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Büttner N, Heemann M, De Neve JW, Verguet S, Vollmer S, Harttgen K. Economic Growth and Childhood Malnutrition in Low- and Middle-Income Countries. JAMA Netw Open 2023; 6:e2342654. [PMID: 37943556 PMCID: PMC10636637 DOI: 10.1001/jamanetworkopen.2023.42654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/30/2023] [Indexed: 11/10/2023] Open
Abstract
Importance Economic growth may reduce childhood malnutrition through improvements of several contributing factors, but the empirical evidence is mixed. Identifying the most important factors that contribute to child malnutrition and their associations with economic growth can inform decision-making about targeted investments to improve children's health. Objective To assess the associations between economic growth and malnutrition, contributing factors and malnutrition, and economic growth and contributing factors of malnutrition in low- and middle-income countries (LMICs). Design, Setting, and Participants This cross-sectional study used data from 239 Demographic and Health Surveys from January 1, 1990, to December 31, 2021. Observations included 1 138 568 children aged 0 to 35 months with valid anthropometric measures and information on contributing factors of malnutrition from 58 LMICs. Data were analyzed from May 20, 2022, to February 16, 2023. Exposure National per-capita gross domestic product (GDP) was used as a proxy for economic growth. Main Outcomes and Measures Six measures of childhood malnutrition were constructed: stunting (height-for-age z score <-2), underweight (weight-for-age z score <-2), wasting (weight-for-height z score <-2), overweight (weight-for-height z score >2), obesity (weight-for-height z score >3), and dietary diversity failure (consumption of less than 5 of 8 different food groups in the past 24 hours). Eighteen contributing factors of malnutrition were constructed, of which 10 were underlying determinants (eg, access to improved sanitation) and 8 were immediate determinants (eg, breastfeeding initiation). Results A total of 1 138 568 children (mean [SD] age, 17.14 [10.26] months; 579 589 [50.9%] boys and 558 979 [49.1%] girls) were included in the analysis. Of these, 27.3% (95% CI, 27.2%-27.4%) had stunting; 25.7% (95% CI, 25.6%-25.8%), underweight; 11.2% (95% CI, 11.1%-11.2%), wasting; 3.8% (95% CI, 3.7%-3.8%), overweight; 1.1% (95% CI, 1.1%-1.1%), obesity; and 79.8% (95% CI, 79.7%-79.9%), dietary diversity failure. Per-capita GDP was weakly associated with childhood malnutrition. The odds ratios associated with a 5% increase in per-capita GDP were 0.99 (95% CI, 0.99-1.00) for stunting, 1.01 (95% CI, 1.00-1.01) for wasting, 1.00 (95% CI, 1.00-1.00) for underweight, 0.98 (95% CI, 0.98-0.98) for overweight, 0.98 (95% CI, 0.97-0.98) for obesity, and 1.03 (95% CI, 1.01-1.04) for dietary diversity failure. Although strong associations were found between many contributing factors and most outcomes for malnutrition, associations identified between per-capita GDP and these contributing factors themselves were ambiguous. Conclusions and Relevance In this multicountry cross-sectional study, economic growth was weakly associated with childhood malnutrition and several contributing factors. To reduce child malnutrition, economic growth may need to be accompanied by more targeted investments to improve contributing factors that are strongly associated with child malnutrition, such as maternal health and education.
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Affiliation(s)
- Nicolas Büttner
- Department of Humanities, Social and Political Sciences, Eidgenössische Technische Hochschule Zürich, Zürich, Switzerland
| | - Markus Heemann
- Department of Economics and Centre for Modern Indian Studies, University of Göttingen, Göttingen, Germany
| | - Jan-Walter De Neve
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Stéphane Verguet
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Sebastian Vollmer
- Department of Economics and Centre for Modern Indian Studies, University of Göttingen, Göttingen, Germany
| | - Kenneth Harttgen
- Department of Humanities, Social and Political Sciences, Eidgenössische Technische Hochschule Zürich, Zürich, Switzerland
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Sato R, Bolongaita S, Memirie ST, Harttgen K, De Neve JW, Verguet S. Joint distribution of child mortality and wealth across 30 sub-Saharan African countries over 2000-2019. J Glob Health 2023; 13:04009. [PMID: 36821467 PMCID: PMC9949559 DOI: 10.7189/jogh.13.04009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Background While reductions in child mortality have been observed across sub-Saharan African countries in the last 30 years, narrowing the gaps in under-five mortality across socioeconomic groups also requires an understanding of the multiple associations between health and welfare and socioeconomic drivers. We examined the probability density distributions in under-five mortality within countries and joint pathways of under-five mortality and wealth over time. Methods We used 69 Demographic and Health Surveys and 19 Malaria Indicator Surveys from 30 sub-Saharan African countries, with each country having at least two surveys conducted since 2000. We constructed a cross-country wealth index and estimated under-five death prevalence. We examined the pure distribution in under-five mortality prevalence and the joint probability distribution of wealth and under-five mortality prevalence over time, including the area of confidence ellipse which spanned the two dimensions of mortality and wealth and covered 75% of the mass of the joint distribution. Results Most countries experienced decreases in under-five mortality along with increases in wealth over time. However, we observed great variations in the evolution of the joint distributions across countries over time. For instance, the areas of confidence ellipse ranged from 0.178 in Ethiopia (2000) to 1.119 in Angola (2006). The change (over time) in the area of confidence ellipses ranged from 0.010 in Tanzania to 0.844 in Angola between the 2000s and 2010s. The ranking of country performance on under-five mortality varied greatly, depending on whether performance summary indicators were based on disaggregation by wealth or on full non-disaggregated distributions. Conclusions Our analysis points to the relevance of full distributions of health and joint distributions of health and wealth as complementary indicators of distributions of health across socioeconomic status, in assessing country performance on health.
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Affiliation(s)
- Ryoko Sato
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Sarah Bolongaita
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Solomon Tessema Memirie
- Department of Pediatrics and Child Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Kenneth Harttgen
- Department of Humanities, Social and Political Sciences, ETH Zurich, Zurich, Switzerland
| | - Jan-Walter De Neve
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Stéphane Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Durizzo K, Harttgen K, Tediosi F, Sahu M, Kuwawenaruwa A, Salari P, Günther I. Toward mandatory health insurance in low-income countries? An analysis of claims data in Tanzania. Health Econ 2022; 31:2187-2207. [PMID: 35933731 PMCID: PMC9543525 DOI: 10.1002/hec.4568] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/17/2022] [Accepted: 06/19/2022] [Indexed: 06/15/2023]
Abstract
Many low-income countries are in the process of scaling up health insurance with the goal of achieving universal coverage. However, little is known about the usage and financial sustainability of mandatory health insurance. This study analyzes 26 million claims submitted to the Tanzanian National Health Insurance Fund (NHIF), which covers two million public servants for whom public insurance is mandatory, to understand insurance usage patterns, cost drivers, and financial sustainability. We find that in 2016, half of policyholders used a health service within a single year, with an average annual cost of 33 US$ per policyholder. About 10% of the population was responsible for 80% of the health costs, and women, middle-age and middle-income groups had the highest costs. Out of 7390 health centers, only five health centers are responsible for 30% of total costs. Estimating the expected health expenditures for the entire population based on the NHIF cost structure, we find that for a sustainable national scale-up, policy makers will have to decide between reducing the health benefit package or increasing revenues. We also show that the cost structure of a mandatory insurance scheme in a low-income country differs substantially from high-income settings. Replication studies for other countries are warranted.
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Affiliation(s)
| | | | - Fabrizio Tediosi
- Swiss Tropical and Public Health InstituteAllschwilSwitzerland
- University of BaselBaselSwitzerland
| | - Maitreyi Sahu
- Swiss Tropical and Public Health InstituteAllschwilSwitzerland
- University of BaselBaselSwitzerland
- University of WashingtonSeattleWashingtonUSA
| | - August Kuwawenaruwa
- Swiss Tropical and Public Health InstituteAllschwilSwitzerland
- Ifakara Health InstituteDar es SalaamTanzania
| | - Paola Salari
- Swiss Tropical and Public Health InstituteAllschwilSwitzerland
- University of BaselBaselSwitzerland
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Günther I, Harttgen K, Seiler J, Utzinger J. An index of access to essential infrastructure to identify where physical distancing is impossible. Nat Commun 2022; 13:3355. [PMID: 35701421 PMCID: PMC9198068 DOI: 10.1038/s41467-022-30812-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 04/28/2022] [Indexed: 11/30/2022] Open
Abstract
To identify areas at highest risk of infectious disease transmission in Africa, we develop a physical distancing index (PDI) based on the share of households without access to private toilets, water, space, transportation, and communication technology and weight it with population density. Our results highlight that in addition to improving health systems, countries across Africa, especially in the western part of Africa, need to address the lack of essential domestic infrastructure. Missing infrastructure prevents societies from limiting the spread of communicable diseases by undermining the effectiveness of governmental regulations on physical distancing. We also provide high-resolution risk maps that show which regions are most limited in protecting themselves. We find considerable spatial heterogeneity of the PDI within countries and show that it is highly correlated with detected COVID-19 cases. Governments could pay specific attention to these areas to target limited resources more precisely to prevent disease transmission. Lack of private infrastructure remains a major challenge potentially hampering a societies’ ability to contain the transmission of communicable diseases. Areas at high risk in Africa are identified based on access to essential basic infrastructure.
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Affiliation(s)
- Isabel Günther
- Development Economics Group, ETH Zürich, Zürich, Switzerland.,NADEL - Center for Development and Cooperation, ETH Zürich, Zürich, Switzerland
| | - Kenneth Harttgen
- Development Economics Group, ETH Zürich, Zürich, Switzerland. .,NADEL - Center for Development and Cooperation, ETH Zürich, Zürich, Switzerland.
| | - Johannes Seiler
- NADEL - Center for Development and Cooperation, ETH Zürich, Zürich, Switzerland.,Department of Statistics, University of Innsbruck, Innsbruck, Austria
| | - Jürg Utzinger
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.,University of Basel, Basel, Switzerland
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5
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Moonga G, Böse-O’Reilly S, Berger U, Harttgen K, Michelo C, Nowak D, Siebert U, Yabe J, Seiler J. Modelling chronic malnutrition in Zambia: A Bayesian distributional regression approach. PLoS One 2021; 16:e0255073. [PMID: 34347795 PMCID: PMC8336812 DOI: 10.1371/journal.pone.0255073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 07/10/2021] [Indexed: 11/19/2022] Open
Abstract
Background The burden of child under-nutrition still remains a global challenge, with greater severity being faced by low- and middle-income countries, despite the strategies in the Sustainable Development Goals (SDGs). Globally, malnutrition is the one of the most important risk factors associated with illness and death, affecting hundreds of millions of pregnant women and young children. Sub-Saharan Africa is one of the regions in the world struggling with the burden of chronic malnutrition. The 2018 Zambia Demographic and Health Survey (ZDHS) report estimated that 35% of the children under five years of age are stunted. The objective of this study was to analyse the distribution, and associated factors of stunting in Zambia. Methods We analysed the relationships between socio-economic, and remote sensed characteristics and anthropometric outcomes in under five children, using Bayesian distributional regression. Georeferenced data was available for 25,852 children from two waves of the ZDHS, 31% observation were from the 2007 and 69% were from the 2013/14. We assessed the linear, non-linear and spatial effects of covariates on the height-for-age z-score. Results Stunting decreased between 2007 and 2013/14 from a mean z-score of 1.59 (credible interval (CI): -1.63; -1.55) to -1.47 (CI: -1.49; -1.44). We found a strong non-linear relationship for the education of the mother and the wealth of the household on the height-for-age z-score. Moreover, increasing levels of maternal education above the eighth grade were associated with a reduced variation of stunting. Our study finds that remote sensed covariates alone explain little of the variation of the height-for-age z-score, which highlights the importance to collect socio-economic characteristics, and to control for socio-economic characteristics of the individual and the household. Conclusions While stunting still remains unacceptably high in Zambia with remarkable regional inequalities, the decline is lagging behind goal two of the SDGs. This emphasises the need for policies that help to reduce the share of chronic malnourished children within Zambia.
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Affiliation(s)
- Given Moonga
- Center for International Health, Ludwig Maximilian University of Munich, Munich, Germany
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT—University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
- Department of Epidemiology and Biostatistics, University of Zambia, Lusaka, Zambia
- * E-mail:
| | - Stephan Böse-O’Reilly
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT—University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Clinical Centre of the Ludwig Maximilian University of Munich, Munich, Germany
| | - Ursula Berger
- Institute for medical Information Processing, Biometry, and Epidemiology, Ludwig Maximilian University of Munich, Munich, Germany
| | - Kenneth Harttgen
- Department of Humanities, Social and Political Sciences, ETH Zurich, Zurich, Switzerland
| | - Charles Michelo
- Department of Epidemiology and Biostatistics, University of Zambia, Lusaka, Zambia
| | - Dennis Nowak
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Clinical Centre of the Ludwig Maximilian University of Munich, Munich, Germany
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT—University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - John Yabe
- School of Veterinary Medicine, University of Zambia, Lusaka, Zambia
| | - Johannes Seiler
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT—University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
- Department of Statistics, University of Innsbruck, Innsbruck, Austria
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Seiler J, Harttgen K, Kneib T, Lang S. Modelling children's anthropometric status using Bayesian distributional regression merging socio-economic and remote sensed data from South Asia and sub-Saharan Africa. Econ Hum Biol 2021; 40:100950. [PMID: 33321408 DOI: 10.1016/j.ehb.2020.100950] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 11/11/2020] [Accepted: 11/11/2020] [Indexed: 06/12/2023]
Abstract
A history of insufficient nutritional intake is reflected by low anthropometric measures and can lead to growth failures, limited mental development, poor health outcomes and a higher risk of dying. Children below five years are among those most vulnerable and, while improvements in the share of children affected by insufficient nutritional intake has been observed, both sub-Saharan Africa and South Asia have a disproportionately high share of growth failures and large disparities at national and sub-national levels. In this study, we use a Bayesian distributional regression approach to develop models for the standard anthropometric measures, stunting and wasting. This approach allows us to model both the mean and the standard deviation of the underlying response distribution. Accordingly, the whole distribution of the anthropometric measures can be evaluated. This is of particular importance, considering the fact that (severe) growth failures of children are defined having a z-score below -2 (-3), emphasising the need to extend the analysis beyond the conditional mean. In addition, we merge individual data taken from the Demographic and Health Surveys with remote sensed data for a large sample of 38 countries located in sub-Saharan Africa and South Asia for the period 1990-2016, in order to combine individual and household specific characteristics with geophysical and environmental characteristics, and to allow for a comparison over time. Our results show besides gender differences across space, and strong non-linear effects of included socio-economic characteristics, in particular for maternal education and the wealth of the household that, surprisingly, in the presence of socio-economic characteristics, remote sensed data does not contribute to variations in growth failures, and including a pure spatial effect excluding remote sensed data leads to even better results. Further, while all regions showed improvements towards the target of the Sustainable Development Goals (SDGs), our analysis identifies hotspots of growth failures at sub-national levels within India, Nigeria, Niger, and Madagascar, emphasising the need to accelerate progress to reach the target set by the SDGs.
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Affiliation(s)
- Johannes Seiler
- Department of Statistics, University of Innsbruck, Universitätsstr. 15, 6020 Innsbruck, Austria.
| | - Kenneth Harttgen
- Department of Humanities, Social and Political Sciences, ETH Zurich, Clausiusstr. 37, 8092 Zurich, Switzerland.
| | - Thomas Kneib
- University of Göttingen, Chair of Statistics, Humboldtallee 3, 37073 Göttingen, Germany.
| | - Stefan Lang
- Department of Statistics, University of Innsbruck, Universitätsstr. 15, 6020 Innsbruck, Austria.
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Monfared IG, Harttgen K, Vollmer S. Individual and social predictors of smoking and obesity: A panel study in Germany. SSM Popul Health 2020; 10:100558. [PMID: 32140542 PMCID: PMC7047176 DOI: 10.1016/j.ssmph.2020.100558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/08/2020] [Accepted: 02/09/2020] [Indexed: 11/25/2022] Open
Abstract
This is a longitudinal study of changes in smoking behaviour as well as becoming overweight/obese (OW/OB) and the strength of their association with personal factors such as self-control, mental health, and socioeconomic status (SES) versus their connection with the behaviour of other household members. Furthermore, we investigate that in terms of roles within a household, who is more vulnerable towards the behaviour of others. We used a hybrid model that followed individual adults (person-level fixed-effect) who participated in a national representative panel survey in Germany, SOEP, between 2008 and 2016 and answered all SF-12 items (N = 6874). The count of members in a household showing the associated adverse health behaviour was the nested random-effect. Compared with other predictors, the likelihood of a person becoming OW/OB had the strongest association with the number of cohabits who were also OW/OB and it became worse as this number increased (OR 7.18, 95% CI: 2.10-24.54 and 12.44, 95% CI: 1.53-100.85, for men and women respectively, e.g. compared with being married 2.83, 95% CI: 2.28-3.53 and 1.82, 95% CI: 1.42-2.34). However, for smoking the same rapid trend was not observed. Particularly, becoming OW/OB in female (adult) children was strongly associated with the behaviour of others (compared with household head or partner). For smoking the strongest link with others was among women who were head of the household. For both behaviours, we found neither mental health nor self-control to be strong predictors. Our findings indicate that various factors do not play equal roles in changes in health behaviour and particularly for women, becoming OW/OB is strongly connected with the behaviour of others. We further discuss the potential importance of social norms that might be helpful in developing more effective policies incorporating social connections as well as norms.
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Affiliation(s)
- Ida G. Monfared
- Centre for Modern Indian Studies & Department of Economics, University of Göttingen, Göttingen, Germany
| | | | - Sebastian Vollmer
- Centre for Modern Indian Studies & Department of Economics, University of Göttingen, Göttingen, Germany
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Adjaye-Gbewonyo K, Vollmer S, Avendano M, Harttgen K. Correction to: Agricultural trade policies and child nutrition in low- and middle-income countries: a cross-national analysis. Global Health 2019; 15:28. [PMID: 30971287 PMCID: PMC6456992 DOI: 10.1186/s12992-019-0471-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Harttgen K, Lang S, Seiler J. Selective mortality and the anthropometric status of children in low- and middle-income countries. Econ Hum Biol 2019; 34:257-273. [PMID: 31047818 DOI: 10.1016/j.ehb.2019.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 02/11/2019] [Accepted: 04/01/2019] [Indexed: 06/09/2023]
Abstract
Despite a close relationship between the childrens' anthropometric status and mortality rates, the highest mortality rates are concentrated in sub-Saharan Africa, while the lowest anthropometric indicators, in particular the height-for-age z-scores, are concentrated in South Asia. This discrepancy should, however, be expected to decrease when one accounts for the survivorship bias, i.e. selective mortality. We analyse whether the survivorship bias can explain these observed differences in three standard anthropometric indicators (stunting, underweight and wasting) by using individual data of children from six waves of Demographic and Health Surveys for a large cross-section of 37 low- and middle-income countries between 1991 and 2016. We use both a matching approach and semi-parametric regression to estimate the values for the anthropometric status of deceased children. The results are twofold: first, both methods reveal that the imputed values for the anthropometric indicators are, on average, between 0.10 and 0.25 standard deviations lower than the observed anthropometric indicators. Second, since the share of deceased children in our sample is below ten per cent, the contribution of the anthropometric status of deceased children to overall anthropometric indicators is small and therefore only influences it marginally.
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Affiliation(s)
- Kenneth Harttgen
- Department of Humanities, Social and Political Sciences, ETH Zurich, Clausiusstr. 37, 8092 Zurich, Switzerland.
| | - Stefan Lang
- Department of Statistics, University of Innsbruck, Universitätsstr. 15, 6020 Innsbruck, Austria.
| | - Johannes Seiler
- Department of Statistics, University of Innsbruck, Universitätsstr. 15, 6020 Innsbruck, Austria.
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Adjaye-Gbewonyo K, Vollmer S, Avendano M, Harttgen K. Agricultural trade policies and child nutrition in low- and middle-income countries: a cross-national analysis. Global Health 2019; 15:21. [PMID: 30876446 PMCID: PMC6420724 DOI: 10.1186/s12992-019-0463-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 02/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There has been growing interest in understanding the role of agricultural trade policies in diet and nutrition. This cross-country study examines associations between government policies on agricultural trade prices and child nutrition outcomes, particularly undernutrition. METHODS This study links panel data on government distortions to agricultural incentives to data from 212,258 children aged 6 to 35 months participating in Demographic and Health Surveys from 22 countries between 1991 and 2010. Country fixed-effects regression models were used to examine the association between within-country changes in nominal rates of assistance to tradable agriculture (government price distortions as a percentage of original prices) and child nutritional outcomes (height-for-age, weight-for-age, and weight-for-height Z-scores) while controlling for a range of time-varying country covariates. RESULTS Five-year average nominal rates of assistance to tradable agriculture ranged from - 72.0 to 45.5% with a mean of - 5.0% and standard deviation of 18.9 percentage points. A 10-percentage point increase in five-year average rates of assistance to tradable agriculture was associated with improved height-for-age (0.02, 95% CI: 0.00-0.05) and weight-for-age (0.05, 95% CI: 0.02-0.09) Z-scores. Improvements in nutritional status were greatest among children who had at least one parent earning wages in agriculture, and effects decreased as a country's proportion of tradable agriculture increased, particularly for weight-for-age Z-scores. CONCLUSIONS Government assistance to tradable agriculture, such as through reduced taxation, was associated with small but significant improvements in child nutritional status, especially for children with a parent earning wages in agriculture when the share of tradable agriculture was not high.
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Affiliation(s)
- Kafui Adjaye-Gbewonyo
- Innovative Methods & Metrics for Agriculture and Nutrition Actions, Tufts University Friedman School of Nutrition Science and Policy, 150 Harrison Avenue, Boston, MA 02111 USA
- Institute of Advanced Studies, University College London, Gower Street, London, WC1E 6BT UK
- Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115 USA
| | - Sebastian Vollmer
- University of Göttingen; Center for Modern Indian Studies, Waldweg 26, Altbau 1.118, 37073 Göttingen, Germany
| | - Mauricio Avendano
- Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115 USA
- Department of Global Health and Social Medicine, King’s College London, Strand Campus, Strand, London, WC2R2LS UK
| | - Kenneth Harttgen
- ETH Zürich, NADEL Center for Development and Cooperation, Clausiusstrasse 37, 8092 Zurich, Switzerland
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11
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Vollmer S, Bommer C, Krishna A, Harttgen K, Subramanian SV. The association of parental education with childhood undernutrition in low- and middle-income countries: comparing the role of paternal and maternal education. Int J Epidemiol 2018; 46:312-323. [PMID: 27501820 PMCID: PMC5420755 DOI: 10.1093/ije/dyw133] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2016] [Indexed: 12/04/2022] Open
Abstract
Background: Most existing research on the association of parental education with childhood undernutrition focuses on maternal education and often ignores paternal education. We systematically investigate differences in maternal and paternal education and their association with childhood undernutrition. Methods: One hundred and eighty Demographic and Health Surveys from 62 countries performed between 1990 and 2014 were analysed. We used linear-probability models to predict childhood undernutrition prevalences, measured as stunting, underweight and wasting, for all combinations of maternal and paternal attainment in school. Models were adjusted for demographic and socio-economic covariates for the child, mother and household, country-level fixed effects and clustering. Additional specifications adjust for local area characteristics instead of country fixed effects. Results: Both higher maternal and paternal education levels are associated with lower childhood undernutrition. In regressions adjusted for child age and sex as well as country-level fixed effects, the association is stronger for maternal education than for paternal education when their combined level of education is held constant. In the fully adjusted models, the observed differences in predicted undernutrition prevalences are strongly attenuated, suggesting a similar importance of maternal and paternal education. These findings are confirmed by the analysis of composite schooling indicators. Conclusions: We find that paternal education is similarly important for reducing childhood undernutrition as maternal education and should therefore receive increased attention in the literature.
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Affiliation(s)
- Sebastian Vollmer
- University of Göttingen, Germany.,Harvard Center for Population and Development Studies, Cambridge, United States
| | | | - Aditi Krishna
- The Hospital for Sick Children, Global Child Health Centre, Toronto, Canada
| | | | - S V Subramanian
- Harvard Center for Population and Development Studies, Cambridge, United States
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Vollmer S, Harttgen K, Kupka R, Subramanian SV. Levels and trends of childhood undernutrition by wealth and education according to a Composite Index of Anthropometric Failure: evidence from 146 Demographic and Health Surveys from 39 countries. BMJ Glob Health 2017; 2:e000206. [PMID: 29081994 PMCID: PMC5656130 DOI: 10.1136/bmjgh-2016-000206] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 03/28/2017] [Accepted: 03/31/2017] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Governments have endorsed global targets to reduce childhood undernutrition as part of the Sustainable Development Goals. Understanding the socioeconomic differences in childhood undernutrition has the potential to be helpful for targeting policy to reach these goals. METHODS We specify a logistic regression model with the Composite Index of Anthropometric Failure (CIAF) as the outcome and indicator variables for wealth quartiles, maternal education categories and a set of covariates as explanatory variables. Wealth and education variables are interacted with a period indicator for 1990-2000 compared with 2001-2014 to observe differences over time. Based on these regressions we calculate predicted CIAF prevalence by wealth and education categories and over time. RESULTS The sample included 146 surveys from 39 low-income and lower-middle-income countries with an overall sample size of 533 217 children. CIAF prevalence was 47.5% in 1990-2000, and it declined to 42.6% in 2001-2014. In 1990-2000 the CIAF prevalence of children with mothers with less than primary education was 31 percentage points higher than for mothers with secondary or higher education. This difference slightly decreased to 27 percentage points in 2001-2014. The difference in predicted CIAF prevalence of children from the highest and lowest wealth quartiles was 21 percentage points and did not change over time. CONCLUSIONS We find evidence for persistent and even increasing socioeconomic inequalities in childhood undernutrition, which underlines the importance of previous calls for equity-driven approaches targeting the most vulnerable to reduce childhood malnutrition.
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Affiliation(s)
- Sebastian Vollmer
- Department of Economics & Centre for Modern Indian Studies, University of Goettingen, Goettingen, Germany
- Harvard T H Chan School of Public Health, Boston, USA
| | | | - Roland Kupka
- Harvard T H Chan School of Public Health, Boston, USA
- UNICEF, New York City, USA
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13
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Vollmer S, Harttgen K, Alfven T, Padayachy J, Ghys P, Bärnighausen T. The HIV Epidemic in Sub-Saharan Africa is Aging: Evidence from the Demographic and Health Surveys in Sub-Saharan Africa. AIDS Behav 2017; 21:101-113. [PMID: 27837426 DOI: 10.1007/s10461-016-1591-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We use the individual-level data from all available Demographic and Health Surveys (DHS) from 27 sub-Saharan African countries conducted between 2003 and 2012 (40 population-based and nationally representative surveys in total) to calculate HIV testing consent rates and HIV prevalence for each country separately, as well as for the pooled sample. The pooled sample comprised of 427,130 individuals. In most countries HIV prevalence in adults aged 45 years and above is higher than in the total population. We further show that over the past decade HIV prevalence has increased in older age groups, while it has decreased in younger ones. While the age patterns of HIV consent rates vary across the 27 countries included in our sample, analysis of the pooled sample across all countries reveals a u-shaped relationship with lowest consent rates around age 35 years and higher consent rates among younger and older people. We argue that future DHS and other population-based HIV surveys should offer HIV testing to all adults without age limits.
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Affiliation(s)
- Sebastian Vollmer
- Department of Economics, University of Göttingen, Göttingen, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health Harvard University 665 Huntington Avenue, Boston, USA
| | | | | | | | | | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health Harvard University 665 Huntington Avenue, Boston, USA.
- Wellcome Trust Africa Centre for Heath and Population Studies, University of KwaZulu-Natal, Kwazulu-Natal, South Africa.
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany.
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Fink G, Victora CG, Harttgen K, Vollmer S, Vidaletti LP, Barros AJD. Measuring Socioeconomic Inequalities With Predicted Absolute Incomes Rather Than Wealth Quintiles: A Comparative Assessment Using Child Stunting Data From National Surveys. Am J Public Health 2017; 107:550-555. [PMID: 28207339 DOI: 10.2105/ajph.2017.303657] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To compare the predictive power of synthetic absolute income measures with that of asset-based wealth quintiles in low- and middle-income countries (LMICs) using child stunting as an outcome. METHODS We pooled data from 239 nationally representative household surveys from LMICs and computed absolute incomes in US dollars based on households' asset rank as well as data on national consumption and inequality levels. We used multivariable regression models to compare the predictive power of the created income measure with the predictive power of existing asset indicator measures. RESULTS In cross-country analysis, log absolute income predicted 54.5% of stunting variation observed, compared with 20% of variation explained by wealth quintiles. For within-survey analysis, we also found absolute income gaps to be predictive of the gaps between stunting in the wealthiest and poorest households (P < .001). CONCLUSIONS Our results suggest that absolute income levels can greatly improve the prediction of stunting levels across and within countries over time, compared with models that rely solely on relative wealth quintiles.
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Affiliation(s)
- Günther Fink
- Günther Fink is with the Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA. Cesar G. Victora, Luís Paulo Vidaletti, and Aluisio J. D. Barros are with the International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil. Kenneth Harttgen is with ETH Zürich, Zürich, Switzerland. Sebastian Vollmer is with the University of Göttingen, Göttingen, Germany
| | - Cesar G Victora
- Günther Fink is with the Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA. Cesar G. Victora, Luís Paulo Vidaletti, and Aluisio J. D. Barros are with the International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil. Kenneth Harttgen is with ETH Zürich, Zürich, Switzerland. Sebastian Vollmer is with the University of Göttingen, Göttingen, Germany
| | - Kenneth Harttgen
- Günther Fink is with the Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA. Cesar G. Victora, Luís Paulo Vidaletti, and Aluisio J. D. Barros are with the International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil. Kenneth Harttgen is with ETH Zürich, Zürich, Switzerland. Sebastian Vollmer is with the University of Göttingen, Göttingen, Germany
| | - Sebastian Vollmer
- Günther Fink is with the Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA. Cesar G. Victora, Luís Paulo Vidaletti, and Aluisio J. D. Barros are with the International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil. Kenneth Harttgen is with ETH Zürich, Zürich, Switzerland. Sebastian Vollmer is with the University of Göttingen, Göttingen, Germany
| | - Luís Paulo Vidaletti
- Günther Fink is with the Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA. Cesar G. Victora, Luís Paulo Vidaletti, and Aluisio J. D. Barros are with the International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil. Kenneth Harttgen is with ETH Zürich, Zürich, Switzerland. Sebastian Vollmer is with the University of Göttingen, Göttingen, Germany
| | - Aluisio J D Barros
- Günther Fink is with the Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA. Cesar G. Victora, Luís Paulo Vidaletti, and Aluisio J. D. Barros are with the International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil. Kenneth Harttgen is with ETH Zürich, Zürich, Switzerland. Sebastian Vollmer is with the University of Göttingen, Göttingen, Germany
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15
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Abstract
Economists have often argued that high fertility rates are mainly driven by women's demand for children (and not by family planning efforts) with low levels of unwanted fertility across countries (and hence with little room for family planning efforts to reduce population growth). We study the relationship between wanted fertility and number of children born in a panel of 200 country-years controlling for country fixed effects and global time trends. In general, we find a close relationship between wanted and actual fertility, with one desired child leading to one additional birth. However, our results also indicate that in the last 20 years, the level of unwanted births has stayed at 2 across African countries but has, on average, decreased from 1 to close to 0 in other developing countries. Hence, women in African countries are less able to translate child preferences into birth outcomes than women in other developing countries, and forces other than fertility demand have been important for previous fertility declines in many developing countries. Family planning efforts only partially explain the observed temporal and spatial differences in achieving desired fertility levels.
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Affiliation(s)
- Isabel Günther
- Center for Development and Cooperation, ETH Zurich, Clausiusstrasse 37, 8092, Zurich, Switzerland.
| | - Kenneth Harttgen
- Center for Development and Cooperation, ETH Zurich, Clausiusstrasse 37, 8092, Zurich, Switzerland.
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16
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Vollmer S, Harttgen K, Subramanyam M, Finlay J, Klasen S, Subramanian SV. Economic growth and child malnutrition - Authors' reply. Lancet Glob Health 2016; 4:e903. [PMID: 27855864 DOI: 10.1016/s2214-109x(16)30249-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 09/13/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Sebastian Vollmer
- Department of Economics, Center for Modern Indian Studies, and Courant Research Centre "Poverty, Equity and Growth in Developing Countries", University of Göttingen, Göttingen, Germany; Harvard Center for Population and Development Studies, Harvard School of Public Health, Cambridge, MA, USA.
| | | | - Malavika Subramanyam
- Social Sciences, Indian Institute of Technology Gandhinagar, Ahmedabad, Gujarat, India
| | - Jocelyn Finlay
- Harvard Center for Population and Development Studies, Harvard School of Public Health, Cambridge, MA, USA
| | - Stephan Klasen
- Department of Economics, Center for Modern Indian Studies, and Courant Research Centre "Poverty, Equity and Growth in Developing Countries", University of Göttingen, Göttingen, Germany
| | - S V Subramanian
- Harvard Center for Population and Development Studies, Harvard School of Public Health, Cambridge, MA, USA
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17
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Biritwum RB, Minicuci N, Yawson AE, Theou O, Mensah GP, Naidoo N, Wu F, Guo Y, Zheng Y, Jiang Y, Maximova T, Kalula S, Arokiasamy P, Salinas-Rodríguez A, Manrique-Espinoza B, Snodgrass JJ, Sterner KN, Eick G, Liebert MA, Schrock J, Afshar S, Thiele E, Vollmer S, Harttgen K, Strulik H, Byles JE, Rockwood K, Mitnitski A, Chatterji S, Kowal P. Prevalence of and factors associated with frailty and disability in older adults from China, Ghana, India, Mexico, Russia and South Africa. Maturitas 2016; 91:8-18. [PMID: 27451316 DOI: 10.1016/j.maturitas.2016.05.012] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 05/18/2016] [Accepted: 05/23/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND The severe burden imposed by frailty and disability in old age is a major challenge for healthcare systems in low- and middle-income countries alike. The current study aimed to provide estimates of the prevalence of frailty and disability in older adult populations and to examine their relationship with socioeconomic factors in six countries. METHODS Focusing on adults aged 50+ years, a frailty index was constructed as the proportion of deficits in 40 variables, and disability was assessed using the World Health Organization Disability Assessment Schedule (WHODAS 2.0), as part of the Study on global AGEing and adult health (SAGE) Wave 1 in China, Ghana, India, Mexico, Russia and South Africa. RESULTS This study included a total of 34,123 respondents. China had the lowest percentages of older adults with frailty (13.1%) and with disability (69.6%), whereas India had the highest percentages (55.5% and 93.3%, respectively). Both frailty and disability increased with age for all countries, and were more frequent in women, although the sex gap varied across countries. Lower levels of both frailty and disability were observed at higher levels of education and wealth. Both education and income were protective factors for frailty and disability in China, India and Russia, whereas only income was protective in Mexico, and only education in South Africa. CONCLUSIONS Age-related frailty and disability are increasing concerns for older adult populations in low- and middle-income countries. The results indicate that lower levels of frailty and disability can be achieved for older people, and the study highlights the need for targeted preventive approaches and support programs.
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Affiliation(s)
- R B Biritwum
- University of Ghana, Department of Community Health, Accra, Ghana.
| | - N Minicuci
- University of Ghana, Department of Community Health, Accra, Ghana; National Research Council, Neuroscience Institute, Padova, Italy.
| | - A E Yawson
- University of Ghana, Department of Community Health, Accra, Ghana.
| | - O Theou
- Dalhousie University, Geriatric Medicine, Halifax, Canada.
| | - G P Mensah
- University of Ghana, Department of Community Health, Accra, Ghana.
| | - N Naidoo
- World Health Organization, SAGE team, Geneva, Switzerland.
| | - F Wu
- Shanghai Municipal Center for Disease Control and Prevention (Shanghai CDC), Shanghai, PR China.
| | - Y Guo
- Shanghai Municipal Center for Disease Control and Prevention (Shanghai CDC), Shanghai, PR China.
| | - Y Zheng
- Shanghai Municipal Center for Disease Control and Prevention (Shanghai CDC), Shanghai, PR China.
| | - Y Jiang
- Capital Medical University, Clinical Trial and Research Center for Stroke, Beijing Tiantan Hospital, Beijing, PR China.
| | - T Maximova
- National Research Institute of Public Health (FSBI, RAMS), Moscow, Russian Federation.
| | - S Kalula
- University of Cape Town, Division of Geriatric Medicine, The Albertina and Walter Sisulu Institute of Ageing in Africa, South Africa; Groote Schuur Hospital, International Longevity Centre, Cape Town, South Africa.
| | - P Arokiasamy
- International Institute of Population Studies, Mumbai, India.
| | - A Salinas-Rodríguez
- National Institute of Public Health, Center for Evaluation Research and Surveys, Cuernavaca, Morelos, Mexico.
| | - B Manrique-Espinoza
- National Institute of Public Health, Center for Evaluation Research and Surveys, Cuernavaca, Morelos, Mexico.
| | - J J Snodgrass
- University of Oregon, Department of Anthropology, Eugene, USA.
| | - K N Sterner
- University of Oregon, Department of Anthropology, Eugene, USA.
| | - G Eick
- University of Oregon, Department of Anthropology, Eugene, USA.
| | - M A Liebert
- University of Oregon, Department of Anthropology, Eugene, USA.
| | - J Schrock
- University of Oregon, Department of Anthropology, Eugene, USA.
| | - S Afshar
- University of Southampton, Faculty of Medicine, United Kingdom
| | - E Thiele
- Vassar College, Department of Biology, Poughkeepsie, NY, USA.
| | - S Vollmer
- University of Göttingen, Department of Economics, Germany; Harvard T.H. Chan School of Public Health, Boston, USA.
| | | | - H Strulik
- University of Gottingen, Department of Economics, Gottingen, Germany.
| | - J E Byles
- University of Newcastle Research Centre for Generational Health and Ageing, Newcastle, Australia.
| | - K Rockwood
- Dalhousie University, Geriatric Medicine, Halifax, Canada.
| | - A Mitnitski
- Dalhousie University, Geriatric Medicine, Halifax, Canada.
| | - S Chatterji
- World Health Organization, SAGE team, Geneva, Switzerland.
| | - P Kowal
- World Health Organization, SAGE team, Geneva, Switzerland; University of Newcastle Research Centre for Generational Health and Ageing, Newcastle, Australia.
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Vollmer S, Harttgen K, Subramanyam MA, Finlay J, Klasen S, Subramanian SV. Association between economic growth and early childhood nutrition--authors' reply. Lancet Glob Health 2015; 3:e81. [PMID: 25617199 DOI: 10.1016/s2214-109x(14)70380-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Sebastian Vollmer
- Department of Economics and Courant Research Centre Poverty, Equity and Growth in Developing Countries, University of Goöttingen, Goöttingen, Germany; Harvard Center for Population and Development Studies, Harvard School of Public Health, Cambridge, MA 02138, USA
| | | | | | - Jocelyn Finlay
- Harvard Center for Population and Development Studies, Harvard School of Public Health, Cambridge, MA 02138, USA
| | - Stephan Klasen
- Department of Economics and Courant Research Centre Poverty, Equity and Growth in Developing Countries, University of Goöttingen, Goöttingen, Germany
| | - S V Subramanian
- Harvard Center for Population and Development Studies, Harvard School of Public Health, Cambridge, MA 02138, USA.
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19
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Vollmer S, Alfven T, Padayachy J, Harttgen K, Ghys PD, Bärnighausen T. HIV surveys in older adults: better data, better health. Lancet HIV 2015; 2:e40-1. [PMID: 26424459 DOI: 10.1016/s2352-3018(15)00004-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 01/05/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Sebastian Vollmer
- Department of Economics, University of Göttingen, Germany; Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, MA, USA
| | | | | | | | | | - Till Bärnighausen
- Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, MA, USA; Wellcome Trust Africa Centre for Heath and Population Studies, University of KwaZulu-Natal, South Africa.
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20
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Vollmer S, Harttgen K, Subramanyam MA, Finlay J, Klasen S, Subramanian SV. Association between economic growth and early childhood nutrition--Authors' reply. Lancet Glob Health 2014; 2:e501-e502. [PMID: 25304409 DOI: 10.1016/s2214-109x(14)70268-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Sebastian Vollmer
- Department of Economics and Courant Research Centre "Poverty, Equity and Growth in Developing Countries", University of Göttingen, Göttingen, Germany; Harvard Center for Population and Development Studies, Harvard School of Public Health, Cambridge, MA 02138, USA
| | | | | | - Jocelyn Finlay
- Harvard Center for Population and Development Studies, Harvard School of Public Health, Cambridge, MA 02138, USA
| | - Stephan Klasen
- Department of Economics and Courant Research Centre "Poverty, Equity and Growth in Developing Countries", University of Göttingen, Göttingen, Germany
| | - S V Subramanian
- Harvard Center for Population and Development Studies, Harvard School of Public Health, Cambridge, MA 02138, USA.
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21
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Vollmer S, Harttgen K, Subramanyam MA, Finlay J, Klasen S, Subramanian SV. Association between economic growth and early childhood undernutrition: evidence from 121 Demographic and Health Surveys from 36 low-income and middle-income countries. Lancet Glob Health 2014; 2:e225-34. [PMID: 25103063 DOI: 10.1016/s2214-109x(14)70025-7] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Economic growth is widely regarded as a necessary, and often sufficient, condition for the improvement of population health. We aimed to assess whether macroeconomic growth was associated with reductions in early childhood undernutrition in low-income and middle-income countries. METHODS We analysed data from 121 Demographic and Health Surveys from 36 countries done between Jan 1, 1990, and Dec 31, 2011. The sample consisted of nationally representative cross-sectional surveys of children aged 0-35 months, and the outcome variables were stunting, underweight, and wasting. The main independent variable was per-head gross domestic product (GDP) in constant prices and adjusted for purchasing power parity. We used logistic regression models to estimate the association between changes in per-head GDP and changes in child undernutrition outcomes. Models were adjusted for country fixed effects, survey-year fixed effects, clustering, and demographic and socioeconomic covariates for the child, mother, and household. FINDINGS Sample sizes were 462,854 for stunting, 485,152 for underweight, and 459,538 for wasting. Overall, 35·6% (95% CI 35·4-35·9) of young children were stunted (ranging from 8·7% [7·6-9·7] in Jordan to 51·1% [49·1-53·1] in Niger), 22·7% (22·5-22·9) were underweight (ranging from 1·8% [1·3-2·3] in Jordan to 41·7% [41·1-42·3] in India), and 12·8% (12·6-12·9) were wasted (ranging from 1·2% [0·6-1·8] in Peru to 28·8% [27·5-30·0] in Burkina Faso). At the country level, no association was seen between average changes in the prevalence of child undernutrition outcomes and average growth of per-head GDP. In models adjusted only for country and survey-year fixed effects, a 5% increase in per-head GDP was associated with an odds ratio (OR) of 0·993 (95% CI 0·989-0·995) for stunting, 0·986 (0·982-0·990) for underweight, and 0·984 (0·981-0·986) for wasting. ORs after adjustment for the full set of covariates were 0·996 (0·993-1·000) for stunting, 0·989 (0·985-0·992) for underweight, and 0·983 (0·979-0·986) for wasting. These findings were consistent across various subsamples and for alternative variable specifications. Notably, no association was seen between per-head GDP and undernutrition in young children from the poorest household wealth quintile. ORs for the poorest wealth quintile were 0·997 (0·990-1·004) for stunting, 0·999 (0·991-1·008) for underweight, and 0·991 (0·978-1·004) for wasting. INTERPRETATION A quantitatively very small to null association was seen between increases in per-head GDP and reductions in early childhood undernutrition, emphasising the need for direct health investments to improve the nutritional status of children in low-income and middle-income countries. FUNDING None.
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Affiliation(s)
- Sebastian Vollmer
- Department of Economics and Courant Research Centre "Poverty, Equity and Growth in Developing Countries", University of Göttingen, Göttingen, Germany; Harvard Center for Population and Development Studies, Harvard School of Public Health, Cambridge, MA, USA.
| | | | | | - Jocelyn Finlay
- Harvard Center for Population and Development Studies, Harvard School of Public Health, Cambridge, MA, USA
| | - Stephan Klasen
- Department of Economics and Courant Research Centre "Poverty, Equity and Growth in Developing Countries", University of Göttingen, Göttingen, Germany
| | - S V Subramanian
- Harvard Center for Population and Development Studies, Harvard School of Public Health, Cambridge, MA, USA.
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Harttgen K, Kowal P, Strulik H, Chatterji S, Vollmer S. Patterns of frailty in older adults: comparing results from higher and lower income countries using the Survey of Health, Ageing and Retirement in Europe (SHARE) and the Study on Global AGEing and Adult Health (SAGE). PLoS One 2013; 8:e75847. [PMID: 24204581 PMCID: PMC3812225 DOI: 10.1371/journal.pone.0075847] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 08/23/2013] [Indexed: 01/10/2023] Open
Abstract
We use the method of deficit accumulation to describe prevalent and incident levels of frailty in community-dwelling older persons and compare prevalence rates in higher income countries in Europe, to prevalence rates in six lower income countries. Two multi-country data collection efforts, SHARE and SAGE, provide nationally representative samples of adults aged 50 years and older. Forty items were used to construct the frailty index in each data set. Our study shows that the level of frailty was distributed along the socioeconomic gradient in both higher and lower income countries such that those individuals with less education and income were more likely to be frail. Frailty increased with age and women were more likely to be frail in most countries. Across samples we find that the level of frailty was higher in the higher income countries than in the lower income countries.
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Affiliation(s)
| | - Paul Kowal
- World Health Organization, Geneva, Switzerland
| | - Holger Strulik
- University of Göttingen, Department of Economics, Göttingen, Germany
| | | | - Sebastian Vollmer
- University of Göttingen, Department of Economics, Göttingen, Germany
- Harvard School of Public Health, Department of Global Health and Population, Boston, Massachusetts, United States of America
- * E-mail:
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23
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Grimm M, Harttgen K, Klasen S, Misselhorn M, Munzi T, Smeeding T. Inequality in Human Development: An Empirical Assessment of 32 Countries. Soc Indic Res 2010; 97:191-211. [PMID: 20461123 PMCID: PMC2861180 DOI: 10.1007/s11205-009-9497-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Accepted: 05/24/2009] [Indexed: 05/29/2023]
Abstract
One of the most frequent critiques of the HDI is that is does not take into account inequality within countries in its three dimensions. In this paper, we apply a simply approach to compute the three components and the overall HDI for quintiles of the income distribution. This allows a comparison of the level in human development of the poor with the level of the non-poor within countries, but also across countries. This is an application of the method presented in Grimm et al. (World Development 36(12):2527-2546, 2008) to a sample of 21 low and middle income countries and 11 industrialized countries. In particular the inclusion of the industrialized countries, which were not included in the previous work, implies to deal with a number of additional challenges, which we outline in this paper. Our results show that inequality in human development within countries is high, both in developed and industrialized countries. In fact, the HDI of the lowest quintiles in industrialized countries is often below the HDI of the richest quintile in many middle income countries. We also find, however, a strong overall negative correlation between the level of human development and inequality in human development.
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Affiliation(s)
- Michael Grimm
- Institute of Social Studies, Erasmus University Rotterdam, Kortenaerkade 12, 2518 AX The Hague, The Netherlands
| | | | | | | | | | - Timothy Smeeding
- Luxembourg Income Study, Luxembourg, Luxembourg
- University of Wisconsin-Madison, Madison, WI USA
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