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Gausman J, Kim R, Li Z, Tu L, Rajpal S, Joe W, Subramanian SV. Comparison of Child Undernutrition Anthropometric Indicators Across 56 Low- and Middle-Income Countries. JAMA Netw Open 2022; 5:e221223. [PMID: 35275168 PMCID: PMC8917428 DOI: 10.1001/jamanetworkopen.2022.1223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The United Nations' Sustainable Development Goal Target 2.2 seeks to end all forms of malnutrition by 2030 by meeting targets, including the elimination of stunting and wasting in all children younger than 5 years. Such indicators are used to monitor childhood undernutrition but may not provide a complete picture at a population level. OBJECTIVE To compare global estimates of the prevalence of undernutrition using conventional indicators of anthropometric failure (AF; stunting, underweight, and wasting); the Composite Index of Anthropometric Failure (CIAF); and a proposed classification system called Categories of Anthropometric Failure (CAF) as well as to investigate the association of the conventional indicators, CIAF, and CAF with diarrheal disease as an assessment of the validity of each measure. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of the prevalence of undernutrition among children in 56 low- and middle-income countries using data from the nationally representative Demographic and Health Surveys. The study included 530 906 children younger than 5 years. Data were collected from June 2005 to December 2018 and analyzed from September 27, 2020, to February 4, 2021. MAIN OUTCOMES AND MEASURES Undernutrition identified according to conventional indicators (stunting, underweight, and wasting), the CIAF, and the proposed CAF classification system was estimated and compared. Six logistic regression models were used to examine the association between different classifications of anthropometric failure (AF) and morbidity. RESULTS A total of 530 906 children (mean [SD] age, 29.0 [17.2] months; 272 355 [51.3%] boys and 258 551 [48.7%] girls) from 56 low- and middle-income countries were included in the analysis. Estimates of undernutrition generated using the conventional indicators of stunting, underweight, and wasting were lower than estimates generated using the CIAF in all countries. The CAF classification system pointed to considerable variation across countries in children with multiple AFs, which does not correspond to the overall prevalence of undernutrition. For example, 7.5% of children in Niger and 7.1% of children in Timor-Leste were stunted, underweight, and wasted, while 56.0% of children in Niger and 71.1% of children in Timor-Leste were undernourished according to the CIAF. In addition, children who had stunting, underweight, and wasting had 1.52 (95% CI, 1.45-1.61) times the odds of diarrhea compared with children who exhibited no AFs. CONCLUSIONS AND RELEVANCE The results of this study highlight the importance of using different approaches to aid understanding of the entire spectrum of AF with regard to research and development of policies and programs to address AF. The use of the CIAF and the CAF classification system may be useful for treatment to prevent AFs and could accelerate progress in meeting targets for the Sustainable Development Goal.
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Affiliation(s)
- Jewel Gausman
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Rockli Kim
- Division of Health Policy and Management, College of Health Science, Korea University, Seoul, South Korea
- Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul, South Korea
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts
| | - Zhihui Li
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Lucia Tu
- Nathan S. Kline Institute for Psychiatric Research, Orangeburg, New York
| | - Sunil Rajpal
- Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul, South Korea
- Department of Economics, FLAME University, New Delhi, India
| | - William Joe
- Population Research Centre, Institute of Economic Growth, Delhi University Enclave, North Campus, Delhi, India
| | - S. V. Subramanian
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Mejía-Guevara I, Cislaghi B, Darmstadt GL. Men's Attitude Towards Contraception and Sexuality, Women's Empowerment, and Demand Satisfied for Family Planning in India. FRONTIERS IN SOCIOLOGY 2021; 6:689980. [PMID: 34977228 PMCID: PMC8717326 DOI: 10.3389/fsoc.2021.689980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 11/15/2021] [Indexed: 05/02/2023]
Abstract
Whilst the prevalence of unmet need and contraceptive use remained unchanged for 10 years (between 2005-2015) in India, gender restrictive norms and power imbalances also have persisted, preventing married women from meeting their family planning desires. Data for this study are from the 2015-6 National Family Household Survey, which contains information on fertility preferences and family planning for women in reproductive age. As a proxy for men's attitudinal norms, we aggregated men's perceptions regarding contraception (contraception is women's business, women who use contraception may become promiscuous) and control over their wife (if his wife refuses to have sex, men have the right to deny financial support, have sex with another woman, or beat wife) at district level. Using a three-level random intercepts model, we assessed individual and contextual-level associations of men's attitudinal norms and met need for contraception among sexually active women (aged 15-49) with any demand for family planning, while adjusting for women's empowerment indicators [education, job status, and adult marriage] and individual demographic factors. Our results indicate that men's attitudinal norms are negatively associated with women's contraceptive use; for instance, a 1 standard deviation increase in the proportion of men who believe that contraception is women's business was associated with a 12% reduced likelihood of contraceptive use (OR = 0.88, 95% CI 0.82-0.95). Similar associations remained or were stronger after considering only modern methods, or when excluding female sterilization. Furthermore, our contextual effects analysis revealed that women's higher education or wealth did not improve contraceptive uptake in communities with strong attitudinal norms, but working women or women married as children were more likely to use contraception in those communities. Our results suggest that men's attitudinal norms may be dominating over women's empowerment regarding family planning choices among reproductive age women. However, employment appeared to play a strong protective role associated with women's contraceptive use. It is important for programs seeking to transform gender equality and empower women in making contraceptive choices to consider women's employment opportunities and to also address male attitudinal norms in the context of the ecosystem in which men and women coexist and interact.
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Affiliation(s)
- Iván Mejía-Guevara
- Stanford Aging and Ethnogeriatrics (SAGE) Research Center, Stanford University School of Medicine, Palo Alto, CA, United States
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Beniamino Cislaghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Global Health, Makerere University, Kampala, Uganda
| | - Gary L. Darmstadt
- Global Center for Gender Equality, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
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Jain A, Rodgers J, Kim R, Subramanian SV. The relative importance of households as a source of variation in child malnutrition: a multilevel analysis in India. Int J Equity Health 2021; 20:225. [PMID: 34641859 PMCID: PMC8507104 DOI: 10.1186/s12939-021-01563-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 09/28/2021] [Indexed: 11/29/2022] Open
Abstract
Background Child malnutrition remains a major public health issue in India. Along with myriad upstream and social determinants of these adverse outcomes, recent studies have highlighted regional differences in mean child malnutrition rates. This research helps policy makers look between urban and rural communities and states to take a population-level approach to addressing the root causes of child malnutrition. However, one gap in this between-population approach has been the omission of households as a unit of analysis. Households could represent important sources of variation in child malnutrition within communities, districts, and states. Methods Using the fourth round of India’s National Family Health Survey from 2015 to 2016, we analyzed four and five-level multilevel models to estimate the proportion of variation in child malnutrition attributable to states, districts, communities, households, and children. Results Overall, we found that of the four levels that children were nested in (households, communities, districts, and states), the greatest proportion of variation in child height-for-age Z score, weight-for-age Z score, weight-for-height Z score, hemoglobin, birthweight, stunting, underweight, wasting, anemia, and low birthweight was attributable to households. Furthermore, we found that when the household level is omitted from models, the variance estimates for communities and children are overestimated. Conclusions These findings highlight the importance of households as an important source of clustering and variation in child malnutrition outcomes. As such, policies and interventions should address household-level social determinants, such as asset and social deprivations, in order to prevent poor child growth outcomes among the most vulnerable households in India. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01563-7.
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Affiliation(s)
- Anoop Jain
- Global Health & Social Medicine, Harvard Medical School, Boston, MA, 02115, USA
| | - Justin Rodgers
- Harvard Center for Population and Development Studies, Cambridge, MA, 02138, USA
| | - Rockli Kim
- Division of Health Policy & Management, College of Health Science, Korea University, Seoul, 02841, South Korea.,Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul, 02841, South Korea
| | - S V Subramanian
- Harvard Center for Population and Development Studies, MA, 02138, Cambridge, USA. .,Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA.
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User fees removal and community-based management of undernutrition in Burkina Faso: what effects on children's nutritional status? Public Health Nutr 2021; 24:3768-3779. [PMID: 33593454 DOI: 10.1017/s1368980021000732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To examine the effect of an intervention combining user fees removal with community-based management of undernutrition on the nutrition status in children under 5 years of age in Burkina Faso. DESIGN The study was a non-equivalent control group post-test-only design based on household survey data collected 4 years after the intervention onset in the intervention and comparison districts. Additionally, we used propensity score weighting to achieve balance on covariates between the two districts, followed by logistic multilevel modelling. SETTING Two health districts in the Sahel region. PARTICIPANTS Totally, 1116 children under 5 years of age residing in 41 intervention communities and 1305 from 51 control communities. RESULTS When comparing children living in the intervention district to children living in a non-intervention district, we determined no differences in terms of stunting (OR = 1·13; 95 % CI 0·83, 1·54) and wasting (OR = 1·21; 95 % CI 0·90, 1·64), nor in severely wasted (OR = 1·27; 95 % CI 0·79, 2·04) and severely stunted (OR = 0·99; 95 % CI 0·76, 1·26). However, we determined that 3 % of the variance of wasting (95 % CI 1·25, 10·42) and 9·4 % of the variance of stunting (95 % CI 6·45, 13·38) were due to systematic differences between communities of residence. The presence of the intervention in the communities explained 2 % of the community-level variance of stunting and 3 % of the community-level variance of wasting. CONCLUSIONS With the scaling-up of the national free health policy in Africa, we stress the need for rigorous evaluations and the means to measure expected changes in order to better inform health interventions.
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Ghosh S, Shivakumar N, Bandyopadhyay S, Sachdev HS, Kurpad AV, Thomas T. An uncertainty estimate of the prevalence of stunting in national surveys: the need for better precision. BMC Public Health 2020; 20:1634. [PMID: 33131489 PMCID: PMC7603753 DOI: 10.1186/s12889-020-09753-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/22/2020] [Indexed: 12/17/2022] Open
Abstract
Background Stunting is determined by using the World Health Organization (WHO) child growth standard which was developed using precise measurements. However, it is unlikely that large scale surveys maintain the same level of rigour and precision when measuring the height of children. The population measure of stunting in children is sensitive to over-dispersion, and the high prevalence of stunting observed in surveys in low and middle-income countries (LMIC) could partly be due to lower measurement precison. Objectives To quantify the incongruence in the dispersion of height-for-age in national surveys of < 5 y children, in relation to the standard WHO Multicenter Growth Reference Study (MGRS), and propose a measure of uncertainty in population measures of stunting. Methods An uncertainty factor was proposed and measured from the observed incongruence in dispersion of the height-for-age of < 5 y children in the MGRS against carefully matched populations from the Demographic Health Survey of 17 countries (‘test datasets’, based on the availability of data). This also allowed for the determination of uncertainty-corrected prevalence of stunting (height-for-age Z score < − 2) in < 5 y children. Results The uncertainty factor was estimated for 17 LMICs. This ranged from 0.9 to 2.1 for Peru and Egypt respectively (reference value 1). As an explicit country example, the dispersion of height-for-age in the Indian National Family Health Survey-4 test dataset was 39% higher than the MGRS study, with an uncertainty factor of 1.39. From this, the uncertainty-adjusted Indian national stunting prevalence estimate reduced to 18.7% from the unadjusted estimate of 36.2%. Conclusions This study proposes a robust statistical method to estimate uncertainty in stunting prevalence estimates due to incongruent dispersions of height measured in national surveys for children < 5 years in relation to the WHO height-for-age standard. The uncertainty is partly due to population heterogeneity, but also due to measurement precision, and calls for better quality in these measurements. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-020-09753-8.
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Affiliation(s)
- Santu Ghosh
- Department of Biostatistics, St. John's Medical College, St. John's Academy of Health Sciences, Bangalore, 560034, India
| | - Nirupama Shivakumar
- Division of Nutrition, St. John's Research Institute, St. John's Academy of Health Sciences, Bangalore, India
| | - Sulagna Bandyopadhyay
- Division of Nutrition, St. John's Research Institute, St. John's Academy of Health Sciences, Bangalore, India
| | | | - Anura V Kurpad
- Division of Nutrition, St. John's Research Institute, St. John's Academy of Health Sciences, Bangalore, India.,Department of Physiology, St. John's Medical College, St. John's National Academy of Health Sciences, Bangalore, India
| | - Tinku Thomas
- Department of Biostatistics, St. John's Medical College, St. John's Academy of Health Sciences, Bangalore, 560034, India.
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Chen CJ, Huang YC, Shie SS. Evolution of Multi-Resistance to Vancomycin, Daptomycin, and Linezolid in Methicillin-Resistant Staphylococcus aureus Causing Persistent Bacteremia. Front Microbiol 2020; 11:1414. [PMID: 32774327 PMCID: PMC7381330 DOI: 10.3389/fmicb.2020.01414] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/02/2020] [Indexed: 01/08/2023] Open
Abstract
The genomic evolution in vivo in persistent infection was critical information for understanding how methicillin-resistant Staphylococcus aureus (MRSA) was adapted to host environments with high antibiotic selective pressure. Thirty-two successive MRSA blood isolates with incremental non-susceptibility to vancomycin (VISA), daptomycin (DRSA), and/or linezolid (LRSA) were isolated from a patient failing multiple courses of antimicrobial therapy during 1,356 days of bacteremia. Whole genome sequencing (WGS) for all consecutive isolates were conducted to characterize the evolutionary pathways, resistance-associated mutations and their temporal relationship with antimicrobial treatment. The WGS-based phylogeny categorized the isogenic strains into three major clades, I (22 isolates), II (7 isolates), and III (3 isolates), respectively, harboring a median (range) of 7 (1–30), 62 (53–65), and 118 (100–130) non-synonymous mutations when compared to the very first isolate. Clade I strains were further grouped into early and late subclades, which, respectively, shared the most recent common ancestor with Clade III strains at day 393.7 and Clade II strain at day 662.5. Clade I and Clade III strains were characterized, respectively, with high rates of VISA (9/22, 40.9%) and VISA-and-DRSA phenotype (2/3, 66.7%). Linezolid-resistance including VISA-DRSA-and-LRSA phenotype was exclusively identified in Clade II strains after eight courses of linezolid treatment. The LRSA displayed a small colony variant phenotype and were associated with G2576T mutations in domain V region of 23S rRNA. Substantial loss of mobile elements or alleles mediating resistance or virulence were identified during the evolution of multi-resistance. However, the gene loss might not be correlated to the development of VISA, DRSA, or LRSA phenotype. In conclusion, MRSA in persistent bacteremia was adapted to harsh host environment through multiple pathways involving both resistance-associated mutations and extensive gene loss.
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Affiliation(s)
- Chih-Jung Chen
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,School of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Yhu-Chering Huang
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,School of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Shian-Sen Shie
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
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Mejía-Guevara I, Cislaghi B, Weber A, Hallgren E, Meausoone V, Cullen MR, Darmstadt GL. Association of collective attitudes and contraceptive practice in nine sub-Saharan African countries. J Glob Health 2020; 10:010705. [PMID: 32257163 PMCID: PMC7101087 DOI: 10.7189/jogh.10.010705] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND There is ample evidence that gender norms affect contraceptive practice; however, data are mostly qualitative with limited geographical scope. We investigated that association quantitatively using collective community-level attitudes towards premarital sex and wife-beating as proxies for gender norms. METHODS Data came from nationally representative Demographic and Health Surveys (2005-2009) for women of reproductive age (15-49 years) in nine sub-Saharan African countries. Using multilevel logistic models, controlling for individual covariates and community-level indicators of women's empowerment, we assessed the community-level association of gender norms regarding premarital sex and wife-beating with individual contraception uptake and demand satisfied among fecund sexually active women. Norms were approximated as 'collective attitudinal norms' from female/male residents (aged 15-49 years) from the same community. We assessed the magnitude and significance of the community-level effects and attributed variance across communities. The same analysis was replicated for each country. RESULTS In a fully-adjusted model with a pooled sample of 24 404 adolescent women, the odds of contraception use increased with a 1 standard deviation (SD) increase in the variation of collective permissive attitudes towards premarital sex of female (odds ratio (OR) = 1.08, 95% confidence interval (CI) = 1.02-1.15) and male (OR = 1.11, 95% CI = 1.05-1.17) peers (15-24 years), while odds of contraceptive use declined by 10% (OR = 0.90, 95% CI = 0.85-0.96) with collective accepting attitudes towards wife-beating of women aged 15-49 years. Similar results were found in separate models that controlled for adults' permissive attitudes towards premarital sex. The community-level attributed variance (V2 = 1.62, 95% CI = 1.45-1.80) represented 33% (intra-class correlation (ICC) = 33.0, 95% CI = 30.0-35.4) of the total variation of contraception use, and attitudes towards premarital sex and violence jointly explained nearly 26% of that V2 variance. The community-level shared of attributed variation of contraceptive use varied significantly across countries, from 3.5% in Swaziland (ICC = 3.5, 95% CI = 0.8-13.7) to 60.2% in Nigeria (OR = 60.2, 95% CI = 56.0-64.2). CONCLUSIONS Overall, significant positive associations of collective permissive attitudes of both adolescent and adult women towards premarital sex were found for use of, and demand for, contraception, whereas collective accepting attitudes towards wife-beating were negatively associated with the use and demand for contraception. Ours is the first study to define quantitatively the influence of proxies for gender norms at the community level on women's family planning decisions. These findings offer new insights for understanding the role of sex-related attitudes and norms as important factors in shaping contraceptive practices and improving the effectiveness of family planning policies by targeting individuals as well as their groups of influence.
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Affiliation(s)
- Iván Mejía-Guevara
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
- Department of Biology, Stanford University, Palo Alto, California, USA
| | | | - Ann Weber
- School of Community Health Sciences, University of Nevada, Reno, Reno, Nevada, USA
| | - Emma Hallgren
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Valerie Meausoone
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Mark R Cullen
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Gary L Darmstadt
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
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Steinholt M, Ha SO, Houy C, Odland JØ, Odland ML. An Increased Risk of Stunting among Newborns in Poorer Rural Settings: A Cross-Sectional Pilot Study among Pregnant Women at Selected Sites in Rural Cambodia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16214170. [PMID: 31671791 PMCID: PMC6861886 DOI: 10.3390/ijerph16214170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/26/2019] [Accepted: 10/27/2019] [Indexed: 02/01/2023]
Abstract
We conducted an observational study of 194 pregnant women from two different study sites in rural Cambodia. Socioeconomic and anthropometric data was obtained from the women and their newborns. In addition, we collected blood and urine samples from the women for further analyses in planned papers. There were significant differences between the two study groups for clinical outcomes. The mothers from the poorer area were shorter and weighed less at the time of inclusion. Their babies had significantly smaller head circumferences and a lower ponderal index. Conclusion: There are significant anthropometric differences between women and their newborns from two separate study sites in Cambodia. Possible associations between stunting and exposure to Persistent Toxic Substances (PTS) as organochlorines and toxic trace elements will be investigated in future studies.
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Affiliation(s)
- Margit Steinholt
- Helgelandssykehuset, 8801 Sandnessjoen, Norland, Norway.
- Department of Public Health and Nursing, Norwegian University of Science and Technology, 7491 Trondheim, Norway.
| | - Sam Ol Ha
- Trauma Care Foundation, Battambang, Cambodia.
| | - Chandy Houy
- Trauma Care Foundation, Battambang, Cambodia.
| | - Jon Øyvind Odland
- Department of Public Health and Nursing, Norwegian University of Science and Technology, 7491 Trondheim, Norway.
| | - Maria Lisa Odland
- Department of Public Health and Nursing, Norwegian University of Science and Technology, 7491 Trondheim, Norway.
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK.
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Rodgers J, Kim R, Subramanian SV. 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. J Epidemiol 2019; 30:485-496. [PMID: 31611523 PMCID: PMC7557174 DOI: 10.2188/jea.je20190064] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
| | - Rockli Kim
- Harvard Center for Population & Development Studies.,Division of Health Policy and Management, College of Health Sciences, Korea University.,Department of Public Health Sciences, Graduate School, Korea University
| | - S V Subramanian
- Harvard Center for Population & Development Studies.,Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health
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Kim R, Pathak PK, Xu Y, Joe W, Kumar A, Venkataramanan R, Subramanian SV. Micro-geographic targeting for precision public policy: Analysis of child sex ratio across 587,043 census villages in India, 2011. Health Place 2019; 57:92-100. [PMID: 31022572 DOI: 10.1016/j.healthplace.2019.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/23/2019] [Accepted: 02/19/2019] [Indexed: 11/16/2022]
Abstract
Child sex ratio (CSR) is a marker of disproportionate sex ratio at birth and discriminatory practices that lead to differential survival in early childhood by sex. We used the 2011 Census on rural India to present the first local analysis of CSR across 587,043 villages. In our multilevel analysis considering villages, tehsils, districts, and states/union territories, we found 96% of the total variation in CSR to be attributed to villages. About 39% of the villages were 'boy' areas (CSR≤88 girls per 100 boys) and another 12% had deficits in girls (88 < CSR≤93), while 11% fell in the normal range of CSR (93<CSR≤98), another 10% had 98 < CSR≤103, and the remaining 28% were 'girl' villages (CSR>103). The magnitude of local variation in CSR was heterogeneous across states/union territories and districts. Our findings provide timely evidence to inform localized programmes like Beti Bachao, Beti Padhao to be implemented with greater precision.
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Affiliation(s)
- Rockli Kim
- Harvard Center for Population and Development Studies, Cambridge, MA, USA
| | - Praveen Kumar Pathak
- Department of Geography, Delhi School of Economics, University of Delhi, Delhi, India
| | - Yun Xu
- SuperMap Software Co. Ltd, Beijing, China
| | - William Joe
- Population Research Centre, Institute of Economic Growth, Delhi, India
| | - Alok Kumar
- National Institution for Transforming India (NITI), Government of India, New Delhi, India
| | | | - S V Subramanian
- Harvard Center for Population and Development Studies, Cambridge, MA, USA; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
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Kim R, Kawachi I, Coull BA, Subramanian SV. Contribution of socioeconomic factors to the variation in body-mass index in 58 low-income and middle-income countries: an econometric analysis of multilevel data. LANCET GLOBAL HEALTH 2019; 6:e777-e786. [PMID: 29903378 DOI: 10.1016/s2214-109x(18)30232-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 03/30/2018] [Accepted: 04/24/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Most epidemiological studies have not simultaneously quantified variance in health within and between populations. We aimed to estimate the extent to which basic socioeconomic factors contribute to variation in body-mass index (BMI) across different populations. METHODS We pooled data from the cross-sectional Demographic and Health Surveys (2005-16) for 15-49 year old women with complete data for anthropometric measures in 58 low-income and middle-income countries (LMICs). We compared estimates from multilevel variance component models for BMI before and after adjusting for age and socioeconomic factors (place of residence, education, household wealth, and marital status). The hierarchical structure of the sample included three levels with women at level 1, communities at level 2, and countries at level 3. The primary outcome was BMI. We did a sensitivity analysis using the 2002-03 World Health Surveys. FINDINGS Of 1 212 758 women nested within 64 764 communities and 58 countries, we found that most unexplained variation for BMI was attributed to between-individual differences (80%) and the remaining was between-population differences (14% for countries and 6% for communities). Socioeconomic factors explained a large proportion of between-population variance in BMI (14·8% for countries and 47·1% for communities), but only about 2% of interindividual variance. In country-specific models, we found substantial variation in the magnitude of between-individual differences (variance estimates ranging from 7·6 to 31·4, or 86·0-98·6% of the total variation) and the proportion explained by socioeconomic factors (0·1-6·4%). The disproportionately large unexplained between-individual variance in BMI was consistently found in additional analyses including more comprehensive set of predictor variables, both men and women, and populations from low-income and high-income countries. INTERPRETATION Our findings on variance decomposition in BMI and explanation by socioeconomic factors at population and individual levels indicate that inferential questions that target within and between populations are importantly inter-related and should be considered simultaneously. FUNDING None.
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Affiliation(s)
- Rockli Kim
- Department of Social and Behavioral Sciences, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Ichiro Kawachi
- Department of Social and Behavioral Sciences, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Brent A Coull
- Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - S V Subramanian
- Department of Social and Behavioral Sciences, Harvard T H Chan School of Public Health, Boston, MA, USA; Harvard Center for Population and Development Studies, Cambridge, MA, USA.
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Sick countries and sick individuals: reassessing the inferential targets in global health research. LANCET GLOBAL HEALTH 2018; 6:e726-e727. [DOI: 10.1016/s2214-109x(18)30262-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 05/16/2018] [Indexed: 12/22/2022]
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13
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Subramanian SV, Kim R, Christakis NA. The "average" treatment effect: A construct ripe for retirement. A commentary on Deaton and Cartwright. Soc Sci Med 2018; 210:77-82. [PMID: 29724462 DOI: 10.1016/j.socscimed.2018.04.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- S V Subramanian
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Harvard Center for Population & Department Studies, Cambridge, MA, USA.
| | - Rockli Kim
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Nicholas A Christakis
- Department of Sociology, Yale University, New Haven, CT, USA; Department of Medicine, Yale University, New Haven, CT, USA; Yale Institute for Network Science, Yale University, New Haven, CT, USA
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