Pascal Geldsetzer is an Assistant Professor of Medicine in the Division of Primary Care and Population Health. He has been a study coordinator and postdoctoral research fellow with the Harvard T.H. Chan School of Public Health in Tanzania and Eswatini, completed the Young Professionals Program of the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) in Namibia, and was a German National Merit Scholar.
Assistant Professor, Medicine - Primary Care and Population Health
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)
PhD, Harvard University (2018)
MPH, Harvard University (2012)
MD, University of Edinburgh (2011)
The effect of eligibility for antiretroviral therapy on body mass index and blood pressure in KwaZulu-Natal, South Africa.
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
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
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
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
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
Climate and the spread of COVID-19.
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
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
2021; 325 (8): 790–91
View details for Web of Science ID 000621957400035
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.
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
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.
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
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)
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
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
View details for DOI 10.1016/S2666-7568(21)00089-1
Questioning a South African hypertension threshold of 150 mm Hg – Authors' reply
The Lancet Healthy Longevity
2021; 2 (5): E248
View details for DOI 10.1016/S2666-7568(21)00095-7
Knowledge about Coronavirus Disease 2019 among adults in China: A cross-sectional online survey.
Journal of medical Internet research
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
2021; 2 (2): E78-E86
View details for DOI 10.1016/S2666-7568(20)30050-7
- Economics and Global Health [German] Global Health: An Introduction [German] De Gruyter. 2021; 1: 523–56
- Economic Evaluation in Global Health [German] Global Health: An Introduction [German] 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
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.
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
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
Lifetime Prevalence of Cervical Cancer Screening in 55 Low- and Middle-Income Countries.
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
Revisiting the association between temperature and COVID-19 transmissibility across 117 countries.
ERJ open research
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%. https://bit.ly/32OTBiS.
View details for DOI 10.1183/23120541.00550-2020
View details for PubMedID 33263060
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
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
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
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
Qualitative accounts of PrEP discontinuation from the general population in Eswatini.
Culture, health & sexuality
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
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.
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
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.
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
Impact of immediate initiation of antiretroviral therapy on HIV patient satisfaction.
AIDS (London, England)
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
Analysis of Attained Height and Diabetes Among 554,122 Adults Across 25 Low- and Middle-Income Countries.
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
The Effect Of Home-Based Hypertension Screening On Blood Pressure Change Over Time In South Africa.
Health affairs (Project Hope)
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
Epidemiology of multimorbidity in conditions of extreme poverty: a population-based study of older adults in rural Burkina Faso.
BMJ global health
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
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
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
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
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.
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 ClinicalTrials.gov under registration number NCT02626351.
View details for DOI 10.1371/journal.pmed.1003150
View details for PubMedID 33027246
- 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 2020
A stepped-wedge randomized trial on the impact of early ART initiation on HIV patients' economic welfare in Eswatini.
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: ClinicalTrials.gov, 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.
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.
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
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
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
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
Anaemia among men in India: a nationally representative cross-sectional study
LANCET GLOBAL HEALTH
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 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
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
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
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
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
ART Denial: Results of a Home-Based Study to Validate Self-reported Antiretroviral Use in Rural South Africa
AIDS AND BEHAVIOR
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
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
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
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
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 2019; 321 (21): 2134–35
- 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 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
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
Hypertension screening, awareness, treatment, and control in India: A nationally representative cross-sectional study among individuals aged 15 to 49 years
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
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
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
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 satisfaction.ClinicalTrials.gov, 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
Community health workers to improve uptake of maternal healthcare services: A cluster-randomized pragmatic trial in Dar es Salaam, Tanzania
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 ANC.ClinicalTrials.gov 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
Shorter Height is Associated with Diabetes in Women but not in Men: Nationally Representative Evidence from Namibia
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
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
Hypertension and diabetes control along the HIV care cascade in rural South Africa
JOURNAL OF THE INTERNATIONAL AIDS SOCIETY
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
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
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 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
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
Community delivery of antiretroviral drugs: A non-inferiority cluster-randomized pragmatic trial in Dar es Salaam, Tanzania
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 patients.ClinicalTrials.gov 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
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
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: www.clinicaltrials.gov, 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 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
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
Geographic and sociodemographic variation of cardiovascular disease risk in India: A cross-sectional study of 797,540 adults
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
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
Sampling for Patient Exit Interviews: Assessment of Methods Using Mathematical Derivation and Computer Simulations
HEALTH SERVICES RESEARCH
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
- What research is needed to address the co-epidemics of HIV and cardiometabolic disease in sub-Saharan Africa? LANCET DIABETES & ENDOCRINOLOGY 2018; 6 (1): 7–9
- 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 Cambridge University Press. 2018; 1: 277–287
Improving the performance of community health workers in Swaziland: findings from a qualitative study
HUMAN RESOURCES FOR HEALTH
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
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
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
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
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
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
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
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
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
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
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 workers.ClinicalTrials.gov: 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 2017; 5 (2): 91–92
- The causal impact of ART on NCDs: leveraging quasi-experiments LANCET DIABETES & ENDOCRINOLOGY 2017; 5 (1): 14
A qualitative and quantitative performance evaluation of Swaziland’s Rural Health Motivator program
2017; 6 (607)
View details for DOI 10.12688/f1000research.11361.1
Population-Level Decline in BMI and Systolic Blood Pressure Following Mass HIV Treatment: Evidence from Rural KwaZulu-Natal
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
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
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
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
MARY ANN LIEBERT, INC. 2016: 154
View details for Web of Science ID 000386774600274
The Influence of Drinking Motives on Hookah use Frequency Among Young Multi-Substance Users
INTERNATIONAL JOURNAL OF MENTAL HEALTH AND ADDICTION
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
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: http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0653-z.
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
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
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
Quasi-experiments to establish causal effects of HIV care and treatment and to improve the cascade of care
CURRENT OPINION IN HIV AND AIDS
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
Innovations in health and demographic surveillance systems to establish the causal impacts of HIV policies
CURRENT OPINION IN HIV AND AIDS
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
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
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
- Benefits and Costs of the HIV/AIDS Targets for the Post-2015 Development Agenda Copenhagen Consensus Center. Copenhagen. 2015 ; Post-2015 Consensus Project
- HIV/AIDS Perspective Paper 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
Institute of Labor Economics.
; IZA Discussion Paper Series
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.
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
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
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 appointments.ClinicalTrials.gov: 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
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
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