Recent Submissions

  • Journal Article

    Public provision of emergency obstetric care: a case study in two districts of Pakistan 

    Brückmann, Peter; Hashmi, Ashfa; Kuch, Marina; Kuhnt, Jana; Monfared, Ida; Vollmer, Sebastian
    BMJ Open 2019; 9(5): Art. e027187
    Objectives Pakistan is one out of five countries where together half of the global neonatal deaths occur. As the provision of services and facilities is one of the key elements vital to reducing this rate as well as the maternal mortality rate, this study investigates the status of the delivery of essential obstetric care provided by the public health sector in two districts in Khyber Pakhtunkhwa in 2015 aiming to highlight areas where critical improvements are needed. Setting We analysed data from a survey of 22 primary and secondary healthcare facilities as well as 85 community midwives (CMWs) in Haripur and Nowshera districts. Participants Using a structured questionnaire we evaluated the performance of emergency obstetric care (EmOC) signal functions and patient statistics in public health facilities. Also, 102 CMWs were interviewed about working hours, basic and specialised delivery service provision, referral system and patient statistics. Primary outcome measures We investigate the public provision of emergency obstetric care using seven key medical services identified by the United Nations (UN). Results Deliveries by public health cadres account for about 30% of the total number of births in these districts. According to the UN benchmark, only a small fraction of basic EmOC (2/18) and half of the comprehensive EmOC (2/4) facilities of the recommended minimum number were available to the population in both districts. Only a minority of health facilities and CMWs carry out several signal functions. Only 8% of the total births in one of the study districts are performed in public EmOC health facilities. Conclusions Both districts show a significant shortage of available public EmOC service provisions. Development priorities need to be realigned to improve the availability, accessibility and quality of EmOC service provisions by the public health sector alongside with existing activities to increase institutional births.
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  • Journal Article

    Hypertension screening, awareness, treatment, and control in India: A nationally representative cross-sectional study among individuals aged 15 to 49 years 

    Prenissl, Jonas; Manne-Goehler, Jennifer; Jaacks, Lindsay M.; Prabhakaran, Dorairaj; Awasthi, Ashish; Bischops, Anne Christine; Atun, Rifat; Bärnighausen, Till; Davies, Justine I.; Vollmer, Sebastian; et al.
    Geldsetzer, Pascal
    PLOS Medicine 2019; 16(5): Art. e1002801
    BACKGROUND: Evidence on where in the hypertension care process individuals are lost to care, and how this varies among states and population groups in a country as large as India, is essential for the design of targeted interventions and to monitor progress. Yet, to our knowledge, there has not yet been a nationally representative analysis of the proportion of adults who reach each step of the hypertension care process in India. This study aimed to determine (i) the proportion of adults with hypertension who have been screened, are aware of their diagnosis, take antihypertensive treatment, and have achieved control and (ii) the variation of these care indicators among states and sociodemographic groups. METHODS AND FINDINGS: We used data from a nationally representative household survey carried out from 20 January 2015 to 4 December 2016 among individuals aged 15-49 years in all states and union territories (hereafter "states") of the country. The stages of the care process-computed among those with hypertension at the time of the survey-were (i) having ever had one's blood pressure (BP) measured before the survey ("screened"), (ii) having been diagnosed ("aware"), (iii) currently taking BP-lowering medication ("treated"), and (iv) reporting being treated and not having a raised BP ("controlled"). We disaggregated these stages by state, rural-urban residence, sex, age group, body mass index, tobacco consumption, household wealth quintile, education, and marital status. In total, 731,864 participants were included in the analysis. Hypertension prevalence was 18.1% (95% CI 17.8%-18.4%). Among those with hypertension, 76.1% (95% CI 75.3%-76.8%) had ever received a BP measurement, 44.7% (95% CI 43.6%-45.8%) were aware of their diagnosis, 13.3% (95% CI 12.9%-13.8%) were treated, and 7.9% (95% CI 7.6%-8.3%) had achieved control. Male sex, rural location, lower household wealth, and not being married were associated with greater losses at each step of the care process. Between states, control among individuals with hypertension varied from 2.4% (95% CI 1.7%-3.3%) in Nagaland to 21.0% (95% CI 9.8%-39.6%) in Daman and Diu. At 38.0% (95% CI 36.3%-39.0%), 28.8% (95% CI 28.5%-29.2%), 28.4% (95% CI 27.7%-29.0%), and 28.4% (95% CI 27.8%-29.0%), respectively, Puducherry, Tamil Nadu, Sikkim, and Haryana had the highest proportion of all adults (irrespective of hypertension status) in the sampled age range who had hypertension but did not achieve control. The main limitation of this study is that its results cannot be generalized to adults aged 50 years and older-the population group in which hypertension is most common. CONCLUSIONS: Hypertension prevalence in India is high, but the proportion of adults with hypertension who are aware of their diagnosis, are treated, and achieve control is low. Even after adjusting for states' economic development, there is large variation among states in health system performance in the management of hypertension. Improvements in access to hypertension diagnosis and treatment are especially important among men, in rural areas, and in populations with lower household wealth.
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  • Journal Article

    Linking Arable Crop Occurrence with Site Conditions by the Use of Highly Resolved Spatial Data 

    Stein, Susanne; Steinmann, Horst-Henning; Isselstein, Johannes
    Land 2019; 8(4): Art. 65
    Agricultural land use is influenced in different ways by local factors such as soil conditions, water supply, and socioeconomic structure. We investigated at regional and field scale how strong the relationship of arable crop patterns and specific local site conditions is. At field scale, a logistic regression analysis for the main crops and selected site variables detected, for each of the analyzed crops, its own specific character of crop–site relationship. Some crops have diverging site relations such as maize and wheat, while other crops show similar probabilities under comparable site conditions, e.g., oilseed rape and winter barley. At the regional scale, the spatial comparison of clustered variables and clustered crop pattern showed a slightly stronger relationship of crop combination and specific combinations of site variables compared to the view of the single crop–site relationship. View Full-Text
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  • Journal Article

    Health system performance for people with diabetes in 28 low- and middle-income countries: A cross-sectional study of nationally representative surveys 

    Manne-Goehler, Jennifer; Geldsetzer, Pascal; Agoudavi, Kokou; Andall-Brereton, Glennis; Aryal, Krishna K.; Bicaba, Brice Wilfried; Bovet, Pascal; Brian, Garry; Dorobantu, Maria; Gathecha, Gladwell; et al.
    Singh Gurung, MongalGuwatudde, DavidMsaidie, MohamedHouehanou, CorineHouinato, DismandJorgensen, Jutta Mari AdelinKagaruki, Gibson B.Karki, Khem B.Labadarios, DemetreMartins, Joao S.Mayige, Mary T.McClure, Roy WongMwalim, OmarMwangi, Joseph KibachioNorov, BolormaaQuesnel-Crooks, SarahSilver, Bahendeka K.Sturua, LelaTsabedze, LindiweWesseh, Chea StanfordStokes, AndrewMarcus, MajaEbert, CaraDavies, Justine I.Vollmer, SebastianAtun, RifatBärnighausen, Till W.Jaacks, Lindsay M.
    PLOS Medicine 2019; 16(3): Art. e1002751
    BACKGROUND: The prevalence of diabetes is increasing rapidly in low- and middle-income countries (LMICs), urgently requiring detailed evidence to guide the response of health systems to this epidemic. In an effort to understand at what step in the diabetes care continuum individuals are lost to care, and how this varies between countries and population groups, this study examined health system performance for diabetes among adults in 28 LMICs using a cascade of care approach. METHODS AND FINDINGS: We pooled individual participant data from nationally representative surveys done between 2008 and 2016 in 28 LMICs. Diabetes was defined as fasting plasma glucose ≥ 7.0 mmol/l (126 mg/dl), random plasma glucose ≥ 11.1 mmol/l (200 mg/dl), HbA1c ≥ 6.5%, or reporting to be taking medication for diabetes. Stages of the care cascade were as follows: tested, diagnosed, lifestyle advice and/or medication given ("treated"), and controlled (HbA1c < 8.0% or equivalent). We stratified cascades of care by country, geographic region, World Bank income group, and individual-level characteristics (age, sex, educational attainment, household wealth quintile, and body mass index [BMI]). We then used logistic regression models with country-level fixed effects to evaluate predictors of (1) testing, (2) treatment, and (3) control. The final sample included 847,413 adults in 28 LMICs (8 low income, 9 lower-middle income, 11 upper-middle income). Survey sample size ranged from 824 in Guyana to 750,451 in India. The prevalence of diabetes was 8.8% (95% CI: 8.2%-9.5%), and the prevalence of undiagnosed diabetes was 4.8% (95% CI: 4.5%-5.2%). Health system performance for management of diabetes showed large losses to care at the stage of being tested, and low rates of diabetes control. Total unmet need for diabetes care (defined as the sum of those not tested, tested but undiagnosed, diagnosed but untreated, and treated but with diabetes not controlled) was 77.0% (95% CI: 74.9%-78.9%). Performance along the care cascade was significantly better in upper-middle income countries, but across all World Bank income groups, only half of participants with diabetes who were tested achieved diabetes control. Greater age, educational attainment, and BMI were associated with higher odds of being tested, being treated, and achieving control. The limitations of this study included the use of a single glucose measurement to assess diabetes, differences in the approach to wealth measurement across surveys, and variation in the date of the surveys. CONCLUSIONS: The study uncovered poor management of diabetes along the care cascade, indicating large unmet need for diabetes care across 28 LMICs. Performance across the care cascade varied by World Bank income group and individual-level characteristics, particularly age, educational attainment, and BMI. This policy-relevant analysis can inform country-specific interventions and offers a baseline by which future progress can be measured.
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  • Journal Article

    How socioeconomic status moderates the stunting-age relationship in low-income and middle-income countries 

    Bommer, Christian; Vollmer, Sebastian; Subramanian, S V
    BMJ Global Health 2019; 4(1)
    Introduction Reducing stunting is an important part of the global health agenda. Despite likely changes in risk factors as children age, determinants of stunting are typically analysed without taking into account age-related heterogeneity. We aim to fill this gap by providing an in-depth analysis of the role of socioeconomic status (SES) as a moderator for the stunting-age pattern. Methods Epidemiological and socioeconomic data from 72 Demographic and Health Surveys (DHS) were used to calculate stunting-age patterns by SES quartiles, derived from an index of household assets. We further investigated how differences in age-specific stunting rates between children from rich and poor households are explained by determinants that could be modified by nutrition-specific versus nutrition-sensitive interventions. Results While stunting prevalence in the pooled sample of 72 DHS is low in children up to the age of 5 months (maximum prevalence of 17.8% (95% CI 16.4;19.3)), stunting rates in older children tend to exceed those of younger ones in the age bracket of 6–20 months. This pattern is more pronounced in the poorest than in the richest quartile, with large differences in stunting prevalence at 20 months (stunting rates: 40.7% (95% CI 39.5 to 41.8) in the full sample, 50.3% (95% CI 48.2 to 52.4) in the poorest quartile and 29.2% (95% CI 26.8 to 31.5) in the richest quartile). When adjusting for determinants related to nutrition-specific interventions only, SES-related differences decrease by up to 30.1%. Much stronger effects (up to 59.2%) occur when determinants related to nutrition-sensitive interventions are additionally included. Conclusion While differences between children from rich and poor households are small during the first 5 months of life, SES is an important moderator for age-specific stunting rates in older children. Determinants related to nutrition-specific interventions are not sufficient to explain these SES-related differences, which could imply that a multifactorial approach is needed to reduce age-specific stunting rates in the poorest children.
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  • Journal Article

    Drosophila Ror is a nervous system-specific co-receptor for Wnt ligands 

    Ripp, Caroline; Loth, Julia; Petrova, Iveta; Linnemannstöns, Karen; Ulepic, Monique; Fradkin, Lee; Noordermeer, Jasprien; Wodarz, Andreas
    Biology Open 2018; 7(11): Art. bio033001
    Wnt ligands are secreted glycoproteins that control many developmental processes and are crucial for homeostasis of numerous tissues in the adult organism. Signal transduction of Wnts involves the binding of Wnts to receptor complexes at the surface of target cells. These receptor complexes are commonly formed between a member of the Frizzled family of seven-pass transmembrane proteins and a co-receptor, which is usually a single-pass transmembrane protein. Among these co-receptors are several with structural homology to receptor tyrosine kinases, including Ror, PTK7, Ryk and MUSK. In vertebrates, Ror-2 and PTK7 are important regulators of planar cell polarity (PCP). By contrast, PCP phenotypes were not reported for mutations in off-track (otk) and off-track2 (otk2), encoding the Drosophila orthologs of PTK7. Here we show that Drosophila Ror is expressed in the nervous system and localizes to the plasma membrane of perikarya and neurites. A null allele of Ror is homozygous viable and fertile, does not display PCP phenotypes and interacts genetically with mutations in otk and otk2 We show that Ror binds specifically to Wingless (Wg), Wnt4 and Wnt5 and also to Frizzled2 (Fz2) and Otk. Our findings establish Drosophila Ror as a Wnt co-receptor expressed in the nervous system.
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  • Journal Article

    Gain-of-Function (GOF) Mutant p53 as Actionable Therapeutic Target 

    Schulz-Heddergott, Ramona; Moll, Ute M.
    Cancers 2018; 10(6)
    p53 missense mutant alleles are present in nearly 40% of all human tumors. Such mutated alleles generate aberrant proteins that not only lose their tumor-suppressive functions but also frequently act as driver oncogenes, which promote malignant progression, invasion, metastasis, and chemoresistance, leading to reduced survival in patients and mice. Notably, these oncogenic gain-of-function (GOF) missense mutant p53 proteins (mutp53) are constitutively and tumor-specific stabilised. This stabilisation is one key pre-requisite for their GOF and is largely due to mutp53 protection from the E3 ubiquitin ligases Mdm2 and CHIP by the HSP90/HDAC6 chaperone machinery. Recent mouse models provide convincing evidence that tumors with highly stabilized GOF mutp53 proteins depend on them for growth, maintenance, and metastasis, thus creating exploitable tumor-specific vulnerabilities that markedly increase lifespan if intercepted. This identifies mutp53 as a promising cancer-specific drug target. This review discusses direct mutp53 protein-targeting drug strategies that are currently being developed at various preclinical levels.
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  • Journal Article

    Antenatal care services and its implications for vital and health outcomes of children: evidence from 193 surveys in 69 low-income and middle-income countries. 

    Kuhnt, Jana; Vollmer, Sebastian
    BMJ open 2017; 7(11): Art. e017122
    OBJECTIVES: Antenatal care (ANC) is an essential part of primary healthcare and its provision has expanded worldwide. There is limited evidence of large-scale cross-country studies on the impact of ANC offered to pregnant women on child health outcomes. We investigate the association of ANC in low-income and middle-income countries with short- and long-term mortality and nutritional child outcomes. SETTING: We used nationally representative health and welfare data from 193 Demographic and Health Surveys conducted between 1990 and 2013 from 69 low-income and middle-income countries for women of reproductive age (15-49 years), their children and their respective household. PARTICIPANTS: The analytical sample consisted of 752 635 observations for neonatal mortality, 574 675 observations for infant mortality, 400 426 observations for low birth weight, 501 484 observations for stunting and 512 424 observations for underweight. MAIN OUTCOMES AND MEASURES: Outcome variables are neonatal and infant mortality, low birth weight, stunting and underweight. RESULTS: At least one ANC visit was associated with a 1.04% points reduced probability of neonatal mortality and a 1.07% points lower probability of infant mortality. Having at least four ANC visits and having at least once seen a skilled provider reduced the probability by an additional 0.56% and 0.42% points, respectively. At least one ANC visit is associated with a 3.82% points reduced probability of giving birth to a low birth weight baby and a 4.11 and 3.26% points reduced stunting and underweight probability. Having at least four ANC visits and at least once seen a skilled provider reduced the probability by an additional 2.83%, 1.41% and 1.90% points, respectively. CONCLUSIONS: The currently existing and accessed ANC services in low-income and middle-income countries are directly associated with improved birth outcomes and longer-term reductions of child mortality and malnourishment.
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  • Journal Article

    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 

    Vollmer, Sebastian; Harttgen, Kenneth; Kupka, Roland; Subramanian, S. V.
    BMJ Global Health 2017; 2(2): Art. e000206
    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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  • Journal Article

    Panya: Economies of Deception and the Discontinuities of Indentured Labour Recruitment and the Slave Trade, Nigeria and Fernando Pó, 1890s–1940s 

    Martino, Enrique
    African Economic History 2016; 44(1) p.91-129
    In the first half of the twentieth century, most of Fernando Pó’s contract workers came from societies in southeastern Nigeria which had been heavily impacted by the transatlantic and internal slave trades. These contract workers were recruited by a new generation of labor recruiters, dispatched covertly by Spanish imperial employers, through a form of kidnapping known as panya. Panya was the largest labor smuggling and trafficking network in colonial West Africa, bringing tens of thousands of migrants to long and obligatory contracts on Fernando Pó. In contrast to scholars who have interpreted this history as a holdover from the pre-colonial period, this article argues that panya arose from the contractual order of Spanish imperial rule. Extensive archival research reveals the voices of those caught in the warp of post-abolition colonial labor regimes, in order to rethink the passage from the pre-colonial slave trade to imperialism within West African history. Using a series of vivid and precise petitions submitted by those who found themselves on the island of Fernando Pó, the article shows how these sources contain the potential to reconceptualize the disjunctures between enslavement in the slave trade and the recruitment of contract labor.
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  • Journal Article

    Dash-peonage: the contradictions of debt bondage in the colonial plantations of Fernando Pó 

    Martino, Enrique
    Africa 2017; 87(1) p.53-78
    Dash in pidgin English means an ancillary gift to an exchange. What happened when the dash became attached to the indentured labour contracts that the Spanish Empire brought from Cuba to their last colony, Spanish Guinea? On the island of Fernando Pó, which came to be almost wholly populated by Nigerian labour migrants, the conditional gift in the form of a large wage advance produced a particularly intense contradiction. In the historiography of unfree labour, the excess wage advance is thought to create conditions for the perpetuation of bondage through debt. However, in imperial contexts, the wage advance did not generate compliance and immobility; exactly the opposite – it produced unprecedented waves of further escalation and dispersed flight. The dash was pushed up by workers themselves and relayed by informal recruiters. Together they turned this lynchpin of indentured labour and debt peonage into a counter-practice that almost led to the collapse of the plantations in the 1950s. The trajectories of the dash led to a more pointed version of the foundational thesis of global labour history: namely, that it was actually free labour, not unfree labour, that was incompatible with labour scarcity-ridden imperial capitalism.
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