A typology of dietary and anthropometric measures of nutritional need among children across districts and parliamentary constituencies in India, 2016

BACKGROUND

Anthropometry is the most commonly used approach for assessing nutritional need among children. Anthropometry alone, however, cannot differentiate between the two immediate causes of undernutrition: inadequate diet vs disease. We present a typology of nutritional need by simultaneously considering dietary and anthropometric measures, dietary and anthropometric failures (DAF), and assess its distribution among children in India.

METHODS

We used the 2015-16 National Family Health Survey, a nationally representative sample of children aged 6-23 months (n = 67 247), from India. Dietary failure was operationalized using World Health Organization (WHO) standards for minimum dietary diversity. Anthropometric failure was operationalized using WHO child growth reference standard z-score of <-2 for height-for-age (stunting), weight-for-age (underweight) and weight-for-height (wasting). We also created a combined anthropometric measure for children who had any one of these three anthropometric failures. We cross-tabulated dietary and anthropometric failures to produce four combinations: Dietary Failure Only (DFO), Anthropometric Failure Only (AFO), Both Failures (BF), and Neither Failure (NF). We estimated the prevalence and distribution of the four types, nationally, and across 640 administrative districts and 543 Parliamentary Constituencies (PCs) in India.

RESULTS

Nationally, 80.3% of children had dietary failure and 53.7% had at least one anthropometric failure. The prevalence for the four DAF types was: 44.0% (BF), 36.3% (DFO), 9.8% (AFO), and 9.9% (NF). Dietary and anthropometric measures were discordant for 46.1% of children; these children had nutritional needs identified by only one of the two measures. Nationally, this translates to 12 181 627 children with DFO and 3 281 913 children with AFO; the nutritional needs of these children would not be captured if using only dietary or anthropometric assessment. Substantial variation was observed across districts and PCs for all DAF types. The interquartile ranges for districts were largest for BF (29.8%-53.0%) and lowest for AFO (5.5%-13.4%).

CONCLUSIONS

The current emphasis on anthropometry for measuring nutritional need should be complemented with diet- and food-based measures. By differentiating inadequate food intake from other causes of undernutrition, the DAF typology brings precision in identifying nutritional needs among children. These insights may improve the development and targeting of nutrition interventions.

The Relative Contributions of Socioeconomic and Genetic Factors to Variations in Body Mass Index Among Young Adults

In light of recent findings on the small proportion of variance in body mass index (BMI) explained by shared environment, and growing interests in the role of genetic susceptibility, we assessed the relative contribution of socioeconomic status (SES) and genome-wide polygenic score for BMI to explaining variation in BMI. Our final analytic sample included 4,918 White and 1,546 Black individuals from the US National Longitudinal Study of Adolescent to Adult Health Wave IV (2007-2008) who had complete measures on BMI, demographics, SES, genetic data, and health behaviors. We used ordinary least-squares regression to assess variation in log(BMI) as a function of the aforementioned predictors, independently and mutually adjusted. All analyses were stratified by race/ethnicity in the main analysis, and further by sex. The age-adjusted variation in log(BMI) was 0.055 among Whites and 0.066 among Blacks. The contribution of SES and polygenic score ranged from less than1% to 6% and from 2% to 8%, respectively, and majority of the variation (87%-96%) in log(BMI) remained unexplained. Differential distribution of socioeconomic resources, stressors, and buffers may interact to produce systematically larger variation in vulnerable populations. More understanding of the contribution of biological, genetic, and environmental factors, as well as stochastic elements, in diverse phenotypic variance is needed in population health sciences.

Malnutrition and poverty in India: does the use of public distribution system matter?

Background

Large scale public investment in Public Distribution System (PDS) have aimed to reduce poverty and malnutrition in India. The PDS is the largest ever welfare programme which provides subsidised food grain to the poor households. This study attempt to examine the extent of stunting and underweight among the children from poor and non-poor households by use of public distribution system (PDS) in India.

Methods

Data from the National Family and Health Survey-4 (NFHS-4), was used for the analysis. A composite variable based on asset deprivation and possession of welfare card provided under PDS (BPL card), was computed for all households and categorised into four mutually exclusive groups, namely real poor, excluded poor, privileged non-poor and non-poor. Real poor are those economically poor and have a welfare card, excluded poor are those economically poor and do not have welfare card, privileged poor are those economically non-poor but have welfare card, and non-poor are those who are not economically poor and do not have welfare card. Estimates of stunting and underweight were provided by these four categories. Descriptive statistics and logistic regression were used for the analysis.

Results

About half of the children from each real poor and excluded poor, two-fifths among privileged non-poor and less than one-third among non-poor households were stunted in India. Controlling for socio-economic and demographic covariates, the adjusted odds ratio of being stunted among real poor was 1.42 [95% CI: 1.38, 1.46], 1.43 [95% CI: 1.39, 1.47], among excluded poor and 1.15 [95% CI: 1.12, 1.18], among privileged non-poor. The pattern was similar for underweight and held true in most of the states of India.

Conclusions

Undernutrition among children from poor households those excluded from PDS is highest, and it warrants inclusion in PDS. Improving the quality of food grains and widening food basket in PDS is recommended for reduction in level of malnutrition in India.

Estimating the influence of adolescent delinquent behavior on adult health using sibling fixed effects

Despite the well-established link between juvenile delinquency and socioeconomic attainment in adulthood, less is known about whether engagement in delinquent behavior during adolescence shapes adult health outcomes. This study examines the association between juvenile delinquency and adult physical and mental health, and whether this association is confounded by unobserved family heterogeneity. Moreover, this study explores the potential underlying mechanisms through which juvenile delinquency shapes adult physical and mental health. Using data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) 1994-1995 (Wave 1) and 2007-2008 (Wave 4), we adopted a sibling fixed effect approach to account for genetic factors, family environment, and childhood social contexts such as school and neighborhood effects. The conventional OLS results show that engagement in delinquent behavior during adolescence strongly predicts higher levels of Framingham cardiovascular disease (CVD) risk score and depressive symptoms in adulthood. Once we account for family-specific heterogeneity, however, the point estimates of the associations of delinquency with CVD risk score and depressive symptoms are attenuated by 33% and 45%, respectively. Despite this attenuation, the association of juvenile delinquency with adult health is robust: a one standard-deviation increase in juvenile delinquency is associated with approximately 8 and 6 percent of one standard-deviation increases in CVD risk and depressive symptoms, respectively. Our mediation analyses suggest that a combination of several mediating pathways jointly explain the association between juvenile delinquency with adult health. The most consistent and significant mediating pathways connecting juvenile delinquency to both physical and mental health included disruption in student-teacher relationship, smoking, criminal justice contact, and educational attainment. Moreover, while binge drinking explained part of the association between delinquency and CVD risk score, student-friend relationship partially mediated the association with depression.

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

OBJECTIVE

The prevalence of type 2 diabetes is rising rapidly in low-income and middle-income countries (LMICs), but the factors driving this rapid increase are not well understood. Adult height, in particular shorter height, has been suggested to contribute to the pathophysiology and epidemiology of diabetes and may inform how adverse environmental conditions in early life affect diabetes risk. We therefore systematically analyzed the association of adult height and diabetes across LMICs, where such conditions are prominent.

RESEARCH DESIGN AND METHODS

We pooled individual-level data from nationally representative surveys in LMICs that included anthropometric measurements and diabetes biomarkers. We calculated odds ratios (ORs) for the relationship between attained adult height and diabetes using multilevel mixed-effects logistic regression models. We estimated ORs for the pooled sample, major world regions, and individual countries, in addition to stratifying all analyses by sex. We examined heterogeneity by individual-level characteristics.

RESULTS

Our sample included 554,122 individuals across 25 population-based surveys. Average height was 161.7 cm (95% CI 161.2-162.3), and the crude prevalence of diabetes was 7.5% (95% CI 6.9-8.2). We found no relationship between adult height and diabetes across LMICs globally or in most world regions. When stratifying our sample by country and sex, we found an inverse association between adult height and diabetes in 5% of analyses (2 out of 50). Results were robust to alternative model specifications.

CONCLUSIONS

Adult height is not associated with diabetes across LMICs. Environmental factors in early life reflected in attained adult height likely differ from those predisposing individuals for diabetes.

Online negative sentiment towards Mexicans and Hispanics and impact on mental well-being: A time-series analysis of social media data during the 2016 United States presidential election

Purpose

The purpose was to use Twitter to conduct online surveillance of negative sentiment towards Mexicans and Hispanics during the 2016 United States presidential election, and to examine its relationship with mental well-being in this targeted group at the population level.

Methods

Tweets containing the terms Mexican(s) and Hispanic(s) were collected within a 20-week period of the 2016 United States presidential election (November 9th 2016). Sentiment analysis was used to capture percent negative tweets. A time series lag regression model was used to examine the association between percent count of negative tweets mentioning Mexicans and Hispanics and percent count of worry among Hispanic Gallup poll respondents.

Results

Of 2,809,641 tweets containing terms Mexican(s) and Hispanic(s), 687,291 tweets were negative. Among 8,314 Hispanic Gallup respondents, a mean of 33.5% responded to be worried on a daily basis. A significant lead time of 1 week was observed, showing that negative tweets mentioning Mexicans and Hispanics appeared to forecast daily worry among Hispanics by 1 week.

Conclusion

Surveillance of online negative sentiment towards racially vulnerable population groups can be captured using social media. This has potential to identify early warning signals for symptoms of mental well-being among targeted groups at the population level.

Association and interplay of surgeon and hospital volume with mortality after open abdominal aortic aneurysm repair in the modern era

OBJECTIVE

Operative volume has been used as a marker of quality. Research from previous decades has suggested minimum open abdominal aortic aneurysm (AAA) repair volume requirements for surgeons of 9 to 13 open AAA repairs annually and for hospitals of 18 open AAA repairs annually to purportedly achieve acceptable results. Given concerns regarding the decreased frequency of open repairs in the endovascular era, we examined the association of surgeon and hospital volume with the 30- and 90-day mortality in the Vascular Quality Initiative (VQI) registry.

METHODS

Patients who had undergone elective open AAA repair from 2013 to 2018 were identified in the VQI registry. We performed a cross-sectional evaluation of the association between the average hospital and surgeon volume and 30-day postoperative mortality using a hierarchical Bayesian model. Cross-level interactions were permitted, and random surgeon- and hospital-level intercepts were used to account for clustering. The mortality results were adjusted by standardizing to the observed distribution of relevant covariates in the overall cohort. The outcomes were compared to the Society for Vascular Surgery guidelines recommended criteria of <5% perioperative mortality.

RESULTS

A total of 3078 patients had undergone elective open AAA repair by 520 surgeons at 128 hospitals. The 30- and 90-day risks of postoperative mortality were 4.1% (n = 126) and 5.4% (n = 166), respectively. The mean surgeon volume and hospital volume both correlated inversely with the 30-day mortality. Averaged across all patients and hospitals, we found a 96% probability that surgeons who performed an average of four or more repairs per year achieved <5% 30-day mortality. Substantial interplay was present between surgeon volume and hospital volume. For example, at lower volume hospitals performing an average of five repairs annually, <5% 30-day mortality would be expected 69% of the time for surgeons performing an average of three operations annually. In contrast, at higher volume hospitals performing an average of 40 repairs annually, a <5% 30-day mortality would be expected 96% of the time for surgeons performing an average of three operations annually. As hospital volume increased, a diminishing difference occurred in 30-day mortality between lower and higher volume surgeons. Likewise, as surgeon volume increased, a diminishing difference was found in 30-day mortality between the lower and higher volume hospitals.

CONCLUSIONS

Surgeons and hospitals in the VQI registry achieved mortality outcomes of <5% (Society for Vascular Surgery guidelines), with an average surgeon volume that was substantially lower compared with previous reports. Furthermore, when considering the development of minimal surgeon volume guidelines, it is important to contextualize the outcomes within the hospital volumes.

Racial and Ethnic Disparities in Patient Experiences in the United States: 4-Year Content Analysis of Twitter

BACKGROUND

Racial and ethnic minority groups often face worse patient experiences compared with the general population, which is directly related to poorer health outcomes within these minority populations. Evaluation of patient experience among racial and ethnic minority groups has been difficult due to lack of representation in traditional health care surveys.

OBJECTIVE

This study aims to assess the feasibility of Twitter for identifying racial and ethnic disparities in patient experience across the United States from 2013 to 2016.

METHODS

In total, 851,973 patient experience tweets with geographic location information from the United States were collected from 2013 to 2016. Patient experience tweets included discussions related to care received in a hospital, urgent care, or any other health institution. Ordinary least squares multiple regression was used to model patient experience sentiment and racial and ethnic groups over the 2013 to 2016 period and in relation to the implementation of the Patient Protection and Affordable Care Act (ACA) in 2014.

RESULTS

Racial and ethnic distribution of users on Twitter was highly correlated with population estimates from the United States Census Bureau's 5-year survey from 2016 (r²=0.99; P<.001). From 2013 to 2016, the average patient experience sentiment was highest for White patients, followed by Asian/Pacific Islander, Hispanic/Latino, and American Indian/Alaska Native patients. A reduction in negative patient experience sentiment on Twitter for all racial and ethnic groups was seen from 2013 to 2016. Twitter users who identified as Hispanic/Latino showed the greatest improvement in patient experience, with a 1.5 times greater increase (P<.001) than Twitter users who identified as White. Twitter users who identified as Black had the highest increase in patient experience postimplementation of the ACA (2014-2016) compared with preimplementation of the ACA (2013), and this change was 2.2 times (P<.001) greater than Twitter users who identified as White.

CONCLUSIONS

The ACA mandated the implementation of the measurement of patient experience of care delivery. Considering that quality assessment of care is required, Twitter may offer the ability to monitor patient experiences across diverse racial and ethnic groups and inform the evaluation of health policies like the ACA.

Association does not imply prediction: the accuracy of birthweight in predicting child mortality and anthropometric failure

PURPOSE

Epidemiologic studies often conflate the strength of association with predictive accuracy and build classification models based on arbitrarily selected probability cutoffs without considering the cost of misclassification. We illustrated these common pitfalls by building association, prediction, and classification models using birthweight as an exposure and child mortality and child anthropometric failure as outcomes.

METHODS

Nationally representative samples of 188,819 and 164,113 children aged less than 5 years across India were used for our analysis of mortality and anthropometric failure, respectively. We assessed outcomes of neonatal, postneonatal, and child mortality as well as stunting, wasting, and underweight. Birthweight was the main exposure. We used adjusted and unadjusted logistic regression models to evaluate association strength, univariable and multivariable logistic regression models trained on 80% of the data using 10-fold cross-validation to evaluate predictive power, and classification models across a series of possible misclassification cost scenarios to evaluate classification accuracy.

RESULTS

Birthweight was strongly associated with five of six outcomes (P < .001), and associations were robust to covariate adjustment. Prediction models evaluated on the test set showed that birthweight was a poor discriminator of all outcomes (area under the curve < 0.62), and that adding birthweight to a multivariable model did not meaningfully improve discrimination. Prediction models for anthropometric failure showed substantially better calibration than prediction models for mortality. Depending on the ratio of false positive (FP) cost to false negative (FN) cost, the probability cutoff that minimized total misclassification cost ranged from 0.116 (cost ratio = 7:93) to 0.706 (cost ratio = 4:1), TPR ranged from 0.999 to 0.004, and PPV ranged from 0.355 to 0.867..

CONCLUSIONS

Although birthweight is strongly associated with mortality and anthropometric failure, it is a poor predictor of child health outcomes, highlighting that strong associations do not imply predictive power. We recommend that (1) future research focus on building predictive models for anthropometric failure given their clinical relevance in diagnosing individual cases, and that (2) studies that build classifiers report performance metrics across a range of cutoffs to account for variation in the cost of FPs and FNs.

Dietary Variation among Children Meeting and Not Meeting Minimum Dietary Diversity: An Empirical Investigation of Food Group Consumption Patterns among 73,036 Children in India

BACKGROUND

Minimum Dietary Diversity (MDD) is a widely used indicator of adequate dietary micronutrient density for children 6-23 mo old. MDD food-group data remain underutilized, despite their potential for further informing nutrition programs and policies.

OBJECTIVES

We aimed to describe the diets of children meeting MDD and not meeting MDD in India using food group data, nationally and subnationally.

METHODS

Food group data for children 6-23 mo old (n = 73,036) from the 2015-16 National Family Health Survey in India were analyzed. Per WHO standards, children consuming ≥5 of the following food groups in the past day or night met MDD: breast milk; grains, roots, or tubers; legumes or nuts; dairy; flesh foods; eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables. Children not meeting MDD consumed <5 food groups. We analyzed the number and types of foods consumed by children meeting MDD and not meeting MDD at the national and subnational geographic levels.

RESULTS

Nationally, children not meeting MDD most often consumed breast milk (84.5%), grains, roots, and tubers (62.0%), and/or dairy (42.9%). Children meeting MDD most often consumed grains, roots, and tubers (97.6%), vitamin A-rich fruits and vegetables (93.8%), breast milk (84.1%), dairy (82.1%), other fruits and vegetables (79.5%), and/or eggs (56.5%). For children not meeting MDD, district-level dairy consumption varied the most (6.4%-79.9%), whereas flesh foods consumption varied the least (0.0%-43.8%). For children meeting MDD, district-level egg consumption varied the most (0.0%-100.0%), whereas grains, roots, and tubers consumption varied the least (66.8%-100.0%).

CONCLUSIONS

Children not meeting MDD had low fruit, vegetable, and protein-rich food consumption. Many children meeting MDD also had low protein-rich food consumption. Examining the number and types of foods consumed highlights priorities for children experiencing the greatest dietary deprivation, providing valuable complementary information to MDD.

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

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

Associations between older adults' parental bereavement and their health and well-being: Evidence from the China health and retirement longitudinal study

OBJECTIVES

Few studies have investigated the association between losing a child and parental health and wellbeing, especially among older Chinese bereaved parents. This study examined depressive symptoms, life satisfaction, and self-rated health of older Chinese bereaved parents to estimate the health and well-being of this group.

METHODS

This research used data from the 2015 China Health and Retirement Longitudinal Study (CHARLS). A total number of 11,507 participants age 45 and older were enrolled in the analysis, including 1,758 bereaved adults who had experienced a child's death and 9,749 non-bereaved counterparts. Multivariate linear and logistic regression models were used to examine the effect of bereavement and its interaction effect by sex and age.

RESULTS

Multivariate analyses revealed that the death of a child is associated with an increasing likelihood of experiencing depressive symptoms (adjusted OR = 1.425, p < 0.001), and a reduced probability of a high level of life satisfaction (adjusted OR = 0.725, p < 0.05), whereas experiencing a child's death is not significantly associated with self-reported health status. The effects of bereavement on health and well-being were found to have a much greater impact among participants who were males (compared to females) and who aged<60 years (compared to those ≥60 years).

DISCUSSION

Future longitudinal prospective research is expected to examine the causal relationship and explore the attributes of child death and its effects on parental health. Interventions to improve the health and well-being of the older bereaved population are warranted, particularly for those who are male and under 60 years of age.

The relationship between Jim Crow laws and social capital from 1997-2014: A 3-level multilevel hierarchical analysis across time, county and state

INTRODUCTION

Jim Crow laws in the United States promoted racial prejudice, which may have reduced social capital. Our study tests the relationship between Jim Crow laws and social capital.

METHODS

We conducted 3-level multilevel hierarchical modeling to study differences in the stock of social capital for 1997, 2005, 2009 in Jim Crow states compared to states without Jim Crow laws. We examined the moderation effects of county level median income, percent Black and percent with high school education and Jim Crow laws on social capital.

RESULTS

Jim Crow laws significantly reduced stock of social capital across 1997, 2005, 2009. The model was robust to the inclusion of random county, states, time and fixed county and state level covariates for median income, percent Black and percent with high school education. The largest percent of between state variations explained for fixed variables was from the addition of Jim Crow laws with 2.86%. These results demonstrate that although Jim Crow laws were abolished in 1965, the effects of racial segregation appear to persist through lower social connectiveness, community and trust. A positive moderation effect was seen for median income and percent Black with Jim Crow laws on social capital.

DISCUSSION

Our study supports a negative association between Jim Crow laws and reduction in the stock of social capital. This may be attributed to the fracturing of trust, reciprocity and collective action produced by legal racial segregation. Findings from this study offer insight on the potential impacts of historical policies on the social structure of a community. Future research is necessary to further identify the mechanistic pathways and develop interventions to improve social capital.

Patterns of Anemia in Married Women and Their Children in Cambodia: A Synthetic Cohort Analysis

AIM

To explore the prevalence of anemia in three cohorts of women, namely, married yet to be mothers, married and are mothers, and currently pregnant, to ascertain the patterns in anemia in women.

METHODS

We analyzed a sample of 130,965 married women from four Demographic Health Surveys: 2000, 2005, 2009 and 2015. The primary focus for the analysis was married women aged 15 to 49 years. In the absence of a longitudinal data that followed the same women over the periods, a synthetic cohort of the women of that age-group was constructed to get women aged 15 to 64 years over the four surveys. Women who were aged 15 to 19 years in 2000 were the same as those 30 to 34 years in 2015, while those aged 45 to 49 years in 2000 were the same as 60 to 64 years in 2015.

RESULTS

Logistic regression revealed that young mothers were significantly more infected (p < .001). Pregnancy affected anemia in the women (p < .001). Being younger and richer were associated with odds ratios of 0.599 (95% confidence interval, CI: [0.560, 0.640]) and 0.765 (95% CI: [0.726, 0.807]) for anemia, respectively. Being pregnant had odds ratio of 1.642 (95% CI: [1.439, 1.872]) for anemia.

CONCLUSION

Public health strategies should target social deprivation at the household level while addressing maternal health issues. An analysis of data on unmarried women and their children is recommended.

Associations of types of green space across the life-course with blood pressure and body mass index

Green space has been associated with better health and well-being. However, most studies have been cross-sectional with limited long-term exposure data. Further, research is limited in what type of green space is beneficial for health. We conducted a longitudinal study to assess sensitive periods (birth, childhood or adulthood) of exposure to different types of green space in association with adult blood pressure and body mass index (BMI). Using longitudinal data from the New England Family Study (1960-2000) and multilevel regression analysis, we examined associations between time-varying markers of residential exposure to green space, and adult BMI, systolic (SBP) and diastolic blood pressure (DBP) (N = 517). We created three exposure metrics: distance, average area, and green space count in the neighborhood throughout the life-course. In adjusted models, living one mile farther away from a green space at birth was associated with a 5.6 mmHg higher adult SBP (95%CI: 0.7, 10.5), and 3.5 mmHg higher DBP (95%CI: 0.3, 6.8). One more green space in the neighborhood at birth was also associated with lower DBP (-0.2 mmHg, 95%CI: -0.4, -0.02) in adulthood. Finally, average area of green space was not associated with SBP, DBP nor BMI. Analysis by type of green space suggested that parks may be more relevant than playgrounds, cemeteries or golf courses. Our study suggests that the perinatal period may be a critical time-period where living closer to green spaces may lower hypertension risk in adulthood, but not obesity.

Identifying spatial variation in the burden of diabetes among women across 640 districts in India: a cross-sectional study

Purpose

Diabetes is one of the leading causes of mortality and morbidity among women in India. The burden of diabetes among women was found to increase with age and exposure to the post-partum period. The present study examines the spatial variation in the prevalence of diabetes among women in the late reproductive age-group of 35-49 years across 640 districts in India.

Methods

The study utilized data from the recent round of the National Family Health Survey, 2015-16. Age-standardized prevalence rates were calculated, followed by an examination of economic inequality using the poor-rich-ratio (PRR) and Wagstaff's concentration index. Spatial variation in the prevalence of diabetes was explored with a series of quantile maps, univariate, and bivariate LISA cluster maps. Further, to explore the district-level diabetes prevalence among women in the country, Ordinary Least Square and Spatial Autoregressive (SAR) models were used.

Results

The study findings affirm the presence of spatial clustering in the burden of diabetes among women. The burden is relatively higher among women from the Southern and Eastern parts of the country. Findings establish obesity, hypertension, and living in urban areas as major correlates of diabetes.

Conclusion

Program with an aim to lower the intensity of community-based prevalence of diabetes, especially among women in their late reproductive ages, should adopt differential approaches across different states/districts in the context of their lifestyle, dietary pattern, working pattern, and other socio-cultural practices.

Are "Obstetrically Underserved Areas" really underserved? Role of a government support program in the context of changing landscape of maternal service utilization in South Korea: A sequential mixed method approach

Objectives

The Korean government has been providing financial support to open and operate the maternal hospital in Obstetrically Underserved Areas (OUAs) since 2011. Our study aims to assess the effectiveness of the government-support program for OUAs and to suggest future directions for it.

Methods

We performed sequential-mixed method approach. Descriptive analyses and multi-level logistic regression were performed based on the 2015 Korean National Health Insurance claim data. Data for the qualitative analysis were obtained from in-depth interviews with health providers and mothers in OUAs.

Results

Descriptive analyses indicated that the share of babies born in the hospitals located in the area among total babies ever born from mothers residing in the area (Delivery concentration Index: DCI) was lower in government-supported OUAs than other areas. Qualitative analyses revealed that physical distance is no longer a barrier in current OUAs. Mothers travel to neighboring big cities to seek elective preferences only available at specialized maternal hospitals rather than true medical need. Increasing one-child families changed the mother’s perception of pregnancy and childbirth, making them willing to pay for more expensive services. Concern about an emergency for mothers or infants, especially of high-risk mothers was also an important factor to make mothers avoid local government-supported hospitals. Adjusted multi-level logistic regression indicated that DCIs of government-supported OUAs were higher than the ones of their counterpart areas.

Conclusion

Our results suggest that current OUAs do not reflect reality. Identification of true OUAs where physical distance is a real barrier to the use of obstetric service and focused investment on them is necessary. In addition, more sophisticated performance indicator other than DCI needs to be developed.

Utilization of Integrated Child Development Services in India: Programmatic Insights from National Family Health Survey, 2016

The Integrated Child Development Services (ICDS) program launched in India in 1975 is one of the world’s largest flagship programs that aims to improve early childhood care and development via a range of healthcare, nutrition and early education services. The key to success of ICDS is in finding solutions to the historical challenges of geographic and socioeconomic inequalities in access to various services under this umbrella scheme. Using birth history data from the National Family Health Survey (Demographic and Health Survey), 2015–2016, this study presents (a) socioeconomic patterning in service uptake across rural and urban India, and (b) continuum in service utilization at three points (i.e., by mothers during pregnancy, by mothers while breastfeeding and by children aged 0–72 months) in India. We used an intersectional approach and ran a series multilevel logistic regression (random effects) models to understand patterning in utilization among mothers across socioeconomic groups. We also computed the area under the receiver operating characteristic curve (ROC-AUC) based on a logistic regression model to examine concordance between service utilization across three different points. The service utilization (any service) by mothers during pregnancy was about 20 percentage points higher for rural areas (60.5 percent; 95% CI: 60.3; 30.7) than urban areas (38.8 percent; 95% CI: 38.4; 39.1). We also found a lower uptake of services related to health and nutrition education during pregnancy (41.9 percent in rural) and early childcare (preschool) (42.4 percent). One in every two mother–child pairs did not avail any benefits from ICDS in urban areas. Estimates from random effects model revealed higher odds of utilization among schedule caste mothers from middle-class households in rural households. AUC estimates suggested a high concordance between service utilization by mothers and their children (AUC: 0.79 in rural; 0.84 in urban) implying a higher likelihood of continuum if service utilization commences at pregnancy.

Inequalities in life expectancy: An analysis of 201 countries, 1950-2015

With global improvements in life expectancy, one important concern is to understand whether there is reduction in inequalities or greater cross-country convergence in expected length of life at various age thresholds. Insights on convergence patterns can help governments and other stakeholders decide upon health investments across age groups. This paper applies a novel econometric approach to test convergence and identify convergent clubs in life expectancy at various age groups for 201 countries/areas between 1950 and 2015. Life expectancy estimates for 201 countries/areas (1950 and 2015) from United Nations Department of Economic and Social Affairs (UNDESA) World Population Prospects (2015 Revision) are used for the analysis. We find global convergence in life expectancy at birth, but do not observe grand convergence for any other age groups. In the case of life expectancy at younger ages, most countries are moving in the same direction, but significant cross-country variations and convergence clubs are noted for older adults and elderly. Most of the better performing countries/areas are from Western Europe, Northern Europe and North America, the average performers are from South America, Eastern Europe, Southern Europe, South Asia, Central Asia, Eastern Africa, Central Africa, and the Caribbean Islands whereas the poor-performing ones are mainly Western Africa, Southern African and Oceania. In addition, we observe increasing between-country variance in life expectancy for older adults and elderly. The analysis reveals increasing global heterogeneity in the survival experience of older adults and the elderly population which has remained a neglected aspect in the discussions on global life expectancy improvements. Data, research and policy focus on life-expectancy at older ages is therefore critical to accelerate survival gains among older adults and elderly, particularly from the developing world.

Child Undernutrition and Convergence of Multisectoral Interventions in India: An Econometric Analysis of National Family Health Survey 2015-16

In India and worldwide, there has been increased strategic focus on multisectoral convergence of nutrition-specific and nutrition-sensitive interventions to attain rapid reductions in child undernutrition. For instance, a Convergence Action Plan in India has been formed to synchronize and converge various nutrition-related interventions across ministries of union and state governments under a single umbrella. Given the large variation in number, nature and impact of these interventions, this paper aims to quantify the contribution of each intervention (proxied by relevant covariates) toward reducing child stunting and underweight in India. The interventions are classified under six sectors: (a) health, (b) women and child development, (c) education, (d) water, sanitation, and hygiene, (e) clean energy, and (f) growth sector. We estimate the potential reduction in child stunting and underweight in a counterfactual scenario of “convergence” where all the interventions across all the sectors are simultaneously and successfully implemented. The findings from our econometric analysis suggests that under this counterfactual scenario, a reduction of 18.37% points (95% CI: 16.77; 19.95) in stunting and 20.26% points (95% CI: 19.13; 21.39) in underweight can be potentially achieved. Across all the sectors, women and child development and clean energy were identified as the biggest contributors to the potential reductions in stunting and underweight, underscoring the importance of improving sanitation-related practices and clean cooking fuel. The overall impact of this convergent action was relatively stronger for less developed districts. These findings reiterate a clear role and scope of convergent action in achieving India's national nutritional goals. This warrants a complete outreach of all the interventions from different sectors.

Azathioprine and Mycophenolate Mofetil Adherence Patterns and Predictors Among Medicaid Beneficiaries With Systemic Lupus Erythematosus

OBJECTIVE

Azathioprine (AZA) and mycophenolate mofetil (MMF) are immunosuppressants frequently used in the treatment of moderate-to-severe systemic lupus erythematosus (SLE). We studied longitudinal patterns and predictors of adherence to AZA and MMF in a nationwide US SLE cohort.

METHODS

In the Medicaid Analytic eXtract (2000-2010) database, we identified patients with SLE who initiated AZA or MMF (no use in the prior 6 months) with ≥12 months of continuous follow-up. We dichotomized adherence at 80%, with ≥24 of 30 days per month considered adherent. We used group-based trajectory models to estimate monthly adherence patterns and multivariable multinomial logistic regression to determine the association between demographic, SLE and utilization-related predictors, and the odds ratios (OR) of belonging to a nonadherent versus the adherent trajectory, separately for AZA and MMF.

RESULTS

We identified 2,309 AZA initiators and 2,070 MMF initiators with SLE. Four-group trajectory models classified 17% of AZA and 21% of MMF initiators as adherent. AZA and MMF nonadherers followed similar trajectory patterns. African American race (OR 1.67 [95% confidence interval (95% CI) 1.20-2.31]) and Hispanic ethnicity (OR 1.58 [95% CI 1.06-2.35]) increased odds of AZA nonadherence; there were no significant associations between race/ethnicity and MMF nonadherence. Male sex and polypharmacy were associated with lower odds of nonadherence to both medications; lupus nephritis was associated with lower odds of nonadherence to MMF (OR 0.74 [95% CI 0.55-0.99]).

CONCLUSION

Adherence to AZA or MMF over the first year of use was rare. Race, sex, and lupus nephritis were modestly associated with adherence, but the magnitude, direction, and significance of predictors differed by medication, suggesting the complexity of predicting adherence behavior.