"I am adhering to HIV treatment so that I can live to support her": A qualitative study of upward intergenerational support in South Africa

Background

Intergenerational family care, which was upended by the HIV epidemic in sub-Saharan Africa (SSA), may return to a pre-HIV era arrangement as access to antiretroviral therapy (ART) expands and treated adults can once again provide support for older household members. Empirical research has demonstrated positive 'spillover effects' of ART uptake from treated adults to younger generations, yet much less is known about the nature and breadth of such effects to older generations. This study explores the role and lived experiences among adults who take up ART and those of an older generation with whom they live.

Methods

We conducted a qualitative study consisting of semi-structured interviews (n = 46) embedded in the Agincourt Health and Demographic Surveillance System (HDSS) in rural South Africa, between July and September 2022. We purposefully sampled two respondent categories: (i) young or middle-aged adults on ART (aged 18-59 years old); and (ii) older adults (aged ≥60 years old) who were affiliated with a young or middle-aged adult on ART. We used thematic content analysis to extract, code, and categorise relevant text by types of upward spillover effects from ART in younger adults to older adults. Quantitative data was extracted from the existing Agincourt HDSS database and matched to qualitative interview data based on Clinic link unique identifiers of study participants.

Results

Mean age was 41 years among young or middle-aged adults (n = 29) and 72 years among older adults (n = 17). Among younger adults, time on ART ranged from five months to more than 21 years. Both young or middle-aged adults on ART and older adults reported positive spillover effects for older adults across five main tiers: caregiving, financial support, physical and mental health, living arrangements and household relationships, and stigma and reputation. Spillover challenges included financial costs and caregiving responsibilities following ART initiation of young or middle-aged adults, although these additional caregiving responsibilities were generally not perceived as particularly burdensome.

Conclusions

ART is likely to benefit older adults in South Africa whose families are affected by HIV. This study identified a wide range of perceived spillover effects from ART in younger adults to older adults, including improvements to upward intergenerational support. These qualitative findings offer a guide to researchers, policymakers, and donors to capitalise on the broader societal effects of a large-scale health intervention to further support family structures and meet the needs of a growing older population.

Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3663 population-representative studies with 222 million children, adolescents, and adults

BACKGROUND

Underweight and obesity are associated with adverse health outcomes throughout the life course. We estimated the individual and combined prevalence of underweight or thinness and obesity, and their changes, from 1990 to 2022 for adults and school-aged children and adolescents in 200 countries and territories.

METHODS

We used data from 3663 population-based studies with 222 million participants that measured height and weight in representative samples of the general population. We used a Bayesian hierarchical model to estimate trends in the prevalence of different BMI categories, separately for adults (age ≥20 years) and school-aged children and adolescents (age 5-19 years), from 1990 to 2022 for 200 countries and territories. For adults, we report the individual and combined prevalence of underweight (BMI <18·5 kg/m2) and obesity (BMI ≥30 kg/m2). For school-aged children and adolescents, we report thinness (BMI <2 SD below the median of the WHO growth reference) and obesity (BMI >2 SD above the median).

FINDINGS

From 1990 to 2022, the combined prevalence of underweight and obesity in adults decreased in 11 countries (6%) for women and 17 (9%) for men with a posterior probability of at least 0·80 that the observed changes were true decreases. The combined prevalence increased in 162 countries (81%) for women and 140 countries (70%) for men with a posterior probability of at least 0·80. In 2022, the combined prevalence of underweight and obesity was highest in island nations in the Caribbean and Polynesia and Micronesia, and countries in the Middle East and north Africa. Obesity prevalence was higher than underweight with posterior probability of at least 0·80 in 177 countries (89%) for women and 145 (73%) for men in 2022, whereas the converse was true in 16 countries (8%) for women, and 39 (20%) for men. From 1990 to 2022, the combined prevalence of thinness and obesity decreased among girls in five countries (3%) and among boys in 15 countries (8%) with a posterior probability of at least 0·80, and increased among girls in 140 countries (70%) and boys in 137 countries (69%) with a posterior probability of at least 0·80. The countries with highest combined prevalence of thinness and obesity in school-aged children and adolescents in 2022 were in Polynesia and Micronesia and the Caribbean for both sexes, and Chile and Qatar for boys. Combined prevalence was also high in some countries in south Asia, such as India and Pakistan, where thinness remained prevalent despite having declined. In 2022, obesity in school-aged children and adolescents was more prevalent than thinness with a posterior probability of at least 0·80 among girls in 133 countries (67%) and boys in 125 countries (63%), whereas the converse was true in 35 countries (18%) and 42 countries (21%), respectively. In almost all countries for both adults and school-aged children and adolescents, the increases in double burden were driven by increases in obesity, and decreases in double burden by declining underweight or thinness.

INTERPRETATION

The combined burden of underweight and obesity has increased in most countries, driven by an increase in obesity, while underweight and thinness remain prevalent in south Asia and parts of Africa. A healthy nutrition transition that enhances access to nutritious foods is needed to address the remaining burden of underweight while curbing and reversing the increase in obesity.

FUNDING

UK Medical Research Council, UK Research and Innovation (Research England), UK Research and Innovation (Innovate UK), and European Union.

Economic Growth and Childhood Malnutrition in Low- and Middle-Income Countries

Importance

Economic growth may reduce childhood malnutrition through improvements of several contributing factors, but the empirical evidence is mixed. Identifying the most important factors that contribute to child malnutrition and their associations with economic growth can inform decision-making about targeted investments to improve children's health.

Objective

To assess the associations between economic growth and malnutrition, contributing factors and malnutrition, and economic growth and contributing factors of malnutrition in low- and middle-income countries (LMICs).

Design, Setting, and Participants

This cross-sectional study used data from 239 Demographic and Health Surveys from January 1, 1990, to December 31, 2021. Observations included 1 138 568 children aged 0 to 35 months with valid anthropometric measures and information on contributing factors of malnutrition from 58 LMICs. Data were analyzed from May 20, 2022, to February 16, 2023.

Exposure

National per-capita gross domestic product (GDP) was used as a proxy for economic growth.

Main Outcomes and Measures

Six measures of childhood malnutrition were constructed: stunting (height-for-age z score <-2), underweight (weight-for-age z score <-2), wasting (weight-for-height z score <-2), overweight (weight-for-height z score >2), obesity (weight-for-height z score >3), and dietary diversity failure (consumption of less than 5 of 8 different food groups in the past 24 hours). Eighteen contributing factors of malnutrition were constructed, of which 10 were underlying determinants (eg, access to improved sanitation) and 8 were immediate determinants (eg, breastfeeding initiation).

Results

A total of 1 138 568 children (mean [SD] age, 17.14 [10.26] months; 579 589 [50.9%] boys and 558 979 [49.1%] girls) were included in the analysis. Of these, 27.3% (95% CI, 27.2%-27.4%) had stunting; 25.7% (95% CI, 25.6%-25.8%), underweight; 11.2% (95% CI, 11.1%-11.2%), wasting; 3.8% (95% CI, 3.7%-3.8%), overweight; 1.1% (95% CI, 1.1%-1.1%), obesity; and 79.8% (95% CI, 79.7%-79.9%), dietary diversity failure. Per-capita GDP was weakly associated with childhood malnutrition. The odds ratios associated with a 5% increase in per-capita GDP were 0.99 (95% CI, 0.99-1.00) for stunting, 1.01 (95% CI, 1.00-1.01) for wasting, 1.00 (95% CI, 1.00-1.00) for underweight, 0.98 (95% CI, 0.98-0.98) for overweight, 0.98 (95% CI, 0.97-0.98) for obesity, and 1.03 (95% CI, 1.01-1.04) for dietary diversity failure. Although strong associations were found between many contributing factors and most outcomes for malnutrition, associations identified between per-capita GDP and these contributing factors themselves were ambiguous.

Conclusions and Relevance

In this multicountry cross-sectional study, economic growth was weakly associated with childhood malnutrition and several contributing factors. To reduce child malnutrition, economic growth may need to be accompanied by more targeted investments to improve contributing factors that are strongly associated with child malnutrition, such as maternal health and education.

The effect of school-entry age on health is understudied in low- and middle-income countries: A scoping review and future directions for research

Background

Substantive literature has assessed the impact of starting school at younger ages relative to peers on health in high-income countries (HICs), but there is little evidence from low- and middle-income countries (LMICs). Conclusions drawn from HICs may not apply to different education contexts and health threats. This study maps the empirical evidence on the effect of school-entry age on health in LMICs and identifies directions for future research.

Methods

We conducted a scoping review between August and September 2022 by systematically searching the health sciences, education, economics, psychology, and general sciences literature and included quantitative and qualitative studies. The exposure of interest was relative age for grade defined as starting or progressing through school at a younger or older age compared to peers who are in the same grade. We extracted key characteristics of included studies and summarized their findings. We categorized results into broad health domains which emerged a posteriori from our analyses of included studies, including neurodevelopment and mental health, sexual and reproductive health, non-communicable diseases, and nutrition.

Findings

We identified 8 studies from middle-income countries published between 2017 and 2022. Among those studies, we identified 3 quasi-experimental studies using data from Brazil, Mexico, and Vietnam, and 5 observational studies primarily from Türkiye. Children starting school earlier had an increased risk of being diagnosed with attention deficit hyperactivity disorder, earlier sexual debut and cohabitation, adolescent pregnancy, adolescent marriage, and engaged more frequently in risky behavior compared to children who started school later. Pregnant women who started school younger also had fewer prenatal care visits and experienced more pregnancy complications. Although most studies identified negative health consequences from starting school earlier, the evidence for nutritional outcomes, such as overweight and stunting, was mixed. No studies were identified from low-income countries.

Conclusions

Little is known about the health consequences of school-entry age in low-resource settings. Additional research is needed to investigate the impact of relative age for grade, whether and how these effects persist into adulthood, and to inform strategies that can offset potential disadvantages stemming from school-entry cut-off dates.

Intergenerational spillover effects of antiretroviral therapy in sub-Saharan Africa: a scoping review and future directions for research

BACKGROUND

Antiretroviral therapy (ART) may influence individuals who do not receive the intervention but who are connected in some way to the person who does. Relatively little is known, however, about the size and scope of, what we term, spillover effects of ART. We explored intergenerational spillover effects of ART in sub-Saharan Africa (SSA) and identified several directions for future research.

METHODS

We conducted a scoping review between March and April 2022. We systematically searched PubMed, PsycINFO, EconLit, OTseeker, AIDSInfo, Web of Science, CINHAL, Google Scholar and African Index Medicus. We analysed the distribution of included studies over time and summarised their findings. We examined the intergenerational impact of ART provision to working-age adults living with HIV on children ('downward' spillover effects) and older adults ('upward' spillover effects). We categorised types of intergenerational spillover effects according to broad themes which emerged from our analysis of included studies.

FINDINGS

We identified 26 studies published between 2005 and 2022 with 16 studies assessing spillover effects from adults to children (downward), and 1 study explicitly assessing spillover effects from working-age adults to older adults (upward). The remaining studies did not fully specify the direction of spillover effects. Most spillover effects of ART to household and family members were beneficial and included improvements in wealth, labour market outcomes, health outcomes and health services utilisation, schooling, and household composition. Both children and older adults benefited from ART availability among adults. Detrimental spillover effects were only reported in three studies and included financial and opportunity costs associated with health services utilisation and food insecurity in the first year after ART.

CONCLUSIONS

ART may lead to substantial spillover effects across generations and sectors in SSA. Further research is needed to capitalise on positive spillover effects while mitigating potential negative spillover effects. The returns to investments in large-scale health interventions such as ART may be underestimated without considering these societal benefits.

Strengthening primary care for diabetes and hypertension in Eswatini: study protocol for a nationwide cluster-randomized controlled trial

BACKGROUND

Diabetes and hypertension are increasingly important population health challenges in Eswatini. Prior to this project, healthcare for these conditions was primarily provided through physician-led teams at tertiary care facilities and accessed by only a small fraction of people living with diabetes or hypertension. This trial tests and evaluates two community-based healthcare service models implemented at the national level, which involve health care personnel at primary care facilities and utilize the country's public sector community health worker cadre (the rural health motivators [RHMs]) to help generate demand for care.

METHODS

This study is a cluster-randomized controlled trial with two treatment arms and one control arm. The unit of randomization is a primary healthcare facility along with all RHMs (and their corresponding service areas) assigned to the facility. A total of 84 primary healthcare facilities were randomized in a 1:1:1 ratio to the three study arms. The first treatment arm implements differentiated service delivery (DSD) models at the clinic and community levels with the objective of improving treatment uptake and adherence among clients with diabetes or hypertension. In the second treatment arm, community distribution points (CDPs), which previously targeted clients living with human immunodeficiency virus, extend their services to clients with diabetes or hypertension by allowing them to pick up medications and obtain routine nurse-led follow-up visits in their community rather than at the healthcare facility. In both treatment arms, RHMs visit households regularly, screen clients at risk, provide personalized counseling, and refer clients to either primary care clinics or the nearest CDP. In the control arm, primary care clinics provide diabetes and hypertension care services but without the involvement of RHMs and the implementation of DSD models or CDPs. The primary endpoints are mean glycated hemoglobin (HbA1c) and systolic blood pressure among adults aged 40 years and older living with diabetes or hypertension, respectively. These endpoints will be assessed through a household survey in the RHM service areas. In addition to the health impact evaluation, we will conduct studies on cost-effectiveness, syndemics, and the intervention's implementation processes.

DISCUSSION

This study has the ambition to assist the Eswatini government in selecting the most effective delivery model for diabetes and hypertension care. The evidence generated with this national-level cluster-randomized controlled trial may also prove useful to policy makers in the wider Sub-Saharan African region.

TRIAL REGISTRATION

NCT04183413. Trial registration date: December 3, 2019.

Predictors of Incidence and Remission of Anemia among Never-Married Adolescents Aged 10-19 Years: A Population-Based Prospective Longitudinal Study in India

Background

Dynamics of the anemia burden among Indian adolescents are poorly understood because of a lack of population-based longitudinal data.

Objectives

To examine the burden of anemia among never-married adolescents aged 10-19 y from the states of Bihar and Uttar Pradesh, India, and a wide range of predictors of its incidence and remission.

Methods

A sample of 3279 adolescents (male: 1787 and female: 1492) aged 10-19 y were included from baseline (2015-2016) and follow-up (2018-2019) surveys of the UDAYA (Understanding the Lives of Adolescents and Young Adults) project in India. In 2018-2019, all new cases of anemia were considered as incidence, whereas a return to the nonanemic status from being anemic in 2015-2016 was considered remission. Univariate and multivariable modified Poisson regression models with robust error variance were deployed to attain the study objective.

Results

The crude prevalence of anemia among males decreased from 33.9% (95% CI: 30.7%-37.3%) in 2015-2016 to 31.6% (95% CI: 28.6%-34.7%) in 2018-2019 but increased among females from 57.7% (95% CI: 53.5%-61.7%) in 2015-2016 to 63.8% (95% CI: 59.9%-67.5%) in 2018-2019. Anemia incidence was estimated to be 33.7% (95% CI: 30.3%-37.2%), whereas nearly 38.5% (95% CI: 35.1%-42.1%) of adolescents experienced remission of anemia. Older adolescents (aged 15-19 y) were less likely to experience anemia incidence. Consumption of eggs daily or weekly was negatively associated with anemia incidence compared with occasional or never consumption. Females had a higher risk of experiencing an incidence of anemia and decreased risk of experiencing anemia remission. The likelihood of adolescents experiencing anemia increased with an increased patient health questionnaire score. Household size was also associated with an increased risk of anemia incidence.

Conclusions

Interventions that are sensitive to socio-demographic factors and encouraging access to mental health services and nutritious food consumption could be helpful in further anemia mitigation.

Joint distribution of child mortality and wealth across 30 sub-Saharan African countries over 2000-2019

Background

While reductions in child mortality have been observed across sub-Saharan African countries in the last 30 years, narrowing the gaps in under-five mortality across socioeconomic groups also requires an understanding of the multiple associations between health and welfare and socioeconomic drivers. We examined the probability density distributions in under-five mortality within countries and joint pathways of under-five mortality and wealth over time.

Methods

We used 69 Demographic and Health Surveys and 19 Malaria Indicator Surveys from 30 sub-Saharan African countries, with each country having at least two surveys conducted since 2000. We constructed a cross-country wealth index and estimated under-five death prevalence. We examined the pure distribution in under-five mortality prevalence and the joint probability distribution of wealth and under-five mortality prevalence over time, including the area of confidence ellipse which spanned the two dimensions of mortality and wealth and covered 75% of the mass of the joint distribution.

Results

Most countries experienced decreases in under-five mortality along with increases in wealth over time. However, we observed great variations in the evolution of the joint distributions across countries over time. For instance, the areas of confidence ellipse ranged from 0.178 in Ethiopia (2000) to 1.119 in Angola (2006). The change (over time) in the area of confidence ellipses ranged from 0.010 in Tanzania to 0.844 in Angola between the 2000s and 2010s. The ranking of country performance on under-five mortality varied greatly, depending on whether performance summary indicators were based on disaggregation by wealth or on full non-disaggregated distributions.

Conclusions

Our analysis points to the relevance of full distributions of health and joint distributions of health and wealth as complementary indicators of distributions of health across socioeconomic status, in assessing country performance on health.

Mapping age- and sex-specific HIV prevalence in adults in sub-Saharan Africa, 2000-2018

BACKGROUND

Human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) is still among the leading causes of disease burden and mortality in sub-Saharan Africa (SSA), and the world is not on track to meet targets set for ending the epidemic by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United Nations Sustainable Development Goals (SDGs). Precise HIV burden information is critical for effective geographic and epidemiological targeting of prevention and treatment interventions. Age- and sex-specific HIV prevalence estimates are widely available at the national level, and region-wide local estimates were recently published for adults overall. We add further dimensionality to previous analyses by estimating HIV prevalence at local scales, stratified into sex-specific 5-year age groups for adults ages 15-59 years across SSA.

METHODS

We analyzed data from 91 seroprevalence surveys and sentinel surveillance among antenatal care clinic (ANC) attendees using model-based geostatistical methods to produce estimates of HIV prevalence across 43 countries in SSA, from years 2000 to 2018, at a 5 × 5-km resolution and presented among second administrative level (typically districts or counties) units.

RESULTS

We found substantial variation in HIV prevalence across localities, ages, and sexes that have been masked in earlier analyses. Within-country variation in prevalence in 2018 was a median 3.5 times greater across ages and sexes, compared to for all adults combined. We note large within-district prevalence differences between age groups: for men, 50% of districts displayed at least a 14-fold difference between age groups with the highest and lowest prevalence, and at least a 9-fold difference for women. Prevalence trends also varied over time; between 2000 and 2018, 70% of all districts saw a reduction in prevalence greater than five percentage points in at least one sex and age group. Meanwhile, over 30% of all districts saw at least a five percentage point prevalence increase in one or more sex and age group.

CONCLUSIONS

As the HIV epidemic persists and evolves in SSA, geographic and demographic shifts in prevention and treatment efforts are necessary. These estimates offer epidemiologically informative detail to better guide more targeted interventions, vital for combating HIV in SSA.

"It's the poverty"-Stakeholder perspectives on barriers to secondary education in rural Burkina Faso

Universal primary and secondary education is a key target of the Sustainable Development Goals. While substantial gains have been made at the primary school level, progress towards universal secondary education has slowed, particularly in sub-Saharan Africa. In this study, we aimed to determine perceived barriers of secondary schooling in rural Burkina Faso, where secondary school completion is among the lowest globally (<10%). We conducted a two-stage qualitative study using semi-structured interviews (N = 49). In the first stage, we sampled enrolled students (n = 10), out-of-school adolescents (n = 9), parents of enrolled students (n = 5), parents of out-of-school adolescents (n = 5) and teachers (n = 10) from a random sample of five secondary schools. In a second stage, we interviewed key informants knowledgeable of the school context using snowball sampling (n = 10). Systematic analysis of the pooled sample was based on a reading of interview transcripts and coding of the narratives in NVivo12 using the diathesis-stress model. Recurring themes were classified using a priori developed categories of hypothesized barriers to secondary schooling. Major reported barriers included school-related expenses and the lack of school infrastructure and resources. Insufficient and heterogeneous French language skills (the official language of instruction in Burkina Faso) were seen as a major barrier to secondary schooling. Forced marriages, adolescent pregnancies, and the low perceived economic benefits of investing in secondary schooling were reported as key barriers among young women. Our results guide future interventions and policy aimed at achieving universal secondary education and gender equity in the region.

Prevalence of Obesity and Anemia Among Early Adolescents in Junior Secondary Schools: A Cross-Sectional Study in Ouagadougou, Burkina Faso

BACKGROUND

The school presents an ideal environment to positively impact the long-term health and nutrition outcomes of early adolescents, who are at risk of obesity and anemia.

METHODS

In this cross-sectional survey, we described differences in weight and anemia by sociodemographic, diet and physical activity indicators among 1059 students aged 11 to 15 years from 22 junior secondary schools in Ouagadougou, Burkina Faso. Weight was based on body mass index (BMI) z-scores according to the WHO reference and anemia status was defined by standardized hemoglobin (Hb) measure cut-offs. We calculated dietary diversity scores (DDS) from a 24-hour dietary recall and a global diet quality score (GDQS) from a 7-day dietary recall.

RESULTS

The prevalence of obesity (5%) and anemia (50%) was relatively high among the students, which differed significantly between gender, household wealth and school grade, but not age groups. Eighteen percent of the female adolescents were overweight or obese and 22% were moderately anemic compared to 13% and 16% of the male adolescents. Dietary diversity was significantly different between weight categories, but not anemia status. For physical activity, those taking transportation to school were significantly more likely to be overweight or obese. In adjusted multivariable Poisson regression analyses, only the DDS was significantly associated with thinness and both thinness and anemia, while taking transportation to school was significantly associated with overweight among adolescents.

CONCLUSION

We encourage the promotion of school-based interventions and provision of a curriculum on health and healthy eating in order to reduce obesity, anemia, and its comorbidities.

Mapping development and health effects of cooking with solid fuels in low-income and middle-income countries, 2000-18: a geospatial modelling study

BACKGROUND

More than 3 billion people do not have access to clean energy and primarily use solid fuels to cook. Use of solid fuels generates household air pollution, which was associated with more than 2 million deaths in 2019. Although local patterns in cooking vary systematically, subnational trends in use of solid fuels have yet to be comprehensively analysed. We estimated the prevalence of solid-fuel use with high spatial resolution to explore subnational inequalities, assess local progress, and assess the effects on health in low-income and middle-income countries (LMICs) without universal access to clean fuels.

METHODS

We did a geospatial modelling study to map the prevalence of solid-fuel use for cooking at a 5 km × 5 km resolution in 98 LMICs based on 2·1 million household observations of the primary cooking fuel used from 663 population-based household surveys over the years 2000 to 2018. We use observed temporal patterns to forecast household air pollution in 2030 and to assess the probability of attaining the Sustainable Development Goal (SDG) target indicator for clean cooking. We aligned our estimates of household air pollution to geospatial estimates of ambient air pollution to establish the risk transition occurring in LMICs. Finally, we quantified the effect of residual primary solid-fuel use for cooking on child health by doing a counterfactual risk assessment to estimate the proportion of deaths from lower respiratory tract infections in children younger than 5 years that could be associated with household air pollution.

FINDINGS

Although primary reliance on solid-fuel use for cooking has declined globally, it remains widespread. 593 million people live in districts where the prevalence of solid-fuel use for cooking exceeds 95%. 66% of people in LMICs live in districts that are not on track to meet the SDG target for universal access to clean energy by 2030. Household air pollution continues to be a major contributor to particulate exposure in LMICs, and rising ambient air pollution is undermining potential gains from reductions in the prevalence of solid-fuel use for cooking in many countries. We estimated that, in 2018, 205 000 (95% uncertainty interval 147 000-257 000) children younger than 5 years died from lower respiratory tract infections that could be attributed to household air pollution.

INTERPRETATION

Efforts to accelerate the adoption of clean cooking fuels need to be substantially increased and recalibrated to account for subnational inequalities, because there are substantial opportunities to improve air quality and avert child mortality associated with household air pollution.

FUNDING

Bill & Melinda Gates Foundation.

Health and economic benefits of secondary education in the context of poverty: Evidence from Burkina Faso

Even though formal education is considered a key determinant of individual well-being globally, enrollment in secondary schooling remains low in many low- and middle-income countries, suggesting that the perceived returns to such schooling may be low. We jointly estimate survival and monetary benefits of secondary schooling using detailed demographic and surveillance data from the Boucle du Mouhoun region, Burkina Faso, where national upper secondary schooling completion rates are among the lowest globally (<10%). We first explore surveillance data from the Nouna Health and Demographic Surveillance System from 1992 to 2016 to determine long-term differences in survival outcomes between secondary and higher and primary schooling using Cox proportional hazards models. To estimate average increases in asset holdings associated with secondary schooling, we use regionally representative data from the Burkina Faso Demographic Health Surveys (2003, 2010, 2014, 2017–18; N = 3,924). Survival was tracked for 14,892 individuals. Each year of schooling was associated with a mortality reduction of up to 16% (95% CI 0.75–0.94), implying an additional 1.9 years of life expectancy for men and 5.1 years for women for secondary schooling compared to individuals completing only primary school. Relative to individuals with primary education, individuals with secondary or higher education held 26% more assets (SE 0.02; CI 0.22–0.30). Economic returns for women were 3% points higher than male returns with 10% (SE 0.03; CI 0.04–0.16) vs. 7% (SE 0.02; CI 0.02–0.012) and in rural areas 20% points higher than in urban areas with 30% (SE 0.06; CI 0.19–0.41) vs. 4% (SE 0.01; CI 0.02–0.07). Our results suggest that secondary education is associated with substantial health and economic benefits in the study area and should therefore be considered by researchers, governments, and other major stakeholders to create for example school promotion programs.

Applying systems thinking to identify enablers and challenges to scale-up interventions for hypertension and diabetes in low-income and middle-income countries: protocol for a longitudinal mixed-methods study

INTRODUCTION

There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions.

METHODS AND ANALYSIS

We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (TP), initiation of implementation (T0) and 1-year postinitiation (T1). We will extract project-related data from secondary documents at TP and conduct multistakeholder qualitative interviews to gather data at T0 and T1. We will undertake descriptive statistical analysis of TP data and analyse T0 and T1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks.

ETHICS AND DISSEMINATION

The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network.

Diabetes mortality and trends before 25 years of age: an analysis of the Global Burden of Disease Study 2019

BACKGROUND

Diabetes, particularly type 1 diabetes, at younger ages can be a largely preventable cause of death with the correct health care and services. We aimed to evaluate diabetes mortality and trends at ages younger than 25 years globally using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

We used estimates of GBD 2019 to calculate international diabetes mortality at ages younger than 25 years in 1990 and 2019. Data sources for causes of death were obtained from vital registration systems, verbal autopsies, and other surveillance systems for 1990-2019. We estimated death rates for each location using the GBD Cause of Death Ensemble model. We analysed the association of age-standardised death rates per 100 000 population with the Socio-demographic Index (SDI) and a measure of universal health coverage (UHC) and described the variability within SDI quintiles. We present estimates with their 95% uncertainty intervals.

FINDINGS

In 2019, 16 300 (95% uncertainty interval 14 200 to 18 900) global deaths due to diabetes (type 1 and 2 combined) occurred in people younger than 25 years and 73·7% (68·3 to 77·4) were classified as due to type 1 diabetes. The age-standardised death rate was 0·50 (0·44 to 0·58) per 100 000 population, and 15 900 (97·5%) of these deaths occurred in low to high-middle SDI countries. The rate was 0·13 (0·12 to 0·14) per 100 000 population in the high SDI quintile, 0·60 (0·51 to 0·70) per 100 000 population in the low-middle SDI quintile, and 0·71 (0·60 to 0·86) per 100 000 population in the low SDI quintile. Within SDI quintiles, we observed large variability in rates across countries, in part explained by the extent of UHC (r2=0·62). From 1990 to 2019, age-standardised death rates decreased globally by 17·0% (-28·4 to -2·9) for all diabetes, and by 21·0% (-33·0 to -5·9) when considering only type 1 diabetes. However, the low SDI quintile had the lowest decline for both all diabetes (-13·6% [-28·4 to 3·4]) and for type 1 diabetes (-13·6% [-29·3 to 8·9]).

INTERPRETATION

Decreasing diabetes mortality at ages younger than 25 years remains an important challenge, especially in low and low-middle SDI countries. Inadequate diagnosis and treatment of diabetes is likely to be major contributor to these early deaths, highlighting the urgent need to provide better access to insulin and basic diabetes education and care. This mortality metric, derived from readily available and frequently updated GBD data, can help to monitor preventable diabetes-related deaths over time globally, aligned with the UN's Sustainable Development Targets, and serve as an indicator of the adequacy of basic diabetes care for type 1 and type 2 diabetes across nations.

FUNDING

Bill & Melinda Gates Foundation.

Patterns of multimorbidity in India: A nationally representative cross-sectional study of individuals aged 15 to 49 years

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

The Food and Health Environment in Junior Secondary Schools in Urban Burkina Faso: A Cross-Sectional Study of Administrators, Food Vendors and Early Adolescents

School enrolment rates have increased globally, making the school environment a unique setting to promote healthy nutrition and eating outcomes among early adolescents. In this cross-sectional study, we describe the food and health environment of junior secondary schools in Ouagadougou (Burkina Faso, West Africa). We evaluated the food and health environment using three components: (1) the implementation of health-related policies or guidelines in the schools, (2) the provision of health, nutrition and water, sanitation & hygiene (WASH) services in the schools, and (3) the quality of the school food environment, including foods sold by vendors. We used stratified random sampling to recruit 22 junior secondary schools from the five Ouagadougou districts in 2020. Trained fieldworkers collected standardized questionnaire data from 19 school administrators, 18 food vendors, and 1059 in-school adolescents. We report that only 7 out of 19 school administrators were aware of existing health-related policies and guidelines at their school and only 3 schools had a school health and nutrition curriculum in place. The overall provision of health, nutrition and WASH services was low or inadequate. Likely because of the lack of school canteens, 69% of the students bought snacks and unhealthy foods from food vendors. There is a critical need to improve the food and health environment of junior secondary schools in urban Burkina Faso.

Tracking development assistance for health and for COVID-19: a review of development assistance, government, out-of-pocket, and other private spending on health for 204 countries and territories, 1990-2050

BACKGROUND

The rapid spread of COVID-19 renewed the focus on how health systems across the globe are financed, especially during public health emergencies. Development assistance is an important source of health financing in many low-income countries, yet little is known about how much of this funding was disbursed for COVID-19. We aimed to put development assistance for health for COVID-19 in the context of broader trends in global health financing, and to estimate total health spending from 1995 to 2050 and development assistance for COVID-19 in 2020.

METHODS

We estimated domestic health spending and development assistance for health to generate total health-sector spending estimates for 204 countries and territories. We leveraged data from the WHO Global Health Expenditure Database to produce estimates of domestic health spending. To generate estimates for development assistance for health, we relied on project-level disbursement data from the major international development agencies' online databases and annual financial statements and reports for information on income sources. To adjust our estimates for 2020 to include disbursements related to COVID-19, we extracted project data on commitments and disbursements from a broader set of databases (because not all of the data sources used to estimate the historical series extend to 2020), including the UN Office of Humanitarian Assistance Financial Tracking Service and the International Aid Transparency Initiative. We reported all the historic and future spending estimates in inflation-adjusted 2020 US$, 2020 US$ per capita, purchasing-power parity-adjusted US$ per capita, and as a proportion of gross domestic product. We used various models to generate future health spending to 2050.

FINDINGS

In 2019, health spending globally reached $8·8 trillion (95% uncertainty interval [UI] 8·7-8·8) or $1132 (1119-1143) per person. Spending on health varied within and across income groups and geographical regions. Of this total, $40·4 billion (0·5%, 95% UI 0·5-0·5) was development assistance for health provided to low-income and middle-income countries, which made up 24·6% (UI 24·0-25·1) of total spending in low-income countries. We estimate that $54·8 billion in development assistance for health was disbursed in 2020. Of this, $13·7 billion was targeted toward the COVID-19 health response. $12·3 billion was newly committed and $1·4 billion was repurposed from existing health projects. $3·1 billion (22·4%) of the funds focused on country-level coordination and $2·4 billion (17·9%) was for supply chain and logistics. Only $714·4 million (7·7%) of COVID-19 development assistance for health went to Latin America, despite this region reporting 34·3% of total recorded COVID-19 deaths in low-income or middle-income countries in 2020. Spending on health is expected to rise to $1519 (1448-1591) per person in 2050, although spending across countries is expected to remain varied.

INTERPRETATION

Global health spending is expected to continue to grow, but remain unequally distributed between countries. We estimate that development organisations substantially increased the amount of development assistance for health provided in 2020. Continued efforts are needed to raise sufficient resources to mitigate the pandemic for the most vulnerable, and to help curtail the pandemic for all.

FUNDING

Bill & Melinda Gates Foundation.

The Impact of Immediate Initiation of Antiretroviral Therapy on Patients' Healthcare Expenditures: A Stepped-Wedge Randomized Trial in Eswatini

Immediate initiation of antiretroviral therapy (ART) for all people living with HIV has important health benefits but implications for the economic aspects of patients' lives are still largely unknown. 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 a CD4 count threshold) 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. In mixed-effects regression models, we found a 49% decrease (RR 0.51, 95% CI 0.36, 0.72, p < 0.001) in past-year total healthcare expenditures in the EAAA group compared 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 initiation appears 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.

Measuring routine childhood vaccination coverage in 204 countries and territories, 1980-2019: a systematic analysis for the Global Burden of Disease Study 2020, Release 1

BACKGROUND

Measuring routine childhood vaccination is crucial to inform global vaccine policies and programme implementation, and to track progress towards targets set by the Global Vaccine Action Plan (GVAP) and Immunization Agenda 2030. Robust estimates of routine vaccine coverage are needed to identify past successes and persistent vulnerabilities. Drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2020, Release 1, we did a systematic analysis of global, regional, and national vaccine coverage trends using a statistical framework, by vaccine and over time.

METHODS

For this analysis we collated 55 326 country-specific, cohort-specific, year-specific, vaccine-specific, and dose-specific observations of routine childhood vaccination coverage between 1980 and 2019. Using spatiotemporal Gaussian process regression, we produced location-specific and year-specific estimates of 11 routine childhood vaccine coverage indicators for 204 countries and territories from 1980 to 2019, adjusting for biases in country-reported data and reflecting reported stockouts and supply disruptions. We analysed global and regional trends in coverage and numbers of zero-dose children (defined as those who never received a diphtheria-tetanus-pertussis [DTP] vaccine dose), progress towards GVAP targets, and the relationship between vaccine coverage and sociodemographic development.

FINDINGS

By 2019, global coverage of third-dose DTP (DTP3; 81·6% [95% uncertainty interval 80·4-82·7]) more than doubled from levels estimated in 1980 (39·9% [37·5-42·1]), as did global coverage of the first-dose measles-containing vaccine (MCV1; from 38·5% [35·4-41·3] in 1980 to 83·6% [82·3-84·8] in 2019). Third-dose polio vaccine (Pol3) coverage also increased, from 42·6% (41·4-44·1) in 1980 to 79·8% (78·4-81·1) in 2019, and global coverage of newer vaccines increased rapidly between 2000 and 2019. The global number of zero-dose children fell by nearly 75% between 1980 and 2019, from 56·8 million (52·6-60·9) to 14·5 million (13·4-15·9). However, over the past decade, global vaccine coverage broadly plateaued; 94 countries and territories recorded decreasing DTP3 coverage since 2010. Only 11 countries and territories were estimated to have reached the national GVAP target of at least 90% coverage for all assessed vaccines in 2019.

INTERPRETATION

After achieving large gains in childhood vaccine coverage worldwide, in much of the world this progress was stalled or reversed from 2010 to 2019. These findings underscore the importance of revisiting routine immunisation strategies and programmatic approaches, recentring service delivery around equity and underserved populations. Strengthening vaccine data and monitoring systems is crucial to these pursuits, now and through to 2030, to ensure that all children have access to, and can benefit from, lifesaving vaccines.

FUNDING

Bill & Melinda Gates Foundation.

CD4+ T-Cell Count at Antiretroviral Therapy Initiation in the "Treat-All" Era in Rural South Africa: An Interrupted Time Series Analysis

BACKGROUND

South Africa implemented universal test and treat (UTT) in September 2016 in an effort to encourage earlier initiation of antiretroviral therapy (ART).

METHODS

We therefore conducted an interrupted time series (ITS) analysis to assess the impact of UTT on mean CD4 count at ART initiation among adults aged ≥16 years attending 17 public sector primary care clinics in rural South Africa, between July 2014 and March 2019.

RESULTS

Among 20 599 individuals (69% women), CD4 counts were available for 74%. Mean CD4 at ART initiation increased from 317.1 cells/μL (95% confidence interval [CI], 308.6 to 325.6) 1 to 8 months prior to UTT to 421.0 cells/μL (95% CI, 413.0 to 429.0) 1 to 12 months after UTT, including an immediate increase of 124.2 cells/μL (95% CI, 102.2 to 146.1). However, mean CD4 count subsequently fell to 389.5 cells/μL (95% CI, 381.8 to 397.1) 13 to 30 months after UTT but remained above pre-UTT levels. Men initiated ART at lower CD4 counts than women (-118.2 cells/μL, 95% CI, -125.5 to -111.0) throughout the study.

CONCLUSIONS

Although UTT led to an immediate increase in CD4 count at ART initiation in this rural community, the long-term effects were modest. More efforts are needed to increase initiation of ART early in those living with human immunodeficiency virus, particularly men.

The effect of bearing and rearing a child on blood pressure: a nationally representative instrumental variable analysis of 444611 mothers in India

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 444 611 mothers aged 15-49 years. 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 116.4 mmHg (SD: 14.4) and diastolic blood pressure of 78.5 mmHg (SD: 9.4). One in seven mothers was hypertensive. In conventional ordinary least squares regression, each child was associated with 0.42 mmHg lower systolic [95% confidence interval (CI): -0.46 to -0.39, P < 0.001] and 0.13 mmHg 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 1.00 mmHg (95% CI: -1.26 to -0.74, P < 0.001) and diastolic blood pressure by an average of 0.35 mmHg (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.

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

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.

Targeting Hypertension Screening in Low- and Middle-Income Countries: A Cross-Sectional Analysis of 1.2 Million Adults in 56 Countries

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 1 170 629 participants in 56 LMICs, of whom 220 636 (18.8%) had hypertension. Hypertension was defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, 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.

Variation in the Proportion of Adults in Need of Blood Pressure-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 effect of guideline choice on the proportion of adults who require treatment is crucial for planning and scaling up hypertension care in low- and middle-income countries.

METHODS

We extracted cross-sectional data on age, sex, blood pressure, hypertension treatment and diagnosis status, smoking, and body mass index for adults 30 to 70 years of age from nationally representative surveys in 50 low- and middle-income countries (N = 1 037 215). We aimed to determine the effect of hypertension guideline choice on the proportion of adults in need of blood pressure-lowering medications. We considered 4 hypertension guidelines: the 2017 American College of Cardiology/American Heart Association guideline, the commonly used 140/90 mm Hg threshold, the 2016 World Health Organization HEARTS guideline, and the 2019 UK National Institute for Health and Care Excellence guideline.

RESULTS

The proportion of adults in need of blood pressure-lowering medications was highest under the American College of Cardiology/American Heart Association, followed by the 140/90 mm Hg, National Institute for Health and Care Excellence, and World Health Organization guidelines (American College of Cardiology/American Heart Association: women, 27.7% [95% CI, 27.2-28.2], men, 35.0% [95% CI, 34.4-35.7]; 140/90 mm Hg: women, 26.1% [95% CI, 25.5-26.6], men, 31.2% [95% CI, 30.6-31.9]; National Institute for Health and Care Excellence: women, 11.8% [95% CI, 11.4-12.1], men, 15.7% [95% CI, 15.3-16.2]; World Health Organization: women, 9.2% [95% CI, 8.9-9.5], men, 11.0% [95% CI, 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 years) age group (American College of Cardiology/American Heart Association: women, 60.2% [95% CI, 58.8-61.6], men, 70.1% [95% CI, 68.8-71.3]; World Health Organization: women, 20.1% [95% CI, 18.8-21.3], men, 24.1.0% [95% CI, 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, whereas 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, policy makers will need to carefully consider which guideline they should adopt when scaling up hypertension care in their country.

Causal effect of children's secondary education on parental health outcomes: findings from a natural experiment in Botswana

OBJECTIVES

A growing literature highlights the intergenerational transmission of human capital from parents to children. However, far less is known about 'upward transmission' from children to parents. In this study, we use a 1996 Botswana education policy reform as a natural experiment to identify the causal effect of children's secondary schooling on their parents' health.

SETTING

Botswana's decennial census (2001 and 2011). Data were obtained through the Integrated Public Use Microdata Series and are 10% random samples of the complete population in each of these census years.

PARTICIPANTS

Survey respondents who were citizens born in Botswana, at least 18 years old at the time of the census and born in or after 1975 (n=89 721).

PRIMARY AND SECONDARY OUTCOME MEASURES

Parental survival and disability at the time of the census, separately for mothers and fathers.

RESULTS

The 1996 reform caused a large increase in grade 10 enrolment, inducing an additional 0.4 years of schooling for the first cohorts affected (95% CI 0.3 to 0.5, p<0.001). The reform, however, had no effect on parental survival and disability by the time exposed child cohorts reach age 30. Results were robust to a wide array of sensitivity analyses.

CONCLUSIONS

This study found little evidence that parents' survival and disability were affected by their offspring's educational attainment in Botswana. Parents' health may not be necessarily affected by increasing their offspring's educational attainment.

A cross-sectional study of cardiovascular disease risk clustering at different socio-geographic levels in India

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.

A Continuous Quality Improvement Intervention to Improve Antenatal HIV Care Testing in Rural South Africa: Evaluation of Implementation in a Real-World Setting

Background: We evaluated continuous quality improvement (CQI) targeting antenatal HIV care quality in rural South Africa using a stepped-wedge cluster-randomised controlled trial (Management and Optimisation of Nutrition, Antenatal, Reproductive, Child health, MONARCH) and an embedded process evaluation. Here, we present results of the process evaluation examining determinants of CQI practice and ‘normalisation.’

Methods: A team of CQI mentors supported public-sector health workers in seven primary care clinics to (1) identify root causes of poor HIV viral load (VL) monitoring among pregnant women living with HIV and repeat HIV testing among pregnant women not living with HIV, and (2) design and iteratively test their own solutions. We used a mixed methods evaluation with field notes from CQI mentors (‘dose’ and ‘reach’ of CQI, causes of poor HIV care testing rates, implemented change ideas); patient medical records (HIV care testing by clinic and time step); and semi-structured interviews with available health workers. We analysed field notes and semi-structured interviews for determinants of CQI implementation and ‘normalisation’ using Normalisation Process Theory (NPT) and Tailored Implementation of Chronic Diseases (TICD) frameworks.

Results: All interviewed health workers found the CQI mentors and methodology helpful for quality improvement. Total administered ‘dose’ was higher than planned but ‘reach’ was limited by resource constraints, particularly staffing shortages. Simple workable improvements to identified root causes were implemented, such as a patient tracking notebook and results filing system. VL monitoring improved over time, but not repeat HIV testing. Besides resource constraints, gaps in knowledge of guidelines, lack of leadership, poor clinical documentation, and data quality gaps reduced CQI implementation fidelity and normalisation.

Conclusion: While CQI holds promise, we identified several health system challenges. Priorities for policy makers include improving staffing and strategies to improve clinical documentation. Additional support with implementing clinical guidelines and improving routine data quality are needed. Normalising CQI may be challenging without concurrent health system improvements.

Lifetime Prevalence of Cervical Cancer Screening in 55 Low- and Middle-Income Countries

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.

Burden of injury along the development spectrum: associations between the Socio-demographic Index and disability-adjusted life year estimates from the Global Burden of Disease Study 2017

BACKGROUND

The epidemiological transition of non-communicable diseases replacing infectious diseases as the main contributors to disease burden has been well documented in global health literature. Less focus, however, has been given to the relationship between sociodemographic changes and injury. The aim of this study was to examine the association between disability-adjusted life years (DALYs) from injury for 195 countries and territories at different levels along the development spectrum between 1990 and 2017 based on the Global Burden of Disease (GBD) 2017 estimates.

METHODS

Injury mortality was estimated using the GBD mortality database, corrections for garbage coding and CODEm-the cause of death ensemble modelling tool. Morbidity estimation was based on surveys and inpatient and outpatient data sets for 30 cause-of-injury with 47 nature-of-injury categories each. The Socio-demographic Index (SDI) is a composite indicator that includes lagged income per capita, average educational attainment over age 15 years and total fertility rate.

RESULTS

For many causes of injury, age-standardised DALY rates declined with increasing SDI, although road injury, interpersonal violence and self-harm did not follow this pattern. Particularly for self-harm opposing patterns were observed in regions with similar SDI levels. For road injuries, this effect was less pronounced.

CONCLUSIONS

The overall global pattern is that of declining injury burden with increasing SDI. However, not all injuries follow this pattern, which suggests multiple underlying mechanisms influencing injury DALYs. There is a need for a detailed understanding of these patterns to help to inform national and global efforts to address injury-related health outcomes across the development spectrum.

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

BACKGROUND

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.

METHODS AND FINDINGS

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.

CONCLUSIONS

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.

TRIAL REGISTRATION

This trial is registered at ClinicalTrials.gov under registration number NCT02626351.

Analysis of Attained Height and Diabetes Among 554,122 Adults Across 25 Low- and Middle-Income Countries

OBJECTIVE

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.

RESEARCH DESIGN AND METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Mapping geographical inequalities in access to drinking water and sanitation facilities in low-income and middle-income countries, 2000-17

BACKGROUND

Universal access to safe drinking water and sanitation facilities is an essential human right, recognised in the Sustainable Development Goals as crucial for preventing disease and improving human wellbeing. Comprehensive, high-resolution estimates are important to inform progress towards achieving this goal. We aimed to produce high-resolution geospatial estimates of access to drinking water and sanitation facilities.

METHODS

We used a Bayesian geostatistical model and data from 600 sources across more than 88 low-income and middle-income countries (LMICs) to estimate access to drinking water and sanitation facilities on continuous continent-wide surfaces from 2000 to 2017, and aggregated results to policy-relevant administrative units. We estimated mutually exclusive and collectively exhaustive subcategories of facilities for drinking water (piped water on or off premises, other improved facilities, unimproved, and surface water) and sanitation facilities (septic or sewer sanitation, other improved, unimproved, and open defecation) with use of ordinal regression. We also estimated the number of diarrhoeal deaths in children younger than 5 years attributed to unsafe facilities and estimated deaths that were averted by increased access to safe facilities in 2017, and analysed geographical inequality in access within LMICs.

FINDINGS

Across LMICs, access to both piped water and improved water overall increased between 2000 and 2017, with progress varying spatially. For piped water, the safest water facility type, access increased from 40·0% (95% uncertainty interval [UI] 39·4-40·7) to 50·3% (50·0-50·5), but was lowest in sub-Saharan Africa, where access to piped water was mostly concentrated in urban centres. Access to both sewer or septic sanitation and improved sanitation overall also increased across all LMICs during the study period. For sewer or septic sanitation, access was 46·3% (95% UI 46·1-46·5) in 2017, compared with 28·7% (28·5-29·0) in 2000. Although some units improved access to the safest drinking water or sanitation facilities since 2000, a large absolute number of people continued to not have access in several units with high access to such facilities (>80%) in 2017. More than 253 000 people did not have access to sewer or septic sanitation facilities in the city of Harare, Zimbabwe, despite 88·6% (95% UI 87·2-89·7) access overall. Many units were able to transition from the least safe facilities in 2000 to safe facilities by 2017; for units in which populations primarily practised open defecation in 2000, 686 (95% UI 664-711) of the 1830 (1797-1863) units transitioned to the use of improved sanitation. Geographical disparities in access to improved water across units decreased in 76·1% (95% UI 71·6-80·7) of countries from 2000 to 2017, and in 53·9% (50·6-59·6) of countries for access to improved sanitation, but remained evident subnationally in most countries in 2017.

INTERPRETATION

Our estimates, combined with geospatial trends in diarrhoeal burden, identify where efforts to increase access to safe drinking water and sanitation facilities are most needed. By highlighting areas with successful approaches or in need of targeted interventions, our estimates can enable precision public health to effectively progress towards universal access to safe water and sanitation.

FUNDING

Bill & Melinda Gates Foundation.

Infant feeding knowledge and practice vary by maternal HIV status: a nested cohort study in rural South Africa

Background

We investigate whether correct infant feeding knowledge and practice differ by maternal HIV status in an era of evolving clinical guidelines in rural South Africa.

Methods

This cohort study was nested within the MONARCH stepped-wedge cluster-randomised controlled trial (www.clinicaltrials.gov: NCT02626351) which tested the impact of continuous quality improvement on antenatal care quality at seven primary care clinics in KwaZulu-Natal, from July 2015 to January 2017. Women aged ≥18 years at delivery were followed up to 6 weeks postpartum. Clinical data were sourced from routine medical records at delivery. Structured interviews at early postnatal visits and the 6-week postnatal immunisation visit provided data on infant feeding knowledge and feeding practices respectively. We measured the relationship between maternal HIV status and (i) correct infant feeding knowledge at the early postnatal visit; and (ii) infant feeding practice at 6 weeks, using Poisson and multinomial regression models, respectively.

Results

We analysed data from 1693 women with early postnatal and 471 with 6-week postnatal interviews. HIV prevalence was 47% (95% confidence interval [CI] 42, 52%). Women living with HIV were more knowledgeable than women not living with HIV on correct infant feeding recommendations (adjusted risk ratio, aRR, 1.08, p <  0.001). More women living with HIV (33%; 95% CI 26, 41%) were not breastfeeding than women not living with HIV (15%; 95% CI 11, 21%). However, among women who were currently breastfeeding their infants, fewer women living with HIV (5%; 95% CI 2, 9%) mixed fed their babies than women not living with HIV (21%; 95% CI 14, 32%). In adjusted analyses, women living with HIV were more likely to avoid breastfeeding (adjusted relative risk ratio, aRRR, 2.78, p <  0.001) and less likely to mixed feed (aRRR 0.22, p <  0.001) than women not living with HIV.

Conclusions

Many mothers in rural South Africa still do not practice exclusive breastfeeding. Women living with HIV were more knowledgeable but had lower overall uptake of breastfeeding, compared with women not living with HIV. Women living with HIV were also more likely to practice exclusive breastfeeding over mixed feeding if currently breastfeeding. Improved approaches are needed to increase awareness of correct infant feeding and exclusive breastfeeding uptake.

A stepped-wedge randomised trial on the impact of early ART initiation on HIV-patients' economic outcomes 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 impact on the economic aspects of patients' lives 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’ individual- and household-level economic outcomes. Fourteen healthcare facilities were non-randomly matched into 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 were collected via standardised paper-based surveys with HIV-positive adults who were neither pregnant nor breastfeeding. Outcomes were patients’ time use, employment status, household expenditures, and household living standards.

Results

A total sample of 3019 participants were interviewed over the duration of the study. The mean number of participants approached at each facility per time step varied from 4 to 112 participants. Using mixed-effects negative binomial regressions accounting for time trends and clustering at the level of the healthcare facility, 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

Our findings do not provide evidence that should discourage further investments into scaling up immediate ART for all HIV patients.

Funding

Funded by the Dutch Postcode Lottery in the Netherlands, Alexander von Humboldt-Stiftung (Humboldt-Stiftung), the Embassy of the Kingdom of the Netherlands in South Africa/Mozambique, British Columbia Centre of Excellence in Canada, Doctors Without Borders (MSF USA), National Center for Advancing Translational Sciences of the National Institutes of Health and Joachim Herz Foundation.

Clinical trial number

NCT02909218 and NCT03789448.

Children's education and parental old-age health: Evidence from a population-based, nationally representative study in India

Previous research has documented intergenerational transmission of human capital from children to parents. Less is known, however, about heterogeneity in this 'upward transmission' in low-resource settings. We examine whether co-resident adult children's education is associated with improved health among older parents in India, using nationally representative data from the 2014 Indian National Sample Survey. Parents of children with tertiary education had a lower probability of reporting poor health than parents of children with less than primary education. The benefits of children's education persisted after controlling for economic factors, suggesting that non-pecuniary pathways-such as health knowledge or skills-may play an important role. The association was more pronounced among economically dependent parents and those living in the North and West regions. Taken together, our results point to a strong positive association between children's education and parental health, the role of non-pecuniary pathways, and the importance of subnational heterogeneity in India.

Mapping geographical inequalities in childhood diarrhoeal morbidity and mortality in low-income and middle-income countries, 2000-17: analysis for the Global Burden of Disease Study 2017

BACKGROUND

Across low-income and middle-income countries (LMICs), one in ten deaths in children younger than 5 years is attributable to diarrhoea. The substantial between-country variation in both diarrhoea incidence and mortality is attributable to interventions that protect children, prevent infection, and treat disease. Identifying subnational regions with the highest burden and mapping associated risk factors can aid in reducing preventable childhood diarrhoea.

METHODS

We used Bayesian model-based geostatistics and a geolocated dataset comprising 15 072 746 children younger than 5 years from 466 surveys in 94 LMICs, in combination with findings of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, to estimate posterior distributions of diarrhoea prevalence, incidence, and mortality from 2000 to 2017. From these data, we estimated the burden of diarrhoea at varying subnational levels (termed units) by spatially aggregating draws, and we investigated the drivers of subnational patterns by creating aggregated risk factor estimates.

FINDINGS

The greatest declines in diarrhoeal mortality were seen in south and southeast Asia and South America, where 54·0% (95% uncertainty interval [UI] 38·1-65·8), 17·4% (7·7-28·4), and 59·5% (34·2-86·9) of units, respectively, recorded decreases in deaths from diarrhoea greater than 10%. Although children in much of Africa remain at high risk of death due to diarrhoea, regions with the most deaths were outside Africa, with the highest mortality units located in Pakistan. Indonesia showed the greatest within-country geographical inequality; some regions had mortality rates nearly four times the average country rate. Reductions in mortality were correlated to improvements in water, sanitation, and hygiene (WASH) or reductions in child growth failure (CGF). Similarly, most high-risk areas had poor WASH, high CGF, or low oral rehydration therapy coverage.

INTERPRETATION

By co-analysing geospatial trends in diarrhoeal burden and its key risk factors, we could assess candidate drivers of subnational death reduction. Further, by doing a counterfactual analysis of the remaining disease burden using key risk factors, we identified potential intervention strategies for vulnerable populations. In view of the demands for limited resources in LMICs, accurately quantifying the burden of diarrhoea and its drivers is important for precision public health.

FUNDING

Bill & Melinda Gates Foundation.

Facilitators and barriers to the implementation of a Mobile Health Wallet for pregnancy-related health care: A qualitative study of stakeholders' perceptions in Madagascar

Financial barriers are a major obstacle to accessing maternal health care services in low-resource settings. In Madagascar, less than half of live births are attended by skilled health staff. Although mobile money-based savings and payment systems are often used to pay for a variety of services, including health care, data on the implications of a dedicated mobile money wallet restricted to health-related spending during pregnancy-a mobile health wallet (MHW)-are not well understood. In cooperation with the Madagascan Ministry of Health, this study aims to elicit the perceptions, experiences, and recommendations of key stakeholders in relation to a MHW amid a pilot study in 31 state-funded health care facilities. We conducted a two-stage qualitative study using semi-structured in-depth interviews with stakeholders (N = 21) representing the following groups: community representatives, health care providers, health officials and representatives from phone provider companies. Interviews were conducted in Atsimondrano and Renivohitra districts, between November and December of 2017. Data was coded thematically using inductive and deductive approaches, and found to align with a social ecological model. Key facilitators for successful implementation of the MHW, include (i) close collaboration with existing communal structures and (ii) creation of an incentive scheme to reward pregnant women to save. Key barriers to the application of the MHW in the study zone include (i) disruption of informal benefits for health care providers related to the current cash-based payment system, (ii) low mobile phone ownership, (iii) illiteracy among the target population, and (iv) failure of the MHW to overcome essential access barriers towards institutional health care services such as fear of unpredictable expenses. The MHW was perceived as a potential solution to reduce disparities in access to maternal health care. To ensure success of the MHW, direct demand-side and provider-side financial incentives merit consideration.

"Because at school, you can become somebody" - The perceived health and economic returns on secondary schooling in rural Burkina Faso

Background

The perceived returns on schooling are critical in schooling decision-making but are not well understood. This study examines the perceived returns on secondary schooling in Burkina Faso, where secondary school completion is among the lowest globally (<10%).

Methods

We conducted a two-staged qualitative study using semi-structured interviews (N = 49). In the first stage, we sampled students, dropouts, parents and teachers from a random sample of five schools (n = 39). In the second stage, we interviewed key informants knowledgeable of the school context using snowball sampling (n = 10). Systematic analysis was based on a grounded theory approach with a reading of transcripts, followed by coding of the narratives in NVivo 12.

Results

Respondents nearly universally perceived health benefits to schooling. In particular, key health benefits included improved sexual and reproductive health outcomes, hygiene knowledge and practices, as well as better interactions with the formal health system. Common economic returns on schooling included improved employment opportunities and the provision of support to family members, in addition to generally attaining success and recognition. Indirect and long-term health returns, however, were infrequently mentioned by respondents.

Conclusions

While respondents reported nearly universally short-term health benefits to schooling, responses with regard to economic as well as indirect and long-term health benefits were more ambiguous. Future intervention studies on the perceived returns on formal education are needed to inform policy and reach education and health targets in the region.

Global, regional, and national incidence, prevalence, and mortality of HIV, 1980-2017, and forecasts to 2030, for 195 countries and territories: a systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017

BACKGROUND

Understanding the patterns of HIV/AIDS epidemics is crucial to tracking and monitoring the progress of prevention and control efforts in countries. We provide a comprehensive assessment of the levels and trends of HIV/AIDS incidence, prevalence, mortality, and coverage of antiretroviral therapy (ART) for 1980-2017 and forecast these estimates to 2030 for 195 countries and territories.

METHODS

We determined a modelling strategy for each country on the basis of the availability and quality of data. For countries and territories with data from population-based seroprevalence surveys or antenatal care clinics, we estimated prevalence and incidence using an open-source version of the Estimation and Projection Package-a natural history model originally developed by the UNAIDS Reference Group on Estimates, Modelling, and Projections. For countries with cause-specific vital registration data, we corrected data for garbage coding (ie, deaths coded to an intermediate, immediate, or poorly defined cause) and HIV misclassification. We developed a process of cohort incidence bias adjustment to use information on survival and deaths recorded in vital registration to back-calculate HIV incidence. For countries without any representative data on HIV, we produced incidence estimates by pulling information from observed bias in the geographical region. We used a re-coded version of the Spectrum model (a cohort component model that uses rates of disease progression and HIV mortality on and off ART) to produce age-sex-specific incidence, prevalence, and mortality, and treatment coverage results for all countries, and forecast these measures to 2030 using Spectrum with inputs that were extended on the basis of past trends in treatment scale-up and new infections.

FINDINGS

Global HIV mortality peaked in 2006 with 1·95 million deaths (95% uncertainty interval 1·87-2·04) and has since decreased to 0·95 million deaths (0·91-1·01) in 2017. New cases of HIV globally peaked in 1999 (3·16 million, 2·79-3·67) and since then have gradually decreased to 1·94 million (1·63-2·29) in 2017. These trends, along with ART scale-up, have globally resulted in increased prevalence, with 36·8 million (34·8-39·2) people living with HIV in 2017. Prevalence of HIV was highest in southern sub-Saharan Africa in 2017, and countries in the region had ART coverage ranging from 65·7% in Lesotho to 85·7% in eSwatini. Our forecasts showed that 54 countries will meet the UNAIDS target of 81% ART coverage by 2020 and 12 countries are on track to meet 90% ART coverage by 2030. Forecasted results estimate that few countries will meet the UNAIDS 2020 and 2030 mortality and incidence targets.

INTERPRETATION

Despite progress in reducing HIV-related mortality over the past decade, slow decreases in incidence, combined with the current context of stagnated funding for related interventions, mean that many countries are not on track to reach the 2020 and 2030 global targets for reduction in incidence and mortality. With a growing population of people living with HIV, it will continue to be a major threat to public health for years to come. The pace of progress needs to be hastened by continuing to expand access to ART and increasing investments in proven HIV prevention initiatives that can be scaled up to have population-level impact.

FUNDING

Bill & Melinda Gates Foundation, National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH.

Are out-of-school adolescents at higher risk of adverse health outcomes? Evidence from 9 diverse settings in sub-Saharan Africa

OBJECTIVES

We analysed mutually comparable surveys on adolescent attitudes and behaviours from nine sites in seven sub-Saharan African countries, to determine the relationship between school enrolment and adolescent health outcomes.

METHODS

Data from the Africa Research, Implementation Science, and Education Network cross-sectional adolescent health surveys were used to examine the associations of current school enrolment, self-reported general health and four major adolescent health domains: (i) sexual and reproductive health; (ii) nutrition and non-communicable diseases; (iii) mental health, violence and injury; and (iv) healthcare utilisation. We used multivariable Poisson regression models to calculate relative risk ratios with 95% confidence intervals (CI), controlling for demographic and socio-economic characteristics. We assessed heterogeneity by gender and study site.

RESULTS

Across 7829 adolescents aged 10-19, 70.5% were in school at the time of interview. In-school adolescents were 14.3% more likely (95% CI: 6-22) to report that their life is going well; 51.2% less likely (95% CI: 45-67) to report ever having had sexual intercourse; 32.6% more likely (95% CI: 9-61) to report unmet need for health care; and 30.1% less likely (95% CI: 15-43) to report having visited a traditional healer. School enrolment was not significantly associated with malnutrition, low mood, violence or injury. Substantial heterogeneity was identified between genders for sexual and reproductive health, and in-school adolescents were particularly less likely to report adverse health outcomes in settings with high average school enrolment.

CONCLUSIONS

School enrolment is strongly associated with sexual and reproductive health and healthcare utilisation outcomes across nine sites in sub-Saharan Africa. Keeping adolescents in school may improve key health outcomes, something that can be explored through future longitudinal, mixed-methods, and (quasi-)experimental studies.

Mapping 123 million neonatal, infant and child deaths between 2000 and 2017

Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2-to end preventable child deaths by 2030-we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000-2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations.

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

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.

Past, present, and future of global health financing: a review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 1995-2050

BACKGROUND

Comprehensive and comparable estimates of health spending in each country are a key input for health policy and planning, and are necessary to support the achievement of national and international health goals. Previous studies have tracked past and projected future health spending until 2040 and shown that, with economic development, countries tend to spend more on health per capita, with a decreasing share of spending from development assistance and out-of-pocket sources. We aimed to characterise the past, present, and predicted future of global health spending, with an emphasis on equity in spending across countries.

METHODS

We estimated domestic health spending for 195 countries and territories from 1995 to 2016, split into three categories-government, out-of-pocket, and prepaid private health spending-and estimated development assistance for health (DAH) from 1990 to 2018. We estimated future scenarios of health spending using an ensemble of linear mixed-effects models with time series specifications to project domestic health spending from 2017 through 2050 and DAH from 2019 through 2050. Data were extracted from a broad set of sources tracking health spending and revenue, and were standardised and converted to inflation-adjusted 2018 US dollars. Incomplete or low-quality data were modelled and uncertainty was estimated, leading to a complete data series of total, government, prepaid private, and out-of-pocket health spending, and DAH. Estimates are reported in 2018 US dollars, 2018 purchasing-power parity-adjusted dollars, and as a percentage of gross domestic product. We used demographic decomposition methods to assess a set of factors associated with changes in government health spending between 1995 and 2016 and to examine evidence to support the theory of the health financing transition. We projected two alternative future scenarios based on higher government health spending to assess the potential ability of governments to generate more resources for health.

FINDINGS

Between 1995 and 2016, health spending grew at a rate of 4·00% (95% uncertainty interval 3·89-4·12) annually, although it grew slower in per capita terms (2·72% [2·61-2·84]) and increased by less than $1 per capita over this period in 22 of 195 countries. The highest annual growth rates in per capita health spending were observed in upper-middle-income countries (5·55% [5·18-5·95]), mainly due to growth in government health spending, and in lower-middle-income countries (3·71% [3·10-4·34]), mainly from DAH. Health spending globally reached $8·0 trillion (7·8-8·1) in 2016 (comprising 8·6% [8·4-8·7] of the global economy and $10·3 trillion [10·1-10·6] in purchasing-power parity-adjusted dollars), with a per capita spending of US$5252 (5184-5319) in high-income countries, $491 (461-524) in upper-middle-income countries, $81 (74-89) in lower-middle-income countries, and $40 (38-43) in low-income countries. In 2016, 0·4% (0·3-0·4) of health spending globally was in low-income countries, despite these countries comprising 10·0% of the global population. In 2018, the largest proportion of DAH targeted HIV/AIDS ($9·5 billion, 24·3% of total DAH), although spending on other infectious diseases (excluding tuberculosis and malaria) grew fastest from 2010 to 2018 (6·27% per year). The leading sources of DAH were the USA and private philanthropy (excluding corporate donations and the Bill & Melinda Gates Foundation). For the first time, we included estimates of China's contribution to DAH ($644·7 million in 2018). Globally, health spending is projected to increase to $15·0 trillion (14·0-16·0) by 2050 (reaching 9·4% [7·6-11·3] of the global economy and $21·3 trillion [19·8-23·1] in purchasing-power parity-adjusted dollars), but at a lower growth rate of 1·84% (1·68-2·02) annually, and with continuing disparities in spending between countries. In 2050, we estimate that 0·6% (0·6-0·7) of health spending will occur in currently low-income countries, despite these countries comprising an estimated 15·7% of the global population by 2050. The ratio between per capita health spending in high-income and low-income countries was 130·2 (122·9-136·9) in 2016 and is projected to remain at similar levels in 2050 (125·9 [113·7-138·1]). The decomposition analysis identified governments' increased prioritisation of the health sector and economic development as the strongest factors associated with increases in government health spending globally. Future government health spending scenarios suggest that, with greater prioritisation of the health sector and increased government spending, health spending per capita could more than double, with greater impacts in countries that currently have the lowest levels of government health spending.

INTERPRETATION

Financing for global health has increased steadily over the past two decades and is projected to continue increasing in the future, although at a slower pace of growth and with persistent disparities in per-capita health spending between countries. Out-of-pocket spending is projected to remain substantial outside of high-income countries. Many low-income countries are expected to remain dependent on development assistance, although with greater government spending, larger investments in health are feasible. In the absence of sustained new investments in health, increasing efficiency in health spending is essential to meet global health targets.

FUNDING

Bill & Melinda Gates Foundation.

A Mobile Health Wallet for Pregnancy-Related Health Care in Madagascar: Mixed-Methods Study on Opportunities and Challenges

Background

Mobile savings and payment systems have been widely adopted to store money and pay for a variety of services, including health care. However, the possible implications of these technologies on financing and payment for maternal health care services—which commonly require large 1-time out-of-pocket payments—have not yet been systematically assessed in low-resource settings.

Objective

The aim of this study was to determine the structural, contextual, and experiential characteristics of a mobile phone–based savings and payment platform, the Mobile Health Wallet (MHW), for skilled health care during pregnancy among women in Madagascar.

Methods

We used a 2-stage cluster random sampling scheme to select a representative sample of women utilizing either routine antenatal (ANC) or routine postnatal care (PNC) in public sector health facilities in 2 of 8 urban and peri-urban districts of Antananarivo, Madagascar (Atsimondrano and Renivohitra districts). In a quantitative structured survey among 412 randomly selected women attending ANC or PNC, we identified saving habits, mobile phone use, media consumptions, and perception of an MHW with both savings and payment functions. To confirm and explain the quantitative results, we used qualitative data from 6 semistructured focus group discussions (24 participants in total) in the same population.

Results

59.3% (243/410, 95% CI 54.5-64.1) saved toward the expected costs of delivery and, out of those, 64.4% (159/247, 95% CI 58.6-70.2) used household cash savings for this purpose. A total of 80.3% (331/412, 95% CI 76.5-84.1) had access to a personal or family phone and 35.7% (147/412, 95% CI 31.1-40.3) previously used Mobile Money services. Access to skilled health care during pregnancy was primarily limited because of financial obstacles such as saving difficulties or unpredictability of costs. Another key barrier was the lack of information about health benefits or availability of services. The general concept of an MHW for saving toward and payment of pregnancy-related care, including the restriction of payments, was perceived as beneficial and practicable by the majority of participants. In the discussions, several themes pointed to opportunities for ensuring the success of an MHW through design features: (1) intuitive technical ease of use, (2) clear communication and information about benefits and restrictions, and (3) availability of personal customer support.

Conclusions

Financial obstacles are a major cause of limited access to skilled maternal health care in Madagascar. An MHW for skilled health care during pregnancy was perceived as a useful and desirable tool to reduce financial barriers among women in urban Madagascar. The design of this tool and the communication strategy will likely be the key to success. Particularly important dimensions of design include technical user friendliness and accessible and personal customer service.

Kenya's Health in All Policies strategy: a policy analysis using Kingdon's multiple streams

BACKGROUND

Health in All Policies (HiAP) is an intersectoral approach that facilitates decision-making among policy-makers to maximise positive health impacts of other public policies. Kenya, as a member of WHO, has committed to adopting HiAP, which has been included in the Kenya Health Policy for the period 2014-2030. This study aims to assess the extent to which this commitment is being translated into the process of governmental policy-making and supported by international development partners as well as non-state actors.

METHODS

To examine HiAP in Kenya, a qualitative case study was performed, including a review of relevant policy documents. Furthermore, 40 key informants with diverse backgrounds (government, UN agencies, development agencies, civil society) were interviewed. Analysis was carried out using the main dimensions of Kingdon's Multiple Streams Approach (problems, policy, politics).

RESULTS

Kenya is facing major health challenges that are influenced by various social determinants, but the implementation of intersectoral action focusing on health promotion is still arbitrary. On the policy level, little is known about HiAP in other government ministries. Many health-related collaborations exist under the concept of intersectoral collaboration, which is prominent in the country's development framework - Vision 2030 - but with no specific reference to HiAP. Under the political stream, the study highlights that political commitment from the highest office would facilitate mainstreaming the HiAP strategy, e.g. by setting up a department under the President's Office. The budgeting process and planning for the Sustainable Development Goals were found to be potential windows of opportunity.

CONCLUSION

While HiAP is being adopted as policy in Kenya, it is still perceived by many stakeholders as the business of the health sector, rather than a policy for the whole government and beyond. Kenya's Vision 2030 should use HiAP to foster progress in all sectors with health promotion as an explicit goal.

Health, financial, and education gains of investing in preventive chemotherapy for schistosomiasis, soil-transmitted helminthiases, and lymphatic filariasis in Madagascar: A modeling study

BACKGROUND

Neglected tropical diseases (NTDs) account for a large disease burden in sub-Saharan Africa. While the general cost-effectiveness of NTD interventions to improve health outcomes has been assessed, few studies have also accounted for the financial and education gains of investing in NTD control.

METHODS

We built on extended cost-effectiveness analysis (ECEA) methods to assess the health gains (e.g. infections, disability-adjusted life years or DALYs averted), household financial gains (out-of-pocket expenditures averted), and education gains (cases of school absenteeism averted) for five NTD interventions that the government of Madagascar aims to roll out nationally. The five NTDs considered were schistosomiasis, lymphatic filariasis, and three soil-transmitted helminthiases (Ascaris lumbricoides, Trichuris trichiura, and hookworm infections).

RESULTS

The estimated incremental cost-effectiveness for the roll-out of preventive chemotherapy for all NTDs jointly was USD125 per DALY averted (95% uncertainty range: 65-231), and its benefit-cost ratio could vary between 5 and 31. Our analysis estimated that, per dollar spent, schistosomiasis preventive chemotherapy, in particular, could avert a large number of infections (176,000 infections averted per $100,000 spent), DALYs (2,000 averted per $100,000 spent), and cases of school absenteeism (27,000 school years gained per $100,000 spent).

CONCLUSION

This analysis incorporates financial and education gains into the economic evaluation of health interventions, and therefore provides information about the efficiency of attainment of three Sustainable Development Goals (SDGs). Our findings reveal how the national scale-up of NTD control in Madagascar can help address health (SDG3), economic (SDG1), and education (SDG4) goals. This study further highlights the potentially large societal benefits of investing in NTD control in low-resource settings.

Global, regional, and national age-sex-specific mortality and life expectancy, 1950-2017: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

Assessments of age-specific mortality and life expectancy have been done by the UN Population Division, Department of Economics and Social Affairs (UNPOP), the United States Census Bureau, WHO, and as part of previous iterations of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD). Previous iterations of the GBD used population estimates from UNPOP, which were not derived in a way that was internally consistent with the estimates of the numbers of deaths in the GBD. The present iteration of the GBD, GBD 2017, improves on previous assessments and provides timely estimates of the mortality experience of populations globally.

METHODS

The GBD uses all available data to produce estimates of mortality rates between 1950 and 2017 for 23 age groups, both sexes, and 918 locations, including 195 countries and territories and subnational locations for 16 countries. Data used include vital registration systems, sample registration systems, household surveys (complete birth histories, summary birth histories, sibling histories), censuses (summary birth histories, household deaths), and Demographic Surveillance Sites. In total, this analysis used 8259 data sources. Estimates of the probability of death between birth and the age of 5 years and between ages 15 and 60 years are generated and then input into a model life table system to produce complete life tables for all locations and years. Fatal discontinuities and mortality due to HIV/AIDS are analysed separately and then incorporated into the estimation. We analyse the relationship between age-specific mortality and development status using the Socio-demographic Index, a composite measure based on fertility under the age of 25 years, education, and income. There are four main methodological improvements in GBD 2017 compared with GBD 2016: 622 additional data sources have been incorporated; new estimates of population, generated by the GBD study, are used; statistical methods used in different components of the analysis have been further standardised and improved; and the analysis has been extended backwards in time by two decades to start in 1950.

FINDINGS

Globally, 18·7% (95% uncertainty interval 18·4-19·0) of deaths were registered in 1950 and that proportion has been steadily increasing since, with 58·8% (58·2-59·3) of all deaths being registered in 2015. At the global level, between 1950 and 2017, life expectancy increased from 48·1 years (46·5-49·6) to 70·5 years (70·1-70·8) for men and from 52·9 years (51·7-54·0) to 75·6 years (75·3-75·9) for women. Despite this overall progress, there remains substantial variation in life expectancy at birth in 2017, which ranges from 49·1 years (46·5-51·7) for men in the Central African Republic to 87·6 years (86·9-88·1) among women in Singapore. The greatest progress across age groups was for children younger than 5 years; under-5 mortality dropped from 216·0 deaths (196·3-238·1) per 1000 livebirths in 1950 to 38·9 deaths (35·6-42·83) per 1000 livebirths in 2017, with huge reductions across countries. Nevertheless, there were still 5·4 million (5·2-5·6) deaths among children younger than 5 years in the world in 2017. Progress has been less pronounced and more variable for adults, especially for adult males, who had stagnant or increasing mortality rates in several countries. The gap between male and female life expectancy between 1950 and 2017, while relatively stable at the global level, shows distinctive patterns across super-regions and has consistently been the largest in central Europe, eastern Europe, and central Asia, and smallest in south Asia. Performance was also variable across countries and time in observed mortality rates compared with those expected on the basis of development.

INTERPRETATION

This analysis of age-sex-specific mortality shows that there are remarkably complex patterns in population mortality across countries. The findings of this study highlight global successes, such as the large decline in under-5 mortality, which reflects significant local, national, and global commitment and investment over several decades. However, they also bring attention to mortality patterns that are a cause for concern, particularly among adult men and, to a lesser extent, women, whose mortality rates have stagnated in many countries over the time period of this study, and in some cases are increasing.

FUNDING

Bill & Melinda Gates Foundation.