Clarifications on the intersectional MAIHDA approach: A conceptual guide and response to Wilkes and Karimi (2024)

Intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) has been welcomed as a new gold standard for quantitative evaluation of intersectional inequalities, and it is being rapidly adopted across the health and social sciences. In their commentary "What does the MAIHDA method explain?", Wilkes and Karimi (2024) raise methodological concerns with this approach, leading them to advocate for the continued use of conventional single-level linear regression models with fixed-effects interaction parameters for quantitative intersectional analysis. In this response, we systematically address these concerns, and ultimately find them to be unfounded, arising from a series of subtle but important misunderstandings of the MAIHDA approach and literature. Since readers new to MAIHDA may share confusion on these points, we take this opportunity to provide clarifications. Our response is organized around four important clarifications: (1) At what level are the additive main effect variables defined in intersectional MAIHDA models? (2) Do MAIHDA models have problems with collinearity? (3) Why does the Variance Partitioning Coefficient (VPC) tend to be small, and the Proportional Change in Variance (PCV) tend to be large in MAIHDA? and (4) What are the goals of MAIHDA analysis?

Temporal change in prevalence of BMI categories in India: patterns across States and Union territories of India, 1999-2021

BACKGROUND

The problem of overweight/obesity often coexists with the burden of undernutrition in most low- and middle-income countries. BMI change in India incorporating the most recent trends has been under-researched.

METHODS

This repeated cross-sectional study of 1,477,885 adults in India analyzed the prevalence of different categories of BMI among adults (age 20-54) in 4 rounds of National Family Health Surveys (1998-1999, 2005-2006, 2015-2016, and 2019-2021) for 36 states/UTs. State differences across time were harmonized for accurate analysis. The categories were Severely/Moderately Thin (BMI < 17.0), Mildly Thin (17.0-18.4), Normal (18.5-24.9), Overweight (25.0-29.9), and Obese (≥ 30.0). We also estimated change in Standardized Absolute Change (SAC), ranking of states, and headcount burden to quantify the trend of BMI distribution across time periods for all-India, urban/rural residence, and by states/UTs.

RESULTS

The prevalence of thinness declined from 31.7% in 1999 to 14.2% in 2021 for women, and from 23.4% in 2006 to 10.0% in 2021 for men. Obesity prevalence increased from 2.9% (1999) to 6.3% (2021) for women, and from 2.0% (2006) to 4.2% (2021) for men. In 2021, the states with the highest obesity prevalence were Puducherry, Chandigarh, and Delhi. These states also had a high prevalence of overweight. Dadra and Nagar Haveli and Diu, Gujarat, Jharkhand, and Bihar had the highest prevalence of severe/moderately thin. Prevalence of extreme categories (severely/moderately thin and obese) was larger in the case of women than men. While States/UTs with a higher prevalence of thin populations tend to have a larger absolute burden of severe or moderate thinness, the relationship between headcount burden and prevalence for overweight and obese is unclear.

CONCLUSIONS

We found persistent interstate inequalities of undernutrition. Tailored efforts at state levels are required to further strengthen existing policies and develop new interventions to target both forms of malnutrition.

Socioeconomic and geographic inequalities in antenatal and postnatal care components in India, 2016-2021

Despite the well-known importance of high-quality care before and after delivery, not every mother and newborn in India receive appropriate antenatal and postnatal care (ANC/PNC). Using India's National Family Health Surveys (2015-2016 and 2019-2021), we quantified the socioeconomic and geographic inequalities in the utilization of ANC/PNC among women aged 15-49 years and their newborns (N = 161,225 in 2016; N = 150,611 in 2021). For each of the eighteen ANC/PNC components, we assessed absolute and relative inequalities by household wealth (poorest vs. richest), maternal education (no education vs. higher than secondary), and type of place of residence (rural vs. urban) and evaluated state-level heterogeneity. In 2021, the national prevalence of ANC/PNC components ranged from 19.8% for 8 + ANC visits to 91.6% for maternal weight measurement. Absolute inequalities were greatest for ultrasound test (33.3%-points by wealth, 30.3%-points by education) and 8 + ANC visits (13.2%-points by residence). Relative inequalities were greatest for 8 + ANC visits (1.8 ~ 4.4 times). All inequalities declined over time. State-specific estimates were overall consistent with national results. Socioeconomic and geographic inequalities in ANC/PNC varied significantly across components and by states. To optimize maternal and newborn health in India, future interventions should aim to achieve universal coverage of all ANC/PNC components.

Historical Redlining and Present-Day Nonsuicide Firearm Fatalities

BACKGROUND

Redlining began in the 1930s with the Home Owners' Loan Corporation (HOLC); this discriminatory practice limited mortgage availability and reinforced concentrated poverty that still exists today. It is important to understand the potential health implications of this federally sanctioned segregation.

OBJECTIVE

To examine the relationship between historical redlining policies and present-day nonsuicide firearm fatalities.

DESIGN

Maps from the HOLC were overlaid with incidence of nonsuicide firearm fatalities from 2014 to 2022. A multilevel negative binomial regression model tested the association between modern-day firearm fatalities and HOLC historical grading (A ["best"] to D ["hazardous"]), controlling for year, HOLC area-level demographics, and state-level factors as fixed effects and a random intercept for city. Incidence rates (IRs) per 100 000 persons, incidence rate ratios (IRRs), and adjusted IRRs (aIRRs) for each HOLC grade were estimated using A-rated areas as the reference.

SETTING

202 cities with areas graded by the HOLC in the 1930s.

PARTICIPANTS

Population of the 8597 areas assessed by the HOLC.

MEASUREMENTS

Nonsuicide firearm fatalities.

RESULTS

From 2014 to 2022, a total of 41 428 nonsuicide firearm fatalities occurred in HOLC-graded areas. The firearm fatality rate increased as the HOLC grade progressed from A to D. In A-graded areas, the IR was 3.78 (95% CI, 3.52 to 4.05) per 100 000 persons per year. In B-graded areas, the IR, IRR, and aIRR relative to A areas were 7.43 (CI, 7.24 to 7.62) per 100 000 persons per year, 2.12 (CI, 1.94 to 2.32), and 1.42 (CI, 1.30 to 1.54), respectively. In C-graded areas, these values were 11.24 (CI, 11.08 to 11.40) per 100 000 persons per year, 3.78 (CI, 3.47 to 4.12), and 1.90 (CI, 1.75 to 2.07), respectively. In D-graded areas, these values were 16.26 (CI, 16.01 to 16.52) per 100 000 persons per year, 5.51 (CI, 5.05 to 6.02), and 2.07 (CI, 1.90 to 2.25), respectively.

LIMITATION

The Gun Violence Archive relies on media coverage and police reports.

CONCLUSION

Discriminatory redlining policies from 80 years ago are associated with nonsuicide firearm fatalities today.

PRIMARY FUNDING SOURCE

Fred Lovejoy Housestaff Research and Education Fund.

Early-Neonatal, Late-Neonatal, Postneonatal, and Child Mortality Rates Across India, 1993-2021

Importance

The global success of the child survival agenda depends on how rapidly mortality at early ages after birth declines in India, and changes need to be monitored to evaluate the status.

Objective

To understand the disaggregated patterns of decrease in early-life mortality across states and union territories (UTs) of India.

Design, Setting, and Participants

Repeated cross-sectional data from the 5 rounds of the National Family Health Survey conducted in 1992-1993, 1998-1999, 2005-2006, 2015-2016, and 2019-2021 were used in a representative population-based study. The study was based on data of children born in the past 5 years with complete information on date of birth and age at death. The analysis was conducted in February 2024.

Exposure

Time and geographic units.

Main Outcomes and Measures

Mortality rates were computed for 4 early-life periods: early-neonatal (first 7 days), late-neonatal (8-28 days), postneonatal (29 days to 11 months), and child (12-59 months). For early and late neonatal periods, the rates are expressed as deaths per 1000 live births, for postneonatal, as deaths per 1000 children aged at least 29 days and for child, deaths per 1000 children aged at least 1 year. These are collectively mentioned as deaths per 1000 for all mortalities. The relative burden of each of the age-specific mortalities to total mortality in children younger than 5 years was also computed.

Results

The final analytical sample included 33 667 (1993), 29 549 (1999), 23 020 (2006), 82 294 (2016), and 64 242 (2021) children who died before their fifth birthday in the past 5 years of each survey. Mortality rates were lowest for the late-neonatal and child periods; early-neonatal was the highest in 2021. Child mortality experienced the most substantial decrease between 1993 and 2021, from 33.5 to 6.9 deaths per 1000, accompanied by a substantial reduction in interstate inequalities. While early-neonatal (from 33.5 to 20.3 deaths per 1000), late-neonatal (from 14.1 to 4.1 deaths per 1000), and postneonatal (from 31.0 to 10.8 deaths per 1000) mortality also decreased, interstate inequalities remained notable. The mortality burden shifted over time and is now concentrated during the early-neonatal (48.3% of total deaths in children younger than 5 years) and postneonatal (25.6%) periods. A stagnation or worsening for certain states and UTs was observed from 2016 to 2021 for early-neonatal, late-neonatal, and postneonatal mortality. If this pattern continues, these states and UTs will not meet the United Nations Sustainable Development Goal targets related to child survival.

Conclusions and Relevance

In this repeated cross-sectional study of 5 time periods, the decrease in mortality during early-neonatal and postneonatal phases of mortality was relatively slower, with notable variations across states and UTs. The findings suggest that policies pertaining to early-neonatal and postneonatal mortalities need to be prioritized and targeting of policies and interventions needs to be context-specific.

Disclosing Recovery: A pilot randomized controlled trial of a patient decision aid to improve disclosure processes for people in treatment for opioid use disorder

INTRODUCTION

People engaged in treatment for opioid use disorder (OUD) report struggling with whether and how to disclose, or share information about their OUD history and/or treatment with others. Yet, disclosure can act as a gateway to re-establishing social connection and support during recovery. The current study describes a pilot randomized controlled trial of Disclosing Recovery: A Decision Aid and Toolkit, a patient decision aid designed to facilitate disclosure decisions and build disclosure skills.

METHODS

Participants (n = 50) were recruited from a community-based behavioral health organization in 2021-2022 and randomized to receive the Disclosing Recovery intervention versus an attention-control comparator. They responded to surveys immediately after receiving the intervention as well as one month following the intervention at a follow-up appointment. Primary outcome analyses examined indicators of implementation of the intervention to inform a future efficacy trial. Secondary outcome analyses explored impacts of the intervention on the decision-making process, disclosure rates, and relationships.

RESULTS

Participants were successfully recruited, randomized, and retained, increasing confidence in the feasibility of future efficacy trials to test the Disclosing Recovery intervention. Moreover, participants in the Disclosing Recovery intervention agreed that the intervention is acceptable, feasible, and appropriate. They additionally reported a higher quality of their decision-making process and decisions than participants in the comparator condition. At their follow-up appointment, participants with illicit opioid use who received the Disclosing Recovery intervention were less likely to disclose than those who received the comparator condition. Moreover, significant interactions between illicit opioid use and the intervention condition indicated that participants without illicit opioid use who received the Disclosing Recovery intervention reported greater closeness to and social support from their planned disclosure recipient than those who received the comparator condition.

CONCLUSIONS

The Disclosing Recovery intervention appears to be an acceptable, feasible, and appropriate patient decision aid for addressing disclosure processes among people in treatment for OUD. Moreover, preliminary results suggest that it shows promise in improving relationship closeness and social support in patients without illicit opioid use. More testing is merited to determine the intervention's efficacy and effectiveness in improving relationship and treatment outcomes for people in treatment for OUD.

Problems accessing health care and under-5 mortality: a pooled analysis of 50 low- and middle-income countries

BACKGROUND

Access to health care remains suboptimal in low- and middle-income countries (LMICs) and continues to hinder survival in early childhood. We systematically assessed the association between problems accessing health care (PAHC) and under-five mortality (U5M).

METHODS

Child mortality data on 724 335 livebirths came from the latest Demographic and Health Surveys of 50 LMICs (2013-2021). Reasons for PAHC were classified into three domains: 'money needed for treatment' (economic), 'distance to health facility' (physical), 'getting permission' or 'not wanting to go alone' (socio-cultural). Multivariable logistic regression was used to estimate the association between PAHC (any and by each type) and U5M.

RESULTS

In our pooled sample, 47.3 children per 1000 livebirths died before age of 5, and 57.1% reported having experienced PAHC (ranging from 45.3% in Europe & Central Asia to 72.7% in Latin America & Caribbean). Children with any PAHC had higher odds of U5M (OR: 1.05, 95% CI: 1.02, 1.09), and this association was especially significant in sub-Saharan Africa. Of different domains of PAHC, socio-cultural PAHC was found to be most significant.

CONCLUSIONS

Access to health care in LMICs needs to be improved by expanding health care coverage, building health facilities, and focusing more on context-specific socio-cultural barriers.

Trends in prevalence of unmet need for family planning in India: patterns of change across 36 States and Union Territories, 1993-2021

BACKGROUND

Eliminating unmet need for family planning by 2030 is a global priority for ensuring healthy lives and promoting well-being for all at all ages. We estimate the sub-national trends in prevalence of unmet need for family planning over 30 years in India and study differences based on socio-economic and demographic factors.

METHODS

We used data from five National Family Health Surveys (NFHS) conducted between 1993 to 2021 for the 36 states/Union Territories (UTs) of India. The study population included women of ages 15-49 years who were married or in a union at the time of the survey. The outcome was unmet need for family planning which captures the prevalence of fecund and sexually active women not using contraception, who want to delay or limit childbearing. We calculated the standardized absolute change to estimate the change in prevalence on an annual basis across all states/UTs. We examined the patterning of prevalence of across demographic and socioeconomic characteristics and estimated the headcount of women with unmet need in 2021.

RESULTS

The prevalence of unmet need in India decreased from 20·6% (95% CI: 20·1- 21·2%) in 1993, to 9·4% (95% CI: 9·3-9·6%) in 2021. Median unmet need prevalence across states/UTs decreased from 17·80% in 1993 to 8·95% in 2021. The north-eastern states of Meghalaya (26·9%, 95% CI: 25·3-28·6%) and Mizoram (18·9%, 95% CI: 17·2-20·6%), followed by the northern states of Bihar (13·6%, 95% CI: 13·1-14·1%) and Uttar Pradesh (12·9%, 95% CI: 12·5-13·2%), had the highest unmet need prevalence in 2021. As of 2021, the estimated number of women with an unmet need for family planning was 24,194,428. Uttar Pradesh, Bihar, Maharashtra, and West Bengal accounted for half of this headcount. Women of ages 15-19 and those belonging the poorest wealth quintile had a relatively high prevalence of unmet need in 2021.

CONCLUSIONS

The existing initiatives under the National Family Planning Programme should be strengthened, and new policies should be developed with a focus on states/UTs with high prevalence, to ensure unmet need for family planning is eliminated by 2030.

Age- and Gender-Specific Prevalence of Intellectually Disabled Population in India

Intellectual disability in India is substantially under-reported, especially amongst females. This study quantifies the prevalence and gender bias in household reporting of intellectual disability by estimating the age-and-gender specific prevalence of the intellectually disabled by education, Socio-Demographic Index (SDI) score, place of residence, (rural/urban) and income of household head. We estimated prevalence (per 100,000) at 179 (95% CI: 173 to 185) for males and 120 (95% CI: 115 to 125) for females. Gender differences declined sharply with increased education, was higher for lower ages and low income and varied little by state development. Under-identification and under-reporting due to stigma are two plausible reasons for the gender differences in prevalence that increase with age.

Prevalence, trend, and inequality of prolonged exclusive breastfeeding among children aged 6-23 months old in India from 1992-2021: A cross-sectional study of nationally representative, individual-level data

Background

Prolonged exclusive breastfeeding (PEB) for children older than six months old is a threat to appropriate complementary feeding practices. This study aims to examine the trend of PEB among children aged 6-23 months in India.

Methods

We adopted five waves of National Family Health Survey (NFHS) data between 1992-93 and 2019-21. PEB was defined as children aged six months and above currently consuming breastmilk as the only source of energy, protein and micronutrients. We generated descriptive statistics and a series of multivariable logistic regressions to estimate the prevalence and trend in the PEB rate. Moreover, we assessed how child age and socioeconomic factors (i.e. child gender and age, place of residence, household wealth, and maternal education) were related with PEB using mutually and single-adjusted model.

Results

There were 184 891 Indian children aged 6-23 months old included in this study with 48.0% being female. We found that the proportion of PEB increased from 4.3% in 1992 to 7.7% in 2021, of which the rate for children aged six-eight months rose from 14.0 to 20.1%. Our results showed that children who were from poorer households or with lower-educated mothers were more likely to experience prolonged exclusive breastfed. Take the year of 2019-21 as an example, compared to the households of the richest quintile, children from households of the poorer quintile were significantly more likely to experience PEB, with odds ratio (OR) of 1.33 (95% confidence interval (CI) = 1.09-1.61). Moreover, children with illiterate mothers had 21% higher odds of having prolonged exclusively breastfeeding (OR = 1.21; 95% CI = 1.01-1.44) compared with children with mothers who have college and above education.

Conclusions

PEB among children over six months old is prevalent in India, particularly among children from disadvantaged households. Poverty reduction and maternal education are of great potential importance for policymakers to promote appropriate complementary feeding practice.

Prevalence of Children Aged 6 to 23 Months Who Did Not Consume Animal Milk, Formula, or Solid or Semisolid Food During the Last 24 Hours Across Low- and Middle-Income Countries

Importance

The introduction of solid or semisolid foods alongside breast milk plays a vital role in meeting nutritional requirements during early childhood, which is crucial for child growth and development. Understanding the prevalence of zero-food children (defined for research purposes as children aged 6 to 23 months who did not consume animal milk, formula, or solid or semisolid food during the last 24 hours) is essential for targeted interventions to improve feeding practices.

Objective

To estimate the percentage of zero-food children in 92 low- and middle-income countries.

Design, Setting, and Participants

This cross-sectional study analyzed nationally representative cross-sectional household data of children aged 6 to 23 months from the Demographic and Health Surveys and the Multiple Indicator Cluster Surveys conducted between May 20, 2010, and January 27, 2022. Data were obtained from 92 low- and middle-income countries. Standardized procedures were followed to ensure data comparability and reliability. Both percentage and number of zero-food children were estimated.

Main Outcomes and Measures

The outcome studied was defined as a binary variable indicating children aged 6 to 23 months who had not been fed any animal milk, formula, or solid or semisolid foods during the 24 hours before each survey, as reported by the mother or caretaker.

Results

A sample of 276 379 children aged 6 to 23 months (mean age, 14.2 months [95% CI, 14.15-14.26 months]) in 92 low- and middle-income countries was obtained, of whom 51.4% (95% CI, 51.1%-51.8%) were boys. The estimated percentage of zero-food children was 10.4% (95% CI, 10.1%-10.7%) in the pooled sample, ranging from 0.1% (95% CI, 0%-0.6%) in Costa Rica to 21.8% (95% CI, 19.3%-24.4%) in Guinea. The prevalence of zero-food children was particularly high in West and Central Africa, where the overall prevalence was 10.5% (95% CI, 10.1%-11.0%), and in India, where the prevalence was 19.3% (95% CI, 18.9%-19.8%). India accounted for almost half of zero-food children in this study.

Conclusions and Relevance

In this cross-sectional study of 276 379 children aged 6 to 23 months, substantial disparities in the estimates of food consumption across 92 low- and middle-income countries were found. The prevalence of zero-food children underscores the need for targeted interventions to improve infant and young child feeding practices and ensure optimal nutrition during this critical period of development. The issue is particularly urgent in West and Central Africa and India.

Spousal multimorbidity and depressive symptoms among older Indian couples: Do one's own health status and sex matter?

With the aging population, increases in non-communicable diseases that require chronic management pose a substantial economic and social burden to individuals with multimorbid conditions and their spousal caregivers. However, little is known about the crossover effect of spousal multimorbidity on mental health outcomes in the context of low- and middle-income countries, and whether it depends on one's own health status and sex. We examined the association between spousal multimorbidity and depressive symptoms using data on 6,158 older couples (12,316 individuals aged 60 years or above) from the Longitudinal Aging Study in India (LASI) 2017-18. Overall, 23.4% of the sample were multimorbid and 27.0% reported having depressive symptoms in the past week. Multivariable logistic regression models showed that spousal multimorbidity was associated with depressive symptoms, even after accounting for one's own multimorbidity status (OR: 1.23; 95% CI: 1.06-1.44). However, this association varied by sex. Among males, their own multimorbidity status was associated with 60% higher odds of having depressive symptoms (OR: 1.60; 95% CI: 1.28-2.00), but spousal multimorbidity was not. Furthermore, for males, the association between spousal multimorbidity and depressive symptoms was contingent upon the presence of their own multimorbidity. Among females, spousal multimorbidity was significantly associated with depressive symptoms, regardless of their own multimorbidity status. Our findings indicate that interventions to promote healthy aging should expand the formal caregiving system and consider family-based approaches to minimize the crossover health consequences of chronic morbidity in conjugal relationships, especially for females.

Prevalence of girl and boy child marriage across states and Union Territories in India, 1993-2021: a repeated cross-sectional study

BACKGROUND

India's success in eliminating child marriage is crucial to the achievement of the Sustainable Development Goal target 5.3. We aimed to estimate the prevalence of child marriage in girls and boys in India and describe its change across 36 states and Union Territories between 1993 and 2021.

METHODS

For this cross-sectional study, data from five National Family Health Surveys from 1993, 1999, 2006, 2016, and 2021 were used. The study included 310 721 women aged 20-24 years between 1993 and 2021 and 43 436 men aged 20-24 years between 2006 and 2021. Child marriage was defined as marriage in individuals younger than 18 years for men and women. We calculated the annual change in prevalence during the study period for states and Union Territories and estimated the population headcount of child brides and grooms.

FINDINGS

Child marriage declined during 1993 to 2021. The all-India prevalence of child marriage in girls declined from 49·4% (95% CI 48·1-50·8) in 1993 to 22·3% (21·9-22·7) in 2021. Child marriage in boys declined from 7·1% (6·9-30·8) in 2006 to 2·2% (1·8-2·7) in 2021. The largest decreases in child marriage occurred between 2006 and 2016. Between 2016 and 2021, a few states and Union Territories saw an increase in prevalence of child marriage in girls (n=6) and boys (n=8) despite declines in the all-India prevalence. In 2021, 13 464 450 women aged 20-24 years and 1 454 894 men aged 20-24 years were estimated to be married as children.

INTERPRETATION

One in five girls and nearly one in six boys are still married below the legal age of marriage in India. There remains an urgent need for strengthened national and state-level policy to eliminate child marriage by 2030.

FUNDING

Bill & Melinda Gates Foundation.

Traffic Exposure and Breast Cancer Mortality by Area of Residence: Incorporating Clinical and Socioeconomic Data

Incorporating clinical and environmental data holds promise for monitoring vulnerable populations at the community level. This spatial epidemiology study explores the link between traffic-related air pollution and breast cancer mortality in Seoul, using public socioeconomic and clinical data from Samsung Medical Center's registry (N=6,089). Traffic and socioeconomic status were collected from official sources and integrated for spatial analysis. The findings revealed a significant association between adult breast cancer mortality and districts with high road density, NO2 emissions, and family income (p<0.05). Significant spatial autocorrelation of residuals was observed (Moran's I test p<0.001).

Complementary and Alternative Medicine Use, Cancer Screening, and Medical Checkups in Japan from 2001 to 2013: A Repeated Cross-Sectional Study

Introduction: The association between complementary and alternative medicine (CAM) use and other health-related behaviors is an important issue. A previous study reported that complementary medicine use is related to greater use of cancer screening, whereas alternative medicine use is related to lower use of cancer screening. Given the sparse evidence from Japan, we aimed to examine the association of CAM use with cancer screening and medical checkups. We used a repeated cross-sectional survey of a nationally representative sample of Japanese people and conducted age-period-cohort analysis. Methods: The study population was 68,217 of 83,827 individuals observed from 2001 to 2013 who received cancer screening. CAM users were defined as individuals who received acupuncture, moxibustion, anma/massage/shiatsu, or judo therapy for their most worrisome symptom. The outcomes of interest were receiving stomach, lung, colorectal, uterine, and breast cancer screenings and medical checkups. Using crossclassified multilevel logistic regression models, we estimated odds ratios (ORs) and 95% credible intervals (CIs) for cancer screening and medical checkups. Results: For CAM users of complementary medicine, the adjusted ORs for stomach, lung, and colorectal cancer screening were 1.40 (95% CI: 1.35-1.44), 1.37 (95% CI: 1.34-1.40), and 1.52 (95% CI: 1.49-1.54), respectively. We found similar results for uterine and breast cancer screening, and medical checkups. Conclusions: Irrespective of whether they use CAM, CAM users in Japan tend to receive a variety of cancer screenings and medical checkups.

The association of a disability-targeted cash transfer programme with disability status and health-care access: a quasi-experimental study using a nationwide cohort of 4·3 million Chinese adults living with severe disabilities

BACKGROUND

Cash transfer is a crucial policy tool to address inequality. The objective of this study was to investigate the association between China's disability-targeted cash transfer programme and disability status, as well as equitable access to rehabilitation and medical services.

METHODS

For this quasi-experimental study, we drew data from the nationwide administrative cohort of individuals with disabilities between Jan 1, 2015, and Dec 31, 2019. Individuals were enrolled in the cohort if they were aged 18 years or older, had severe disabilities as defined by the Chinese Government, and had available cash transfer information for at least 4 consecutive years, without having started receiving cash transfer benefits at the time of enrolment. We used a quasi-experimental design with propensity score matching to estimate the effects of cash transfers on disability status, access to rehabilitation services, and access to medical treatment. The primary outcomes were development of new disability and reduction of existing disabilities. Secondary outcomes were use of rehabilitation services, financial barriers as a major obstacle to accessing rehabilitation services, use of medical services by individuals who had an illness in the previous 2 weeks, and financial barriers as a major obstacle to accessing medical services.

FINDINGS

From an initial pool of 51 356 125 individuals with disabilities registered in the administrative system, 2 686 024 individuals were eligible for analysis, of whom 2 165 335 (80·6%) were cash transfer beneficiaries and 520 689 (19·4%) non-beneficiaries. After propensity score matching, the cohort included 4 330 122 adults with severe disabilities. Cash transfer beneficiaries had significantly lower odds of developing new disabilities over time than non-beneficiaries (odds ratio [OR] 0·90, 95% CI 0·86-0·94; p<0·0001) and higher odds of having a reduced number of disabilities over time (1·17, 1·10-1·25; p<0·0001). Compared with non-beneficiaries, cash transfer beneficiaries were more likely to use rehabilitation services (2·12, 2·11-2·13; p<0·0001) and medical services (1·74, 1·69-1·78; p<0·0001), and less likely to report financial hardship to access rehabilitation services (0·53, 0·52-0·54; p<0·0001) and medical services (0·88, 0·84-0·93; p<0·0001) at the study endpoint.

INTERPRETATION

The receipt of cash transfers was associated with improved disability status and increased access to disability-related services. The findings suggest that cash transfers could be a potential method for promoting universal health coverage among individuals living with disabilities.

FUNDING

China National Natural Science Foundation.

Prevalence and changes of intimate partner violence against women aged 15 to 49 years in 53 low-income and middle-income countries from 2000 to 2021: a secondary analysis of population-based surveys

BACKGROUND

In low-income and middle-income countries (LMICs), intimate partner violence poses a substantial barrier to accomplishing target 5.2 of the Sustainable Development Goals: to eliminate all forms of violence against women and girls. Our study aimed to assess the prevalence and changes of intimate partner violence against women in LMICs. We also explored the association between women's empowerment and intimate partner violence.

METHODS

In this secondary analysis of population-based surveys, we obtained data from the nationally representative Demographic and Health Surveys conducted in LMICs between 2000 and 2021. We selected countries with available data on the domestic violence module, and women aged 15 to 49 years who currently or formerly had a husband or partner, and who had provided information about intimate partner violence, were included in the analysis. We first estimated the weighted prevalence of intimate partner violence in LMICs with available data, and then we assessed the average annual rate of change using Poisson regression with robust error variance in a subset of countries with at least two surveys. We used multilevel analysis to investigate the association between intimate partner violence and women's empowerment measured at both the country and individual levels. Country-level empowerment was measured by gender inequality index, while individual-level empowerment considered social independence, decision making, and attitude to violence.

FINDINGS

A total of 359 479 women aged 15 to 49 years were included from 53 LMICs. 336 811 women from 21 countries with two surveys provided data for assessing the trends of intimate partner violence. The weighted prevalence of any type of intimate partner violence was 37·2% (95% CI 36·6 to 37·8). A significant overall decline in the prevalence of any type of intimate partner violence was observed with an average annual rate of change of -0·2% (95% CI -0·4 to -0·03); however six countries showed significant increasing trends, with average annual rates of change ranging from 1·2% (95% CI 0·7 to 1·7) in Nigeria to 6·6% (5·3 to 7·8) in Sierra Leone. Notably, the prevalence of psychological intimate partner violence has risen (average annual rate of change, 2·3% [95% CI 2·1 to 2·6]), reflected in increased rates across eight countries. Higher levels of country-level women's empowerment were associated with a lower risk of intimate partner violence: women from countries with the highest tertile of gender inequality index had an increased odds of any type of intimate partner violence (odds ratio 1·58 [95% CI 1·12 to 2·23]). Similarly, better individual-level women's empowerment also showed significant associations with a lower risk of intimate partner violence.

INTERPRETATION

The prevalence of intimate partner violence remains high, and some countries have shown an increasing trend. The strong relationship between both country-level and individual-level women's empowerment and the prevalence of intimate partner violence suggests that accelerating women's empowerment could be one strategy to further reduce intimate partner violence against women.

FUNDING

National Natural Science Foundation; Vanke School of Public Health, Tsinghua University; and Sanming Project of Medicine in Shenzhen.

An environmental justice analysis of air pollution in India

Due to the lack of timely data on socioeconomic factors (SES), little research has evaluated if socially disadvantaged populations are disproportionately exposed to higher PM2.5 concentrations in India. We fill this gap by creating a rich dataset of SES parameters for 28,081 clusters (villages in rural India and census-blocks in urban India) from the National Family and Health Survey (NFHS-4) using a precision-weighted methodology that accounts for survey-design. We then evaluated associations between total, anthropogenic and source-specific PM2.5 exposures and SES variables using fully-adjusted multilevel models. We observed that SES factors such as caste, religion, poverty, education, and access to various household amenities are important risk factors for PM2.5 exposures. For example, we noted that a unit standard deviation increase in the cluster-prevalence of Scheduled Caste and Other Backward Class households was significantly associated with an increase in total-PM2.5 levels corresponding to 0.127 μg/m3 (95% CI 0.062 μg/m3, 0.192 μg/m3) and 0.199 μg/m3 (95% CI 0.116 μg/m3, 0.283 μg/m3, respectively. We noted substantial differences when evaluating such associations in urban/rural locations, and when considering source-specific PM2.5 exposures, pointing to the need for the conceptualization of a nuanced EJ framework for India that can account for these empirical differences. We also evaluated emerging axes of inequality in India, by reporting associations between recent changes in PM2.5 levels and different SES parameters.

Small Area Geographic Estimates of Cardiovascular Disease Risk Factors in India

Importance

With an aging population, India is facing a growing burden of cardiovascular diseases (CVDs). Existing programs on CVD risk factors are mostly based on state and district data, which overlook health disparities within macro units.

Objective

To quantify and geovisualize the extent of small area variability within districts in CVD risk factors (hypertension, diabetes, and obesity) in India.

Design, Setting, and Participants

This cross-sectional study analyzed nationally representative data from the National Family Health Survey 2019-2021, encompassing individuals aged 15 years or older, for hypertension (n = 1 715 895), diabetes (n = 1 807 566), and obesity (n = 776 023). Data analyses were conducted from July 1, 2022, through August 1, 2023.

Exposures

Geographic units consisting of more than 30 000 small areas, 707 districts, and 36 states or Union Territories across India.

Main Outcomes and Measures

For primary outcomes, CVD risk factors, including hypertension, diabetes, and obesity, were considered. Four-level logistic regression models were used to partition the geographic variability in each outcome by state or Union Territory (level 4), district (level 3), and small area (level 2) and compute precision-weighted small area estimates. Spatial distribution of district-wide means, within-district small area variability, and their correlation were estimated.

Results

The final analytic sample consisted of 1 715 895 individuals analyzed for hypertension (mean [SD] age, 39.8 [17.3] years; 921 779 [53.7%] female), 1 807 566 for diabetes (mean [SD] age, 39.5 [17.2] years; 961 977 [53.2%] female), and 776 023 for obesity (mean [SD] age, 30.9 [10.2] years; 678 782 [87.5%] women). Overall, 21.2% of female and 24.1% of male participants had hypertension, 5.0% of female and 5.4% of men had diabetes, and 6.3% of female and 4.0% of male participants had obesity. For female participants, small areas (32.0% for diabetes, 34.5% for obesity, and 56.2% for hypertension) and states (30.0% for hypertension, 46.6% for obesity, and 52.8% for diabetes) accounted for the majority of the total geographic variability, while districts accounted for the least (13.8% for hypertension, 15.2% for diabetes, and 18.9% for obesity). There were moderate to strong positive correlations between district-wide mean and within-district variability (r = 0.66 for hypertension, 0.94 for obesity, and 0.96 for diabetes). For hypertension, a significant discordance between district-wide mean and within-district small area variability was found. Results were largely similar for male participants across all categories.

Conclusions and Relevance

This cross-sectional study found a substantial small area variability, suggesting the necessity of precise policy attention specifically to small areas in program formulation and intervention to prevent and manage CVD risk factors. Targeted action on policy-priority districts with high prevalence and substantial inequality is required for accelerating India's efforts to reduce the burden of noncommunicable diseases.

Socio-economic distribution of modifiable risk factors for cardiovascular diseases: An analysis of the national longitudinal ageing study in India

The association of socioeconomic status (SES) with modifiable risk factors for cardiovascular diseases (CVDs) is unclear in developing nations. We studied SES variations in major risk factors and their percentage distribution for adults aged 45 years or above in India. Using individual records of 59,672 individuals aged 45 years or above from the Longitudinal Ageing Study in India Wave 1 (cross-sectional study design), 2017-18, we chart age-and-sex-adjusted prevalence of clinical risk factors such as measured high blood pressure, hypertension, overweight, obesity, central adiposity and self-reported high blood glucose; and lifestyle risk factors such as excessive use of alcohol, current use of smoking and smokeless tobacco and physical inactivity across SES variables of education, quintiles of mean per capita expenditure and social caste. Multivariable analysis was used to explore the SES gradient of risk factors. The sample used in the study is predominantly rural (69.9%), illiterate (50.7%), has more females (54.2%), and belongs to other backward classes (45.6%). Prevalence of high blood pressure, overweight, obesity, central adiposity, high blood glucose, and physical inactivity increased; and excessive alcohol consumption and current use of smoking/smokeless tobacco decreased with income, education, and social caste. However, no significant income gradient was noted for lifestyle risk factors except the use of smokeless tobacco. The income gradient was largest for central adiposity (waist-circumference) with a difference of 23.4 percentage points as it increased from 38.7% among the poorest to 62.1% among the richest. The major burden of CVDs risk factors among older adults aged 45+ years falls among high SES.

Patterns in child stunting by age: A cross-sectional study of 94 low- and middle-income countries

Child stunting prevalence is primarily used as an indicator of impeded physical growth due to undernutrition and infections, which also increases the risk of mortality, morbidity and cognitive problems, particularly when occurring during the 1000 days from conception to age 2 years. This paper estimated the relationship between stunting prevalence and age for children 0-59 months old in 94 low- and middle-income countries. The overall stunting prevalence was 32%. We found higher stunting prevalence among older children until around 28 months of age-presumably from longer exposure times and accumulation of adverse exposures to undernutrition and infections. In most countries, the stunting prevalence was lower for older children after around 28 months-presumably mostly due to further adverse exposures being less detrimental for older children, and catch-up growth. The age for which stunting prevalence was the highest was fairly consistent across countries. Stunting prevalence and gradient of the rise in stunting prevalence by age varied across world regions, countries, living standards and sex. Poorer countries and households had a higher prevalence at all ages and a sharper positive age gradient before age 2. Boys had higher stunting prevalence but had peak stunting prevalence at lower ages than girls. Stunting prevalence was similar for boys and girls after around age 45 months. These results suggest that programmes to prevent undernutrition and infections should focus on younger children to optimise impact in reducing stunting prevalence. Importantly, however, since some catch-up growth may be achieved after age 2, screening around this time can be beneficial.

The plyometric treatment effects on change of direction speed and reactive agility in young tennis players: a randomized controlled trial

Aim: The aim of this paper is to determine the effect of 6 weeks of plyometric training on speed, explosive power, pre-planned agility, and reactive agility in young tennis players. Methods: The participants in this study included 35 male tennis players (age 12.14 ± 1.3 years, height 157.35 ± 9.53 cm and body mass 45.84 ± 8.43 kg at the beginning of the experiment). The biological age was calculated and determined for all participants. 18 of the participants were randomly assigned to the control group, and 17 were assigned to the experimental group. Running speed (sprints at 5, 10, and 20 m), change of direction speed (4 × 10, 20 yards, t-test, TENCODS), reactive agility (TENRAG), and explosive power (long jump, single leg triple jump, countermovement jump, squat jump, and single leg countermovement jump) were all tested. The Mixed model (2 × 2) ANOVA was used to determine the interactions and influence of a training program on test results. Furthermore, Bonferroni post hoc test was performed on variables with significant time*group interactions. Results: The results of this research indicate that an experimental training program affected results in a set time period, i.e. 5 out of total 15 variables showed significant improvement after experimental protocol when final testing was conducted. The experimental group showed significantly improved results in the 5 m sprint test in the final testing phase compared to the initial testing phase, this was also the case in comparison to the control group in both measurements. Furthermore, the experimental group showed significant improvement in the single leg countermovement jump in the final test, as well as in comparison to the control group in both measurements. The change of direction speed and reactive agility test also exhibited significant improvement in the final testing phase of the experimental group. Conclusion: The results of this research indicated that a 6-week program dominated by plyometric training can have a significant effect on the improvement of specific motor abilities within younger competitive categories. These results offer valuable insights for coaches in designing diverse tennis-specific scenarios to enhance overall performance, particularly focusing on the neuromuscular fitness of their players.

The puzzle of underreporting disability among tribal population in India: is it a statistical artifact or reality?

India is undergoing a demographic transition, and so is the tribal population of India. The outcome of this is ageing, and ageing is associated with disability. The tribals are the most vulnerable and marginalized section, despite being significant in numbers, there has not been much exploration of disability among tribals and non-tribals. We used secondary data from the nationally representative, Longitudinal Ageing Study in India (2017-2018). Our sample size consisted of 64,417 adults ages 45 years and older. We defined the disability as having functional limitations. Regression analysis was done to examine the association between disability and caste. Further, to eliminate selection bias, we employed the propensity score matching. Also, lifestyle factors that may have a positive and negative impact on the functional health were analyzed. The results of the study found that the prevalence of functional limitation is lower among the tribal population. After controlling other socio-economic variables, we found that scheduled tribes have lower likelihood of functional limitations. Further, the propensity score matching was done to control for the observable group differences with respect to socioeconomic characteristics; the results still held true. We also found that the positive lifestyle was more prevalent among the tribal groups, which may have impacted their healthy living. The study empirically found that tribal population have lower disability in comparison to the non-tribal population in India. The tribal are more active physically and socially, which may reduce the level of functional disability.

Prevalence of zero-sanitation in India: Patterns of change across the states and Union Territories, 1993-2021

Background

Ensuring universal access to safe sanitation by 2030 is a development priority for India. Doing so can help ensure improved physical and mental health outcomes. While the proportion of people in India with safe sanitation has risen dramatically over the past thirty years, much less is known about who has been most at risk for not having access to safe sanitation across India's states and Union Territories (UT) over this time period. We introduce the concept of zero-sanitation to fill this gap.

Methods

Data from five National Family Health Surveys (NFHS) conducted in 1993, 1999, 2006, 2016, and 2021 from 36 states and UT were used for this study. The study population consisted for all household individuals regardless of age in each survey round. Zero-sanitation was defined as those who have no access to a household toilet, and thus defecate in the open. We analyzed the percent prevalence of zero-sanitation in every state / UT at each time period in both urban and rural communities, as well as the population headcount burden in 2021. We calculated the absolute change on an annual basis to assess the change in percentage points of zero-sanitation across time periods at the all-India and state / UT levels.

Results

The all-India prevalence of zero-sanitation declined from 70.3% (95% confidence interval (CI) = 70.2%-70.5%) in 1993 to 17.8% (95% CI = 17.7%-17.9%) in 2021. The median percent prevalence of zero-sanitation across states and UTs was 65.9% in 1993. By 2021, the median percent prevalence of zero-sanitation across states and UTs was 5.7%. This reduction corresponded with a reduction in the between state / UT inequality in zero-sanitation. Nevertheless, as of 2021, the prevalence of zero-sanitation was still above 20% in Bihar, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, and Uttar Pradesh. Additionally, as of 2021, almost 92% of individuals who were defecating in the open were experiencing zero-sanitation. Zero-sanitation remains most common in states such as Bihar, Punjab, Uttar Pradesh, and Assam. Nevertheless, at this current rate of improvement, every state and UT except for Sikkim and Chandigarh are on track to end open defecation by 2030.

Conclusions

The concept of zero-sanitation is a useful tool in helping policy makers assess the extent to which sanitation coverage remains incomplete. When viewed through this lens, we see that open defecation remains most common among those who do not have a toilet. Addressing the myriad social determinants of sanitation access can help fill these gaps and ensure equitable sanitation coverage throughout India.

Modeling to explore and challenge inherent assumptions when cultural norms have changed: a case study on left-handedness and life expectancy

BACKGROUND

In 1991, Halpern and Coren claimed that left-handed people die nine years younger than right-handed people. Most subsequent studies did not find support for the difference in age of death or its magnitude, primarily because of the realization that there have been historical changes in reported rates of left-handedness.

METHODS

We created a model that allowed us to determine whether the historical change in left-handedness explains the original finding of a nine-year difference in life expectancy. We calculated all deaths in the United States by birth year, gender, and handedness for 1989 (the Halpern and Coren study was based on data from that year) and contrasted those findings with the modeled age of death by reported and counterfactual estimated handedness for each birth year, 1900-1989.

RESULTS

In 1989, 2,019,512 individuals died, of which 6.4% were reportedly left-handed based on concurrent annual handedness reporting. However, it is widely believed that cultural pressures may have caused an underestimation of the true rate of left-handedness. Using a simulation that assumed no age of death difference between left-handed and right-handed individuals in this cohort and adjusting for the reported rates of left-handedness, we found that left-handed individuals were expected to die 9.3 years earlier than their right-handed counterparts due to changes in the rate of left-handedness over time. This difference of 9.3 years was not found to be statistically significant compared to the 8.97 years reported by Halpern and Coren. When we assumed no change in the rate of left-handedness over time, the survival advantage for right-handed individuals was reduced to 0.02 years, solely driven by not controlling for gender. When we considered the estimated age of death for each birth cohort, we found a mean difference of 0.43 years between left-handed and right-handed individuals, also driven by handedness difference by gender.

CONCLUSION

We found that the changing rate of left-handedness reporting over the years entirely explains the originally reported observation of nine-year difference in life expectancy. In epidemiology, new information on past reporting biases could warrant re-exploration of initial findings. The simulation modeling approach that we use here might facilitate such analyses.

Socioeconomic and geographic variation in coverage of health insurance across India

Introduction

In India, regular monitoring of health insurance at district levels (the most essential administrative unit) is important for its effective uptake to contain the high out of pocket health expenditures. Given that the last individual data on health insurance coverage at district levels in India was in 2016, we update the evidence using the latest round of the National Family Health Survey conducted in 2019-2021.

Methods

We use the unit records of households from the latest round (2021) of the nationally representative National Family Health Survey to calculate the weighted percentage (and 95% CI) of households with at least one member covered by any form of health insurance and its types across socio-economic characteristics and geographies of India. Further, we used a random intercept logistic regression to measure the variation in coverage across communities, district and state. Such household level study of coverage is helpful as it represents awareness and outreach for at least one member, which can percolate easily to the entire household with further interventions.

Results

We found that only 2/5^th of households in India had insurance coverage for at least one of its members, with vast geographic variation emphasizing need for aggressive expansion. About 15.5% were covered by national schemes, 47.1% by state health scheme, 13.2% by employer provided health insurance, 3.3% had purchased health insurance privately and 25.6% were covered by other health insurance schemes (not covered above). About 30.5% of the total variation in coverage was attributable to state, 2.7% to districts and 9.5% to clusters. Household size, gender, marital status and education of household head show weak gradient for coverage under "any" insurance.

Discussion

Despite substantial increase in population eligible for state sponsored health insurance and rise in private health insurance companies, nearly 60% of families do not have a single person covered under any health insurance scheme. Further, the existing coverage is fragmented, with significant rural/urban and geographic variation within districts. It is essential to consider these disparities and adopt rigorous place-based interventions for improving health insurance coverage.

When social identities intersect: understanding inequities in growth outcomes by religion- caste and religion-tribe as intersecting strata of social hierarchy for Muslim and Hindu children in India

BACKGROUND

Minority social status determined by religion, caste and tribal group affiliations, are usually treated as independent dimensions of inequities in India. This masks relative privileges and disadvantages at the intersections of religion-caste and religion-tribal group affiliations, and their associations with population health disparities.

METHODS

Our analysis was motivated by applications of the intersectionality framework in public health, which underlines how different systems of social stratification mutually inform relative access to material resources and social privilege, that are associated with distributions of population health. Based on this framework and using nationally representative National Family Health Surveys of 1992-93, 1998-99, 2005-06, 2015-16 and 2019-21, we estimated joint disparities by religion-caste and religion-tribe, for prevalence of stunting, underweight and wasting in children between 0-5 years of age. As indicators of long- and short-term growth interruptions, these are key population health indicators capturing developmental potential of children. Our sample included Hindu and Muslim children of <  = 5 years, who belonged to Other (forward) castes (the most privileged social group), Other Backward Classes (OBCs), Schedule Castes (SCs) and Schedule Tribe (STs). Hindu-Other (forward) caste, as the strata with the dual advantages of religion and social group was specified as the reference category. We specified Log Poisson models to estimate multiplicative interactions of religion- caste and religion-tribe identities on risk ratio scales. We specified variables that may be associated with caste, tribe, or religion, as dimensions of social hierarchy, and/or with child growth as covariates, including fixed effects for states, survey years, child's age, sex, household urbanicity, wealth, maternal education, mother's height, and weight. We assessed patterns in growth outcomes by intersectional religion-caste and religion-tribe subgroups nationally, assessed their trends over the last 30 years, and across states.

FINDINGS

The sample comprised 6,594, 4,824, 8,595, 40,950 and 3,352 Muslim children, and 37,231, 24,551, 35,499, 1,87,573 and 171,055 Hindu children over NFHS 1, 2, 3, 4, and 5, respectively. As one example anthropometric outcome, predicted prevalence of stunting among different subgroups were as follows- Hindu Other: 34.7% (95%CI: 33.8, 35.7), Muslim Other: 39.2% (95% CI: 38, 40.5), Hindu OBC: 38.2 (95%CI: 37.1, 39.3), Muslim OBC: 39.6% (95%CI: 38.3, 41), Hindu SCs: 39.5% (95%CI: 38.2, 40.8), Muslims identifying as SCs: 38.5% (95%CI: 35.1, 42.3), Hindu STs: 40.6% (95% CI: 39.4, 41.9), Muslim STs: 39.7% (95%CI: 37.2, 42.4). Over the last three decades, Muslims always had higher prevalence of stunting than Hindus across caste groups. But this difference doubled for the most advantaged castes (Others) and reduced for OBCs (less privileged caste group). For SCs, who are the most disadvantaged caste group, the Muslim disadvantage reversed to an advantage. Among tribes (STs), Muslims always had an advantage, which reduced over time. Similar directions and effect sizes were estimated for prevalence of underweight. For prevalence of wasting, effect sizes were in the same range, but not statistically significant for two minority castes-OBCs and SCs.

INTERPRETATION

Hindu children had the highest advantages over Muslim children when they belonged to the most privileged castes. Muslim forward caste children were also disadvantaged compared to Hindu children from deprived castes (Hindu OBCs and Hindu SCs), in the case of stunting. Thus, disadvantages from a socially underprivileged religious identity, seemed to override relative social advantages of forward caste identity for Muslim children. Disadvantages born of caste identity seemed to take precedence over the social advantages of Hindu religious identity, for Hindu children of deprived castes and tribes. The doubly marginalized Muslim children from deprived castes were always behind their Hindu counter parts, although their differentials were less than that of Muslim-Hindu children of forward castes. For tribal children, Muslim identity seemed to play a protective role. Our findings indicate monitoring child development outcomes by subgroups capturing intersectional social experiences of relative privilege and access from intersecting religion and social group identities, could inform policies to target health disparities.

Uncovering inequities in Covid-19 vaccine coverage for adults and elderly in Brazil: A multilevel study of 2021-2022 data

Vaccination is crucial for reducing severe COVID-19 cases, hospitalizations, and deaths. However, vaccine access disparities within countries, particularly in low- and middle-income nations, may leave disadvantaged regions and populations behind. This study aimed to investigate potential inequalities in vaccine coverage among Brazilian aged 18 years and older based on demographic, geographic, and socioeconomic characteristics at the municipal level. A total of 389 million vaccination records from the National Immunization Program Information System were analyzed to calculate vaccine coverage rates for the first, second, and booster doses among adults (18-59 years) and elderly (60 + years) vaccinated between January 2021 and December 2022. We analyzed the data by gender and used a three-level (municipalities, states, regions) multilevel regression analysis to assess the association between vaccine coverage and municipal characteristics. Vaccination coverage was higher among the elderly than among adults, particularly for the second and booster doses. Adult women showed higher coverage rates than men (ranging from 118 % to 25 % higher along the analyzed period). Significant inequalities were observed when analyzing the evolution of vaccination coverage by sociodemographic characteristics of municipalities. In the early stages of the vaccination campaign, municipalities with higher per capita Gross Domestic Product (pGDP), educational level, and fewer Black residents reached higher population coverages earlier. In December 2022, adult and elderly booster vaccine coverage was 43 % and 19 %, respectively, higher in municipalities in the highest quintile of educational level. Higher vaccine uptake was also observed in municipalities with fewer Black residents and higher pGDP. Municipalities accounted for most of the variance in vaccine coverage (59.7 %-90.4 % depending on the dose and age group). This study emphasizes the inadequate booster coverage and the presence of socioeconomic and demographic disparities in COVID-19 vaccination rates. These issues must be addressed through equitable interventions to avoid potential disparities in morbidity and mortality.

Area level indirect exposure to extended conflicts and early childhood anthropometric outcomes in India: a repeat cross-sectional analysis

BACKGROUND

Protracted, internal conflicts with geographic variations within countries, are an important understudied community exposure for adverse child health outcomes.

METHODS

Violent events from the Uppsala Conflict Data Program (UCDP) between January 2016-December 2020 and January 2010-December 2015, were included as exposure events for children sampled in National Family Health Surveys (NFHS) 5 (2019-21) and NFHS 4 (2015-16), respectively. Geocoded data from UCDP were merged with residential clusters from NFHS, to identify children living in villages or urban blocks situated at <= 50 km from conflict sites. Within these clusters, which we defined as conflict exposed, we studied risks of stunting, underweight and wasting in children, prenatally, and in 0-3 years. We assessed sensitivity on a subsample of siblings with discordant conflict exposures.

RESULTS

For NFHS 5, exposure to violence between 0 and 3 years was associated with 1.16 times (95% CI 1.11-1.20) higher risks of stunting, 1.08 (1.04, 1.12) times higher risks of underweight, and no change in wasting. In-utero violence exposure was associated with 1.11 times (95% CI 1.04-1.17) higher risks of stunting, 1.08 (95% CI 1.02-1.14) times higher risks of underweight, and no change in wasting, among children <= 2 years. In 17,760 siblings of 8333 mothers, exposure to violence during 0-3 years, was associated with a 1.19 times higher risk of stunting (95% CI - 0.24 to 0.084). Incremental quartiles of violence exposure had higher risks of stunting and underweight until quartile 3.

CONCLUSION

In-utero and early childhood indirect exposure to protracted conflicts were associated with increased stunting and underweight in India. Given the continued exposures of such historically and contextually rooted internal conflicts in many LMICs, chronic violence exposures should be targeted in public health policies as important social and political determinant of child health.

Role of seasonality variation in prevalence and trend of childhood wasting in India: An empirical analysis using National Family Health Surveys, 2005-2021

Background

Wasting develops over a short period and can be reversed with short-term interventions. The prevalence of wasting typically varies from season to season-becoming higher during the monsoon (June to September) season as compared to the winter (October to January) and summer (February to May) seasons every year in a cyclical fashion. However, to the best of our knowledge, using nationally representative demographic surveys to extensively study the impact of the timing of the survey on the results and trends around wasting has not been done so far.

Objectives

The goal of this study is to ascertain whether seasonality has an impact on the trend and levels of wasting between NFHS-3 (2005-2006) and NFHS-5 (2019-2021).

Methods

The analysis was based on data on 51,555, 259,627, and 232,920 children under 5 years included in NFHS-3, NFHS-4, and NFHS-5 respectively. Multivariable logistic regression analysis and the predicted probabilities approach were employed to examine the effect of the months of interview on the prevalence of wasting. The analysis was conducted for 9 states of India which had data for comparable months to compute wasting levels.

Results

We found that at the national level, wasting increased in India by one per cent from NFHS-3 to NFHS-4 but declined by 2% from NFHS-4 to NFHS-5. The results show that seasonality significantly influenced the prevalence of wasting. It was observed that compared to January, the odds of wasting were particularly higher in summer and monsoon seasons, especially in the month of August across all three rounds, indicating the influence of seasonality in the prevalence of wasting in the country.

Discussion

The prevalence of wasting in India needs to be interpreted across seasonal changes as seasonality affects many of the variables intrinsically related to child health and nutritional status.

The Association between Anthropometric Failure and Toilet Types: A Cross-Sectional Study from India

Sustainable Development Goal 6.2 aims to end open defecation by 2030 by ensuring universal access to private household toilets. However, private toilets might not be feasible for poor households. As a result, policy makers and academics have suggested well-managed shared sanitation facilities as an alternative solution. Less is known about the associations between shared sanitation use and health. Using data from the fifth round of the National Family Health Survey from 2019 to 2021, we estimated the association between usual defecation location and child anthropometry outcomes among children under 2 years in India. The primary exposure was usual defecation location at the household level. We compared both shared improved toilet use and open defecation to private, improved toilet use. We used linear regression to estimate the associations between the exposures and linear outcomes: height-for-age Z-score, weight-for-height Z-score, and weight-for-age Z-score. We used Poisson regression with a log link to estimate the prevalence ratios of stunting, wasting, and underweight. After controlling for environmental, maternal, socioeconomic, and child confounders, we found no differences in six child anthropometry outcomes when comparing shared toilet use or open defecation to private toilet use. This finding was consistent across both urban and rural households. Our findings confirm the null associations between private toilet use and child growth found in previous studies, and that this association does not vary if the toilet is being shared. Future research should examine these differences between private and shared toilets in the context of other health outcomes.

Patterns in the Prevalence of Unvaccinated Children Across 36 States and Union Territories in India, 1993-2021

IMPORTANCE

Children who do not receive any routine vaccinations (ie, who have 0-dose status) are at elevated risk of death, morbidity, and socioeconomic vulnerabilities that limit their development over the life course. India has the world's highest number of children with 0-dose status; analysis of national and subnational patterns is the first important step to addressing this problem.

OBJECTIVES

To examine the patterns among children with 0-dose immunization status across all 36 states and union territories (UTs) in India over 29 years, from 1993 to 2021, and to elucidate the relative share of multiple geographic regions in the total geographic variation in 0-dose immunization.

DESIGN, SETTING, AND PARTICIPANTS

This repeated cross-sectional study analyzed all 5 rounds of India's National Family Health Survey (1992-1993, 1998-1999, 2005-2006, 2015-2016, and 2019-2021) to compare the prevalence of children with 0-dose status across time-space and geographic regions. The Integrated Public Use of Microdata Series was used to construct comparable geographic boundaries for states and UTs across surveys. The study included a total of 125 619 live children aged 12 to 23 months who were born to participating women.

MAIN OUTCOMES AND MEASURES

The outcome was a binary indicator of children's 0-dose vaccination status, coded as children aged 12 to 23 months at the time of the survey who had not received the first dose of the diphtheria-tetanus-pertussis-containing vaccine. The significance of each geographic unit was computed using the variance partition coefficient (VPC).

RESULTS

Among 125 619 children, the national prevalence of those with 0-dose status in India decreased from 33.4% (95% CI, 32.5%-34.2%) in 1993 to 6.6% (95% CI, 6.4%-6.8%) in 2021. A substantial reduction in the IQR of 0-dose prevalence across states from 30.1% in 1993 to 3.1% in 2021 suggested a convergence in state disparities. The prevalence in the northeastern states of Meghalaya (17.0%), Nagaland (16.1%), Mizoram (14.3%), and Arunachal Pradesh (12.6%) remained relatively high in 2021. Prevalence increased between 2016 and 2021 in 10 states, including several traditionally high-performing states and UTs, such as Telangana (1.16 percentage points) and Sikkim (0.92 percentage points). In 2021, 53.0% of children with 0-dose status resided in the populous states of Uttar Pradesh, Bihar, and Maharashtra. A multilevel analysis comparing the share of variation at the state, district, and cluster (primary sampling unit) levels revealed that clusters accounted for the highest share of the total variation in 2016 (44.7%; VPC [SE], 1.04 [0.32]) and 2021 (64.3%; VPC [SE], 0.38 [0.12]).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, findings from approximately 3 decades of analysis suggest the need for sustained efforts to target populous states like Uttar Pradesh and Bihar and northeastern parts of India. The resurgence of 0-dose prevalence in 10 states highlights the importance of programs like Intensified Mission Indradhanush 4.0, a major national initiative to improve immunization coverage. Prioritizing small administrative units will be important to strengthening India's efforts to bring every child into the immunization regime.

Small area variations in four measures of poverty among Indian households: Econometric analysis of National Family Health Survey 2019-2021

India has seen enormous reductions in poverty in the past few decades. However, much of this progress has been unequal throughout the country. This paper examined the 2019-2021 National Family Health Survey to examine small area variations in four measures of household poverty. Overall, the results show that clusters and states were the largest sources of variation for the four measures of poverty. These findings also show persistent within-district inequality when examining the bottom 10th wealth percentile, bottom 20th wealth percentile, and multidimensional poverty. Thus, these findings pinpoint the precise districts where between-cluster inequality in poverty is most prevalent. This can help guide policy makers in terms of targeting policies aimed at reducing poverty.

Association Between Parental Education and Simultaneous Malnutrition Among Parents and Children in 45 Low- and Middle-Income Countries

IMPORTANCE

Parental education is known to be associated with the health status of parents and their offspring. However, the association between parental education and the simultaneous manifestation of multiple forms of malnutrition within households remains underinvestigated globally.

OBJECTIVE

To assess the association between parental education and the simultaneous manifestation of malnutrition of both parent and child (either overnutrition or undernutrition)-referred to as the double burden of malnutrition (DBM)-at the household level in mother-child and father-child pairs in low- and middle-income countries (LMICs).

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the US Agency for International Development Demographic and Health Surveys (January 1, 2010, to December 31, 2021) to identify mother-child pairs and father-child pairs from LMICs. The eligibility criteria were as follows: (1) children aged 0 to 59 months; (2) nonpregnant mothers at the time of the survey in the sample of mother-child pairs; and (3) valid measures of the weight, height, and hemoglobin level for the child and at least 1 of their parents.

EXPOSURES

Highest level of parental education obtained and number of years of education completed.

MAIN OUTCOMES AND MEASURES

Four sets of multivariable logistic regression models were constructed to assess the association between parental education and DBM, and analysis was performed between March 10 and May 15, 2022.

RESULTS

This study included 423 340 mother-child pairs from 45 LMICs and 56 720 father-child pairs from 16 LMICs. The mean (SD) age of the mother-child pairs was 28.2 (6.1) and 1.9 (1.4) years, respectively; 48.8% of the children were female. We observed that 49.0% of mother-child pairs experienced DBM. Compared with mother-child pairs with no maternal education, higher maternal education was associated with a lower risk of DBM. For example, the odds ratio (OR) for tertiary maternal education was 0.71 (95% CI, 0.67-0.74). However, the association differed by DBM subtypes: higher maternal education was associated with a lower risk of both mothers and children being undernourished but with a higher risk of almost all DBM subtypes involving overnutrition. For example, compared with mother-child pairs with no maternal education, those with secondary education were less likely to develop simultaneous maternal and child undernutrition (OR, 0.83 [95% CI, 0.80-0.86]) but were more likely to experience simultaneous maternal and child overnutrition (OR, 2.20 [95% CI, 1.61-3.00]); similar results were observed for pairs with primary and tertiary education. The results in mother-child pairs remained consistent after controlling for paternal education. Among the father-child pairs, 26.5% had DBM, with fathers with tertiary education significantly more likely to experience simultaneous paternal overnutrition and child undernutrition (OR, 1.55 [95% CI, 1.23-1.95]) compared with pairs with no paternal education; they were also less likely to have both paternal and child undernutrition (OR, 0.70 [95% CI, 0.59-0.84]).

CONCLUSIONS AND RELEVANCE

In this study, maternal education and paternal education were independently associated with DBM, and the associations differed by DBM subtypes. These findings suggest that the different risks of malnutrition faced by households with various levels of education should thus be considered in policy evaluation.

Distribution of self-reported health in India: The role of income and geography

An important new large-scale survey database is brought to bear on measuring and analysing self-reported health in India. The most important correlates are age, income and location. There is substantial variation of health across the 102 'homogeneous regions' within the country, after controlling for household and individual characteristics. Higher income is correlated with better health in only 40% of India. We create novel maps showing regions with poor health, that is attributable to the location, that diverge from the conventional wisdom. These results suggest the need for epidemiological studies in the hotspots of ill-health and in regions where higher income does not correlate with improved health.

Impact of air pollution on stunting among children in Africa

BACKGROUND

Undernutrition is a global public health crisis, causing nearly half of deaths for children under age 5 years. Little is known regarding the impact of air pollution in-utero and early childhood on health outcomes related to undernutrition. The aim of our study is to evaluate the association of prenatal and early-life exposure to PM_2.5 and child malnutrition as captured by the height-for-age z-score (HAZ), and stunting in 32 countries in Africa. We also evaluated critical windows of susceptibility during pregnancy to each environmental risk.

METHODS

We linked nationally representative anthropometric data from 58 Demographic and Health Surveys (DHS) (n = 264,207 children < 5 years of age) with the average in-utero PM_2.5 concentrations derived from satellite imagery. We then estimated associations between PM_2.5 and stunting and HAZ after controlling for child, mother and household factors, and trends in time and seasonality.

RESULTS

We observed lower HAZ and increased stunting with higher in-utero PM_2.5 exposure, with statistically significant associations observed for stunting (OR: 1.016 (95% CI: 1.002, 1.030), for a 10 μg/m³ increase). The associations observed were robust to various model specifications. Wald tests revealed that sex, wealth quintile and urban/rural were not significant effect modifiers of these associations. When evaluating associations between trimester-specific PM_2.5 levels, we observed that associations between PM_2.5 and stunting was the largest.

CONCLUSIONS

This is one of the first studies for the African continent to investigate in-utero and early-life exposure to PM_2.5 is an important marker of childhood undernutrition. Our results highlight that PM_2.5 concentrations need to be urgently mitigated to help address undernutrition in children on the continent.

The Psychological Costs of the COVID-19 Pandemic and Heterogeneous Effects in South Korea: Evidence from a Difference-in-Differences Analysis

This study estimates the effects of the COVID-19 pandemic on life satisfaction and stress and examines whether these effects vary across different sociodemographic groups using a nationally representative sample in South Korea. We estimate the causal effects of COVID-19 on psychological well-being by exploiting regional variation in the spread of the pandemic in South Korea. While the number of confirmed cases was very small in other provinces in the first half of 2020, the coronavirus spread rapidly in Daegu after an outbreak in one church. We employ a difference-in-differences approach that compares changes in people's life satisfaction and stress before-and-after the initial surge of COVID-19 cases in Daegu and other provinces. Our results show that the proportion of people who are dissatisfied with life increased by 2.8-6.5 percentage points more in Daegu than in other provinces after the COVID-19 outbreak. During the same period, the proportion of people who reported feeling stressed increased more in Daegu than in other provinces by 5.8-8.9 percentage points. Our results also suggest that the negative impact of the COVID-19 outbreak on psychological well-being is significantly greater for men, young adults, middle-aged adults, self-employed workers, and middle-income individuals. On the other hand, the proportion of people who report feeling stressed among the highest-educated (a master's degree or higher) and high-income individuals decreased after the onset of the COVID-19 outbreak.

Small Area Variation in the Quality of Maternal and Newborn Care in India

IMPORTANCE

In India, the district serves as the primary policy unit for implementing and allocating resources for various programs aimed at improving key developmental and health indicators. Recent evidence highlights that high-quality care for mothers and newborns is critical to reduce preventable mortality. However, the geographic variation in maternal and newborn health service quality has never been investigated.

OBJECTIVE

To examine the variation between smaller areas within districts in the quality of maternal and newborn care in India.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study assessed data from women aged 15 to 49 years on the most recent birth (singleton or multiples) in the 5 years that preceded the fifth National Family Health Survey (June 17, 2019, to April 30, 2021).

EXPOSURES

Maternal and newborn care in 36 states and union territories (UTs), 707 districts, and 28 113 clusters (small areas) in India.

MAIN OUTCOMES AND MEASURES

The composite quality score of maternal and newborn care was defined as the proportion of components of care received of the total 11 essential components of antenatal and postnatal care. Four-level logistic and linear regression was used for analyses of individual components of care and composite score, respectively. Precision-weighted prevalence of each component of care and mean composite score across districts as well as their between-small area SD were calculated.

RESULTS

The final analytic sample for the composite score was composed of 123 257 births nested in 28 113 small areas, 707 districts, and 36 states/UTs. For the composite score, 58.3% of the total geographic variance was attributable to small areas, 29.3% to states and UTs, and 12.4% to districts. Of 11 individual components of care, the small areas accounted for the largest proportion of geographic variation for 6 individual components of care (ranging from 42.3% for blood pressure taken to 73.0% for tetanus injection), and the state/UT was the largest contributor for 4 components of care (ranging from 41.7% for being weighed to 52.3% for ultrasound test taken). District-level composite score and prevalence of individual care components and their variation across small areas within the districts showed a consistently strong negative correlation (Spearman rank correlation ρ = -0.981 to -0.886). Low-quality scores and large between-small area disparities were not necessarily concentrated in aspirational districts (mean district composite score [SD within districts], 92.7% [2.1%] among aspirational districts and 93.7% [1.8%] among nonaspirational districts).

CONCLUSIONS AND RELEVANCE

The findings of this cross-sectional study suggest that the policy around maternal and child health care needs to be designed more precisely to consider district mean and between-small area heterogeneity in India. This study may have implications for other low- and middle-income countries seeking to improve maternal and newborn outcomes, particularly for large countries with geographic heterogeneity.

Association of Neighborhood Conditions and Resources for Children With Life Expectancy at Birth in the US

Importance

To address inequities in life expectancy, we must understand the associations of modifiable socioeconomic and structural factors with life expectancy. However, the association of limited neighborhood resources and deleterious physical conditions with life expectancy is not well understood.

Objective

To evaluate the association of community social and economic conditions and resources for children with life expectancy at birth.

Design, Setting, and Participants

This cross-sectional study examined neighborhood child opportunity and life expectancy using data from residents of 65 662 US Census tracts in 2015. The analysis was conducted from July 6 to October 1, 2021.

Exposures

Neighborhood conditions and resources for children in 2015.

Main Outcomes and Measures

The primary outcome was life expectancy at birth at the Census tract level based on data from the US Small-Area Life Expectancy Estimates Project (January 1, 2010, to December 31, 2015). Neighborhood conditions and resources for children were quantified by Census tract Child Opportunity Index (COI) 2.0 scores for 2015. This index captures community conditions associated with children's health and long-term outcomes categorized into 5 levels, from very low to very high opportunity. It includes 29 indicators in 3 domains: education, health and environment, and social and economic factors. Mixed-effects and simple linear regression models were used to estimate the associations between standardized COI scores (composite and domain-specific) and life expectancy.

Results

The study included residents from 65 662 of 73 057 US Census tracts (89.9%). Life expectancy at birth across Census tracts ranged from 56.3 years to 93.6 years (mean [SD], 78.2 [4.0] years). Life expectancy in Census tracts with very low COI scores was lower than life expectancy in Census tracts with very high COI scores (-7.06 years [95% CI, -7.13 to -6.99 years]). Stepwise associations were observed between COI scores and life expectancy. For each domain, life expectancy was shortest in Census tracts with very low compared with very high COI scores (education: β = -2.02 years [95% CI, -2.12 to -1.92 years]); health and environment: β = -2.30 years [95% CI, -2.41 to -2.20 years]; social and economic: β = -4.16 years [95% CI, -4.26 to -4.06 years]). The models accounted for 41% to 54% of variability in life expectancy at birth (R2 = 0.41-0.54).

Conclusions and Relevance

In this study, neighborhood conditions and resources for children were significantly associated with life expectancy at birth, accounting for substantial variability in life expectancy at the Census tract level. These findings suggest that community resources and conditions are important targets for antipoverty interventions and policies to improve life expectancy and address health inequities.

Small area variation in severe, moderate, and mild anemia among women and children: A multilevel analysis of 707 districts in India

India is home to the highest global number of women and children suffering from anemia, with one in every two women impacted. India's current strategy for targeting areas with a high anemia burden is based on district-level averages, yet this fails to capture the substantial small area variation in micro-geographical (small area) units such as villages. We conducted statistical and econometric analyses to quantify the extent of small area variation in the three grades of anemia (severe, moderate, and mild) among women and children across 36 states/union territories and 707 districts of India. We utilized data from the fifth round of the National Family Health Survey conducted in 2019-21. The final analytic sample for analyses was 183,883 children aged 6-59 months and 690,153 women aged 15-49 years. The primary outcome variable for the analysis was the three anemia grades among women and children. We adopted a three-level and four-level logistic regression model to compute variance partitioning of anemia among women and children. We also computed precision-weighted prevalence estimates of women and childhood anemia across 707 districts and within-district, between-cluster variation using standard deviation (SD). For severe anemia among women, small area (villages or urban blocks) account for highest share (46.1%; Var: 0.494; SE: 0.150) in total variation followed by states (39.4%; Var: 0.422; SE: 0.134) and districts (12.8%; Var: 0.156; SE: 0.012). Similarly, clusters account for the highest share in the variation in severe (61.3%; Var: 0.899; SE: 0.069) and moderate (46.4%: Var: 0.398; SE: 0.011) anemia among children. For mild and moderate anemia among women, however, states were the highest source of variation. Additionally, we found a high and positive correlation between mean prevalence and inter-cluster SD of moderate and severe anemia among women and children. In contrast, the correlation was weaker for mild anemia among women (r = 0.61) and children (0.66). In this analysis, we are positing the critical importance of small area variation within districts when designing strategies for targeting high burden areas for anemia interventions.

Assessment of the predictive power of a causal variable: An application to the Head Start impact study

In a study attempting to estimate a causal effect of a causal variable, an assessment of the predictive power of the causal variable can shed light on the heterogeneity around its average effect. Using data from the Head Start Impact Study, a randomized controlled trial of the Head Start, a nation-wide early childhood education program in the United States, we provide a parallel comparison between measures of average effect and predictive power of the Head Start on five cognitive outcomes. We observed that one year of the Head Start increased scores for all five outcomes, with effect sizes ranging from 0.12 to 0.19 standard deviations. Percent variation explained by the Head Start ranged from 0.56 to 1.62%. For binary versions of the outcomes, the overall pattern remained; the Head Start on average improved the outcomes by meaningful magnitudes. In contrast, in a fully adjusted model, the Head Start only improved area under the curve (AUC) by less than 1% and its influence on the variance of predicted probabilities was negligible. The Head-Start-only model only achieved AUC ranging from 50.22 to 55.24%. Negligible predictive power despite the significant average effect suggests that the heterogeneity in effects may be large. The average effect estimates may not generalize well to different populations or different Head Start program settings. Assessment of the predictive power of a causal variable in randomized data should be a routine practice as it can provide helpful information on the causal effect and especially its heterogeneity.

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The average effect and predictive power of Head Start were assessed.

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Head Start increased scores for five cognitive outcomes with effect sizes ranging from 0.12 to 0.19 standard deviations.

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Head Start only explained less than 2% of the child-level variance in cognitive outcomes.

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Head Start only achieved about 50% in AUC and improved less than 1% in AUC when added to a full model.

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The impact of Head Start is meaningfully sized on average but the effect heterogeneity is large.

Small area variations in low birth weight and small size of births in India

The states and districts are the primary focal points for policy formulation and programme intervention in India. The within‐districts variation of key health indicators is not well understood and consequently underemphasised. This study aims to partition geographic variation in low birthweight (LBW) and small birth size (SBS) in India and geovisualize the distribution of small area estimates. Applying a four‐level logistic regression model to the latest round of the National Family Health Survey (2015–2016) covering 640 districts within 36 states and union territories of India, the variance partitioning coefficient and precision‐weighted prevalence of LBW (<2.5 kg) and SBS (mother's self‐report) were estimated. For each outcome, the spatial distribution by districts of mean prevalence and small area variation (as measured by standard deviation) and the correlation between them were computed. Of the total valid sample, 17.6% (out of 193,345 children) had LBW and 12.4% (out of 253,213 children) had SBS. The small areas contributed the highest share of total geographic variance in LBW (52%) and SBS (78%). The variance of LBW attributed to small areas was unevenly distributed across the regions of India. While a strong correlation between district‐wide percent and within‐district standard deviation was identified in both LBW (r = 0.88) and SBS (r = 0.87), they were not necessarily concentrated in the aspirational districts. We find the necessity of precise policy attention specifically to the small areas in the districts of India with a high prevalence of LBW and SBS in programme formulation and intervention that may be beneficial to improve childbirth outcomes.

The small areas contribute the highest share of the total geographic variance of low birth weight (LBW) and small birth size (SBS) in India.

A high burden of LBW is found mostly in the central‐western part of India and Odisha. The prevalence of SBS is high across the district of northern‐western regions and the north‐eastern regions of India.

The mean prevalence and standard deviation are strongly correlated in the case of both LBW (r = 0.88) and SBS (r = 0.87) in India. It indicates that the districts which have a higher prevalence of LBW and SBS also have a higher between small area disparity within the districts.

We find a similar pattern of distribution in LBW and SBS between the policy‐focused aspirational districts and other districts of India.

Findings indicate reprioritizing the policy intervention, focusing on the small areas of India for better childbirth outcomes.

Assessing the prevalence of young children living in households prepared for COVID-19 in 56 low- and middle-income countries

BACKGROUND

The COVID-19 pandemic and governments' attempts to contain it are negatively affecting young children's health and development in ways we are only beginning to understand and measure. Responses to the pandemic are driven largely by confining children and families to their homes. This study aims to assess the levels of and associated socioeconomic disparities in household preparedness for protecting young children under the age of five from being exposed to communicable diseases, such as COVID-19, in low- and middle-income countries (LMICs).

METHODS

Using data from nationally representative household surveys in 56 LMICs since 2016, we estimated the percentages of young children under the age of five living in households prepared for communicable diseases (e.g., COVID-19) and associated residential and wealth disparities at the country- and aggregate-level. Preparedness was defined on the basis of space for quarantine, adequacy of toilet facilities and hand hygiene, mass media exposure at least once a week, and phone ownership. Disparities within countries were measured as the absolute gap in two domains-household wealth and residential area - and compared across regions and country income groups.

RESULTS

The final data set included 766,313 children under age five. On average, 19.4% of young children in the 56 countries lived in households prepared for COVID-19, ranging from 0.6% in Ethiopia in 2016 to 70.9% in Tunisia in 2018. In close to 90% of countries (50), fewer than 50% of young children lived in prepared households. Young children in rural areas or in the poorest households were less likely to live in prepared households than their counterparts.

CONCLUSIONS

A large portion of young children under the age of five in LMICs were living in households that did not meet all preparedness guidelines for preventing COVID-19 and caring for patients at home. This study highlights the need to ensure all families in LMICs have the means to prevent the spread of the pandemic or other communicable illnesses to young children during pandemics.

Trends in Diet Quality and Cardiometabolic Risk Factors Among Korean Adults, 2007-2018

IMPORTANCE

Few studies have examined the dietary trends in Korea beyond evaluating selected food groups. To help prevent cardiometabolic disease burdens, a comprehensive investigation of the trends in overall diet quality and identification of possible contributing factors would be useful.

OBJECTIVE

To investigate the trends and independent associations of age, period, and birth cohort with diet quality and cardiometabolic risk factors among Korean adults.

DESIGN, SETTING, AND PARTICIPANTS

Serial cross-sectional and age-period-cohort analyses were conducted of nationally representative 24-hour dietary recall data from the Korea National Health and Nutrition Examination Survey 2007-2018. The study population included 65 416 Korean adults aged 19 to 79 years. Data analyses were conducted from March 1, 2020, through April 30, 2021.

EXPOSURES

Age, calendar year, birth cohort, and population sociodemographic characteristics.

MAIN OUTCOMES AND MEASURES

Korean Healthy Eating Index (KHEI), a validated diet quality score (range, 0-90, with higher scores indicating greater diet quality), and 8 cardiometabolic risk factors (waist circumference and systolic blood pressure, diastolic blood pressure, serum total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglyceride, and fasting blood glucose levels).

RESULTS

Among 65 416 participants, mean age (SD) was 44.5 (0.1) years and 36 631 were women (55.8%). In 2007-2018, the age-standardized mean (SE) KHEI score increased from 51.0 (0.4) to 52.1 (0.5), which was associated with reduced sodium intake and increased whole grain, dairy, and protein-rich food intakes. The mean (SE) KHEI score was lowest at age 39 years (50.1 [0.3]) and increased at older ages (58.0 [0.3] at 79 years). Controlling for age and period effects, the highest KHEI score was observed among the birth cohorts of 1960-1964 (53.6 [0.9]) and decreased in subsequent cohorts (45.5 [1.2] in the 1990-1999 birth cohort). Similar cohort effects in cardiometabolic risk factors were observed, showing the lowest waist circumference, blood pressure, and total cholesterol levels among the birth cohorts of the 1960s and 1970s and higher levels among more recent birth cohorts (1990-1999 vs 1960-1964: waist circumference, 83.8 [0.5] vs 81.4 [0.4] cm; systolic blood pressure, 118.7 [0.7] vs 116.4 [0.4] mm Hg; total cholesterol, 200.2 [0.9] vs 198.9 [0.7] mg/dL). At most ages, periods, and birth cohorts, the mean KHEI score was consistently higher in adults living in urban areas (at age 45 years: 50.5 [1.0] vs 49.7 [0.9] rural) and among high-income (at age 45 years: 50.7 [1.1] vs 49.3 [0.9] low income) and educational levels (at age 45 years: 53.1 [0.9] vs 49.1 [1.0] low educational level).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that, from 2007 to 2018, the diet quality of Korean adults modestly improved. Despite the improvement, inequalities in diet among age, birth cohort, and socioeconomic subgroups persisted, suggesting that more intense interventions may be needed to target the susceptible groups.

Components of Out-of-Pocket Expenditure and Their Relative Contribution to Economic Burden of Diseases in India

Importance

High out-of-pocket expenditure (OOPE) on health in India may limit achieving universal health coverage. A clear insight on the components of health expenditure may be necessary to make allocative decisions to reduce OOPE, and such details by sociodemographic group and state have not been studied in India.

Objective

To analyze the relative contribution of drugs, diagnostic tests, doctor and surgeon fees, and expenditure on other medical services and nonmedical health-related services, such as transport, lodging, and food, by sociodemographic characteristics of patients, geography, and type of illness.

Design, Setting, and Participants

A population-based cross-sectional health consumption survey conducted by the National Sample Survey Organisation in 2018 was analyzed in this cross-sectional study. Respondents who provided complete information on costs of medicine, doctors, diagnostics tests, other medical costs, and nonmedical costs were selected. Data were analyzed from August through September 2021.

Main Outcomes and Measures

Mean and median share of components (ie, medicine, diagnostic tests, doctor fees, other medical costs, and nonmedical costs) in total health care expenditure and income were calculated. Bivariate survey-weighted mean (with 95% CI) and median (IQR) expenditures were calculated for each component across sociodemographic characteristics. The proportion of total expenditure and income contributed by each cost was calculated for each individual. Mean and median were then used to summarize such proportions at the population level. The association between state net domestic product per capita and component share of each health care service was graphically explored.

Results

Health expenditure details were analyzed for 43 781 individuals for inpatient costs (27 272 [64.3%] women; 26 830 individuals aged 25-64 years [59.9%]) and 8914 individuals for outpatient costs (4176 [48.2%] women; 4901 individuals aged 25-64 years [54.2%]); most individuals were rural residents (24 106 inpatients [67.0]; 4591 outpatients [63.9%]). Medicines accounted for a mean of 29.1% (95% CI, 28.9%-29.2%) of OOPE among inpatients and 60.3% (95% CI, 59.7%-60.9%) of OOPE among outpatients. Doctor consultation charges were a mean of 15.3% (95% CI, 15.1%-15.4%) of OOPE among inpatients and 12.4% (95% CI, 12.1%-12.6%) of OOPE among outpatients. Diagnostic tests accounted for a mean of 12.3% (95% CI, 12.2%-12.4%) of OOPE for inpatient and 9.2% (95% CI, 8.9%-9.5%) of OOPE for outpatient services. Nonmedical costs accounted for a mean of 23.6% (95% CI, 23.3%-23.8%) of OOPE among inpatients and 14.6% (95% CI, 14.1%-15.1%) of OOPE among outpatients. Mean share of OOPE from doctor consultations and diagnostic test charges increased with socioeconomic status. For example, for the lowest vs highest monthly per capita income quintile among inpatients, doctor consultations accounted for 11.5% (95% CI, 11.1%-11.8%) vs 21.2% (95% CI, 20.8%-21.6%), and diagnostic test charges accounted for 10.9% (95% CI, 10.6%-11.1%) vs 14.3% (95% CI, 14.0%-14.5%). The proportion of mean annual health expenditure from mean annual income was $299 of $1918 (15.6%) for inpatient and $391 of $1788 (21.9%) for outpatient services.

Conclusions and Relevance

This study found that nonmedical costs were significant, share of total health care OOPE from doctor consultation and diagnostic test charges increased with socioeconomic status, and annual cost as a proportion of annual income was lower for inpatient than outpatient services.