed up against the effects of later retirement on physical and mental health and wellbeing. We aimed to determine the causal effect of retirement on perceived stress, an important measure of mental well-being. We used data from the China Health and Nutrition Survey in 2015 and adopted a non-parametric regression discontinuity design (RDD) to measure the causal effect of retirement on stress. Stress was assessed using the Perceived Stress Scale (PSS)-14. On average, the effect of retirement on stress was close to the null value and insignificant. In subgroup analyses, we found that retirement reduces stress in men but raises stress in women. Though these gender-specific effects were not statistically significant, their magnitudes were large. Thus, the average null result in the entire population appears to hide opposite gender-specific effects. More research is needed to confirm this finding in studies with larger sample sizes and understand the gender-specific pathways leading from retirement to stress.

    View details for DOI 10.1016/j.ssmph.2019.100462

    View details for PubMedID 32083164

  • Diabetes Prevalence and Its Relationship With Education, Wealth, and BMI in Twenty-Nine Low- and Middle-Income Countries. Diabetes care Seiglie, J. A., Marcus, M., Ebert, C., Prodromidis, N., Geldsetzer, P., Theilmann, M., Agoudavi, K., Andall-Brereton, G., Aryal, K. K., Bicaba, B. W., Bovet, P., Brian, G., Dorobantu, M., Gathecha, G., Singh Gurung, M., Guwatudde, D., Msaidie, M., Houehanou, C., Houinato, D., Adelin Jorgensen, J. M., Kagaruki, G. B., Karki, K. B., Labadarios, D., Martins, J. S., Mayige, M. T., McClure, R. W., Mwangi, J. K., Mwalim, O., Norov, B., Quesnel-Crooks, S., Silver, B. K., Sturua, L., Tsabedze, L., Stanford Wesseh, C., Stokes, A., Atun, R., Davies, J. I., Vollmer, S., Barnighausen, T. W., Jaacks, L. M., Meigs, J. B., Wexler, D. J., Manne-Goehler, J. 2020


    OBJECTIVE: Diabetes is a rapidly growing health problem in low- and middle-income countries (LMICs), but empirical data on its prevalence and relationship to socioeconomic status are scarce. We estimated diabetes prevalence and the subset with undiagnosed diabetes in 29 LMICs and evaluated the relationship of education, household wealth, and BMI with diabetes risk.RESEARCH DESIGN AND METHODS: We pooled individual-level data from 29 nationally representative surveys conducted between 2008 and 2016, totaling 588,574 participants aged ≥25 years. Diabetes prevalence and the subset with undiagnosed diabetes was calculated overall and by country, World Bank income group (WBIG), and geographic region. Multivariable Poisson regression models were used to estimate relative risk (RR).RESULTS: Overall, prevalence of diabetes in 29 LMICs was 7.5% (95% CI 7.1-8.0) and of undiagnosed diabetes 4.9% (4.6-5.3). Diabetes prevalence increased with increasing WBIG: countries with low-income economies (LICs) 6.7% (5.5-8.1), lower-middle-income economies (LMIs) 7.1% (6.6-7.6), and upper-middle-income economies (UMIs) 8.2% (7.5-9.0). Compared with no formal education, greater educational attainment was associated with an increased risk of diabetes across WBIGs, after adjusting for BMI (LICs RR 1.47 [95% CI 1.22-1.78], LMIs 1.14 [1.06-1.23], and UMIs 1.28 [1.02-1.61]).CONCLUSIONS: Among 29 LMICs, diabetes prevalence was substantial and increased with increasing WBIG. In contrast to the association seen in high-income countries, diabetes risk was highest among those with greater educational attainment, independent of BMI. LMICs included in this analysis may be at an advanced stage in the nutrition transition but with no reversal in the socioeconomic gradient of diabetes risk.

    View details for DOI 10.2337/dc19-1782

    View details for PubMedID 32051243

  • The relationship between adult height and diabetes in India: A countrywide cross-sectional study JOURNAL OF DIABETES Al Ssabbagh, M., Geldsetzer, P., Baernighausen, T., Deckert, A. 2020; 12 (2): 158–68


    One major aspect of the epidemiological transition happening in India is the increased diabetes prevalence. Poor environmental conditions in early childhood potentially can increase the risk of developing diabetes in adulthood. Adults' height as an indirect indicator might reflect such conditions. In this paper, we investigate the relationship between adult height as a proxy for early childhood conditions and the risk of developing diabetes in India.This cross-sectional study used national representative data of the latest National Family Health Survey (2015-2016), comprising 512 616 women aged 20 to 49 and 87 281 men aged 20 to 54. We applied the multivariable fractional polynomials approach in logistic regression models to allow for nonlinear relationships between height and diabetes, separated by sex. Additionally, we fitted logistic regression models with height categories. Fixed effects linear probability models were used to control for potential confounding.The study revealed a linear relationship between increasing height and increasing diabetes risk among men. Among women, the shortest were at the highest risk (not significant).Among Indian men, being taller increases the risk of developing diabetes, which contradicts findings from other countries. In contrast, the shortest women seem to be at the greatest risk. Hence, public health interventions in India might be well advised to focus more on the nutrition status of young girls.

    View details for DOI 10.1111/1753-0407.12977

    View details for Web of Science ID 000506373100009

    View details for PubMedID 31420914

  • Evaluation of sex differences in dietary behaviours and their relationship with cardiovascular risk factors: a cross-sectional study of nationally representative surveys in seven low- and middle-income countries. Nutrition journal McKenzie, B. L., Santos, J. A., Geldsetzer, P., Davies, J., Manne-Goehler, J., Gurung, M. S., Sturua, L., Gathecha, G., Aryal, K. K., Tsabedze, L., Andall-Brereton, G., Barnighausen, T., Atun, R., Vollmer, S., Woodward, M., Jaacks, L. M., Webster, J. 2020; 19 (1): 3


    BACKGROUND: Cardiovascular diseases (CVD) are the leading causes of death for men and women in low-and-middle income countries (LMIC). The nutrition transition to diets high in salt, fat and sugar and low in fruit and vegetables, in parallel with increasing prevalence of diet-related CVD risk factors in LMICs, identifies the need for urgent action to reverse this trend. To aid identification of the most effective interventions it is crucial to understand whether there are sex differences in dietary behaviours related to CVD risk.METHODS: From a dataset of 46 nationally representative surveys, we included data from seven countries that had recorded the same dietary behaviour measurements in adults; Bhutan, Eswatini, Georgia, Guyana, Kenya, Nepal and St Vincent and the Grenadines (2013-2017). Three dietary behaviours were investigated: positive salt use behaviour (SUB), meeting fruit and vegetable (F&V) recommendations and use of vegetable oil rather than animal fats in cooking. Generalized linear models were used to investigate the association between dietary behaviours and waist circumference (WC) and undiagnosed and diagnosed hypertension and diabetes. Interaction terms between sex and dietary behaviour were added to test for sex differences.RESULTS: Twenty-four thousand three hundred thirty-two participants were included. More females than males reported positive SUB (31.3 vs. 27.2% p-value <0.001), yet less met F&V recommendations (13.2 vs. 14.8%, p-value<0.05). The prevalence of reporting all three dietary behaviours in a positive manner was 2.7%, varying by country, but not sex. Poor SUB was associated with a higher prevalence of undiagnosed hypertension for females (13.1% vs. 9.9%, p-value=0.04), and a higher prevalence of undiagnosed diabetes for males (2.4% vs. 1.5%, p-value=0.02). Meeting F&V recommendations was associated with a higher prevalence of high WC (24.4% vs 22.6%, p-value=0.01), but was not associated with undiagnosed or diagnosed hypertension or diabetes.CONCLUSION: Interventions to increase F&V intake and positive SUBs in the included countries are urgently needed. Dietary behaviours were not notably different between sexes. However, our findings were limited by the small proportion of the population reporting positive dietary behaviours, and further research is required to understand whether associations with CVD risk factors and interactions by sex would change as the prevalence of positive behaviours increases.

    View details for DOI 10.1186/s12937-019-0517-4

    View details for PubMedID 31928531

  • Use of Rapid Online Surveys to Assess People's Perceptions During Infectious Disease Outbreaks: A Cross-sectional Survey on COVID-19. Journal of medical Internet research Geldsetzer, P. n. 2020; 22 (4): e18790


    Given the extensive time needed to conduct a nationally representative household survey and the commonly low response rate of phone surveys, rapid online surveys may be a promising method to assess and track knowledge and perceptions among the general public during fast-moving infectious disease outbreaks.This study aimed to apply rapid online surveying to determine knowledge and perceptions of coronavirus disease 2019 (COVID-19) among the general public in the United States and the United Kingdom.An online questionnaire was administered to 3000 adults residing in the United States and 3000 adults residing in the United Kingdom who had registered with Prolific Academic to participate in online research. Prolific Academic established strata by age (18-27, 28-37, 38-47, 48-57, or ≥58 years), sex (male or female), and ethnicity (white, black or African American, Asian or Asian Indian, mixed, or "other"), as well as all permutations of these strata. The number of participants who could enroll in each of these strata was calculated to reflect the distribution in the US and UK general population. Enrollment into the survey within each stratum was on a first-come, first-served basis. Participants completed the questionnaire between February 23 and March 2, 2020.A total of 2986 and 2988 adults residing in the United States and the United Kingdom, respectively, completed the questionnaire. Of those, 64.4% (1924/2986) of US participants and 51.5% (1540/2988) of UK participants had a tertiary education degree, 67.5% (2015/2986) of US participants had a total household income between US $20,000 and US $99,999, and 74.4% (2223/2988) of UK participants had a total household income between £15,000 and £74,999. US and UK participants' median estimate for the probability of a fatal disease course among those infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was 5.0% (IQR 2.0%-15.0%) and 3.0% (IQR 2.0%-10.0%), respectively. Participants generally had good knowledge of the main mode of disease transmission and common symptoms of COVID-19. However, a substantial proportion of participants had misconceptions about how to prevent an infection and the recommended care-seeking behavior. For instance, 37.8% (95% CI 36.1%-39.6%) of US participants and 29.7% (95% CI 28.1%-31.4%) of UK participants thought that wearing a common surgical mask was "highly effective" in protecting them from acquiring COVID-19, and 25.6% (95% CI 24.1%-27.2%) of US participants and 29.6% (95% CI 28.0%-31.3%) of UK participants thought it was prudent to refrain from eating at Chinese restaurants. Around half (53.8%, 95% CI 52.1%-55.6%) of US participants and 39.1% (95% CI 37.4%-40.9%) of UK participants thought that children were at an especially high risk of death when infected with SARS-CoV-2.The distribution of participants by total household income and education followed approximately that of the US and UK general population. The findings from this online survey could guide information campaigns by public health authorities, clinicians, and the media. More broadly, rapid online surveys could be an important tool in tracking the public's knowledge and misperceptions during rapidly moving infectious disease outbreaks.

    View details for DOI 10.2196/18790

    View details for PubMedID 32240094

  • Analysis of Attained Height and Diabetes Among 554,122 Adults Across 25 Low- and Middle-Income Countries. Diabetes care Teufel, F. n., Geldsetzer, P. n., Manne-Goehler, J. n., Karlsson, O. n., Koncz, V. n., Deckert, A. n., Theilmann, M. n., Marcus, M. E., Ebert, C. n., Seiglie, J. A., Agoudavi, K. n., Andall-Brereton, G. n., Gathecha, G. n., Gurung, M. S., Guwatudde, D. n., Houehanou, C. n., Hwalla, N. n., Kagaruki, G. B., Karki, K. B., Labadarios, D. n., Martins, J. S., Msaidie, M. n., Norov, B. n., Sibai, A. M., Sturua, L. n., Tsabedze, L. n., Wesseh, C. S., Davies, J. n., Atun, R. n., Vollmer, S. n., Subramanian, S. V., Bärnighausen, T. n., Jaacks, L. M., De Neve, J. W. 2020


    The prevalence of type 2 diabetes is rising rapidly in low-income and middle-income countries (LMICs), but the factors driving this rapid increase are not well understood. Adult height, in particular shorter height, has been suggested to contribute to the pathophysiology and epidemiology of diabetes and may inform how adverse environmental conditions in early life affect diabetes risk. We therefore systematically analyzed the association of adult height and diabetes across LMICs, where such conditions are prominent.We pooled individual-level data from nationally representative surveys in LMICs that included anthropometric measurements and diabetes biomarkers. We calculated odds ratios (ORs) for the relationship between attained adult height and diabetes using multilevel mixed-effects logistic regression models. We estimated ORs for the pooled sample, major world regions, and individual countries, in addition to stratifying all analyses by sex. We examined heterogeneity by individual-level characteristics.Our sample included 554,122 individuals across 25 population-based surveys. Average height was 161.7 cm (95% CI 161.2-162.3), and the crude prevalence of diabetes was 7.5% (95% CI 6.9-8.2). We found no relationship between adult height and diabetes across LMICs globally or in most world regions. When stratifying our sample by country and sex, we found an inverse association between adult height and diabetes in 5% of analyses (2 out of 50). Results were robust to alternative model specifications.Adult height is not associated with diabetes across LMICs. Environmental factors in early life reflected in attained adult height likely differ from those predisposing individuals for diabetes.

    View details for DOI 10.2337/dc20-0019

    View details for PubMedID 32764150

  • Epidemiology of multimorbidity in conditions of extreme poverty: a population-based study of older adults in rural Burkina Faso. BMJ global health Odland, M. L., Payne, C., Witham, M. D., Siedner, M. J., Barnighausen, T., Bountogo, M., Coulibaly, B., Geldsetzer, P., Harling, G., Manne-Goehler, J., Ouermi, L., Sie, A., Davies, J. I. 2020; 5 (3): e002096


    Introduction: Multimorbidity is a health issue of increasing importance worldwide, and is likely to become particularly problematic in low-income countries (LICs) as they undergo economic, demographic and epidemiological transitions. Knowledge of the burden and consequences of multimorbidity in LICs is needed to inform appropriate interventions.Methods: A cross-sectional household survey collected data on morbidities and frailty, disability, quality of life and physical performance on individuals aged over 40 years of age living in the Nouna Health and Demographic Surveillance System area in northwestern Burkina Faso. We defined multimorbidity as the occurrence of two or more conditions, and evaluated the prevalence of and whether this was concordant (conditions in the same morbidity domain of communicable, non-communicable diseases (NCDs) or mental health (MH)) or discordant (conditions in different morbidity domains) multimorbidity. Finally, we fitted multivariable regression models to determine associated factors and consequences of multimorbidity.Results: Multimorbidity was present in 22.8 (95% CI, 21.4 to 24.2) of the study population; it was more common in females, those who are older, single, more educated, and wealthier. We found a similar prevalence of discordant 11.1 (95% CI, 10.1 to 12.2) and concordant multimorbidity 11.7 (95% CI, 10.6 to 12.8). After controlling for age, sex, marital status, education, and wealth, an increasing number of conditions was strongly associated with frailty, disability, low quality of life, and poor physical performance. We found no difference in the association between concordant and discordant multimorbidity and outcomes, however people who were multimorbid with NCDs alone had better outcomes than those with multimorbidity with NCDs and MH disorders or MH multimorbidity alone.Conclusions: Multimorbidity is prevalent in this poor, rural population and is associated with markers of decreased physical performance and quality of life. Preventative and management interventions are needed to ensure that health systems can deal with increasing multimorbidity and its downstream consequences.

    View details for DOI 10.1136/bmjgh-2019-002096

    View details for PubMedID 32337079

  • Change in clinical knowledge of diabetes among primary healthcare providers in Indonesia: repeated cross-sectional survey of 5105 primary healthcare facilities. BMJ open diabetes research & care Stein, D. T., Sudharsanan, N. n., Dewi, S. n., Manne-Goehler, J. n., Witoelar, F. n., Geldsetzer, P. n. 2020; 8 (1)


    Indonesia is experiencing a rapid rise in the number of people with diabetes. There is limited evidence on how well primary care providers are equipped to deal with this growing epidemic. This study aimed to determine the level of primary healthcare providers' knowledge of diabetes, change in knowledge from 2007 to 2014/2015 and the extent to which changes in the diabetes workforce composition, geographical distribution of providers, and provider characteristics explained the change in diabetes knowledge.In 2007 and 2014/2015, a random sample of public and private primary healthcare providers who reported providing diabetes care across 13 provinces in Indonesia completed a diabetes clinical case vignette. A provider's diabetes vignette score represents the percentage of all correct clinical actions for a hypothetical diabetes patient that were spontaneously mentioned by the provider. We used standardization and fixed-effects linear regression models to determine the extent to which changes in diabetes workforce composition, geographical distribution of providers, and provider characteristics explained any change in diabetes knowledge between survey rounds, and how knowledge varied among provinces.The mean unadjusted vignette score decreased from 37.1% (95% CI 36.4% to 37.9%) in 2007 to 29.1% (95% CI 28.4% to 29.8%, p<0.001) in 2014/2015. Vignette scores were, on average, 6.9 (95% CI -8.2 to 5.6, p<0.001) percentage points lower in 2014/2015 than in 2007 after adjusting for provider cadre, geographical distribution, and provider experience and training. Physicians and providers with postgraduate diabetes training had the highest vignette scores.Diabetes knowledge among primary healthcare providers in Indonesia decreased, from an already low level, between 2007 and 2014/2015. Policies that improve preservice training, particularly at newer schools, and investment in on-the-job training in diabetes might halt and reverse the decline in diabetes knowledge among Indonesia's primary healthcare workforce.

    View details for DOI 10.1136/bmjdrc-2020-001415

    View details for PubMedID 33020133

    View details for PubMedCentralID PMC7536835

  • The impact of continuous quality improvement on coverage of antenatal HIV care tests in rural South Africa: Results of a stepped-wedge cluster-randomised controlled implementation trial. PLoS medicine Yapa, H. M., De Neve, J. W., Chetty, T. n., Herbst, C. n., Post, F. A., Jiamsakul, A. n., Geldsetzer, P. n., Harling, G. n., Dhlomo-Mphatswe, W. n., Moshabela, M. n., Matthews, P. n., Ogbuoji, O. n., Tanser, F. n., Gareta, D. n., Herbst, K. n., Pillay, D. n., Wyke, S. n., Bärnighausen, T. n. 2020; 17 (10): e1003150


    Evidence for the effectiveness of continuous quality improvement (CQI) in resource-poor settings is very limited. We aimed to establish the effects of CQI on quality of antenatal HIV care in primary care clinics in rural South Africa.We conducted a stepped-wedge cluster-randomised controlled trial (RCT) comparing CQI to usual standard of antenatal care (ANC) in 7 nurse-led, public-sector primary care clinics-combined into 6 clusters-over 8 steps and 19 months. Clusters randomly switched from comparator to intervention on pre-specified dates until all had rolled over to the CQI intervention. Investigators and clusters were blinded to randomisation until 2 weeks prior to each step. The intervention was delivered by trained CQI mentors and included standard CQI tools (process maps, fishbone diagrams, run charts, Plan-Do-Study-Act [PDSA] cycles, and action learning sessions). CQI mentors worked with health workers, including nurses and HIV lay counsellors. The mentors used the standard CQI tools flexibly, tailored to local clinic needs. Health workers were the direct recipients of the intervention, whereas the ultimate beneficiaries were pregnant women attending ANC. Our 2 registered primary endpoints were viral load (VL) monitoring (which is critical for elimination of mother-to-child transmission of HIV [eMTCT] and the health of pregnant women living with HIV) and repeat HIV testing (which is necessary to identify and treat women who seroconvert during pregnancy). All pregnant women who attended their first antenatal visit at one of the 7 study clinics and were ≥18 years old at delivery were eligible for endpoint assessment. We performed intention-to-treat (ITT) analyses using modified Poisson generalised linear mixed effects models. We estimated effect sizes with time-step fixed effects and clinic random effects (Model 1). In separate models, we added a nested random clinic-time step interaction term (Model 2) or individual random effects (Model 3). Between 15 July 2015 and 30 January 2017, 2,160 participants with 13,212 ANC visits (intervention n = 6,877, control n = 6,335) were eligible for ITT analysis. No adverse events were reported. Median age at first booking was 25 years (interquartile range [IQR] 21 to 30), and median parity was 1 (IQR 0 to 2). HIV prevalence was 47% (95% CI 42% to 53%). In Model 1, CQI significantly increased VL monitoring (relative risk [RR] 1.38, 95% CI 1.21 to 1.57, p < 0.001) but did not improve repeat HIV testing (RR 1.00, 95% CI 0.88 to 1.13, p = 0.958). These results remained essentially the same in both Model 2 and Model 3. Limitations of our study include that we did not establish impact beyond the duration of the relatively short study period of 19 months, and that transition steps may have been too short to achieve the full potential impact of the CQI intervention.We found that CQI can be effective at increasing quality of primary care in rural Africa. Policy makers should consider CQI as a routine intervention to boost quality of primary care in rural African communities. Implementation research should accompany future CQI use to elucidate mechanisms of action and to identify factors supporting long-term success.This trial is registered at under registration number NCT02626351.

    View details for DOI 10.1371/journal.pmed.1003150

    View details for PubMedID 33027246

  • A stepped-wedge randomized trial on the impact of early ART initiation on HIV patients' economic welfare in Eswatini. eLife Steinert, J. I., Khan, S. n., Mlambo, K. n., Walsh, F. J., Mafara, E. n., Lejeune, C. n., Wong, C. n., Hettema, A. n., Ogbouji, O. n., Vollmer, S. n., De Neve, J. W., Mazibuko, S. n., Okello, V. n., Bärnighausen, T. n., Geldsetzer, P. n. 2020; 9


    Background: Since 2015, the World Health Organisation (WHO) recommends immediate initiation of antiretroviral therapy (ART) for all HIV-positive patients. Epidemiological evidence points to important health benefits of immediate ART initiation; however, the policy's economic impact remains unknown. Methods: We conducted a stepped-wedge cluster-randomised controlled trial in Eswatini to determine the causal impact of immediate ART initiation on patients' economic welfare. Fourteen healthcare facilities were non-randomly matched in pairs and then randomly allocated to transition from the standard of care (ART eligibility at CD4 counts of < 350 cells/mm3 until September 2016 and <500 cells/mm3 thereafter) to the 'Early Initiation of ART for All' (EAAA) intervention at one of seven timepoints. Patients, healthcare personnel, and outcome assessors remained unblinded. Data was collected via standardised paper-based surveys with HIV-positive, ART-naïve adults who were neither pregnant nor breastfeeding. Outcomes were patients' time use, employment status, household expenditures and household wealth. Results: A total sample of 3,019 participants were interviewed over the duration of the study. The mean number of participants approached at each facility and time step varied from 4 to 112 participants. Using mixed-effects negative binomial regressions accounting for time trends and clustering, we found no significant difference between study arms for any economic outcome. Specifically, the EAAA intervention had no significant effect on non-resting time use (RR= 1.00, [CI: 0.96, 1.05, p=0.93]) or income-generating time use (RR= 0.94, [CI: 0.73,1.20, p=0.61]). Employment and household expenditures decreased slightly but not significantly in the EAAA group, with risk ratios of 0.93 [CI: 0.82, 1.04, p=0.21] and 0.92 [CI: 0.79, 1.06, p=0.26], respectively. We also found no significant treatment effect on households' asset ownership and living standards (RR=0.96, [CI 0.92, 1.00, p=0.253]). Lastly, there was no evidence of heterogeneity in effect estimates by patients' sex, age, education, timing of HIV diagnosis and ART initiation. Conclusions: Given the neutral effect on patients' economic welfare but positive effects on health, our findings support further investments into scaling-up immediate ART for all HIV patients. Trial Registration:, NCT02909218 and NCT03789448; ethical approval: Eswatini National Health Service Review Board & Harvard T.H. Chan School of Public Health Review Board.

    View details for DOI 10.7554/eLife.58487

    View details for PubMedID 32831169

  • A cross-sectional study of cardiovascular disease risk clustering at different socio-geographic levels in India. Nature communications Bischops, A. C., De Neve, J., Awasthi, A., Vollmer, S., Barnighausen, T., Geldsetzer, P. 2020; 11 (1): 5891


    Despite its importance for the targeting of interventions, little is known about the degree to which cardiovascular disease (CVD) risk factors cluster within different socio-geographic levels in South Asia. Using two jointly nationally representative household surveys, which sampled 1,082,100 adults across India, we compute the intra-cluster correlation coefficients (ICCs) of five major CVD risk factors (raised blood glucose, raised blood pressure, smoking, overweight, and obesity) at the household, community, district, and state level. Here we show that except for smoking, the level of clustering is generally highest for households, followed by communities, districts, and then states. On average, more economically developed districts have a higher household ICC in rural areas. These findings provide critical information for sample size calculations of cluster-randomized trials and household surveys, and inform the targeting of policies and prevention programming aimed at reducing CVD in India.

    View details for DOI 10.1038/s41467-020-19647-3

    View details for PubMedID 33208739

  • "It's hard for us men to go to the clinic. We naturally have a fear of hospitals." Men's risk perceptions, experiences and program preferences for PrEP: A mixed methods study in Eswatini. PloS one Berner-Rodoreda, A., Geldsetzer, P., Barnighausen, K., Hettema, A., Barnighausen, T., Matse, S., McMahon, S. A. 2020; 15 (9): e0237427


    Few studies on HIV Pre-Exposure Prophylaxis (PrEP) have focused on men who have sex with women. We present findings from a mixed-methods study in Eswatini, the country with the highest HIV prevalence in the world (27%). Our findings are based on risk assessments, in-depth interviews and focus-group discussions which describe men's motivations for taking up or declining PrEP. Quantitatively, men self-reported starting PrEP because they had multiple or sero-discordant partners or did not know the partner's HIV-status. Men's self-perception of risk was echoed in the qualitative data, which revealed that the hope of facilitated sexual performance or relations, a preference for pills over condoms and the desire to protect themselves and others also played a role for men to initiate PrEP. Trust and mistrust and being able or unable to speak about PrEP with partner(s) were further considerations for initiating or declining PrEP. Once on PrEP, men's sexual behavior varied in terms of number of partners and condom use. Men viewed daily pill-taking as an obstacle to starting PrEP. Side-effects were a major reason for men to discontinue PrEP. Men also worried that taking anti-retroviral drugs daily might leave them mistaken for a person living with HIV, and viewed clinic-based PrEP education and initiation processes as a further obstacle. Given that men comprise only 29% of all PrEP users in Eswatini, barriers to men's uptake of PrEP will need to be addressed, in terms of more male-friendly services as well as trialing community-based PrEP education and service delivery.

    View details for DOI 10.1371/journal.pone.0237427

    View details for PubMedID 32966307

  • Positive impact of facility-based isolation of mild COVID-19 cases on effectively curbing the pandemic: a mathematical modelling study. Journal of travel medicine Chen, S. n., Chen, Q. n., Yang, J. n., Lin, L. n., Li, L. n., Jiao, L. n., Geldsetzer, P. n., Wang, C. n., Wilder-Smith, A. n., Bärnighausen, T. n. 2020


    In many countries, patients with mild coronavirus disease 2019 (COVID-19) are told to self-isolate at home, but imperfect compliance and shared living space with uninfected people limit the effectiveness of home-based isolation. We aim to examine the impact of facility-based isolation compared to self-isolation at home on the continuing epidemic in the United States.We developed a compartment model to simulate the dynamic transmission of COVID-19 and calibrated it to key epidemic measures in the United States from March to September. We simulated facility-based isolation strategies with various capacities and starting times under different diagnosis rates. The primary model outcomes included the reduction of new infections and deaths over two months from October onwards. We further explored different effects of facility-based isolation under different epidemic burdens by major US Census Regions, and performed sensitivity analyses by varying key model assumptions and parameters.We projected that facility-based isolation with moderate capacity of 5 beds per 10 000 total population could avert 4.17 (95% Credible Interval 1.65-7.11) million new infections and 16 000 (8000-23 000) deaths in two months compared with home-based isolation, equivalent to relative reductions of 57% (44-61%) in new infections and 37% (27-40%) in deaths. Facility-based isolation with high capacity of 10 beds per 10 000 population would achieve greater reduction of 76% (62-84%) in new infections and 52% (37-64%) in deaths when supported by the expanded testing with a 20% daily diagnosis rate. Delays in implementation would substantially reduce the impact of facility-based isolation. The effective capacity and the impact of facility-based isolation varied by epidemic stage across regions.Timely facility-based isolation for mild COVID-19 cases could substantially reduce the number of new infections and effectively curb the continuing epidemic compared to home-based isolation. The local epidemic burden should determine the effective scale of facility-based isolation strategies.

    View details for DOI 10.1093/jtm/taaa226

    View details for PubMedID 33274387

  • Impact of immediate initiation of antiretroviral therapy on HIV patient satisfaction. AIDS (London, England) Ogbuoji, O., Geldsetzer, P., Wong, C., Khan, S., Mafara, E., Lejeune, C., Walsh, F., Okello, V., Barnighausen, T. 2020; 34 (2): 267–76


    OBJECTIVES: Immediate ART (or early access to ART for all, EAAA) is becoming a national policy in many countries in sub-Saharan Africa. It is plausible that the switch from delayed to immediate ART could either increase or decrease patient satisfaction with treatment. A decrease in patient satisfaction would likely have detrimental consequences for long-term retention and adherence, in addition to the value lost because of the worsening patient experience itself. We conducted a pragmatic stepped-wedge cluster-randomized controlled trial (SW-cRCT) to determine the causal impact of immediate treatment for HIV on patient satisfaction.DESIGN: This seven-step SW-cRCT took place in 14 public-sector health facilities in Eswatini's Hhohho region, from September 2014 to August 2017.METHODS: During each step of the trial, we randomly selected days for data collection at each study facility. During these days, a random sample of HIV patients were selected for outcome assessment. In total, 2629 patients provided data on their overall patient satisfaction and satisfaction with the following four domains of the patient experience using a five-point Likert scale: wait time, consultation time, involvement in treatment decisions, and respectful treatment. Higher values on the Likert scale indicated lower patient satisfaction. We analyzed the data using a multilevel ordered logistic regression model with individuals at the first level and health facilities at the second (cluster) level.RESULTS: The proportional odds ratio (OR) comparing EAAA to control was 0.91 (95% CI 0.66-1.25) for overall patient satisfaction. For the specific domains of the patient experience, the ORs describing the impact of EAAA on satisfaction were 1.04 (95% CI 0.61-1.78) for wait time, 0.90 (95% CI 0.62-1.31) for involvement in treatment decisions, 0.86 (95% CI 0.61-1.20) for consultation time, and 1.35 (95% CI 0.93-1.96) for respectful treatment. These results were robust across a wide range of sensitivity analyses. Over time - and independent of EAAA - we observed a worsening trend for both overall patient satisfaction and satisfaction in the four domains of the patient experience we measured.CONCLUSION: Our findings support the policy change from delayed to immediate ART in sub-Saharan Africa. Immediate (versus delayed) ART in public-sector health facilities in Eswatini had no effect on either overall patient satisfaction or satisfaction with four specific domains of the patient experience. At the same time, we observed a strong secular trend of decreasing patient satisfaction in both the intervention and the control arm of the trial. Further implementation research should identify approaches to ensure high patient satisfaction as ART programs grow and mature.

    View details for DOI 10.1097/QAD.0000000000002392

    View details for PubMedID 31634194

  • Nationally representative household survey data for studying the interaction between district-level development and individual-level socioeconomic gradients of cardiovascular disease risk factors in India DATA IN BRIEF Jung, L., De Neve, J., Chen, S., Manne-Goehler, J., Jaacks, L. M., Corsi, D. J., Awasthi, A., Subramanian, S. V., Vollmer, S., Baernighausen, T., Geldsetzer, P. 2019; 27: 104486


    In this article, we describe the dataset used in our study entitled "The interaction between district-level development and individual-level socioeconomic gradients of cardiovascular disease risk factors in India: A cross-sectional study of 2.4 million adults", recently published in Social Science & Medicine, and present supplementary analyses. We used data from three different household surveys in India, which are representative at the district level. Specifically, we analyzed pooled data from the District-Level Household Survey 4 (DLHS-4) and the second update of the Annual Health Survey (AHS), and separately analyzed data from the National Family Health Survey (NFHS-4). The DLHS-4 and AHS sampled adults aged 18 years or older between 2012 and 2014, while the NFHS-4 sampled women aged 15-49 years and - in a subsample of 15% of households - men aged 15-54 years in 2015 and 2016. The measures of individual-level socio-economic status that we used in both datasets were educational attainment and household wealth quintiles. The measures of district-level development, which we calculated from these data, were i) the percentage of participants living in an urban area, ii) female literacy rate, and iii) the district-level median of the continuous household wealth index. An additional measure of district-level development that we used was Gross Domestic Product per capita, which we obtained from the Planning Commission of the Government of India for 2004/2005. Our outcome variables were diabetes, hypertension, obesity, and current smoking. The data were analyzed using both district-level regressions and multilevel modelling.

    View details for DOI 10.1016/j.dib.2019.104486

    View details for Web of Science ID 000501988200009

    View details for PubMedID 31720318

    View details for PubMedCentralID PMC6838398

  • The interaction between district-level development and individual-level socioeconomic gradients of cardiovascular disease risk factors in India: A cross-sectional study of 2.4 million adults SOCIAL SCIENCE & MEDICINE Jung, L., De Neve, J., Chen, S., Manne-Goehler, J., Jaacks, L. M., Corsi, D. J., Awasthi, A., Subramanian, S. V., Vollmer, S., Barnighausen, T., Geldsetzer, P. 2019; 239: 112514


    Diabetes, hypertension, and obesity tend to be positively associated with socio-economic status in low- and middle-income countries (LMICs). It has been hypothesized that these positive socio-economic gradients will reverse as LMICs continue to undergo economic development. We use population-based cross-sectional data in India to examine how a district's economic development is associated with socio-economic differences in cardiovascular disease (CVD) risk factor prevalence between individuals.We separately analyzed two nationally representative household survey datasets - the NFHS-4 and the DLHS-4/AHS - that are representative at the district level in India. Diabetes was defined based on a capillary blood glucose measurement, hypertension on blood pressure measurements, obesity on measurements of height and weight, and current smoking on self-report. Five different measures of a district's economic development were used. We analyzed the data using district-level regressions (plotting the coefficient comparing high to low socio-economic status against district-level economic development) and multilevel modeling.757,655 and 1,618,844 adults participated in the NFHS-4 and DLHS-4/AHS, respectively. Higher education and household wealth were associated with a higher probability of having diabetes, hypertension, and obesity, and a lower probability of being a current smoker. For diabetes, hypertension, and obesity, we found that a higher economic development of a district was associated with a less positive (or even negative) association between the CVD risk factor and education. For smoking, the association with education tended to become less negative as districts had a higher level of economic development. In general, these associations did not show clear trends when household wealth quintile was used as the measure of socio-economic status instead of education.While this study provides some evidence for the "reversal hypothesis", large-scale longitudinal studies are needed to determine whether LMICs should expect a likely reversal of current positive socioeconomic gradients in diabetes, hypertension, and obesity as their countries continue to develop economically.

    View details for DOI 10.1016/j.socscimed.2019.112514

    View details for Web of Science ID 000504513200009

    View details for PubMedID 31541939

  • The prevalence of concurrently raised blood glucose and blood pressure in India: a cross-sectional study of 2035 662 adults JOURNAL OF HYPERTENSION Bischops, A. C., Manne-Goehler, J., Jaacks, L. M., Awasthi, A., Theilmann, M., Davies, J., Atun, R., Barnighausen, T., Vollmer, S., Geldsetzer, P. 2019; 37 (9): 1822–31


    To inform integrated, person-centered interventions, this study aimed to determine the prevalence of having both a raised blood glucose and blood pressure (BP) in India, and its variation among states and population groups.We pooled data from three large household surveys (the Annual Health Survey, District Level Household and Facility Survey, and National Family Health Survey), which were carried out between 2012 and 2016 and included adults aged at least 15 years. Raised blood glucose was defined as having a plasma glucose reading at least 126 mg/dl if fasted and at least 200 mg/dl if not fasted, and raised BP as a SBP of at least 140 mmHg or DBP of at least 90 mmHg. The prevalence of having a concurrently raised blood glucose and BP (comorbid) was age-standardized to India's national population structure, and disaggregated by sex, age group, BMI group, rural-urban residency, household wealth quintile, education, state, and region.The age-standardized prevalence of this comorbidity was 1.5% [95% confidence interval (CI), 1.5-1.5], and varied by a factor of 8.3 between states. Among those aged at least 50 years, 4.5% (95% CI, 4.3-4.7) with a BMI less than 23.0 kg/m and 16.1% (95% CI, 15.0-17.4) with a BMI at least 30 kg/m were comorbid. Age, BMI, household wealth quintile, male sex, and urban location were all positively associated with this comorbidity.A substantial proportion of India's population had both a raised blood glucose and BP, calling for integrated interventions to reduce cardiovascular disease risk. We identified large variation among states, age groups, and by rural-urban residency, which can inform health system planning and the targeting of interventions, such as appropriate screening programs, to those most in need.

    View details for DOI 10.1097/HJH.0000000000002114

    View details for Web of Science ID 000501621900012

    View details for PubMedID 31368919

  • ART Denial: Results of a Home-Based Study to Validate Self-reported Antiretroviral Use in Rural South Africa AIDS AND BEHAVIOR Manne-Goehler, J., Rohr, J., Montana, L., Siedner, M., Harling, G., Gomez-Olive, F., Geldsetzer, P., Wagner, R., Wiesner, L., Kahn, K., Tollman, S., Baernighausen, T. W. 2019; 23 (8): 2072–78


    There is increasing interest in home based testing and treatment of HIV to expand access to treatment in sub-Saharan Africa. Such programs rely on self-reported HIV history and use of antiretroviral therapy (ART). However, the accuracy of self-reported ART use in community settings is not well described. In this study, we compared self-reported ART (SR-ART) use in a home based survey against biological exposure to ART (BE-ART), in a population study of older adults in South Africa. Health and Aging in Africa: a Longitudinal Study of an INDEPTH community in South Africa (HAALSI) is a cohort of adults aged 40 +. The baseline home-based interview included self-reported HIV status and ART use. All participants also underwent biological testing for HIV antibodies, viral load and exposure to emtricitabine (FTC) or lamivudine (3TC), which are included in all first-line and second-line ART regimens in the public-sector South African HIV program. We calculated the performance characteristics for SR-ART compared to BE-ART and fit multivariable logistic regression models to identify correlates of invalid SR-ART responses. Of 4560 HAALSI participants with a valid HIV test result available, 1048 (23%) were HIV-positive and 734 [70% of people living with HIV (PLWH)] were biologically validated ART users (BE-ART). The sensitivity of SR-ART use was 64% (95% CI 61-68%) and the specificity was 94% (95% CI 91-96%); the positive predictive value (PPV) was 96% (95% CI 94-98%) and negative predictive value (NPV) was 52% (95% CI 48-56%). We found no sociodemographic predictors of accurate SR-ART use. Over one in three individuals with detectable ART in their blood denied current ART use during a home-based interview. These results demonstrate ongoing stigma related to HIV and its treatment, and have important implications for community health worker programs, clinical programs, and research studies planning community-based ART initiation in the region.

    View details for DOI 10.1007/s10461-018-2351-7

    View details for Web of Science ID 000476707100008

    View details for PubMedID 30523490

    View details for PubMedCentralID PMC6551321

  • Impact of community based screening for hypertension on blood pressure after two years: regression discontinuity analysis in a national cohort of older adults in China BMJ-BRITISH MEDICAL JOURNAL Chen, S., Sudharsanan, N., Huang, F., Liu, Y., Geldsetzer, P., Barnighausen, T. 2019; 366: l4064


    To estimate the causal impact of community based blood pressure screening on subsequent blood pressure levels among older adults in China.Regression discontinuity analysis using data from a national cohort study.2011-12 and 2014 waves of the Chinese Longitudinal Healthy Longevity Survey, a national cohort of older adults in China.3899 older adults who had previously undiagnosed hypertension.Community based hypertension screening among older adults in 2011-12.Blood pressure two years after initial screening.The intervention reduced systolic blood pressure: -6.3 mm Hg in the model without covariates (95% confidence interval -11.2 to -1.3) and -8.3 mm Hg (-13.6 to -3.1) in the model that adjusts additionally for demographic, social, and behavioural covariates. The impact on diastolic blood pressure was smaller and non-significant in all models. The results were similar when alternative functional forms were used to estimate the impact and the bandwidths around the intervention threshold were changed. The results did not vary by demographic and social subgroups.Community based hypertension screening and encouraging people with raised blood pressure to seek care and adopt blood pressure lowering behaviour changes could have important long term impact on systolic blood pressure at the population level. This approach could address the high burden of cardiovascular diseases in China and other countries with large unmet need for hypertension diagnosis and care.

    View details for DOI 10.1136/bmj.l4064

    View details for Web of Science ID 000475736300001

    View details for PubMedID 31296584

    View details for PubMedCentralID PMC6619453

  • HIV, antiretroviral therapy and non-communicable diseases in sub-Saharan Africa: empirical evidence from 44 countries over the period 2000 to 2016 JOURNAL OF THE INTERNATIONAL AIDS SOCIETY Coetzee, L., Bogler, L., De Neve, J., Baernighausen, T., Geldsetzer, P., Vollmer, S. 2019; 22 (7): e25364


    The HIV-infected population is growing due to the increased accessibility of antiretroviral therapy (ART) that extends the lifespan of people living with HIV (PLHIV). We aimed to assess whether national HIV prevalence and ART use are associated with an increased prevalence of cardiovascular risk factors.Using country-level data, we analysed the effect of HIV prevalence and use of ART on cardiovascular risk factors in 44 countries in sub-Saharan Africa between 2000 and 2016. We used fixed-effects estimation to quantify the effect of HIV and ART on the prevalence of diabetes, mean body mass index, the prevalence of overweight, obesity and hypertension, and mean systolic blood pressure. The models were adjusted for calendar time, the age structure of the population, income and education.Diabetes prevalence among PLHIV was 5.8 percentage points higher (95% confidence interval (CI) 1.8 pp to 9.8 pp) compared to individuals without HIV. People receiving ART had a 4.6 percentage point higher prevalence (95% CI 2.6 pp to 6.6 pp). The prevalence of obesity was increased by 14.7 percentage points (95% CI 2.5 pp to 26.9 pp) for PLHIV. Receiving ART was associated with an increased obesity prevalence by 14.0 percentage points (95% CI 4.8 pp to 23.2 pp), whereas it had no significant association with the prevalence of overweight. The population aged 40 to 59 had a significantly higher prevalence of diabetes, overweight and obesity. HIV prevalence and ART use had no significant association with the prevalence of hypertension.An ageing HIV-infected population on ART is associated with a significant increase in the prevalence of diabetes and obesity in sub-Saharan Africa. The increasing prevalence of these cardiovascular risk factors emphasizes the need for comprehensive healthcare programmes that screen and treat both HIV and non-communicable diseases to decrease the associated morbidity and mortality rates.

    View details for DOI 10.1002/jia2.25364

    View details for Web of Science ID 000478602900008

    View details for PubMedID 31353831

    View details for PubMedCentralID PMC6661400

  • Consumption of Fruits and Vegetables Among Individuals 15 Years and Older in 28 Low- and Middle-Income Countries JOURNAL OF NUTRITION Frank, S. M., Webster, J., McKenzie, B., Geldsetzer, P., Manne-Goehler, J., Andall-Brereton, G., Houehanou, C., Houinato, D., Gurung, M., Bicaba, B., McClure, R., Supiyev, A., Zhumadilov, Z., Stokes, A., Labadarios, D., Sibai, A., Norov, B., Aryal, K. K., Karki, K., Kagaruki, G. B., Mayige, M. T., Martins, J. S., Atun, R., Baernighausen, T., Vollmer, S., Jaacks, L. M. 2019; 149 (7): 1252–59


    The WHO recommends 400 g/d of fruits and vegetables (the equivalent of ∼5 servings/d) for the prevention of noncommunicable diseases (NCDs). However, there is limited evidence regarding individual-level correlates of meeting these recommendations in low- and middle-income countries (LMICs). In order to target policies and interventions aimed at improving intake, global monitoring of fruit and vegetable consumption by socio-demographic subpopulations is required.The aims of this study were to 1) assess the proportion of individuals meeting the WHO recommendation and 2) evaluate socio-demographic predictors (age, sex, and educational attainment) of meeting the WHO recommendation.Data were collected from 193,606 individuals aged ≥15 y in 28 LMICs between 2005 and 2016. The prevalence of meeting the WHO recommendation took into account the complex survey designs, and countries were weighted according to their World Bank population estimates in 2015. Poisson regression was used to estimate associations with socio-demographic characteristics.The proportion (95% CI) of individuals aged ≥15 y who met the WHO recommendation was 18.0% (16.6-19.4%). Mean intake of fruits was 1.15 (1.10-1.20) servings per day and for vegetables, 2.46 (2.40-2.51) servings/d. The proportion of individuals meeting the recommendation increased with increasing country gross domestic product (GDP) class (P < 0.0001) and with decreasing country FAO food price index (FPI; indicating greater stability of food prices; P < 0.0001). At the individual level, those with secondary education or greater were more likely to achieve the recommendation compared with individuals with no formal education: risk ratio (95% CI), 1.61 (1.24-2.09).Over 80% of individuals aged ≥15 y living in these 28 LMICs consumed lower amounts of fruits and vegetables than recommended by the WHO. Policies to promote fruit and vegetable consumption in LMICs are urgently needed to address the observed inequities in intake and prevent NCDs.

    View details for DOI 10.1093/jn/nxz040

    View details for Web of Science ID 000473550000021

    View details for PubMedID 31152660

  • HIV treatment cascade for older adults in rural South Africa. Sexually transmitted infections Rohr, J. K., Manne-Goehler, J., Gomez-Olive, F. X., Wagner, R. G., Rosenberg, M., Geldsetzer, P., Kabudula, C., Kahn, K., Tollman, S., Barnighausen, T., Salomon, J. A. 2019


    OBJECTIVES: The HIV treatment cascade is a powerful framework for understanding progress from initial diagnosis to successful treatment. Data sources for cascades vary and often are based on clinical cohorts, population cohorts linked to clinics, or self-reported information. We use both biomarkers and self-reported data from a large population-based cohort of older South Africans to establish the first HIV cascade for this growing segment of the HIV-positive population and compare results using the different data sources.METHODS: Data came from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) 2015 baseline survey of 5059 adults aged 40+ years. Dried blood spots (DBS) were screened for HIV, antiretroviral drugs and viral load. In-home surveys asked about HIV testing, diagnosis and antiretroviral therapy (ART) use. We calculated proportions and CIs for each stage of the cascade, conditional on attainment of the previous stage, using (1) biomarkers, (2) self-report and (3) both biomarkers and self-report, and compared with UNAIDS 90-90-90 targets.RESULTS: 4560 participants had DBS results, among whom 1048 (23%) screened HIV-positive and comprised the denominator for each cascade. The biomarker cascade showed 63% (95% CI 60 to 66) on ART and 72% (95% CI 69 to 76) of those on ART with viral suppression. Self-reports underestimated testing, diagnosis and ART, with only 47% (95% CI 44 to 50) of HIV-positive individuals reporting ART use. The combined cascade indicated high HIV testing (89% (95% CI 87 to 91)), but lower knowledge of HIV-positive status (71% (95% CI 68 to 74)).CONCLUSIONS: Older South Africans need repeated HIV testing and sustained ART to reach 90-90-90 targets. HIV cascades relying on self-reports are likely to underestimate true cascade attainment, and biomarkers provide substantial improvements to cascade estimates.

    View details for DOI 10.1136/sextrans-2018-053925

    View details for PubMedID 31243144

  • Alternatives to Intention-to-Treat Analyses JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Geldsetzer, P., Baernighausen, T., Sudharsanan, N. 2019; 321 (21): 2134–35

    View details for DOI 10.1001/jama.2019.3092

    View details for Web of Science ID 000470158700023

    View details for PubMedID 31162563

  • Depressive Symptoms and Their Relation to Age and Chronic Diseases Among Middle-Aged and Older Adults in Rural South Africa JOURNALS OF GERONTOLOGY SERIES A-BIOLOGICAL SCIENCES AND MEDICAL SCIENCES Geldsetzer, P., Vaikath, M., Wagner, R., Rohr, J. K., Montana, L., Gomez-Olive, F. X., Rosenberg, M. S., Manne-Goehler, J., Mateen, F. J., Payne, C. F., Kahn, K., Tollman, S. M., Salomon, J. A., Gaziano, T. A., Baernighausen, T., Berkman, L. F. 2019; 74 (6): 957–63
  • Variation in health system performance for managing diabetes among states in India: a cross-sectional study of individuals aged 15 to 49years BMC MEDICINE Prenissl, J., Jaacks, L. M., Mohan, V., Manne-Goehler, J., Davies, J. I., Awasthi, A., Bischops, A., Atun, R., Baernighausen, T., Vollmer, S., Geldsetzer, P. 2019; 17: 92


    Understanding where adults with diabetes in India are lost in the diabetes care cascade is essential for the design of targeted health interventions and to monitor progress in health system performance for managing diabetes over time. This study aimed to determine (i) the proportion of adults with diabetes in India who have reached each step of the care cascade and (ii) the variation of these cascade indicators among states and socio-demographic groups.We used data from a population-based household survey carried out in 2015 and 2016 among women and men aged 15-49 years in all states of India. Diabetes was defined as a random blood glucose (RBG) ≥ 200 mg/dL or reporting to have diabetes. The care cascade-constructed among those with diabetes-consisted of the proportion who (i) reported having diabetes ("aware"), (ii) had sought treatment ("treated"), and (iii) had sought treatment and had a RBG < 200 mg/dL ("controlled"). The care cascade was disaggregated by state, rural-urban location, age, sex, household wealth quintile, education, and marital status.This analysis included 729,829 participants. Among those with diabetes (19,453 participants), 52.5% (95% CI, 50.6-54.4%) were "aware", 40.5% (95% CI, 38.6-42.3%) "treated", and 24.8% (95% CI, 23.1-26.4%) "controlled". Living in a rural area, male sex, less household wealth, and lower education were associated with worse care cascade indicators. Adults with untreated diabetes constituted the highest percentage of the adult population (irrespective of diabetes status) aged 15 to 49 years in Goa (4.2%; 95% CI, 3.2-5.2%) and Tamil Nadu (3.8%; 95% CI, 3.4-4.1%). The highest absolute number of adults with untreated diabetes lived in Tamil Nadu (1,670,035; 95% CI, 1,519,130-1,812,278) and Uttar Pradesh (1,506,638; 95% CI, 1,419,466-1,589,832).There are large losses to diabetes care at each step of the care cascade in India, with the greatest loss occurring at the awareness stage. While health system performance for managing diabetes varies greatly among India's states, improvements are particularly needed for rural areas, those with less household wealth and education, and men. Although such improvements will likely have the greatest benefits for population health in Goa and Tamil Nadu, large states with a low diabetes prevalence but a high absolute number of adults with untreated diabetes, such as Uttar Pradesh, should not be neglected.

    View details for DOI 10.1186/s12916-019-1325-6

    View details for Web of Science ID 000468057600001

    View details for PubMedID 31084606

    View details for PubMedCentralID PMC6515628

  • The effect of a community health worker intervention on public satisfaction: evidence from an unregistered outcome in a cluster-randomized controlled trial in Dar es Salaam, Tanzania HUMAN RESOURCES FOR HEALTH Larson, E., Geldsetzer, P., Mboggo, E., Lema, I., Sando, D., Ekstrom, A., Fawzi, W., Foster, D. W., Kilewo, C., Li, N., Machumi, L., Magesa, L., Mujinja, P., Mungure, E., Mwanyika-Sando, M., Naburi, H., Siril, H., Spiegelman, D., Ulenga, N., Baernighausen, T. 2019; 17: 23


    There is a dearth of evidence on the causal effects of different care delivery approaches on health system satisfaction. A better understanding of public satisfaction with the health system is particularly important within the context of task shifting to community health workers (CHWs). This paper determines the effects of a CHW program focused on maternal health services on public satisfaction with the health system among women who are pregnant or have recently delivered.From January 2013 to April 2014, we carried out a cluster-randomized controlled health system implementation trial of a CHW program. Sixty wards in Dar es Salaam, Tanzania, were randomly allocated to either a maternal health CHW program (36 wards) or the standard of care (24 wards). From May to August 2014, we interviewed a random sample of women who were either currently pregnant or had recently delivered a child. We used five-level Likert scales to assess women's satisfaction with the CHW program and with the public-sector health system in Dar es Salaam.In total, 2329 women participated in the survey (response rate 90.2%). Households in intervention areas were 2.3 times as likely as households in control areas to have ever received a CHW visit (95% CI 1.8, 3.0). The intervention led to a 16-percentage-point increase in women reporting they were satisfied or very satisfied with the CHW program (95% CI 3, 30) and a 15-percentage-point increase in satisfaction with the public-sector health system (95% CI 3, 27).A CHW program for maternal and child health in Tanzania achieved better public satisfaction than the standard CHW program. Policy-makers and implementers who are involved in designing and organizing CHW programs should consider the potential positive impact of the program on public, EJF22802.

    View details for DOI 10.1186/s12960-019-0355-7

    View details for Web of Science ID 000463437000001

    View details for PubMedID 30922341

    View details for PubMedCentralID PMC6440091

  • Hypertension and diabetes control along the HIV care cascade in rural South Africa JOURNAL OF THE INTERNATIONAL AIDS SOCIETY Manne-Goehler, J., Siedner, M. J., Montana, L., Harling, G., Geldsetzer, P., Rohr, J., Gomez-Olive, F. X., Goehler, A., Wade, A., Gaziano, T., Kahn, K., Davies, J. I., Tollman, S., Baernighausen, T. W. 2019; 22 (3): e25213


    Participation in antiretroviral therapy (ART) programmes has been associated with greater utilization of care for hypertension and diabetes in rural South Africa. The objective of this study was to assess whether people living with HIV on ART with comorbid hypertension or diabetes also have improved chronic disease management indicators.The Health and Aging in Africa: a longitudinal study of an INDEPTH Community in South Africa (HAALSI) is a cohort of 5059 adults >40 years old. Enrollment took place between November 2014 and November 2015. The study collected population-based data on demographics, healthcare utilization, height, weight, blood pressure (BP) and blood glucose as well as HIV infection, HIV-1 RNA viral load (VL) and ART exposure. We used regression models to determine whether HIV care cascade stage (HIV-negative, HIV+ /No ART, ART/Detected HIV VL, and ART/Undetectable VL) was associated with diagnosis or treatment of hypertension or diabetes, and systolic blood pressure and glucose among those with diagnosed hypertension or diabetes. ART use was measured from drug level testing on dried blood spots.Compared to people without HIV, ART/Undetectable VL was associated with greater awareness of hypertension diagnosis (adjusted risk ratio (aRR) 1.18, 95% CI: 1.09 to 1.28) and treatment of hypertension (aRR 1.24, 95% CI: 1.10 to 1.41) among those who met hypertension diagnostic criteria. HIV care cascade stage was not significantly associated with awareness of diagnosis or treatment of diabetes. Among those with diagnosed hypertension or diabetes, ART/Undetectable VL was associated with lower mean systolic blood pressure (5.98 mm Hg, 95% CI: 9.65 to 2.32) and lower mean glucose (3.77 mmol/L, 95% CI: 6.85 to 0.69), compared to being HIV-negative.Participants on ART with an undetectable VL had lower systolic blood pressure and blood glucose than the HIV-negative participants. HIV treatment programmes may provide a platform for health systems strengthening for cardiometabolic disease.

    View details for DOI 10.1002/jia2.25213

    View details for Web of Science ID 000462816700001

    View details for PubMedID 30916897

    View details for PubMedCentralID PMC6436499

  • Shorter Height is Associated with Diabetes in Women but not in Men: Nationally Representative Evidence from Namibia OBESITY Koncz, V., Geldsetzer, P., Manne-Goehler, J., Wendt, A. S., Teufel, F., Subramanian, S. V., Baernighausen, T., De Neve, J. 2019; 27 (3): 505–12


    This study aimed to test the hypothesis that attained adult height, as an indicator of childhood nutrition, is associated with diabetes in adulthood in Namibia, a country where stunting is highly prevalent.Data from 1,898 women and 1,343 men aged 35 to 64 years included in the Namibia Demographic and Health Survey in 2013 were analyzed. Multiple logistic regression models were used to calculate odds ratios (ORs) and 95% CIs of having diabetes in relation to height. The following three models were considered: Model 1 included only height, Model 2 included height as well as demographic and socioeconomic variables, and Model 3 included body mass index in addition to the covariates from Model 2.Overall crude diabetes prevalence was 6.1% (95% CI: 5.0-7.2). Being taller was inversely related with diabetes in women but not in men. In Model 3, a 1-cm increase in women's height was associated with 4% lower odds of having diabetes (OR, 0.96; 95% CI: 0.94-0.99; P = 0.023).Height is associated with a large reduction in diabetes in women but not in men in Namibia. Interventions that allow women to reach their full growth potential may help prevent the growing diabetes burden in the region.

    View details for DOI 10.1002/oby.22394

    View details for Web of Science ID 000459626000020

    View details for PubMedID 30801987

    View details for PubMedCentralID PMC6646871

  • Health system performance for people with diabetes in 28 low- and middle-income countries: A cross-sectional study of nationally representative surveys PLOS MEDICINE Manne-Goehler, J., Geldsetzer, P., Agoudavi, K., Andall-Brereton, G., Aryal, K. K., Bicaba, B., Bovet, P., Brian, G., Dorobantu, M., Gathecha, G., Gurung, M., Guwatudde, D., Msaidie, M., Houehanou, C., Houinato, D., Jorgensen, J., Kagaruki, G. B., Karki, K. B., Labadarios, D., Martins, J. S., Mayige, M. T., McClure, R., Mwalim, O., Mwangi, J., Norov, B., Quesnel-Crooks, S., Silver, B. K., Sturua, L., Tsabedze, L., Wesseh, C., Stokes, A., Marcus, M., Ebert, C., Davies, J. I., Vollmer, S., Atun, R., Baernighausen, T. W., Jaacks, L. M. 2019; 16 (3): e1002751


    The prevalence of diabetes is increasing rapidly in low- and middle-income countries (LMICs), urgently requiring detailed evidence to guide the response of health systems to this epidemic. In an effort to understand at what step in the diabetes care continuum individuals are lost to care, and how this varies between countries and population groups, this study examined health system performance for diabetes among adults in 28 LMICs using a cascade of care approach.We pooled individual participant data from nationally representative surveys done between 2008 and 2016 in 28 LMICs. Diabetes was defined as fasting plasma glucose ≥ 7.0 mmol/l (126 mg/dl), random plasma glucose ≥ 11.1 mmol/l (200 mg/dl), HbA1c ≥ 6.5%, or reporting to be taking medication for diabetes. Stages of the care cascade were as follows: tested, diagnosed, lifestyle advice and/or medication given ("treated"), and controlled (HbA1c < 8.0% or equivalent). We stratified cascades of care by country, geographic region, World Bank income group, and individual-level characteristics (age, sex, educational attainment, household wealth quintile, and body mass index [BMI]). We then used logistic regression models with country-level fixed effects to evaluate predictors of (1) testing, (2) treatment, and (3) control. The final sample included 847,413 adults in 28 LMICs (8 low income, 9 lower-middle income, 11 upper-middle income). Survey sample size ranged from 824 in Guyana to 750,451 in India. The prevalence of diabetes was 8.8% (95% CI: 8.2%-9.5%), and the prevalence of undiagnosed diabetes was 4.8% (95% CI: 4.5%-5.2%). Health system performance for management of diabetes showed large losses to care at the stage of being tested, and low rates of diabetes control. Total unmet need for diabetes care (defined as the sum of those not tested, tested but undiagnosed, diagnosed but untreated, and treated but with diabetes not controlled) was 77.0% (95% CI: 74.9%-78.9%). Performance along the care cascade was significantly better in upper-middle income countries, but across all World Bank income groups, only half of participants with diabetes who were tested achieved diabetes control. Greater age, educational attainment, and BMI were associated with higher odds of being tested, being treated, and achieving control. The limitations of this study included the use of a single glucose measurement to assess diabetes, differences in the approach to wealth measurement across surveys, and variation in the date of the surveys.The study uncovered poor management of diabetes along the care cascade, indicating large unmet need for diabetes care across 28 LMICs. Performance across the care cascade varied by World Bank income group and individual-level characteristics, particularly age, educational attainment, and BMI. This policy-relevant analysis can inform country-specific interventions and offers a baseline by which future progress can be measured.

    View details for DOI 10.1371/journal.pmed.1002751

    View details for Web of Science ID 000462996000001

    View details for PubMedID 30822339

    View details for PubMedCentralID PMC6396901

  • Non-technical health care quality and health system responsiveness in middle-income countries: a cross-sectional study in China, Ghana, India, Mexico, Russia, and South Africa JOURNAL OF GLOBAL HEALTH Geldsetzer, P., Haakenstad, A., James, E., Atun, R. 2018; 8 (2): 020417


    While there is increasing recognition that the non-technical aspects of health care quality - particularly the inter-personal dimensions of care - are important components of health system performance, evidence from population-based studies on these outcomes in low- and middle-income countries is sparse. This study assesses these non-technical aspects of care using two measures: health system responsiveness (HSR), which quantifies the degree to which the health system meets the expectations of the population, and non-technical health care quality (QoC), for which we 'filtered out' these expectations. Pooling data from six large middle-income countries, this study therefore aimed to determine how HSR and QoC vary between countries and by individuals' sociodemographic characteristics within countries.We pooled individual-level data, collected between 2007 and 2010, from nationally representative household surveys of (primarily) adults aged 50 years and older in China, Ghana, India, Mexico, Russia, and South Africa. The outcome measure was a binary indicator for a 'bad' rating (HSR: "very bad" or "bad" on a five-point Likert scale; QoC: a worse rating of one's own visit than that of the character in an anchoring vignette) on at least one of seven dimensions for the most recent primary care visit.23 749 adults who reported to have sought primary care during the preceding 12 months were includedin the analysis. The proportion of participants who gave a bad rating for their last primary care visit on at least one of seven dimensions varied from 4.3% (95% confidence interval (CI) = 2.8-6.7) in China to 33.1% (95% CI = 23.6-44.2) in South Africa for HSR, and from 17.0% (95% CI = 11.4-24.5) in Russia to 50.8% (95% CI = 46.0-55.6) in Ghana for QoC. There was a strong negative association between increasing household wealth and both bad HSR and QoC in India and South Africa.Achieving universal health coverage (UHC) with good-quality health services ("effective UHC") will require efforts to improve HSR and QoC across the population in Ghana and South Africa. Additionally, a particular focus on raising HSR and QoC for the poorest population groups is needed in India and South Africa.

    View details for DOI 10.7189/jogh.08.020417

    View details for Web of Science ID 000452645100029

    View details for PubMedID 30356805

    View details for PubMedCentralID PMC6189548

  • Implications of the New American College of Cardiology Guidelines for Hypertension Prevalence in India JAMA INTERNAL MEDICINE Venkateshmurthy, N., Geldsetzer, P., Jaacks, L., Prabhakaran, D. 2018; 178 (10): 1416–18
  • The impact of lay counselors on HIV testing rates: quasi-experimental evidence from lay counselor redeployment in KwaZulu-Natal, South Africa AIDS Hu, J., Geldsetzer, P., Steele, S., Matthews, P., Ortblad, K., Solomon, T., Shroufi, A., van Cutsem, G., Tanser, F., Wyke, S., Vollmer, S., Pillay, D., McConnell, M., Barnighausen, T. 2018; 32 (14): 2067–73


    This study aimed to determine the causal effect of the number of lay counselors removed from a primary care clinic in rural South Africa on the number of clinic-based HIV tests performed.Fixed-effects panel analysis.We collected monthly data on the number of lay counselors employed and HIV tests performed at nine primary care clinics in rural KwaZulu-Natal from January 2014 to December 2015. Using clinic-level and month-level fixed-effects regressions, we exploited the fact that lay counselors were removed from clinics at two quasi-random time points by a redeployment policy.A total of 24 526 HIV tests were conducted over the study period. Twenty-one of 27 lay counselors were removed across the nine clinics in the two redeployment waves. A 10% reduction in the number of lay counselors at a clinic was associated with a 4.9% [95% confidence interval (CI) 2.8-7.0, P < 0.001] decrease in the number of HIV tests performed. In absolute terms, losing one lay counselor from a clinic was associated with a mean of 29.7 (95% CI 21.2-38.2, P < 0.001) fewer HIV tests carried out at the clinic per month.This study provides some evidence that lay counselors play an important role in the HIV response in rural South Africa. More broadly, this analysis adds some empirical support to plans to increase the involvement of lay health workers in the HIV response.

    View details for DOI 10.1097/QAD.0000000000001924

    View details for Web of Science ID 000453902200018

    View details for PubMedID 29912066

    View details for PubMedCentralID PMC6115282

  • The MONARCH intervention to enhance the quality of antenatal and postnatal primary health services in rural South Africa: protocol for a stepped-wedge cluster-randomised controlled trial BMC HEALTH SERVICES RESEARCH Chetty, T., Yapa, H. N., Herbst, C., Geldsetzer, P., Naidu, K. K., De Neve, J., Herbst, K., Matthews, P., Pillay, D., Wyke, S., Baernighausen, T., MONARCH Study Team 2018; 18: 625


    Gaps in maternal and child health services can slow progress towards achieving the Sustainable Development Goals. The Management and Optimization of Nutrition, Antenatal, Reproductive, Child Health & HIV Care (MONARCH) study will evaluate a Continuous Quality Improvement (CQI) intervention targeted at improving antenatal and postnatal health service outcomes in rural South Africa where HIV prevalence among pregnant women is extremely high. Specifically, it will establish the effectiveness of CQI on viral load (VL) testing in pregnant women who are HIV-positive and repeat HIV testing in pregnant women who are HIV-negative.This is a stepped-wedge cluster-randomised controlled trial (RCT) of 7 nurse-led primary healthcare clinics to establish the effect of CQI on selected routine antenatal and postnatal services. Each clinic was a cluster, with the exception of the two smallest clinics, which jointly formed one cluster. The intervention was applied at the cluster level, where staff received training on CQI methodology and additional mentoring as required. In the control exposure state, the clusters received the South African Department of Health standard of care. After a baseline data collection period of 2 months, the first cluster crossed over from control to intervention exposure state; subsequently, one additional cluster crossed over every 2 months. The six clusters were divided into 3 groups by patient volume (low, medium and high). We randomised the six clusters to the sequences of crossing over, such that both the first three and the last three sequences included one cluster with low, one with medium, and one with high patient volume. The primary outcome measures were (i) viral load testing among pregnant women who were HIV-positive, and (ii) repeat HIV testing among pregnant women who were HIV-negative. Consenting women ≥18 years attending antenatal and postnatal care during the data collection period completed outcome measures at delivery, and postpartum at three to 6 days, and 6 weeks. Data collection started on 15 July 2015. The total study duration, including pre- and post-exposure phases, was 19 months. Data will be analyzed by intention-to-treat based on first booked clinic of study participants.The results of the MONARCH trial will establish the effectiveness of CQI in improving antenatal and postnatal clinic processes in primary care in sub-Saharan Africa. More generally, the results will contribute to our knowledge on quality improvement interventions in resource-poor settings.This trial was registered on 10 December 2015:, identifier NCT02626351 .

    View details for DOI 10.1186/s12913-018-3404-3

    View details for Web of Science ID 000441357800008

    View details for PubMedID 30089485

    View details for PubMedCentralID PMC6083494

  • Collaboration for impact in global health LANCET GLOBAL HEALTH Byass, P., Cole, C., Davies, J. I., Geldsetzer, P., Witham, M. D., Wu, Y. 2018; 6 (8): E836–E837
  • Depressive Symptoms and their Relation to Age and Chronic diseases among middle-aged and Older Adults in rural South Africa. The journals of gerontology. Series A, Biological sciences and medical sciences Geldsetzer, P., Vaikath, M., Wagner, R., Rohr, J. K., Montana, L., Gomez-Olive, F. X., Rosenberg, M. S., Manne-Goehler, J., Mateen, F. J., Payne, C. F., Kahn, K., Tollman, S. M., Salomon, J. A., Gaziano, T. A., Barnighausen, T., Berkman, L. F. 2018


    Background: Understanding how depression is associated with chronic conditions and socio-demographic characteristics can inform the design and effective targeting of depression screening and care interventions. In this study, we present some of the first evidence from sub-Saharan Africa on the association between depressive symptoms and a range of chronic conditions (diabetes, HIV, hypertension, and obesity) as well as socio-demographic characteristics.Methods: A questionnaire was administered to a population-based simple random sample of 5,059 adults aged 40 years in Agincourt, South Africa. Depressive symptoms were measured using a modified version of the eight-item Center for Epidemiological Studies Depression screening tool. Diabetes was assessed using a capillary blood glucose measurement and HIV using a dried blood spot.Results: 17.0% (95% CI: 15.9% - 18.1%) of participants had at least three depressive symptoms. None of the chronic conditions were significantly associated with depressive symptoms in multivariable regressions. Older age was the strongest correlate of depressive symptoms with those aged 80 years and older having on average 0.63 (95% CI: 0.40 - 0.86; p<0.001) more depressive symptoms than those aged 40-49 years. Household wealth quintile and education were not significant correlates.Conclusions: This study provides some evidence that the positive associations of depression with diabetes, HIV, hypertension, and obesity that are commonly reported in high-income settings might not exist in rural South Africa. Our finding that increasing age is strongly associated with depressive symptoms suggests that there is a particularly high need for depression screening and treatment among the elderly in rural South Africa.

    View details for PubMedID 29939214

  • Sampling for Patient Exit Interviews: Assessment of Methods Using Mathematical Derivation and Computer Simulations HEALTH SERVICES RESEARCH Geldsetzer, P., Fink, G., Vaikath, M., Baernighausen, T. 2018; 53 (1): 256–72


    (1) To evaluate the operational efficiency of various sampling methods for patient exit interviews; (2) to discuss under what circumstances each method yields an unbiased sample; and (3) to propose a new, operationally efficient, and unbiased sampling method.Literature review, mathematical derivation, and Monte Carlo simulations.Our simulations show that in patient exit interviews it is most operationally efficient if the interviewer, after completing an interview, selects the next patient exiting the clinical consultation. We demonstrate mathematically that this method yields a biased sample: patients who spend a longer time with the clinician are overrepresented. This bias can be removed by selecting the next patient who enters, rather than exits, the consultation room. We show that this sampling method is operationally more efficient than alternative methods (systematic and simple random sampling) in most primary health care settings.Under the assumption that the order in which patients enter the consultation room is unrelated to the length of time spent with the clinician and the interviewer, selecting the next patient entering the consultation room tends to be the operationally most efficient unbiased sampling method for patient exit interviews.

    View details for DOI 10.1111/1475-6773.12611

    View details for Web of Science ID 000423416400015

    View details for PubMedID 27882543

    View details for PubMedCentralID PMC5785309

  • The Cost-Benefit of Two Targets for HIV: Findings from a Mathematical Model Prioritising Development: A cost-benefit analysis of the United Nation's Global Goals Geldsetzer, P., Bloom, D. E., Humair, S., Bärnighausen, T. Cambridge University Press. 2018; 1: 277–287
  • What research is needed to address the co-epidemics of HIV and cardiometabolic disease in sub-Saharan Africa? LANCET DIABETES & ENDOCRINOLOGY Geldsetzer, P., Manne-Goehler, J., Baernighausen, T., Davies, J. 2018; 6 (1): 7–9
  • Improving the performance of community health workers in Swaziland: findings from a qualitative study HUMAN RESOURCES FOR HEALTH Geldsetzer, P., De Neve, J., Boudreaux, C., Barnighausen, T., Bossert, T. J. 2017; 15: 68


    The performance of community health workers (CHWs) in Swaziland has not yet been studied despite the existence of a large national CHW program in the country. This qualitative formative research study aimed to inform the design of future interventions intended to increase the performance of CHW programs in Swaziland. Specifically, focusing on four CHW programs, we aimed to determine what potential changes to their program CHWs and CHW program managers perceive as likely leading to improved performance of the CHW cadre.The CHW cadres studied were the rural health motivators, mothers-to-mothers (M2M) mentors, HIV expert clients, and a community outreach team for HIV. We conducted semi-structured, face-to-face qualitative interviews with all (15) CHW program managers and a purposive sample of 54 CHWs. Interview transcripts were analyzed using conventional content analysis to identify categories of changes to the program that participants perceived would result in improved CHW performance.Across the four cadres, participants perceived the following four changes to likely lead to improved CHW performance: (i) increased monetary compensation of CHWs, (ii) a more reliable supply of equipment and consumables, (iii) additional training, and (iv) an expansion of CHW responsibilities to cover a wider array of the community's healthcare needs. The supervision of CHWs and opportunities for career progression were rarely viewed as requiring improvement to increase CHW performance.While this study is unable to provide evidence on whether the suggested changes would indeed lead to improved CHW performance, these views should nonetheless inform program reforms in Swaziland because CHWs and CHW program managers are familiar with the day-to-day operations of the program and the needs of the target population. In addition, program reforms that agree with their views would likely experience a higher degree of buy-in from these frontline health workers.

    View details for DOI 10.1186/s12960-017-0236-x

    View details for Web of Science ID 000411350300002

    View details for PubMedID 28923076

    View details for PubMedCentralID PMC5604406

  • Job satisfaction and turnover intentions among health care staff providing services for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania HUMAN RESOURCES FOR HEALTH Naburi, H., Mujinja, P., Kilewo, C., Orsini, N., Baernighausen, T., Manji, K., Biberfeld, G., Sando, D., Geldsetzer, P., Chalamila, G., Ekstrom, A. 2017; 15: 61


    Option B+ for the prevention of mother-to-child transmission (PMTCT) of HIV (i.e., lifelong antiretroviral treatment for all pregnant and breastfeeding mothers living with HIV) was initiated in Tanzania in 2013. While there is evidence that this policy has benefits for the health of the mother and the child, Option B+ may also increase the workload for health care providers in resource-constrained settings, possibly leading to job dissatisfaction and unwanted workforce turnover.From March to April 2014, a questionnaire asking about job satisfaction and turnover intentions was administered to all nurses at 36 public-sector health facilities offering antenatal and PMTCT services in Dar es Salaam, Tanzania. Multivariable logistic regression models were used to identify factors associated with job dissatisfaction and intention to quit one's job.Slightly over half (54%, 114/213) of the providers were dissatisfied with their current job, and 35% (74/213) intended to leave their job. Most of the providers were dissatisfied with low salaries and high workload, but satisfied with workplace harmony and being able to follow their moral values. The odds of reporting to be globally dissatisfied with one's job were high if the provider was dissatisfied with salary (adjusted odds ratio (aOR) 5.6, 95% CI 1.2-26.8), availability of protective gear (aOR 4.0, 95% CI 1.5-10.6), job description (aOR 4.3, 95% CI 1.2-14.7), and working hours (aOR 3.2, 95% CI 1.3-7.6). Perceiving clients to prefer PMTCT Option B+ reduced job dissatisfaction (aOR 0.2, 95% CI 0.1-0.8). The following factors were associated with providers' intention to leave their current job: job stability dissatisfaction (aOR 3.7, 95% CI 1.3-10.5), not being recognized by one's superior (aOR 3.6, 95% CI 1.7-7.6), and poor feedback on the overall unit performance (aOR 2.7, 95% CI 1.3-5.8).Job dissatisfaction and turnover intentions are comparatively high among nurses in Dar es Salaam's public-sector maternal care facilities. Providing reasonable salaries and working hours, clearer job descriptions, appropriate safety measures, job stability, and improved supervision and feedback will be key to retaining satisfied PMTCT providers and thus to sustain successful implementation of Option B+ in Tanzania.

    View details for DOI 10.1186/s12960-017-0235-y

    View details for Web of Science ID 000410206500001

    View details for PubMedID 28874156

    View details for PubMedCentralID PMC5585985

  • Quasi-experimental study designs series-paper 2: complementary approaches to advancing global health knowledge JOURNAL OF CLINICAL EPIDEMIOLOGY Geldsetzer, P., Fawzi, W. 2017; 89: 12–16


    Quasi-experiments have been infrequently used in the health sciences. Focusing on health systems implementation research, this article details key advantages of quasi-experiments and argues that they can complement (but not replace) randomized evaluations. Specifically, it may be possible to use a quasi-experiment to study the causal effect of an intervention that cannot feasibly be randomized or that would be unethical (e.g., because the intervention has become the standard of care) to test in a randomized controlled trial (RCT). In addition, because they usually take advantage of routinely collected data, quasi-experiments may be feasible when it is too costly (either financially or in terms of the required time) to carry out a RCT - an important advantage in research on health systems, which vary widely between settings. Nonetheless, we argue that RCTs will continue to be indispensable for implementation research because i) the assumptions needed to establish causality with a quasi-experiment are often unverifiable, ii) available data frequently do not allow for a rigorous quasi-experiment, and iii) randomized designs tend to lend themselves more to informing policy makers of causal effects prior to (or during) the full-scale rollout of an intervention than quasi-experiments.

    View details for DOI 10.1016/j.jclinepi.2017.03.015

    View details for Web of Science ID 000414887500003

    View details for PubMedID 28365307

  • Quasi-experimental study designs series-paper 4: uses and value JOURNAL OF CLINICAL EPIDEMIOLOGY Baernighausen, T., Tugwell, P., Rottingen, J., Shemilt, I., Rockers, P., Geldsetzer, P., Lavis, J., Grimshaw, J., Daniels, K., Brown, A., Bor, J., Tanner, J., Rashidian, A., Barreto, M., Vollmer, S., Atun, R. 2017; 89: 21–29


    Quasi-experimental studies are increasingly used to establish causal relationships in epidemiology and health systems research. Quasi-experimental studies offer important opportunities to increase and improve evidence on causal effects: (1) they can generate causal evidence when randomized controlled trials are impossible; (2) they typically generate causal evidence with a high degree of external validity; (3) they avoid the threats to internal validity that arise when participants in nonblinded experiments change their behavior in response to the experimental assignment to either intervention or control arm (such as compensatory rivalry or resentful demoralization); (4) they are often well suited to generate causal evidence on long-term health outcomes of an intervention, as well as nonhealth outcomes such as economic and social consequences; and (5) they can often generate evidence faster and at lower cost than experiments and other intervention studies.

    View details for DOI 10.1016/j.jclinepi.2017.03.012

    View details for Web of Science ID 000414887500005

    View details for PubMedID 28365303

  • The ART Advantage: Health Care Utilization for Diabetes and Hypertension in Rural South Africa JAIDS-JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES Manne-Goehler, J., Montana, L., Gomez-Olive, F., Rohr, J., Harling, G., Wagner, R. G., Wade, A., Kabudula, C. W., Geldsetzer, P., Kahn, K., Tollman, S., Berkman, L. F., Baernighausen, T. W., Gaziano, T. A. 2017; 75 (5): 561–67


    The prevalence of diabetes and hypertension has increased in HIV-positive populations, but there is limited understanding of the role that antiretroviral therapy (ART) programs play in the delivery of services for these conditions. The aim of this study is to assess the relationship between ART use and utilization of health care services for diabetes and hypertension.Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa is a cohort of 5059 adults. The baseline study collects biomarker-based data on HIV, ART, diabetes, and hypertension and self-reported data on health care utilization. We calculated differences in care utilization for diabetes and hypertension by HIV and ART status and used multivariable logistic regressions to estimate the relationship between ART use and utilization of services for these conditions, controlling for age, sex, body mass index, education, and household wealth quintile.Mean age, body mass index, hypertension, and diabetes prevalence were lower in the HIV-positive population (all P < 0.001). Multivariable logistic regression showed that ART use was significantly associated with greater odds of blood pressure measurement [adjusted odds ratio (aOR) 1.27, 95% confidence interval (CI): 1.04 to 1.55] and blood sugar measurement (aOR 1.26, 95% CI: 1.05 to 1.51), counseling regarding exercise (aOR 1.57, 95% CI: 1.11 to 2.22), awareness of hypertension diagnosis (aOR 1.52, 95% CI: 1.12 to 2.05), and treatment for hypertension (aOR 1.63, 95% CI: 1.21 to 2.19).HIV-positive patients who use ART are more likely to have received health care services for diabetes and hypertension. This apparent ART advantage suggests that ART programs may be a vehicle for strengthening health systems for chronic care.

    View details for DOI 10.1097/QAI.0000000000001445

    View details for Web of Science ID 000405556900010

    View details for PubMedID 28696346

    View details for PubMedCentralID PMC5516957

  • Harmonization of community health worker programs for HIV: A four-country qualitative study in Southern Africa PLOS MEDICINE De Neve, J., Garrison-Desany, H., Andrews, K. G., Sharara, N., Boudreaux, C., Gill, R., Geldsetzer, P., Vaikath, M., Baernighausen, T., Bossert, T. J. 2017; 14 (8): e1002374


    Community health worker (CHW) programs are believed to be poorly coordinated, poorly integrated into national health systems, and lacking long-term support. Duplication of services, fragmentation, and resource limitations may have impeded the potential impact of CHWs for achieving HIV goals. This study assesses mediators of a more harmonized approach to implementing large-scale CHW programs for HIV in the context of complex health systems and multiple donors.We undertook four country case studies in Lesotho, Mozambique, South Africa, and Swaziland between August 2015 and May 2016. We conducted 60 semistructured interviews with donors, government officials, and expert observers involved in CHW programs delivering HIV services. Interviews were triangulated with published literature, country reports, national health plans, and policies. Data were analyzed based on 3 priority areas of harmonization (coordination, integration, and sustainability) and 5 components of a conceptual framework (the health issue, intervention, stakeholders, health system, and context) to assess facilitators and barriers to harmonization of CHW programs. CHWs supporting HIV programs were found to be highly fragmented and poorly integrated into national health systems. Stakeholders generally supported increasing harmonization, although they recognized several challenges and disadvantages to harmonization. Key facilitators to harmonization included (i) a large existing national CHW program and recognition of nongovernmental CHW programs, (ii) use of common incentives and training processes for CHWs, (iii) existence of an organizational structure dedicated to community health initiatives, and (iv) involvement of community leaders in decision-making. Key barriers included a wide range of stakeholders and lack of ownership and accountability of non-governmental CHW programs. Limitations of our study include subjectively selected case studies, our focus on decision-makers, and limited generalizability beyond the countries analyzed.CHW programs for HIV in Southern Africa are fragmented, poorly integrated, and lack long-term support. We provide 5 policy recommendations to harmonize CHW programs in order to strengthen and sustain the role of CHWs in HIV service delivery.

    View details for DOI 10.1371/journal.pmed.1002374

    View details for Web of Science ID 000408766300011

    View details for PubMedID 28792502

    View details for PubMedCentralID PMC5549708

  • Household coverage of Swaziland's national community health worker programme: a cross-sectional population-based study TROPICAL MEDICINE & INTERNATIONAL HEALTH Geldsetzer, P., Vaikath, M., De Neve, J., Bossert, T. J., Sibandze, S., Baernighausen, T. 2017; 22 (8): 1012–20


    To ascertain household coverage achieved by Swaziland's national community health worker (CHW) programme and differences in household coverage across clients' sociodemographic characteristics.Household survey from June to September 2015 in two of Swaziland's four administrative regions using two-stage cluster random sampling. Interviewers administered a questionnaire to all household members in 1542 households across 85 census enumeration areas.While the CHW programme aims to cover all households in the country, only 44.5% (95% confidence interval: 38.0% to 51.1%) reported that they had ever been visited by a CHW. In both uni- and multivariable regressions, coverage was negatively associated with household wealth (OR for most vs. least wealthy quartile: 0.30 [0.16 to 0.58], P < 0.001) and education (OR for >secondary schooling vs. no schooling: 0.65 [0.47 to 0.90], P = 0.009), and positively associated with residing in a rural area (OR: 2.95 [1.77 to 4.91], P < 0.001). Coverage varied widely between census enumeration areas.Swaziland's national CHW programme is falling far short of its coverage goal. To improve coverage, the programme would likely need to recruit additional CHWs and/or assign more households to each CHW. Alternatively, changing the programme's ambitious coverage goal to visiting only certain types of households would likely reduce existing arbitrary differences in coverage between households and communities. This study highlights the need to evaluate and reform large long-standing CHW programmes in sub-Saharan Africa.

    View details for DOI 10.1111/tmi.12904

    View details for Web of Science ID 000406775200008

    View details for PubMedID 28556502

  • Performance of self-reported HIV status in determining true HIV status among older adults in rural South Africa: a validation study JOURNAL OF THE INTERNATIONAL AIDS SOCIETY Rohr, J. K., Gomez-Olive, F., Rosenberg, M., Manne-Goehler, J., Geldsetzer, P., Wagner, R. G., Houle, B., Salomon, J. A., Kahn, K., Tollman, S., Berkman, L., Baernighausen, T. 2017; 20: 21691


    In South Africa, older adults make up a growing proportion of people living with HIV. HIV programmes are likely to reach older South Africans in home-based interventions where testing is not always feasible. We evaluate the accuracy of self-reported HIV status, which may provide useful information for targeting interventions or offer an alternative to biomarker testing.Data were taken from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) baseline survey, which was conducted in rural Mpumalanga province, South Africa. A total of 5059 participants aged ≥40 years were interviewed from 2014 to 2015. Self-reported HIV status and dried bloodspots for HIV biomarker testing were obtained during at-home interviews. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for self-reported status compared to "gold standard" biomarker results. Log-binomial regression explored associations between demographic characteristics, antiretroviral therapy (ART) status and sensitivity of self-report.Most participants (93%) consented to biomarker testing. Of those with biomarker results, 50.9% reported knowing their HIV status and accurately reported it. PPV of self-report was 94.1% (95% confidence interval (CI): 92.0-96.0), NPV was 87.2% (95% CI: 86.2-88.2), sensitivity was 51.2% (95% CI: 48.2-54.3) and specificity was 99.0% (95% CI: 98.7-99.4). Participants on ART were more likely to report their HIV-positive status, and participants reporting false-negatives were more likely to have older HIV tests.The majority of participants were willing to share their HIV status. False-negative reports were largely explained by lack of testing, suggesting HIV stigma is retreating in this setting, and that expansion of HIV testing and retesting is still needed in this population. In HIV interventions where testing is not possible, self-reported status should be considered as a routine first step to establish HIV status.

    View details for PubMedID 28782333

  • Harmonizing community-based health worker programs for HIV: a narrative review and analytic framework HUMAN RESOURCES FOR HEALTH De Neve, J., Boudreaux, C., Gill, R., Geldsetzer, P., Vaikath, M., Barnighausen, T., Bossert, T. J. 2017; 15: 45


    Many countries have created community-based health worker (CHW) programs for HIV. In most of these countries, several national and non-governmental initiatives have been implemented raising questions of how well these different approaches address the health problems and use health resources in a compatible way. While these questions have led to a general policy initiative to promote harmonization across programs, there is a need for countries to develop a more coherent and organized approach to CHW programs and to generate evidence about the most efficient and effective strategies to ensure their optimal, sustained performance.We conducted a narrative review of the existing published and gray literature on the harmonization of CHW programs. We searched for and noted evidence on definitions, models, and/or frameworks of harmonization; theoretical arguments or hypotheses about the effects of CHW program fragmentation; and empirical evidence. Based on this evidence, we defined harmonization, introduced three priority areas for harmonization, and identified a conceptual framework for analyzing harmonization of CHW programs that can be used to support their expanding role in HIV service delivery. We identified and described the major issues and relationships surrounding the harmonization of CHW programs, including key characteristics, facilitators, and barriers for each of the priority areas of harmonization, and used our analytic framework to map overarching findings. We apply this approach of CHW programs supporting HIV services across four countries in Southern Africa in a separate article.There is a large number and immense diversity of CHW programs for HIV. This includes integration of HIV components into countries' existing national programs along with the development of multiple, stand-alone CHW programs. We defined (i) coordination among stakeholders, (ii) integration into the broader health system, and (iii) assurance of a CHW program's sustainability to be priority areas of harmonization. While harmonization is likely a complex political process, with in many cases incremental steps toward improvement, a wide range of facilitators are available to decision-makers. These can be categorized using an analytic framework assessing the (i) health issue, (ii) intervention itself, (iii) stakeholders, (iv) health system, and (v) broad context.There is a need to address fragmentation of CHW programs to advance and sustain CHW roles and responsibilities for HIV. This study provides a narrative review and analytic framework to understand the process by which harmonization of CHW programs might be achieved and to test the assumption that harmonization is needed to improve CHW performance.

    View details for DOI 10.1186/s12960-017-0219-y

    View details for Web of Science ID 000405672900001

    View details for PubMedID 28673361

    View details for PubMedCentralID PMC5496353

  • Distrusting community health workers with confidential health information: a convergent mixed-methods study in Swaziland HEALTH POLICY AND PLANNING Geldsetzer, P., Vaikath, M., De Neve, J., Bossert, T. J., Sibandze, S., Mkhwanazi, M., Baernighausen, T. 2017; 32 (6): 882–89


    Patients are unlikely to share the personal information that is critical for effective healthcare, if they do not trust that this information will remain confidential. Trust in confidentiality may be particularly low in interactions with community health workers (CHW) because CHW deliver healthcare outside the clinic setting. This study aims to determine the proportion of Swaziland's population that does not trust the national CHW cadre with confidential medical information, and to identify reasons for distrust.Using two-stage cluster random sampling, we carried out a household survey covering 2000 households across 100 census enumeration areas in two of Swaziland's four regions. To confirm and explain the quantitative survey results, we used qualitative data from 19 semi-structured focus group discussions in the same population.49% of household survey participants stated that they distrust the national CHW cadre with confidential health information. Having ever been visited by a CHW was positively associated with trust (aOR: 2.11; P  < 0.001), while higher levels of schooling of the respondent were negatively associated (aOR for more than secondary schooling versus no schooling: 0.21; P  < 0.001). The following three primary reasons for distrusting CHW with confidential health information emerged in the qualitative analyses: (1) CHW are members of the same community as their clients and may thus share information with people who know the client, (2) CHW are mostly women and several focus group participants assumed that women are more likely than men to share information with other community members, and (3) CHW are not sufficiently trained in confidentiality issues.Our findings suggest that confidentiality concerns could be a significant obstacle to the successful rollout of CHW services for stigmatized conditions in Swaziland. Increasing coverage of the CHW program, raising the population's confidence in CHWs' training, assigning CHW to work in communities other than the ones in which they live, changing the CHW gender composition, and addressing gender biases may all increase trust with regards to confidentiality.

    View details for DOI 10.1093/heapol/czx036

    View details for Web of Science ID 000407607900013

    View details for PubMedID 28407083

  • The impact of community health worker-led home delivery of antiretroviral therapy on virological suppression: a non-inferiority cluster-randomized health systems trial in Dar es Salaam, Tanzania BMC HEALTH SERVICES RESEARCH Geldsetzer, P., Francis, J. M., Ulenga, N., Sando, D., Lema, I. A., Mboggo, E., Vaikath, M., Koda, H., Lwezaula, S., Hu, J., Noor, R. A., Olofin, I., Larson, E., Fawzi, W., Barnighausen, T. 2017; 17: 160


    Home delivery of antiretroviral therapy (ART) by community health workers (CHWs) may improve ART retention by reducing the time burden and out-of-pocket expenditures to regularly attend an ART clinic. In addition, ART home delivery may shorten waiting times and improve quality of care for those in facility-based care by decongesting ART clinics. This trial aims to determine whether ART home delivery for patients who are clinically stable on ART combined with facility-based care for those who are not stable on ART is non-inferior to the standard of care (facility-based care for all ART patients) in achieving and maintaining virological suppression.This is a non-inferiority cluster-randomized trial set in Dar es Salaam, Tanzania. A cluster is one of 48 healthcare facilities with its surrounding catchment area. 24 clusters were randomized to ART home delivery and 24 to the standard of care. The intervention consists of home visits by CHWs to provide counseling and deliver ART to patients who are stable on ART, while the control is the standard of care (facility-based ART and CHW home visits without ART home delivery). In addition, half of the healthcare facilities in each study arm were randomized to standard counseling during home visits (covering family planning, prevention of HIV transmission, and ART adherence), and half to standard plus nutrition counseling (covering food production and dietary advice). The non-inferiority design applies to the endpoints of the ART home delivery trial; the primary endpoint is the proportion of ART patients at a healthcare facility who are virally suppressed at the end of the study period. The margin of non-inferiority for this primary endpoint was set at nine percentage points.As the number of ART patients in sub-Saharan Africa is expected to rise, this trial provides causal evidence on the effectiveness of a home-based care model that could decongest ART clinics and reduce patients' healthcare expenditures. More broadly, this trial will inform the increasing policy interest in task-shifting of chronic disease care from facility- to community-based healthcare NCT02711293 . Registration date: 16 March 2016.

    View details for DOI 10.1186/s12913-017-2032-7

    View details for Web of Science ID 000394599500001

    View details for PubMedID 28228134

    View details for PubMedCentralID PMC5322683

  • Late-stage research for diabetes and related NCDs receives little funding: evidence from the NIH RePORTER tool LANCET DIABETES & ENDOCRINOLOGY Geldsetzer, P., Baernighausen, T. 2017; 5 (2): 91–92

    View details for DOI 10.1016/S2213-8587(16)30421-1

    View details for Web of Science ID 000396338100010

    View details for PubMedID 27993513

    View details for PubMedCentralID PMC5902680

  • The causal impact of ART on NCDs: leveraging quasi-experiments LANCET DIABETES & ENDOCRINOLOGY Manne-Goehler, J., Geldsetzer, P., Baernighausen, T. 2017; 5 (1): 14
  • A qualitative and quantitative performance evaluation of Swaziland’s Rural Health Motivator program F1000Research Geldsetzer, P., Vaikath, M., De Neve, J., Bärnighausen, T., Bossert, T. J. 2017; 6 (607)
  • Population-Level Decline in BMI and Systolic Blood Pressure Following Mass HIV Treatment: Evidence from Rural KwaZulu-Natal OBESITY Geldsetzer, P., Feigl, A. B., Tanser, F., Gareta, D., Pillay, D., Barnighausen, T. 2017; 25 (1): 200–206


    Clinic-based studies have shown that patients with human immunodeficiency virus (HIV) gain weight after initiation of antiretroviral therapy (ART). This study aimed to determine whether the scale-up of ART was associated with a population-level increase in body mass index (BMI) and blood pressure (BP) in a community with high HIV and obesity prevalence.A household survey was conducted in rural KwaZulu-Natal before ART scale-up (in 2004) and when ART coverage had reached 25% (in 2010). Anthropometric data was linked with HIV surveillance data.Mean BMI decreased in women from 29.9 to 29.1 kg/m2 (P = 0.002) and in men from 24.2 to 23.0 kg/m2 (P < 0.001). Similarly, overweight and obesity prevalence declined significantly in both sexes. Mean systolic BP decreased from 123.0 to 118.2 mm Hg (P < 0.001) among women and 128.4 to 123.2 mm Hg (P < 0·001) among men.Large-scale ART provision is likely to have caused a decline in BMI at the population level, because ART has improved the survival of those with substantial HIV-related weight loss. The ART scale-up may have created an unexpected opportunity to sustain population-level weight loss in communities with high HIV and obesity prevalence though targeted lifestyle and nutrition interventions.

    View details for DOI 10.1002/oby.21663

    View details for Web of Science ID 000391215200025

    View details for PubMedID 27925407

    View details for PubMedCentralID PMC5940485

  • Diabetes diagnosis and care in sub-Saharan Africa: pooled analysis of individual data from 12 countries. The lancet. Diabetes & endocrinology Manne-Goehler, J., Atun, R., Stokes, A., Goehler, A., Houinato, D., Houehanou, C., Hambou, M. M., Mbenza, B. L., Sobngwi, E., Balde, N., Mwangi, J. K., Gathecha, G., Ngugi, P. W., Wesseh, C. S., Damasceno, A., Lunet, N., Bovet, P., Labadarios, D., Zuma, K., Mayige, M., Kagaruki, G., Ramaiya, K., Agoudavi, K., Guwatudde, D., Bahendeka, S. K., Mutungi, G., Geldsetzer, P., Levitt, N. S., Salomon, J. A., Yudkin, J. S., Vollmer, S., Bärnighausen, T. 2016; 4 (11): 903-912


    Despite widespread recognition that the burden of diabetes is rapidly growing in many countries in sub-Saharan Africa, nationally representative estimates of unmet need for diabetes diagnosis and care are in short supply for the region. We use national population-based survey data to quantify diabetes prevalence and met and unmet need for diabetes diagnosis and care in 12 countries in sub-Saharan Africa. We further estimate demographic and economic gradients of met need for diabetes diagnosis and care.We did a pooled analysis of individual-level data from nationally representative population-based surveys that met the following inclusion criteria: the data were collected during 2005-15; the data were made available at the individual level; a biomarker for diabetes was available in the dataset; and the dataset included information on use of core health services for diabetes diagnosis and care. We first quantified the population in need of diabetes diagnosis and care by estimating the prevalence of diabetes across the surveys; we also quantified the prevalence of overweight and obesity, as a major risk factor for diabetes and an indicator of need for diabetes screening. Second, we determined the level of met need for diabetes diagnosis, preventive counselling, and treatment in both the diabetic and the overweight and obese population. Finally, we did survey fixed-effects regressions to establish the demographic and economic gradients of met need for diabetes diagnosis, counselling, and treatment.We pooled data from 12 nationally representative population-based surveys in sub-Saharan Africa, representing 38 311 individuals with a biomarker measurement for diabetes. Across the surveys, the median prevalence of diabetes was 5% (range 2-14) and the median prevalence of overweight or obesity was 27% (range 16-68). We estimated seven measures of met need for diabetes-related care across the 12 surveys: (1) percentage of the overweight or obese population who received a blood glucose measurement (median 22% [IQR 11-37]); and percentage of the diabetic population who reported that they (2) had ever received a blood glucose measurement (median 36% [IQR 27-63]); (3) had ever been told that they had diabetes (median 27% [IQR 22-51]); (4) had ever been counselled to lose weight (median 15% [IQR 13-23]); (5) had ever been counselled to exercise (median 15% [IQR 11-30]); (6) were using oral diabetes drugs (median 25% [IQR 18-42]); and (7) were using insulin (median 11% [IQR 6-13]). Compared with those aged 15-39 years, the adjusted odds of met need for diabetes diagnosis (measures 1-3) were 2·22 to 3·53 (40-54 years) and 3·82 to 5·01 (≥55 years) times higher. The adjusted odds of met need for diabetes diagnosis also increased consistently with educational attainment and were between 3·07 and 4·56 higher for the group with 8 years or more of education than for the group with less than 1 year of education. Finally, need for diabetes care was significantly more likely to be met (measures 4-7) in the oldest age and highest educational groups.Diabetes has already reached high levels of prevalence in several countries in sub-Saharan Africa. Large proportions of need for diabetes diagnosis and care in the region remain unmet, but the patterns of unmet need vary widely across the countries in our sample. Novel health policies and programmes are urgently needed to increase awareness of diabetes and to expand coverage of preventive counselling, diagnosis, and linkage to diabetes care. Because the probability of met need for diabetes diagnosis and care consistently increases with age and educational attainment, policy makers should pay particular attention to improved access to diabetes services for young adults and people with low educational attainment.None.

    View details for DOI 10.1016/S2213-8587(16)30181-4

    View details for PubMedID 27727123

  • Predictors of Patient Dissatisfaction with Services for Prevention of Mother-To-Child Transmission of HIV in Dar es Salaam, Tanzania PLOS ONE Naburi, H., Mujinja, P., Kilewo, C., Barnighausen, T., Orsini, N., Manji, K., Biberfeld, G., Sando, D., Geldsetzer, P., Chalamila, G., Ekstrom, A. 2016; 11 (10): e0165121


    Mother-to-child transmission (MTCT) of HIV remains a major source of new HIV infections in children. Prevention of mother-to-child transmission of HIV (PMTCT) using lifelong antiretroviral treatment (ART) for all pregnant and breastfeeding women living with HIV (Option B+) is the major strategy for eliminating paediatric HIV. Ensuring that patients are satisfied with PMTCT services is important for optimizing uptake, adherence and retention in treatment.We conducted a facility based quantitative cross-sectional survey in Dar-es-Salaam, Tanzania, between March and April 2014, when the country was transitioning to the implementation of PMTCT Option B+. We interviewed 595 pregnant and breastfeeding women living with HIV, who received PMTCT care in 36 public health facilities. Predictors of overall dissatisfaction with PMTCT services were identified using a multiple logistic regression.Overall 8% of the patients expressed dissatisfaction with PMTCT services. Patients who perceived health care workers (HCW) communication skills as poor, had a 5-fold (OR 4.9, 95% CI 1.8-13.4) increased risk of dissatisfaction and those who perceived HCW capacity to understand client concerns as poor, had a 6-fold (OR 5.7, 95% CI 2.3-14.0) increased risk. Having a total visit time longer than two hours was associated with a 2-fold increased risk of being dissatisfied (OR 2.3, 95% CI 1.1-4.7). Every 30-minute increment in total visit time was associated with a 10% higher (OR 1.1, 95% CI 1.0-1.2) risk of being dissatisfied. The probability of being dissatisfied ranged from 4% (95% CI 2% - 6%) in the presence of patient-perceived good communication, good understanding of patient concerns, and a total visit time below two hours, to 70% (95% CI 47% - 86%) if HCW failed in all of these aspects.Patient dissatisfaction with PMTCT services was generally low; reflecting that quality of care was maintained during Tanzania's transition to Option B+ strategy aiming to increase the number of women initiating life-long ART in PMTCT clinics. Improved HCW communication with clients, their understanding of patient concerns and a reduction of the total visit time would further optimize women's overall satisfaction with PMTCT services in Tanzania.

    View details for DOI 10.1371/journal.pone.0165121

    View details for Web of Science ID 000386205400052

    View details for PubMedID 27768731

    View details for PubMedCentralID PMC5074583

  • Do countries rely on the World Health Organization for translating research findings into clinical guidelines? A case study GLOBALIZATION AND HEALTH Noor, R. A., Geldsetzer, P., Barnighausen, T., Fawzi, W. 2016; 12: 58


    The World Health Organization's (WHO) antiretroviral therapy (ART) guidelines have generally been adopted rapidly and with high fidelity by countries in sub-Saharan Africa. Thus far, however, WHO has not published specific guidance on nutritional care and support for (non-pregnant) adults living with HIV despite a solid evidence base for some interventions. This offers an opportunity for a case study on whether national clinical guidelines in sub-Saharan Africa provide concrete recommendations in the face of limited guidance by WHO. This study, therefore, aims to determine if national HIV treatment guidelines in sub-Saharan Africa contain specific guidance on nutritional care and support for non-pregnant adults living with HIV.We identified the most recent national HIV treatment guidelines in sub-Saharan African countries with English as an official language. Using pre-specified criteria, we determined for each guideline whether it provides guidance to clinicians on each of five components of nutritional care and support for adults living with HIV: assessment of nutritional status, dietary counseling, micronutrient supplementation, ready-to-use therapeutic or supplementary foods, and food subsidies.We found that national HIV treatment guidelines in sub-Saharan Africa generally do not contain concrete recommendations on nutritional care and support for non-pregnant adults living with HIV.Given that decisions on nutritional care and support are inevitably being made at the clinician-patient level, and that clinicians have a relative disadvantage in systematically identifying, summarizing, and weighing up research evidence compared to WHO and national governments, there is a need for more specific clinical guidance. In our view, such guidance should at a minimum recommend daily micronutrient supplements for adults living with HIV who are in pre-ART stages, regular dietary counseling, periodic assessment of anthropometric status, and additional nutritional management of undernourished patients. More broadly, our findings suggest that countries in sub-Saharan Africa look to WHO for guidance in translating evidence into clinical guidelines. It is, thus, likely that the development of concrete recommendations by WHO on nutritional interventions for people living with HIV would lead to more specific guidelines at the country-level and, ultimately, better clinical decisions and treatment outcomes.

    View details for DOI 10.1186/s12992-016-0196-2

    View details for Web of Science ID 000384695600001

    View details for PubMedID 27716252

    View details for PubMedCentralID PMC5053105

  • Patient Satisfaction with Services for Prevention of Mother-to-Child Transmission of HIV in Dar es Salaam, Tanzania Naburi, H., Mujinja, P., Barnighausen, T., Kilewo, C., Manji, K., Sando, D., Geldsetzer, P., Biberfeld, G., Ekstrom, A. MARY ANN LIEBERT, INC. 2016: 154
  • The Influence of Drinking Motives on Hookah use Frequency Among Young Multi-Substance Users INTERNATIONAL JOURNAL OF MENTAL HEALTH AND ADDICTION Foster, D. W., Greene, M. R., Allan, N. P., Geldsetzer, P. 2016; 14 (5): 791–802


    The present work examined the influence of drinking motives on hookah use frequency among individuals reporting both alcohol and hookah use (multi-substance users). Despite growing documentation of cross-substance effects between motives and substance use, limited research has examined these relationships specifically with respect to hookah use.Participants were 134 (75.37% female) hookah and alcohol users, aged 18-47 years (M = 22.17, SD = 3.66) who completed measures of substance use, drinking motives, and reported demographic information. Structural equation modeling (SEM) was employed to investigate the predictive value of drinking motives on hookah use frequency, age taken into account.Findings showed that hookah use was negatively associated with age (β = -.22, p ≤ .01). The model regressing hookah use on the four drinking motives provided adequate fit (χ2 = 314.31, df = 180, p < .05, CFI = .92, RMSEA = .075 [95% CI, .06-.09]). Hookah use was associated negatively with social motives (β = -.43, p < .001) and positively with conformity motives (β = .24, p ≤ .05).These findings are consistent with multi-substance use literature suggesting that drinking motives are associated with the use of other substances, including increased hookah use frequency. Additional examinations of cross-substance cognitive processes are needed, particularly with respect to understanding whether hookah use among multi-substance users may be contingent in part on individual factors including negative affectivity.

    View details for DOI 10.1007/s11469-016-9633-y

    View details for Web of Science ID 000383595800014

    View details for PubMedID 27713680

    View details for PubMedCentralID PMC5047663

  • The efficiency of chronic disease care in sub-Saharan Africa BMC MEDICINE Geldsetzer, P., Ortblad, K., Baernighausen, T. 2016; 14: 127


    The number of people needing chronic disease care is projected to increase in sub-Saharan Africa as a result of expanding human immunodeficiency virus (HIV) treatment coverage, rising life expectancies, and lifestyle changes. Using nationally representative data of healthcare facilities, Di Giorgio et al. found that many HIV clinics in Kenya, Uganda, and Zambia appear to have considerable untapped capacity to provide care for additional patients. These findings highlight the potential for increasing the efficiency of clinical processes for chronic disease care at the facility level. Important questions for future research are how estimates of comparative technical efficiency across facilities change, when they are adjusted for quality of care and the composition of patients by care complexity. Looking ahead, substantial research investment will be needed to ensure that we do not forgo the opportunity to learn how efficiency changes, as chronic care is becoming increasingly differentiated by patient type and integrated across diseases and health systems functions.Please see related article:

    View details for DOI 10.1186/s12916-016-0675-6

    View details for Web of Science ID 000382735100001

    View details for PubMedID 27566531

    View details for PubMedCentralID PMC5002156

  • Interventions to improve the rate or timing of initiation of antiretroviral therapy for HIV in sub-Saharan Africa: meta-analyses of effectiveness JOURNAL OF THE INTERNATIONAL AIDS SOCIETY Fox, M. P., Rosen, S., Geldsetzer, P., Baernighausen, T., Negussie, E., Beanland, R. 2016; 19: 20888


    As global policy evolves toward initiating lifelong antiretroviral therapy (ART) regardless of CD4 count, initiating individuals newly diagnosed with HIV on ART as efficiently as possible will become increasingly important. To inform progress, we conducted a systematic review of pre-ART interventions aiming to increase ART initiation in sub-Saharan Africa.We searched PubMed, Embase and the ISI Web of Knowledge from 1 January 2008 to 1 March 2015, extended in PubMed to 25 May 2016, for English language publications pertaining to any country in sub-Saharan Africa and reporting on general adult populations. We included studies describing interventions aimed at increasing linkage to HIV care, retention in pre-ART or uptake of ART, which reported ART initiation as an outcome. We synthesized the evidence on causal intervention effects in meta-analysis of studies belonging to distinct intervention categories.We identified 22 studies, which evaluated 25 interventions and included data on 45,393 individual patients. Twelve of twenty-two studies were observational. Rapid/point-of-care (POC) CD4 count technology (seven interventions) (relative risk, RR: 1.26; 95% confidence interval, CI: 1.02-1.55), interventions within home-based testing (two interventions) (RR: 2.00; 95% CI: 1.36-2.92), improved clinic operations (three interventions) (RR: 1.36; 95% CI: 1.25-1.48) and a package of patient-directed services (three interventions) (RR: 1.54; 95% CI: 1.20-1.97) were all associated with increased ART initiation as was HIV/TB service integration (three interventions) (RR: 2.05; 95% CI: 0.59-7.09) but with high imprecision. Provider-initiated testing (three interventions) was associated with reduced ART initiation (RR: 0.91; 95% CI: 0.86-0.97). Counselling and support interventions (two interventions) (RR 1.08; 95% CI: 0.94-1.26) had no impact on ART initiation. Overall, the evidence was graded as low or moderate quality using the GRADE criteria.The literature on interventions to increase uptake of ART is limited and of mixed quality. POC CD4 count and improving clinic operations show promise. More implementation research and evaluation is needed to identify how best to offer treatment initiation in a manner that is both efficient for service providers and effective for patients without jeopardizing treatment outcomes.

    View details for DOI 10.7448/IAS.19.1.20888

    View details for Web of Science ID 000381911000001

    View details for PubMedID 27507249

    View details for PubMedCentralID PMC4978859

  • A systematic review of interventions to improve postpartum retention of women in PMTCT and ART care JOURNAL OF THE INTERNATIONAL AIDS SOCIETY Geldsetzer, P., Yapa, H. N., Vaikath, M., Ogbuoji, O., Fox, M. P., Essajee, S. M., Negussie, E. K., Barnighausen, T. 2016; 19: 20679


    The World Health Organization recommends lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women living with HIV. Effective transitioning from maternal and child health to ART services, and long-term retention in ART care postpartum is crucial to the successful implementation of lifelong ART for pregnant women. This systematic review aims to determine which interventions improve (1) retention within prevention of mother-to-child HIV transmission (PMTCT) programmes after birth, (2) transitioning from PMTCT to general ART programmes in the postpartum period, and (3) retention of postpartum women in general ART programmes.We searched Medline, Embase, ISI Web of Knowledge, the regional World Health Organization databases and conference abstracts for data published between 2002 and 2015. The quality of all included studies was assessed using the GRADE criteria.After screening 8324 records, we identified ten studies for inclusion in this review, all of which were from sub-Saharan Africa except for one from the United Kingdom. Two randomized trials found that phone calls and/or text messages improved early (six to ten weeks) postpartum retention in PMTCT. One cluster-randomized trial and three cohort studies found an inconsistent impact of different levels of integration between antenatal care/PMTCT and ART care on postpartum retention. The inconsistent results of the four identified studies on care integration are likely due to low study quality, and heterogeneity in intervention design and outcome measures. Several randomized trials on postpartum retention in HIV care are currently under way.Overall, the evidence base for interventions to improve postpartum retention in HIV care is weak. Nevertheless, there is some evidence that phone-based interventions can improve retention in PMTCT in the first one to three months postpartum.

    View details for DOI 10.7448/IAS.19.1.20679

    View details for Web of Science ID 000376175200001

    View details for PubMedID 27118443

    View details for PubMedCentralID PMC4846797

  • Innovations in health and demographic surveillance systems to establish the causal impacts of HIV policies CURRENT OPINION IN HIV AND AIDS Herbst, K., Law, M., Geldsetzer, P., Tanser, F., Harling, G., Baernighausen, T. 2015; 10 (6): 483–94


    Health and demographic surveillance systems (HDSS), in conjunction with HIV treatment cohorts, have made important contributions to our understanding of the impact of HIV treatment and treatment-related interventions in sub-Saharan Africa. The purpose of this review is to describe and discuss innovations in data collection and data linkage that will create new opportunities to establish the impacts of HIV treatment, as well as policies affecting the treatment cascade, on population health and economic and social outcomes.Novel approaches to routine collection of biomarkers, behavioural data, spatial data, social network information, migration events and mobile phone records can significantly strengthen the potential of HDSS to generate exposure and outcome data for causal analysis of HIV treatment impact and policies affecting the HIV treatment cascade. Additionally, by linking HDSS data to health service administration, education and welfare service records, researchers can substantially broaden opportunities to establish how HIV treatment affects health and economic outcomes when delivered through public sector health systems and at scale.As the HIV treatment scaleup in sub-Saharan Africa enters its second decade, it is becoming increasingly important to understand the long-term causal impacts of large-scale HIV treatment and related policies on broader population health outcomes, such as noncommunicable diseases, as well as on economic and social outcomes, such as family welfare and children's educational attainment. By collecting novel data and linking existing data to public sector records, HDSS can create near-unique opportunities to contribute to this research agenda.

    View details for DOI 10.1097/COH.0000000000000203

    View details for Web of Science ID 000369718800013

    View details for PubMedID 26371462

    View details for PubMedCentralID PMC4982533

  • Quasi-experiments to establish causal effects of HIV care and treatment and to improve the cascade of care CURRENT OPINION IN HIV AND AIDS Bor, J., Geldsetzer, P., Venkataramani, A., Baernighausen, T. 2015; 10 (6): 495–501


    Randomized, population-representative trials of clinical interventions are rare. Quasi-experiments have been used successfully to generate causal evidence on the cascade of HIV care in a broad range of real-world settings.Quasi-experiments exploit exogenous, or quasi-random, variation occurring naturally in the world or because of an administrative rule or policy change to estimate causal effects. Well designed quasi-experiments have greater internal validity than typical observational research designs. At the same time, quasi-experiments may also have potential for greater external validity than experiments and can be implemented when randomized clinical trials are infeasible or unethical. Quasi-experimental studies have established the causal effects of HIV testing and initiation of antiretroviral therapy on health, economic outcomes and sexual behaviors, as well as indirect effects on other community members. Recent quasi-experiments have evaluated specific interventions to improve patient performance in the cascade of care, providing causal evidence to optimize clinical management of HIV.Quasi-experiments have generated important data on the real-world impacts of HIV testing and treatment and on interventions to improve the cascade of care. With the growth in large-scale clinical and administrative data, quasi-experiments enable rigorous evaluation of policies implemented in real-world settings.

    View details for DOI 10.1097/COH.0000000000000191

    View details for Web of Science ID 000369718800014

    View details for PubMedID 26371463

    View details for PubMedCentralID PMC4768633

  • Predictors of Nonadherence to Antiretroviral Therapy among HIV-Infected Adults in Dar es Salaam, Tanzania. Journal of the International Association of Providers of AIDS Care Muya, A. N., Geldsetzer, P., Hertzmark, E., Ezeamama, A. E., Kawawa, H., Hawkins, C., Sando, D., Chalamilla, G., Fawzi, W., Spiegelman, D. 2015; 14 (2): 163–71


    BACKGROUND: Adherence rates of ≥95% to antiretroviral therapy (ART) are necessary to maintain viral suppression in HIV-infected individuals. We identified predictors of nonadherence to scheduled antiretroviral drug pickup appointments in a large HIV care and treatment program in Tanzania.METHODS: We performed a prospective cohort study of 44, 204 HIV-infected adults on ART between November 2004 and September 2012. Multivariate generalized estimating equation for repeated binary data was used to estimate the relative risk and 95% confidence intervals of nonadherence.RESULTS: Nonadherence was significantly greater among patients with high CD4 counts, high body mass indices, males, younger patients, patients with longer durations on ART, and those with perceived low social support.CONCLUSIONS: Targeted interventions should be developed to improve ART adherence among healthier, younger, and more experienced patients who are on ART for longer durations within HIV care and treatment programs. Social support for patients on ART should be emphasized.

    View details for DOI 10.1177/2325957414539193

    View details for PubMedID 24966305

  • HIV/AIDS Perspective Paper Geldsetzer, P., Bloom, D. E., Humair, S., Bärnighausen, T. Harvard University. Cambridge, MA. 2015 ; Program on the Global Demography of Aging (123.201):
  • Increasing Coverage of Antiretroviral Therapy and Male Medical Circumcision in HIV Hyperendemic Countries: A Cost-Benefit Analysis Geldsetzer, P., Bloom, D. E., Humair, S., Bärnighausen, T. Institute of Labor Economics. Bonn. 2015 ; IZA Discussion Paper Series (9143):


    HIV continues to cause the largest number of disability-adjusted life years of any disease in HIV hyperendemic countries (i.e., countries with an adult HIV prevalence >15%). We compare the benefits and costs of two proven biological interventions to reduce the health losses due to the HIV epidemic in hyperendemic countries from 2015 through 2030: 1) increasing ART coverage to 90% among HIV-infected adults with a CD4-cell count <350 cells/microliter, before expanding the HIV treatment scale-up to people with higher CD4-cell counts; and 2) increasing male medical circumcision coverage to at least 90% among HIVuninfected adult men. We developed a mathematical model to determine the benefits and costs of increasing the coverage of both ART under different CD4-cell count thresholds and of circumcision in HIV-hyperendemic countries. The results show that scaling up ART and circumcision are both cost-beneficial. However, the benefit-to-cost ratio (BCR) for circumcision is significantly higher than for ART: 7.4 vs. 3.0 (at US$1,000 per life year and a 5% discount rate) and 56.4 vs. 16.3 (at US$5,000 per life year and a 3% discount rate). The additional cost of scaling up circumcision is approximately $US500 million while the additional cost of increasing ART coverage lies between $US17 and $US19 billion. We conclude that increasing the coverage of ART among HIV-infected adults with a CD4-cell count <350 cells/microliter and, in particular, scaling up male medical circumcision among HIV-negative men are both highly cost-beneficial interventions to reduce the health burdens resulting from the HIV epidemic in hyperendemic countries over the next 15 years.

  • Benefits and Costs of the HIV/AIDS Targets for the Post-2015 Development Agenda Geldsetzer, P., Bloom, D. E., Humair, S., Bärnighausen, T. Copenhagen Consensus Center. Copenhagen. 2015 ; Post-2015 Consensus Project
  • Community Health Workers to Improve Antenatal Care and PMTCT Uptake in Dar es Salaam, Tanzania: A Quantitative Performance Evaluation JAIDS-JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES Lema, I. A., Sando, D., Magesa, L., Machumi, L., Mungure, E., Sando, M., Geldsetzer, P., Foster, D., Kajoka, D., Naburi, H., Ekstrom, A. M., Spiegelman, D., Li, N., Chalamilla, G., Fawzi, W., Baernighausen, T. 2014; 67: S195–S201


    Home visits by community health workers (CHW) could be effective in identifying pregnant women in the community before they have presented to the health system. CHW could thus improve the uptake of antenatal care (ANC), HIV testing, and prevention of mother-to-child transmission (PMTCT) services.Over a 16-month period, we carried out a quantitative evaluation of the performance of CHW in reaching women early in pregnancy and before they have attended ANC in Dar es Salaam, Tanzania.As part of the intervention, 213 CHW conducted more than 45,000 home visits to about 43,000 pregnant women. More than 75% of the pregnant women identified through home visits had not yet attended ANC at the time of the first contact with a CHW and about 40% of those who had not yet attended ANC were in the first trimester of pregnancy. Over time, the number of pregnant women the CHW identified each month increased, as did the proportion of women who had not yet attended ANC. The median gestational age of pregnant women contacted for the first time by a CHW decreased steadily and significantly over time (from 21/22 to 16 weeks, P-value for test of trend <0.0001).A large-scale CHW intervention was effective in identifying pregnant women in their homes early in pregnancy and before they had attended ANC. The intervention thus fulfills some of the conditions that are necessary for CHW to improve timely ANC uptake and early HIV testing and PMTCT enrollment in pregnancy.

    View details for DOI 10.1097/QAI.0000000000000371

    View details for Web of Science ID 000354120600005

    View details for PubMedID 25436818

    View details for PubMedCentralID PMC4252140

  • Evaluation of a community health worker intervention and the World Health Organization's Option B versus Option A to improve antenatal care and PMTCT outcomes in Dar es Salaam, Tanzania: study protocol for a cluster-randomized controlled health systems implementation trial TRIALS Sando, D., Geldsetzer, P., Magesa, L., Lema, I., Machumi, L., Mwanyika-Sando, M., Li, N., Spiegelman, D., Mungure, E., Siril, H., Mujinja, P., Naburi, H., Chalamilla, G., Kilewo, C., Ekstrom, A., Fawzi, W. W., Baernighausen, T. W. 2014; 15: 359


    Mother-to-child transmission of HIV remains an important public health problem in sub-Saharan Africa. As HIV testing and linkage to PMTCT occurs in antenatal care (ANC), major challenges for any PMTCT option in developing countries, including Tanzania, are delays in the first ANC visit and a low overall number of visits. Community health workers (CHWs) have been effective in various settings in increasing the uptake of clinical services and improving treatment retention and adherence. At the beginning of this trial in January 2013, the World Health Organization recommended either of two medication regimens, Option A or B, for prevention of mother-to-child transmission of HIV (PMTCT). It is still largely unclear which option is more effective when implemented in a public healthcare system. This study aims to determine the effectiveness, cost-effectiveness, acceptability, and feasibility of: (1) a community health worker (CWH) intervention and (2) PMTCT Option B in improving ANC and PMTCT outcomes.This study is a cluster-randomized controlled health systems implementation trial with a two-by-two factorial design. All 60 administrative wards in the Kinondoni and Ilala districts in Dar es Salaam were first randomly allocated to either receiving the CHW intervention or not, and then to receiving either Option B or A. Under the standard of care, facility-based health workers follow up on patients who have missed scheduled appointments for PMTCT, first through a telephone call and then with a home visit. In the wards receiving the CHW intervention, the CHWs: (1) identify pregnant women through home visits and refer them to antenatal care; (2) provide education to pregnant women on antenatal care, PMTCT, birth, and postnatal care; (3) routinely follow up on all pregnant women to ascertain whether they have attended ANC; and (4) follow up on women who have missed ANC or PMTCT EJF22802. Registration date: 14 May 2013.

    View details for DOI 10.1186/1745-6215-15-359

    View details for Web of Science ID 000344700300001

    View details for PubMedID 25224756

    View details for PubMedCentralID PMC4247663

  • The Recognition of and Care Seeking Behaviour for Childhood Illness in Developing Countries: A Systematic Review PLOS ONE Geldsetzer, P., Williams, T., Kirolos, A., Mitchell, S., Ratcliffe, L., Kohli-Lynch, M., Bischoff, E., Cameron, S., Campbell, H. 2014; 9 (4): e93427


    Pneumonia, diarrhoea, and malaria are among the leading causes of death in children. These deaths are largely preventable if appropriate care is sought early. This review aimed to determine the percentage of caregivers in low- and middle-income countries (LMICs) with a child less than 5 years who were able to recognise illness in their child and subsequently sought care from different types of healthcare providers.We conducted a systematic literature review of studies that reported recognition of, and/or care seeking for episodes of diarrhoea, pneumonia or malaria in LMICs. The review is registered with PROSPERO (registration number: CRD42011001654). Ninety-one studies met the inclusion criteria. Eighteen studies reported data on caregiver recognition of disease and seventy-seven studies on care seeking. The median sensitivity of recognition of diarrhoea, malaria and pneumonia was low (36.0%, 37.4%, and 45.8%, respectively). A median of 73.0% of caregivers sought care outside the home. Care seeking from community health workers (median: 5.4% for diarrhoea, 4.2% for pneumonia, and 1.3% for malaria) and the use of oral rehydration therapy (median: 34%) was low.Given the importance of this topic to child survival programmes there are few published studies. Recognition of diarrhoea, malaria and pneumonia by caregivers is generally poor and represents a key factor to address in attempts to improve health care utilisation. In addition, considering that oral rehydration therapy has been widely recommended for over forty years, its use remains disappointingly low. Similarly, the reported levels of care seeking from community health workers in the included studies are low even though global action plans to address these illnesses promote community case management. Giving greater priority to research on care seeking could provide crucial evidence to inform child mortality programmes.

    View details for DOI 10.1371/journal.pone.0093427

    View details for Web of Science ID 000334339000032

    View details for PubMedID 24718483

    View details for PubMedCentralID PMC3981715

  • SMN deficiency disrupts brain development in a mouse model of severe spinal muscular atrophy HUMAN MOLECULAR GENETICS Wishart, T. M., Huang, J., Murray, L. M., Lamont, D. J., Mutsaers, C. A., Ross, J., Geldsetzer, P., Ansorge, O., Talbot, K., Parson, S. H., Gillingwater, T. H. 2010; 19 (21): 4216–28


    Reduced expression of the survival motor neuron (SMN) gene causes the childhood motor neuron disease spinal muscular atrophy (SMA). Low levels of ubiquitously expressed SMN protein result in the degeneration of lower motor neurons, but it remains unclear whether other regions of the nervous system are also affected. Here we show that reduced levels of SMN lead to impaired perinatal brain development in a mouse model of severe SMA. Regionally selective changes in brain morphology were apparent in areas normally associated with higher SMN levels in the healthy postnatal brain, including the hippocampus, and were associated with decreased cell density, reduced cell proliferation and impaired hippocampal neurogenesis. A comparative proteomics analysis of the hippocampus from SMA and wild-type littermate mice revealed widespread modifications in expression levels of proteins regulating cellular proliferation, migration and development when SMN levels were reduced. This study reveals novel roles for SMN protein in brain development and maintenance and provides the first insights into cellular and molecular pathways disrupted in the brain in a severe form of SMA.

    View details for DOI 10.1093/hmg/ddq340

    View details for Web of Science ID 000282751500009

    View details for PubMedID 20705736

    View details for PubMedCentralID PMC2951867