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.

Factors Associated With Child Stunting, Wasting, and Underweight in 35 Low- and Middle-Income Countries

IMPORTANCE

Evidence on the relative importance of various factors associated with child anthropometric failures (ie, stunting, underweight, and wasting) and their heterogeneity across countries can inform global and national health agendas.

OBJECTIVE

To assess the relative significance of factors associated with child anthropometric failures in 35 low- and middle-income countries (LMICs).

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of 299 353 children who were born singleton and aged 12 to 59 months with nonpregnant mothers and valid anthropometric measures assessed the strengths of associations of 26 factors with child stunting, underweight, and wasting, using Demographic and Health Surveys (2007-2018) from 35 LMICs. Data analysis was conducted from July 2019 to February 2020.

EXPOSURES

A total of 9 direct factors (ie, dietary diversity score; breastfeeding initiation; vitamin A supplements; use of iodized salt; infectious disease in past 2 weeks; oral rehydration therapy for children with diarrhea; care seeking for suspected pneumonia; full vaccination; and indoor pollution) and 17 indirect factors (household wealth; maternal and paternal education; maternal and paternal height and body mass index; maternal autonomy for health care, movement, and money; water source; sanitation facility; stool disposal; antenatal care; skilled birth attendant at delivery; family planning needs; and maternal marriage age) were assessed.

MAIN OUTCOMES AND MEASURES

Three anthropometric failure outcomes were constructed based on the 2006 World Health Organization child growth standards: stunting (height-for-age z score less than -2 standard deviations [SDs]), underweight (weight-for-age z score less than -2 SDs), and wasting (weight-for-height z score less than -2 SDs).

RESULTS

Among the 299 353 children aged 12 to 59 months included in the analysis, 38.8% (95% CI, 38.6%-38.9%) had stunting, 27.5% (95% CI, 27.3%-27.6%) had underweight, and 12.9% (95% CI, 12.8%-13.0%) had wasting. In the pooled sample, short maternal height was the strongest factor associated with child stunting (odds ratio [OR], 4.7; 95% CI, 4.5-5.0; P < .001), followed by lack of maternal education (OR, 1.9; 95% CI, 1.8-2.0; P < .001), poorest household wealth (OR, 1.7; 95% CI,1.6-1.8; P < .001), and low maternal body mass index (OR, 1.6; 95% CI, 1.6-1.7; P < .001). Short paternal height was also significantly associated with higher odds of stunting (OR, 1.9; 95% CI, 1.7-2.2; P < .001). Consistent results were found for underweight (eg, short maternal height: OR, 3.5; 95% CI, 3.3-3.7; P < .001; lack of maternal education: OR, 1.8; 95% CI, 1.7-2.0; P < .001) and wasting (eg, low maternal body mass index: OR, 2.3; 95% CI, 2.1-2,4; P < .001; poorest household wealth: OR, 1.2; 95% CI, 1.1-1.3; P < .001). Parental nutritional status and household socioeconomic conditions ranked the strongest (1st to 4th) for most countries, with a few exceptions (eg, lack of maternal education ranked 18th-20th in 8 countries for child wasting). Other factors were not associated with anthropometric failures in pooled analysis and had large country-level heterogeneity; for example, unsafe water was not associated with child underweight in the pooled analysis (OR, 0.97; 95% CI, 0.95-1.00; P < .001), and it ranked from 4th to 20th across countries.

CONCLUSIONS AND RELEVANCE

In this study, socioeconomic conditions and parental nutritional status were the strongest factors associated with child anthropometric failures. Poverty reduction, women's education, and nutrition programs for households could be important strategies for reducing child undernutrition; however, country-specific contexts should be considered in national policy discussions.

Association of Maternal History of Neonatal Death With Subsequent Neonatal Death in India

IMPORTANCE

Among the United Nations' Sustainable Development Goals is to reduce the neonatal mortality rate to 12 per 1000 live births by 2030. Identifying high-risk pregnancies can help achieve this target in low-resource countries, such as India, which accounts for one-fourth of global neonatal deaths.

OBJECTIVE

To analyze the association of maternal history of neonatal death with subsequent neonatal mortality.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included a nationally representative sample of singleton live births from multiparous women. Data were obtained from the 2016 National Family Health Survey in India. Data were analyzed from November 2018 to January 2020.

EXPOSURES

Maternal history of neonatal death and a comprehensive set of covariates, including socioeconomic environment, maternal anthropometry, and pregnancy care.

MAIN OUTCOMES AND MEASURES

Subsequent neonatal mortality. Population-attributable risk associated with history of neonatal death was calculated, and sensitivity analyses were performed.

RESULTS

The overall study population consisted of 127 336 singleton live births from multiparous women aged 15 to 49 (mean [SD] age, 28.8 [5.2] years) years when the survey was undertaken. In our analytic sample, 11 101 (8.7%) mothers had a history of neonatal death, and 506 of 2224 total neonatal deaths (22.8%) were attributed to women with history of neonatal death. The prevalence of history of neonatal death differed by selected covariates and across states or union territories. Maternal history of neonatal death was associated with significantly higher odds of neonatal mortality (adjusted odds ratio, 2.23; 95% CI, 1.96-2.55), and this remained consistent across different subgroups. The population-attributable risk associated with maternal history of neonatal death was 11.8%. Stronger associations were found for maternal history of multiple neonatal deaths (adjusted odds ratio, 3.50; 95% CI, 2.78-4.41) and in respect to the risk of mortality in early neonatal period (ie, 0-2 completed days) (adjusted odds ratio, 2.45; 95% CI, 2.09-2.86).

CONCLUSIONS AND RELEVANCE

These findings suggest that maternal history of neonatal death is a potentially useful risk factor to identify women and neonates who may need extended and enhanced pregnancy care.

Levels and determinants of malnutrition among India's urban poor women: An analysis of Demographic Health Surveys 2006 and 2016

A quarter of 400 million urban Indian residents are poor. Urban poor women are as undernourished as or worse than rural women but urban averages mask this disparity. We present the spectrum of malnutrition and their determinants for more than 26,000 urban women who gave birth within 5 years from the last two rounds of Demographic Health Survey 2006 and 2016. Among urban mothers in the lowest quartile by wealth index (urban poor), 12.8% (95% CI [11.3%, 14.5%]) were short or with height < 145 cm; 20.6% (95% CI [19%, 22.3%]) were thin or with body mass index < 18.5 kg/m² ; 57.4% (95% CI [55.5%, 59.3%]) had any anaemia (haemoglobin < 12 g/dL), whereas 32.4% (95% CI [30.5%, 34.3%]) had moderate to severe anaemia; and 21.1% (95% CI [19.3%, 23%]) were obese (body mass index ≥ 25 kg/m² ). Decadal gains were significant for thinness reduction (17p.p.) but obesity increased by 12 p.p. Belonging to a tribal household increased odds of thinness by 1.5 (95% CI [1.06, 2.18]) times among urban poor mothers compared with other socially vulnerable groups. Secondary education reduced odds of thinness (0.61; 95% CI [0.48, 0.77]) and higher education of short stature (0.41; 95% CI [0.18, 0.940]). Consuming milk/milk products, pulses/beans/eggs/meats, and dark green leafy vegetables daily reduced the odds of short stature (0.52; 95% CI [0.35, 0.78]) and thinness (0.72; 95% CI [0.54, 0.98]). Urban poor mothers should be screened for nutritional risks due to the high prevalence of all forms of malnutrition and counselled or treated as per risk.

Young Adult Sexual Behavior in South Africa: How Important is Parental Social Support?

Risky sexual behavior exposes young adults to poor reproductive health outcomes. Parental social support is associated with reduced incidence of risky sexual behavior, but this association has not been adequately investigated in South Africa. We used data from Waves 1 and 3 of the Cape Area Panel Study (a longitudinal study of adolescents and young adults aged 14-22 years and living in the Cape Town metropolitan area) to investigate the associations between parental social support and young adult risky sexual behavior in South Africa. We conducted multivariable logistic regression analyses to assess whether lack of specific categories of parental social supports at wave 1 (baseline) are associated with higher risky sexual behaviors by young adults at wave 3 (follow-up). We found that young adults who never ate meals with their mothers and those who never discussed personal matters with their fathers had increased risks of multiple sexual partnerships. Also, young adults who never got pocket money or money for gifts from their mothers had increased risk to engage in unprotected sex during their first sexual encounter. Our findings suggest that eating family meals, discussing personal matters with youth, and providing them with pocket money, may protect young adults in South Africa from risky sexual behavior.

Area-Level Predictors of Medication Nonadherence Among US Medicaid Beneficiaries With Lupus: A Multilevel Study

OBJECTIVE

Adherence to hydroxychloroquine (HCQ) treatment in patients with systemic lupus erythematous (SLE) is suboptimal. Although individual-level factors, including younger age and non-white race/ethnicity, have been implicated, contextual factors have not been explored. The aim of this study was to investigate the effect of contextual factors, including racial composition, socioeconomic status, and the concentration of health care resources, on adherence to HCQ among SLE patients enrolled in Medicaid.

METHODS

We identified SLE patients from 28 states in the US who enrolled in Medicaid (2000-2010) and in whom HCQ treatment was newly initiated (no use for ≥6 months). We required 12 months of continuous enrollment with complete drug dispensing data and measured adherence using the proportion of days covered (PDC). We identified individual-level variables from Medicaid, zip code-level, county-level and state-level sociodemographic variables from the American Community Survey, and health resources from Area Health Resources Files. We used 4-level hierarchical multivariable logistic regression models to examine the odds ratios (ORs) and 95% credible intervals (95% CrIs) of adherence (PDC ≥80%) versus nonadherence.

RESULTS

Among 10,268 patients with SLE in whom HCQ treatment was initiated, 15% were adherent to treatment. After we adjusted for individual-level characteristics, we observed lower odds of adherence among patients living in zip code areas with a higher percentage of black individuals (highest tertile OR 0.81 [95% CrI 0.69-0.96] versus lowest tertile). This association persisted after controlling for area-level educational attainment, percent below federal poverty level (FPL), urbanicity, and health care resources. We did not observe statistically significant associations with zip code-level percent Hispanic, percent white, education, or percent below FPL. The odds of adherence were higher in counties with more hospitals (OR 1.30 [95% CrI 1.07-1.58]).

CONCLUSION

Among Medicaid beneficiaries with SLE, we observed significant effects of racial composition and hospital concentration on HCQ adherence. Interventions that acknowledge and address contextual factors should be considered in order to reduce high rates of nonadherence in vulnerable populations.

Contraceptive Use in Adolescent Girls and Adult Women in Low- and Middle-Income Countries

IMPORTANCE

Preventing unwanted pregnancy through adequate use of contraceptives among adolescent girls is essential for improving maternal and child health and social well-being.

OBJECTIVE

To estimate the levels and trends of contraceptive use in adolescent girls (age 15-19 years) compared with adult women (age 20-34 years).

DESIGN, SETTING, AND PARTICIPANTS

This survey study used data from 261 Demographic and Health Surveys or Multiple Cluster Indicator Surveys conducted in 103 low- and middle-income countries between 2000 and 2017. Modern contraceptive use in 90 countries and unmet need for family planning in 73 countries for adolescent girls and adult women were assessed at country and aggregate levels. Data analyses for this study were conducted between March 2019 and December 2019.

MAIN OUTCOMES AND MEASURES

Modern contraceptive use and unmet need for family planning, estimated between adolescent girls and adult women for absolute inequality and relative inequality (defined as the ratio in service use between adult women and adolescent girls). Inequalities by wealth and place of residence in each age group were also assessed.

RESULTS

A total of 832 673 adolescent girls and 2 156 268 adult women were included in the analysis. Adolescent girls were significantly less likely to use modern contraceptives (31.6% [95% CI, 30.3% to 32.8%] vs 43.5% [95% CI, 42.4% to 44.7%]; absolute inequality, 11.9 percentage points [PPs] [95% CI, 11.7 to 12.1 PPs]; relative inequality, 1.38 PPs [95% CI, 1.36 to 1.40 PPs]) and more likely to have an unmet need for family planning (50.8% [95% CI, 49.0% to 52.5%] vs 36.4% [95% CI, 34.9% to 35.8%]; absolute inequality, -14.4 PPs [95% CI, -15.8 to -15.0 PPs]; relative inequality, 0.72 PPs [95% CI, 0.69 to 0.75 PPs]). Contraceptive use generally improved over time (aggregate-level use of contraceptives increased from 17.8% [95% CI, 16.6% to 19.0%] in 2000-2006 to 27.2% [95% CI, 26.6% to 27.8%] in 2013-2017 for adolescents and from 30.9% [95% CI, 29.8% to 32.0%] in 2000-2006 to 40.3% [95% CI, 39.8% to 40.8%] in 2013-2017 for adult women), but inequalities between adolescents and adult women persisted. Aggregate-level prevalence of unmet need for family planning decreased only among adult women (from 45.8% [95% CI, 44.9% to 46.7%] in 2000-2006 to 38.0% [95% CI, 37.3% to 38.7%] in 2013-2017). For adolescents, the prevalence remained at approximately 52% over time. The inequality between the 2 age groups therefore significantly increased from 7.5 PPs (95% CI, 6.5 to 8.4 PPs) in 2000 to 2006 to 14.0 PPs (95% CI, 13.4 to 14.6 PPs) in 2013 to 2017. An increasing gap between adolescent girls and adult women was found in 18 countries for modern contraceptive use and in 20 countries for unmet need for family planning. In India, for example, both age groups had increased percentage of unmet need for family planning over time, from 16.2% (95% CI, 15.9% to 16.6%) in 2006 to 29.8% (95% CI, 29.6% to 30.1%) in 2015 for adult women and from 23.9% (95% CI, 23.0% to 24.9%) to 64.5% (95% CI, 63.3% to 65.7%) among adolescents. Thus, inequality increased from 7.7 PPs (95% CI, 7.2 to 8.2 PPs) in 2006 to 34.7 PPs (95% CI, 34.2 to 35.1 PPs) in 2015.

CONCLUSIONS AND RELEVANCE

Despite a growing focus on contraception in the past decade with initiatives such as Family Planning 2020, adolescent girls continue to lag behind adult women in contraceptive use. There is a pressing need to develop age-appropriate strategies for increasing access and maintaining contraceptive use in sexually active adolescent girls.

Multivariate spatiotemporal modeling of drug- and alcohol-poisoning deaths in New York City, 2009-2014

Drug- and alcohol-poisoning deaths remain current public health problems. Studies to date have typically focused on individual-level predictors of drug overdose deaths, and there remains a limited understanding of the spatiotemporal patterns and predictors of the joint outcomes. We use a hierarchical Bayesian spatiotemporal multivariate Poisson regression model on data from (N = 167) ZIP-codes between 2009 and 2014 in New York City to examine the spatiotemporal patterns of the joint occurrence of drug (opioids) and alcohol-poisoning deaths, and the covariates associated with each outcome. Results indicate that rates of both outcomes were highly positively correlated across ZIP-codes (cross-correlation: 0.57, 95% credible interval (CrI): 0.29, 0.77). ZIP-codes with a higher prevalence of heavy drinking had higher alcohol-poisoning deaths (relative risk (RR):1.63, 95% CrI: 1.26, 2.05) and drug-poisoning deaths (RR: 1.29, 95% CrI: 1.03, 1.59). These spatial patterns may guide public health planners to target specific areas to address these co-occurring epidemics.

Gentrification, Neighborhood Change, and Population Health: a Systematic Review

Despite a proliferation of research on neighborhood effects on health, how neighborhood economic development, in the form of gentrification, affects health and well-being in the USA is poorly understood, and no systematic assessment of the potential health impacts has been conducted. Further, we know little about whether health impacts differ for residents of neighborhoods undergoing gentrification versus urban development, or other forms of neighborhood socioeconomic ascent. We followed current guidelines for systematic reviews and present data on the study characteristics of the 22 empirical articles that met our inclusion criteria and were published on associations between gentrification, and similar but differently termed processes (e.g., urban regeneration, urban development, neighborhood upgrading), and health published between 2000 and 2018. Our results show that impacts on health vary by outcome assessed, exposure measurement, the larger context-specific determinants of neighborhood change, and analysis decisions including which reference and treatment groups to examine. Studies of the health impacts of gentrification, urban development, and urban regeneration describe similar processes, and synthesis and comparison of their results helps bridge differing theoretical approaches to this emerging research. Our article helps to inform the debate on the impacts of gentrification and urban development for health and suggests that these neighborhood change processes likely have both detrimental and beneficial effects on health. Given the influence of place on health and the trend of increasing gentrification and urban development in many American cities, we discuss how future research can approach understanding and researching the impacts of these processes for population health.

Adversity, social capital, and mental distress among mothers of small children: A cross-sectional study in three low and middle-income countries

BACKGROUND

Maternal mental health is becoming recognized as a global health priority. Mental distress among mothers of young children may be exacerbated by exposure to adversity. Social capital may buffer the impact of adversity on mental distress during the postnatal period and beyond. This paper examines the relationship between adversity, cognitive social capital and mental distress among mothers of young children in three low and middle-income countries.

METHODS

This study uses data from the Young Lives study on 5,485 women from Ethiopia, India, and Vietnam. Logistic regression was used to examine the association between exposure to stressful life events (SLEs) and mental distress in women between 6 months and 1.5 years post-partum. Logistic and linear regression was used to examine the potential for effect modification by social capital.

RESULTS

The proportion of women with mental distress during the period between 6-18 months following the birth of a child in the sample was 32.6% in Ethiopia, 30.5% in India and 21.1% in Vietnam. For each additional SLE to which a woman was exposed, the odds of MMD increased by 1.28 (95% CI: 1.22, 1.36; p<0.001) in Ethiopia, 1.17 (1.11, 1.25; p<0.001) in India, and 1.98 (1.75, 2.25; p<0.001) in Vietnam. Exposure to family SLEs was significantly associated with MMD in all three countries with odds ratios of 1.76 (95% CI: 1.30, 2.38; p<0.001), 1.62 (95% CI: 1.12, 2.33; p<0.01 in India), 1.93 (95% CI: 1.27, 2.92; p<0.01), respectively. In Ethiopia and India, economic SLEs were also significantly associated with MMD after adjustment (Ethiopia OR: 1.68; 95% CI: 1.12, 2.52; p<0.01 and India OR: 1.44; 95% CI: 1.01, 2.05; p<0.05), while in India, crime SLEs (OR: 1.93; 95% CI: 1.27, 2.92; p<0.01) were associated with MMD. Cognitive social capital was found to modify the association between SLEs and symptomology of mental distress in Ethiopia, India and Vietnam.

CONCLUSIONS

This study suggests that adversity may increase the risk of maternal mental distress in three LMICs, while social capital may buffer its effect.

A new tool for identifying risk of repeated intimate partner violence adjusted for the population of Montenegro: a cohort study

Current estimates suggest that approximately 20% of women and 11% of men have been victims of intimate partner violence. Risk identification tools for repeated domestic violence currently exist and have typically been designed by police and judicial authorities, based on the criminal history of the perpetrator. A follow-up cohort study of 238 cases of intimate partner violence (judicially processed and officially judged as DV according to Montenegrin Criminal Act) was conducted by reviewing randomly selected court files. The results showed that certain perpetrator characteristics (unemployment, lack of regret, other violent criminal history, and history of being beaten by a family member) and victim characteristics (nonqualified education and predictions of future harm) were associated with reassault. Relationship characteristics such as different ethnicity, poor socioeconomic status, difference in incomes, living in a rental property, alcohol and drug use, and unprocessed previous history of physical violence were also associated with repeated violence. A risk identification tool for repeated intimate violence was computed based on the significant variables, with a sensitivity of 85% and a specificity of 89%. This study demonstrates a new tool for repeated intimate partner violence prediction in patriarchal societies, widespread in Eastern Europe and the Middle East. The majority of factors associated with reassault in this sample have been shown to be predictive for repeated intimate partner violence in previous studies. The applicability of our tool in egalitarian societies should be investigated in order to see whether the combination of these factors is universal or specific to patriarchal societies.

Effects of gentrification on health status after Hurricane Katrina

Despite substantial debate about the impacts of gentrification on cities, neighborhoods, and their residents, there is limited evidence to demonstrate the implications of gentrification for health. We examine the impacts of gentrification on several health measures using a unique individual-level longitudinal data set. We employ data from the Resilience in Survivors of Hurricane Katrina (RISK) project, a study of low-income parents, predominantly non-Hispanic Black single mothers, who participated in a New Orleans-based study before and after Hurricane Katrina. After Katrina, all participants were displaced, at least temporarily, from New Orleans, and had little or no control over neighborhood placement immediately following the storm. This near-random displacement after Katrina created a natural experiment. We employ a quasi-experimental intent to treat design to assess the causal effects of gentrification on health in the RISK population. We do not find evidence of significant main effects of being displaced to a gentrified neighborhood on BMI, self-rated health, or psychological distress. The analysis employs a quasi-experimental design and has several additional unique features--homogeneous population, limited selection bias, and longitudinal data collection-- that improve our ability to draw causal conclusions about the relationship between gentrification and health. However, the unique context of displacement by natural disaster may limit the generalizability of our findings to other circumstances or residents experiencing gentrification.

Association between area-level education and the co-occurrence of behavior-related risk factors: a multilevel analysis

INTRODUCTION

This study aimed to investigate the association of four different risk factors for chronic diseases and accumulation of these health behaviors with area-level education, regardless of individual-level characteristics in Brazil.

METHODS

A population-based cross-sectional study was carried out in Southern Brazil including 1,720 adults in 2009/2010. The simultaneous occurrence of tobacco smoking, abusive drinking, unhealthy eating habits, and physical inactivity was investigated. Using multilevel models, we tested whether area-level education was associated with each risk factor and with the co-occurrence of them after controlling sociodemographic individual-level variables.

RESULTS

We observed a between-group variance of 7.79, 7.11, 6.84 and 1.08% for physical inactivity, problematic use of alcohol, unhealthy eating habits, and smoking, respectively. The between-group variance for the combination of four behaviors was 14.2%. Area-level education explained a significant proportion of the variance observed in physical inactivity and unhealthy eating habits. Residents of low educational level neighborhoods showed a 2.40 (95%CI 1.58 - 3.66) times higher chance of unhealthy eating and 1.78 (95%CI 1.19 - 2.67) times higher chance of physical inactivity. The likelihood of individuals with two or three/four risk factors was simultaneously higher among residents of low educational level neighborhoods.

CONCLUSION

Public policies should consider the area-level characteristics, including education to control risk factors for chronic diseases.

How important is school environment in explaining individual variance of health behaviors?

We analyzed data from the National School-based Health Survey (PeNSE) carried out in Brazil in 2015 (n = 102,072 adolescents) to estimate how much of the individual variance in the prevalence of health behaviors is attributable to the school level. Multilevel logistic regression models were calculated to estimate the variance partitional coefficient (VPC) of the use of drugs, intake of unhealthy food, leisure physical activity and weight-related behaviors. The between-schools variance was significant in all tested models. The highest VPCs were observed when the use of drugs was analyzed (15%-20% of the total variance of smoking and use of illegal drugs). Lower, but still significant, values were observed in the other outcomes. The school context plays an important role in the adolescents’ health and should be considered in the design of public policies and actions in public health.

Association of violence in schools' vicinity and smoking in schools' premises with tobacco use among Brazilian adolescents

This study aims to quantify the overall importance of schools in explaining the individual variance of tobacco use and to test the association between characteristics of the school environment and its vicinity with the experimentation and current use of cigarettes. We analyzed data from 102,072 Brazilian adolescents interviewed in the 2015 National School Health Survey (PeNSE). Multilevel logistic regression models were performed to estimate the between-schools variance and to test the association between school-level variables and the use of tobacco. Violence in the vicinity of the school and presence of teachers or students smoking on school premises were the school-level characteristics. The analyses were adjusted by individual covariates and stratified by gender. Around 12.5% of the individual variance in ever smoking was explained by between-school variation among girls (9.2% among boys). The figures were even higher for current smoking (14.9% girls; 12.2% boys) and current use of other tobacco products (27.7% girls; 17.8% boys). In general, the use of tobacco was associated with the existence of violence in the vicinity of the schools and was higher among students whose schools reported that students and teachers (teachers only for use of other tobacco products among girls) smoke on school premises. Tobacco use on school premises and the safety of the neighborhood where the school is located are associated with some smoking behaviors among adolescents. Such findings reinforce the necessity to effectively consider interventions in the school environment and neighborhood to fight smoking among adolescents.

Association between numeracy and self-rated poor health in 33 high- and upper middle- income countries

The association between numeracy proficiency and health outcomes has been the subject of several studies. However, it is not known if this association is independent of educational attainment and literacy proficiency. In this study, we used logistic regression to model numeracy proficiency as a predictor of self-rated poor health after accounting for educational attainment and literacy proficiency. The prevalence of self-rated poor health among 166,863 adults aged 16-65 years from 33 high- and upper middle-income countries was 24%. Compared to those with the highest numeracy proficiency (level 4), the odds ratio of self-rated poor health for those with the lowest numeracy proficiency (level 1) was 2.2 (95% CI 1.9-2.7) and attenuated to 1.8 (95% CI 1.5-2.1) and 1.5 (95% CI 1.1, 2.0), respectively, after sequential addition of self-education and literacy proficiency. For those who were assessed to have low levels of both numeracy and literacy proficiency, the odds ratio of self-rated poor health was 1.4 (95% CI 1.3 to 1.5), relative to those who had high levels of both numeracy and literacy proficiencies. Numeracy and literacy proficiencies show both independent and interdependent correlations with poor self-rated health. Further, these associations varied by sociodemographic characteristics and across countries. Policies aimed at improving numeracy and literacy may be beneficial in preventing adverse health outcomes.

Identifying geospatial patterns in wealth disparity in child malnutrition across 640 districts in India

We assessed district-level geospatial trends in precision weighted prevalence and absolute wealth disparity in stunting, underweight, wasting, low birthweight, and anemia among children under five in India. The largest wealth disparities were found for anthropometric failures and substantial variation existed across states. We identified statistically significant (p < 0.001) geospatial patterns in district-wide wealth disparities for all outcomes, which differed from geospatial patterns for the overall prevalence. We characterized each district as either a “Disparity”, “Pitfall”, “Intensity”, or “Prosperity” area based on its overall burden and wealth disparity, as well as discuss the importance of considering both measures for geographically-targeted public health interventions to improve health equity.

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District-wide prevalence and wealth disparity in child malnutrition were assessed.

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The largest wealth disparities were found for anthropometric failures.

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Distinct geospatial distribution of wealth disparity was found for different outcomes.

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The correlation between mean prevalence and wealth disparity was moderate to strong for all outcomes, except anemia.

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Both measures are needed for geographically targeted public health interventions to improve health equity.

Validity of Maternal Report of Birthweight in a Cohort Study and Its Implication on Low Birthweight Rate Using Simulations

OBJECTIVE

Maternal recall of birthweight is a convenient and cost-effective way to obtain birthweight measurements when official records are unavailable. It is important to assess the validity of maternal recall of birthweight before using these measurements to draw conclusions about a population.

METHODS

This is secondary analysis of data from a previous cohort study. We analyzed actual and reported birthweights of 200 mother-and-child pairs from Southern India. We validated maternal report of birthweight by generating correlation coefficients, summary statistics, and Bland-Altman plots. We ran simulations to evaluate how misclassification as low or normal birthweight changed with the mean birthweight of the cohort.

RESULTS

Reported birthweight was strongly correlated with actual birthweight (r=0.80, P<0.001); 55%, 78.5%, and 93% of subjects reported values within 50 g, 250 g, and 500 g, respectively of actual birthweight. None of sociodemographic covariates was significantly associated with the accuracy of maternal recall of birthweight. 7.5% of children were misclassified as either low or normal birthweight by reported birthweight. Simulations revealed that increasing the reported and actual birthweights by 500g reduces the misclassification rate from 7.5% to 1.5%.

CONCLUSIONS

Maternal recall is a sufficiently accurate measure of actual birthweight. However, the distribution of actual birthweight in the population must be taken into consideration when classifying babies as low or normal birthweight, especially in populations where mean birthweight is close to 2500g.

Determinants of Childhood Anemia in India

We analyzed a sample of 112714 children from the 2015-2016 Indian National Fertility and Health Survey with available data on hemoglobin. Multinomial logistic regression models were used to establish associations between parent anemia, household characteristics and nutritional intake of children. Linear regression analysis was also conducted to see the link between the household characteristic and childhood nutritional intake on one hand and hemoglobin levels on the other hand. A number of socio-demographic factors, namely maternal age, type of residence and maternal education, as well as wealth index, among others correlate with incidence of childhood anemia. For instance, whereas 52.9% of children in the richest households were anemic, 63.2% of children in the poorest household were anemic (p < 0.001). Mean Vitamin A intake in the last six months was 0.63 (0.626-0.634) which was 0.18% of the recommended intake. Mean iron intake, from sources other than breast milk, in the last 24 hours was 0.29 (0.286-0.294) and 2.42% of the recommended daily intake. Fifty-nine percent (58.5%) of the children surveyed were anemic (Hb level: 9.75 g/dL [9.59-9.91]). Children with anemia were more prone to being iron deficient (odds ratio [OR]: 0.981 (0.961-1.001), Vitamin A deficient (OR: 0.813 (0.794-0.833)), and have lower maternal hemoglobin level (OR: 1.992 (1.957-2.027)). Combining nutritional supplementation and food-fortification programmes with reduction in maternal anemia and family poverty may yield optimal improvement of childhood anemia in India.

Variation in Chronic Diseases Across Households, Communities, Districts, and States in India

INTRODUCTION

Globally, chronic noncommunicable diseases are the leading cause of death and accounted for 6 million deaths in India in 2016. However, the extent to which variation in chronic disease can be attributed to different population levels in India is unknown, as is whether variation in individual-level factors explains outcome variation at different population levels.

METHODS

Cross-sectional data from the District Level Household and Facility Survey 2012-2013 conducted across 21 states, 275 districts, 14,235 villages, 378,487 households, and 1,098,940 individuals aged ≥18 years in India were analyzed in 2018‒2019. Multilevel logistic models were used to partition variation in outcomes and attribute it to individual, household, village, district and state population levels. Outcomes included experiencing respiratory, cardiovascular, musculoskeletal, or eye symptoms; reporting a positive diagnosis by a doctor for chronic heart disease, hypertension, diabetes, or vision problems; and objectively assessed real-time measures of hypertension and diabetes.

RESULTS

For reported diagnosis of hypertension or diabetes, a much larger percentage of variation in these outcomes was attributed to differences among households as compared to differences among units within other population levels. However, for objectively measured hypertension and diabetes, variation in these outcomes was important at the village level, followed by variation at the household level. Wealth status was positively associated with respiratory and cardiovascular symptoms, as well as all reported diagnoses and real-time measurements except for vision problems. Inclusion of individual-level sociodemographic variables explained 0%-30% of variation attributed to the household level for most chronic disease symptoms and diagnoses, but almost none at the higher levels.

CONCLUSIONS

These findings imply that household- and village-level factors explain substantial variation in the prevalence of chronic disease symptoms and reported diagnoses in India.

Heterogeneity in adult anthropometry by socioeconomic factors: Indian National Family Health Survey 2006 and 2016

BACKGROUND/OBJECTIVES

Recent evidence suggests nonconstant nature of dispersion in adult women's body mass index (BMI) across sociodemographic groups. The overall variances in BMI and height are also shown to have substantially changed over time. We modeled complex variation in adults' anthropometry-BMI and height-by wealth and education, and assessed their differences over time in India.

SUBJECTS/METHODS

Data from a total of 768,130 women and 180,691 men from the Indian National Family Health Survey (NFHS) 2006 and 2016 were used for the analysis. The average association between wealth and education with anthropometry was assessed from linear regression models assuming constant variance. Individual heterogeneity was modeled to obtain separate variances in anthropometry for each wealth quintile and education level. All analyses were stratified by survey year and sex.

RESULTS

On average, the positive socioeconomic gradient in adult's BMI and height persisted over time with slight attenuation. The residual variance in BMI ranged from 10.1 to 14.9 (7.2-11.3) by education level and 6.1 to 17.4 (5.0-13.0) by household wealth for women (men) in 2006, and they increased over time for the lower socioeconomic groups but remained the same or decreased for the higher socioeconomic groups. No significant pattern was observed for variation in height for both genders.

CONCLUSIONS

We found potential reversal in the socioeconomic patterning in BMI variability in India as suggested by the increasing dispersion among the least educated and poorest populations. For a comprehensive understanding of nutrition transition in developing countries, it is necessary to assess the changes in means and variances of anthropometry in tandem.

Explaining Within- vs Between-Population Variation in Child Anthropometry and Hemoglobin Measures in India: A Multilevel Analysis of the National Family Health Survey 2015-2016

Background

The complex etiology of child growth failure and anemia—commonly used indicators of child undernutrition—involving proximate and distal risk factors at multiple levels is generally recognized. However, their independent and joint effects are often assessed with no clear conceptualization of inferential targets.

Methods

We utilized hierarchical linear modeling and a nationally representative sample of 139,116 children aged 6–59 months from India (2015–2016) to estimate the extent to which a comprehensive set of 27 covariates explained the within- and between-population variation in height-for-age, weight-for-age, weight-for-height, and hemoglobin level.

Results

Most of the variation in child anthropometry and hemoglobin measures was attributable to within-population differences (80–85%), whereas between-population differences (including communities, districts, and states) accounted for only 15–20%. The proximate and distal covariates explained 0.2–7.5% of within-population variation and 2.1–34.0% of between-population variation, depending on the indicator of interest. Substantial heterogeneity was observed in the magnitude of within-population variation, and the fraction explained, in child anthropometry and hemoglobin measures across the 36 states/union territories of India.

Conclusions

Policies and interventions aimed at reducing between-population inequalities in child undernutrition may require a different set of components than those concerned with within-population inequalities. Both are needed to promote the health of the general population, as well as that of high-risk children.