Items 1-20 of 25

    • Journal Article

      Mental distress and its association with sociodemographic and economic characteristics: community-based household survey in Aceh, Indonesia 

      Reuter, Anna; Vollmer, Sebastian; Aiyub, A.; Susanti, Suryane Sulistiana; Marthoenis, M.
      BJPsych Open 2020; 6(6) p.1-9: Art. e134
      Background: The role of sociodemographic and economic characteristics in mental distress has been rarely investigated in Indonesia. Aims: To investigate the prevalence of common mental disorders (CMD) and identify any associations between mental distress and sociodemographic and economic characteristics among communities living in urban and rural (peri-urban) areas. Method: A community-based household survey was conducted in the province of Aceh, Indonesia, in 2018. The 20-item Self Reporting: Questionnaire (SRQ-20) screening tool was used to measure symptoms of CMD. Information on sociodemographic characteristics, family functioning, labour market outcomes and healthcare costs was collected. Multivariate regressions were conducted to analyse the relationships between the measures of mental distress and sociodemographic and economic characteristics. Results: We found that 14% of the respondents had CMD symptoms. SRQ-20 scores were higher for female, older and lower-educated individuals. CMD prevalence was higher among non-married participants and clustered within families. Participants with CMD perceive their families as performing significantly better in the dimensions of affective involvement and behaviour control compared with their counterparts. Their work was more often affected by negative feelings; they were also twice as likely to report a recent physical or mental health complaint and faced twice the treatment costs compared with their non-affected counterparts. Conclusions: The prevalence of mental disorders is especially high in disadvantaged population groups. Moreover, mental distress is associated with a lower perceived productivity and a higher physical health burden.
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    • Journal Article

      Validating the Efficiency of the FeS$_2$ Method for Elucidating the Mechanisms of Contaminant Removal Using Fe$_0$/H$_2$O Systems 

      Xiao, Minhui; Cui, Xuesong; Hu, Rui; Gwenzi, Willis; Noubactep, Chicgoua
      Processes 2020; 8(9) p.1-16: Art. 1162
      There is growing interest in using pyrite minerals (FeS$_2$) to enhance the efficiency of metallic iron (Fe$^0$) for water treatment (Fe$^0$/H$_2$O systems). This approach contradicts the thermodynamic predicting suppression of FeS$_2$ oxidation by Fe$^0$ addition. Available results are rooted in time series correlations between aqueous and solid phases based on data collected under various operational conditions. Herein, the methylene blue method (MB method) is used to clarify the controversy. The MB method exploits the differential adsorptive affinity of MB onto sand and sand coated with iron corrosion products to assess the extent of Fe$^0$ corrosion in Fe$^0$/H$_2$O systems. The effects of the addition of various amounts of FeS$_2$ to a Fe$^0$/sand mixture (FeS$_2$ method) on MB discoloration were characterized in parallel quiescent batch experiments for up to 71 d (pH$_0$ = 6.8). Pristine and aged FeS$_2$ specimens were used. Parallel experiments with methyl orange (MO) and reactive red 120 (RR120) enabled a better discussion of the achieved results. The results clearly showed that FeS$_2$ induces a pH shift and delays Fe precipitation and sand coating. Pristine FeS$_2$ induced a pH shift to values lower than 4.5, but no quantitative MB discoloration occurred after 45 d. Aged FeS$_2$ could not significantly shift the pH value (final pH ≥ 6.4) but improved the MB discoloration. The used systematic sequence of experiments demonstrated that adsorption and coprecipitation are the fundamental mechanisms of contaminant removal in Fe$^0$/H$_2$O systems. This research has clarified the reason why a FeS$_2$ addition enhances the efficiency of Fe$^0$ environmental remediation.
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    • Journal Article

      Association between milk consumption and child growth for children aged 6–59 months 

      Herber, Christine; Bogler, Lisa; Subramanian, S. V.; Vollmer, Sebastian
      Scientific Reports 2020; 10(1) p.1-9: Art. 6730
      Apart from high levels of energy, proteins, micro- and macronutrients, milk contains calcium and the insulin-like growth factor-1 that are of major relevance for children’s development and growth. Using Demographic and Health Survey data between 1990 and 2017 with information on milk consumption and anthropometric measurements from all low- and middle-income countries available, we investigate whether milk consumption in childhood is associated with stunting, wasting, and underweight. We specify logistic regression models and adjust for a range of covariates and fixed effects on the primary sampling unit level. We analyze heterogeneity in the association by wealth quintiles and age groups and present country-specific estimates. The final samples for wasting, underweight and stunting include 668.463, 693.376, and 673.177 observations of children aged 6 to 59 months, respectively. Our results suggest that milk consumption is associated with a reduced probability of being underweight of 1.4 percentage points (95% confidence interval −0.02, −0.01) and a reduced probability of being stunted of 1.9 percentage points (95% confidence interval −0.02, −0.01). The association for wasting is not robust. The association is stronger for children from wealthier households, which might indicate that milk consumption is a proxy for better overall nutrition or socio-economic status.
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    • Journal Article

      Individual and social predictors of smoking and obesity: A panel study in Germany 

      Monfared, Ida G.; Harttgen, Kenneth; Vollmer, Sebastian
      SSM - Population Health 2020; 10 p.1-10: Art. 100558
      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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    • Journal Article

      Evaluation of sex differences in dietary behaviours and their relationship with cardiovascular risk factors: a cross-sectional study of nationally representative surveys in seven low- and middle-income countries 

      McKenzie, Briar L.; Santos, Joseph A.; Geldsetzer, Pascal; Davies, Justine; Manne-Goehler, Jennifer; Gurung, Mongal S.; Sturua, Lela; Gathecha, Gladwell; Aryal, Krishna K.; Tsabedze, Lindiwe; et al.
      Andall-Brereton, GlennisBärnighausen, TillAtun, RifatVollmer, SebastianWoodward, MarkJaacks, Lindsay M.Webster, Jacqui
      Nutrition Journal. 2020 Jan 13;19(1):3
      Background Cardiovascular diseases (CVD) are the leading causes of death for men and women in low-and-middle income countries (LMIC). The nutrition transition to diets high in salt, fat and sugar and low in fruit and vegetables, in parallel with increasing prevalence of diet-related CVD risk factors in LMICs, identifies the need for urgent action to reverse this trend. To aid identification of the most effective interventions it is crucial to understand whether there are sex differences in dietary behaviours related to CVD risk. Methods From a dataset of 46 nationally representative surveys, we included data from seven countries that had recorded the same dietary behaviour measurements in adults; Bhutan, Eswatini, Georgia, Guyana, Kenya, Nepal and St Vincent and the Grenadines (2013–2017). Three dietary behaviours were investigated: positive salt use behaviour (SUB), meeting fruit and vegetable (F&V) recommendations and use of vegetable oil rather than animal fats in cooking. Generalized linear models were used to investigate the association between dietary behaviours and waist circumference (WC) and undiagnosed and diagnosed hypertension and diabetes. Interaction terms between sex and dietary behaviour were added to test for sex differences. Results Twenty-four thousand three hundred thirty-two participants were included. More females than males reported positive SUB (31.3 vs. 27.2% p-value < 0.001), yet less met F&V recommendations (13.2 vs. 14.8%, p-value< 0.05). The prevalence of reporting all three dietary behaviours in a positive manner was 2.7%, varying by country, but not sex. Poor SUB was associated with a higher prevalence of undiagnosed hypertension for females (13.1% vs. 9.9%, p-value = 0.04), and a higher prevalence of undiagnosed diabetes for males (2.4% vs. 1.5%, p-value = 0.02). Meeting F&V recommendations was associated with a higher prevalence of high WC (24.4% vs 22.6%, p-value = 0.01), but was not associated with undiagnosed or diagnosed hypertension or diabetes. Conclusion Interventions to increase F&V intake and positive SUBs in the included countries are urgently needed. Dietary behaviours were not notably different between sexes. However, our findings were limited by the small proportion of the population reporting positive dietary behaviours, and further research is required to understand whether associations with CVD risk factors and interactions by sex would change as the prevalence of positive behaviours increases.
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    • Journal Article

      Healthcare providers’ perception of the referral system in maternal care facilities in Aceh, Indonesia: a cross-sectional study 

      Diba, Farah; Ichsan, Ichsan; Muhsin, Muhsin; Marthoenis, Marthoenis; Sofyan, Hizir; Andalas, Mohammad; Monfared, Ida; Richert, Katharina; Kaplan, Lennart; Rogge, Lisa; et al.
      Doria, SiobhanSamadi, SamadiVollmer, Sebastian
      BMJ Open 2019; 9(12): Art. e031484
      OBJECTIVES: Our study investigates the barriers perceived by staff in the referral systems in maternal healthcare facilities across Aceh province in Indonesia. DESIGN: With a cross-sectional approach, two sets of surveys were administered during September to October 2016 in 32 sampling units of our study. We also collected referral data in the form of the frequency of ingoing and outgoing referral cases per facility. SETTING: In three districts, Aceh Besar, Banda Aceh and Bireuen, a total of 32 facilities including hospitals, community health centres, and private midwife clinics that met the criteria of providing at least basic emergency obstetric and neonatal care (BEonC) were covered. PARTICIPANTS: Across the 32 healthcare centres, 149 members of staff (mainly midwives) agreed to participate in our surveys. PRIMARY AND SECONDARY OUTCOME MEASURES: The first survey consisted of 65 items focusing on organisational measures as well as case numbers for example, patient counts, mortality rate and complications. The second survey with 68 items asked healthcare providers about a range of factors including attitudes towards the referral process in their facility and potential barriers to a well-functioning system in their district. RESULTS: Overall, mothers'/families' consent as well as the complex administration process were found to be the main barriers (36% and 12%, respectively). Healthcare providers noted that information about other facilities has the biggest room for improvement (37%) rather than transport, timely referral of mothers and babies, or the availability of referral facilities. CONCLUSIONS: The largest barrier perceived by healthcare providers in our study was noted to be family consent and administrative burden. Moreover, lack of information about the referral system itself and other facilities seemed to be affecting healthcare providers and mothers/families alike and improvements perhaps through a shared information system is needed.
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    • Journal Article

      Anaemia among men in India: a nationally representative cross-sectional study 

      Didzun, Oliver; De Neve, Jan-Walter; Awasthi, Ashish; Dubey, Manisha; Theilmann, Michaela; Bärnighausen, Till; Vollmer, Sebastian; Geldsetzer, Pascal
      The Lancet Global Health 2019; 7(12) p.e1685-e1694
      BACKGROUND: Population-based studies on anaemia in India have mostly focused on women and children, with men with anaemia receiving much less attention despite anaemia's adverse effect on health, wellbeing, and economic productivity. This study aimed to determine the national prevalence of anaemia among men in India; how the prevalence of anaemia in men varies across India among states and districts and by sociodemographic characteristics; and whether the geographical and sociodemographic variation in the prevalence of anaemia among men is similar to that among women to inform whether anaemia reduction efforts for men should be coupled with existing efforts for women. METHODS: In this cross-sectional study, we analysed data from a nationally representative household survey carried out from January, 2015, to December, 2016, among men aged 15-54 years and women aged 15-49 years in all 29 states and seven Union Territories of India. Haemoglobin concentration was measured using the portable HemoCue Hb 201+ (HemoCue AB, Ängelholm, Sweden) and a capillary blood sample. In addition to disaggregating anaemia prevalence (separately in men and women) by state and age group, we used mixed-effects Poisson regression to determine individual-level and district-level predictors of anaemia. FINDINGS: 106 298 men and 633 305 women were included in our analysis. In men, the prevalence of any anaemia was 23·2% (95% CI 22·7-23·7), moderate or severe anaemia was 5·1% (4·9-5·4), and severe anaemia was 0·5% (0·5-0·6). An estimated 21·7% (20·9-22·5) of men with any degree of anaemia had moderate or severe anaemia compared with 53·2% (52·9-53·5) of women with any anaemia. Men aged 20-34 years had the lowest probability of having anaemia whereas anaemia prevalence among women was similar across age groups. State-level prevalence of any anaemia in men varied from 9·2% (7·7-10·9) in Manipur to 32·9% (31·0-34·7) in Bihar. The individual-level predictors of less household wealth, lower education, living in a rural area, smoking, consuming smokeless tobacco, and being underweight and the district-level predictors of living in a district with a lower rate of primary school completion, level of urbanisation, and household wealth were all associated with a higher probability of anaemia in men. Although some important exceptions were noted, district-level and state-level prevalence of anaemia among men correlated strongly with that among women. INTERPRETATION: Anaemia among men in India is an important public health problem. Because of the similarities in the patterns of geographical and sociodemographic variation of anaemia between men and women, future efforts to reduce anaemia among men could target similar population groups as those targeted in existing efforts to reduce anaemia among women.
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    • Journal Article

      Mothers’ experiences of quality of care and potential benefits of implementing the WHO safe childbirth checklist: a case study of Aceh Indonesia 

      Doria, Siobhan; Diba, Farah; Susanti, Suryane S.; Vollmer, Sebastian; Monfared, Ida G.
      BMC Pregnancy and Childbirth. 2019 Dec 03;19(1):461
      Background In an effort to mitigate missed opportunities to provide high-quality care, the World Health Organization (WHO) has developed the Safe Childbirth Checklist (SCC) to support health providers perform essential tasks. Our qualitative study is a baseline assessment of quality of care (QoC) perceived by mothers who gave birth at health facilities aiming to highlight areas where implementing the SCC can potentially improve the QoC as well as areas that are not part of the SCC yet require improvement. Methods Assessing the overall experience of care, our qualitative study focuses on 8 out of 29 items in the checklist that are related to the personal interactions between healthcare provider and mothers. Using a set of semi-structured questions, we interviewed 26 new mothers who gave institutional births in Aceh province in Indonesia. Results Our findings revealed some gaps where implementing the SCC can potentially improve safety and QoC. They include communicating danger signs at critical points during birth and after discharge, encouraging breastfeeding, and providing mothers with information on family planning. Moreover, taking a qualitative approach allowed us to identify additional aspects such as need for clarity at the point of admission, maintaining dignity, and protecting mothers’ rights in the decision-making process to be also essential for better QoC. Conclusions Our study highlights the need to actively listen to and engage with the experiences of women in the adaptation and implementation of the checklist. While our findings indicate that implementing the SCC has the potential to improve the quality of maternal care and overall birth experience, a more holistic understanding of the lived experiences of women and the dynamics of their interactions with health facilities, care providers, and their birth companions can complement the implementation of the checklist.
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    • Journal Article

      HIV, antiretroviral therapy and non‐communicable diseases in sub‐Saharan Africa: empirical evidence from 44 countries over the period 2000 to 2016 

      Coetzee, Lelani; Bogler, Lisa; De Neve, Jan‐Walter; Bärnighausen, Till; Geldsetzer, Pascal; Vollmer, Sebastian
      Journal of the International AIDS Society 2019; 22(7): Art. e25364
      NTRODUCTION: The HIV-infected population is growing due to the increased accessibility of antiretroviral therapy (ART) that extends the lifespan of people living with HIV (PLHIV). We aimed to assess whether national HIV prevalence and ART use are associated with an increased prevalence of cardiovascular risk factors. METHODS: Using country-level data, we analysed the effect of HIV prevalence and use of ART on cardiovascular risk factors in 44 countries in sub-Saharan Africa between 2000 and 2016. We used fixed-effects estimation to quantify the effect of HIV and ART on the prevalence of diabetes, mean body mass index, the prevalence of overweight, obesity and hypertension, and mean systolic blood pressure. The models were adjusted for calendar time, the age structure of the population, income and education. RESULTS: Diabetes prevalence among PLHIV was 5.8 percentage points higher (95% confidence interval (CI) 1.8 pp to 9.8 pp) compared to individuals without HIV. People receiving ART had a 4.6 percentage point higher prevalence (95% CI 2.6 pp to 6.6 pp). The prevalence of obesity was increased by 14.7 percentage points (95% CI 2.5 pp to 26.9 pp) for PLHIV. Receiving ART was associated with an increased obesity prevalence by 14.0 percentage points (95% CI 4.8 pp to 23.2 pp), whereas it had no significant association with the prevalence of overweight. The population aged 40 to 59 had a significantly higher prevalence of diabetes, overweight and obesity. HIV prevalence and ART use had no significant association with the prevalence of hypertension. CONCLUSIONS: An ageing HIV-infected population on ART is associated with a significant increase in the prevalence of diabetes and obesity in sub-Saharan Africa. The increasing prevalence of these cardiovascular risk factors emphasizes the need for comprehensive healthcare programmes that screen and treat both HIV and non-communicable diseases to decrease the associated morbidity and mortality rates.
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    • Journal Article

      Using peer education to improve diabetes management and outcomes in a low-income setting: a randomized controlled trial 

      Seuring, Till; Marthoenis; Rhode, Sabrina; Rogge, Lisa; Rau, Holger; Besançon, Stéphane; Zufry, Hendra; Sofyan, Hizir; Vollmer, Sebastian
      Trials. 2019 Sep 02;20(1):548
      Abstract Background Diabetes is an important health burden in Indonesia. However, diabetes management and treatment remain poor, with most people with diabetes in Indonesia not achieving the recommended blood glucose levels. Peer education may have particular potential in low-income settings in complementing diabetes care without being a large additional strain on the health system. Methods/design This cluster randomized controlled trial aims to identify the effect of the implementation of peer education for patients with type 2 diabetes on diabetes-related outcomes in Aceh, Indonesia, which will complement the diabetes treatment provided at primary-care health posts (puskesmas). Altogether, 29 puskesmas were recruited in Banda Aceh and Aceh Besar, each of which was randomly assigned to either the control or the intervention group. Then, 534 people with diabetes were identified and recruited through their respective puskesmas. The intervention consists of up to two peer education groups per puskesmas, which are led by previously trained people with diabetes. Peer education sessions are held every month for 18 months, with follow-up data being collected 9 and 18 months after the first peer education session. The main objective is to improve diabetes management and the health behavior of participants receiving peer education to reduce their average blood glucose levels as measured by glycated hemoglobin (HbA1c) levels. Secondary outcomes are the effects of peer education on lipid levels, waist circumference, blood pressure, quality of life, treatment adherence, diabetes knowledge, physical activity, and dietary diversity. Data sources for the measurement of outcomes include patient and health facility surveys and biomarker measurements. An economic evaluation will be conducted to assess the cost-effectiveness of the intervention. Discussion This trial will contribute to the evidence on the effectiveness and cost-effectiveness of peer education in improving diabetes management in a low-income setting in Indonesia and in other comparable contexts. Trial registration ISRCTN registry, ISRCTN68253014 . Registered on 18 February 2019.
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    • 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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      Variation in health system performance for managing diabetes among states in India: a cross-sectional study of individuals aged 15 to 49 years 

      Prenissl, Jonas; Jaacks, Lindsay M; Mohan, Viswanathan; Manne-Goehler, Jennifer; Davies, Justine I; Awasthi, Ashish; Bischops, Anne C; Atun, Rifat; Bärnighausen, Till; Vollmer, Sebastian; et al.
      Geldsetzer, Pascal
      BMC Medicine. 2019 May 13;17(1):92
      Abstract Background Understanding where adults with diabetes in India are lost in the diabetes care cascade is essential for the design of targeted health interventions and to monitor progress in health system performance for managing diabetes over time. This study aimed to determine (i) the proportion of adults with diabetes in India who have reached each step of the care cascade and (ii) the variation of these cascade indicators among states and socio-demographic groups. Methods We used data from a population-based household survey carried out in 2015 and 2016 among women and men aged 15–49 years in all states of India. Diabetes was defined as a random blood glucose (RBG) ≥ 200 mg/dL or reporting to have diabetes. The care cascade—constructed among those with diabetes—consisted of the proportion who (i) reported having diabetes (“aware”), (ii) had sought treatment (“treated”), and (iii) had sought treatment and had a RBG < 200 mg/dL (“controlled”). The care cascade was disaggregated by state, rural-urban location, age, sex, household wealth quintile, education, and marital status. Results This analysis included 729,829 participants. Among those with diabetes (19,453 participants), 52.5% (95% CI, 50.6–54.4%) were “aware”, 40.5% (95% CI, 38.6–42.3%) “treated”, and 24.8% (95% CI, 23.1–26.4%) “controlled”. Living in a rural area, male sex, less household wealth, and lower education were associated with worse care cascade indicators. Adults with untreated diabetes constituted the highest percentage of the adult population (irrespective of diabetes status) aged 15 to 49 years in Goa (4.2%; 95% CI, 3.2–5.2%) and Tamil Nadu (3.8%; 95% CI, 3.4–4.1%). The highest absolute number of adults with untreated diabetes lived in Tamil Nadu (1,670,035; 95% CI, 1,519,130–1,812,278) and Uttar Pradesh (1,506,638; 95% CI, 1,419,466–1,589,832). Conclusions There are large losses to diabetes care at each step of the care cascade in India, with the greatest loss occurring at the awareness stage. While health system performance for managing diabetes varies greatly among India’s states, improvements are particularly needed for rural areas, those with less household wealth and education, and men. Although such improvements will likely have the greatest benefits for population health in Goa and Tamil Nadu, large states with a low diabetes prevalence but a high absolute number of adults with untreated diabetes, such as Uttar Pradesh, should not be neglected.
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      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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      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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      Correction to: Agricultural trade policies and child nutrition in low- and middle-income countries: a cross-national analysis 

      Adjaye-Gbewonyo, Kafui; Vollmer, Sebastian; Avendano, Mauricio; Harttgen, Kenneth
      Globalization and Health. 2019 Apr 10;15(1):28
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      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

      Agricultural trade policies and child nutrition in low- and middle-income countries: a cross-national analysis 

      Adjaye-Gbewonyo, Kafui; Vollmer, Sebastian; Avendano, Mauricio; Harttgen, Kenneth
      Globalization and Health. 2019 Mar 15;15(1):21
      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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      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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      Geographic and sociodemographic variation of cardiovascular disease risk in India: A cross-sectional study of 797,540 adults 

      Geldsetzer, Pascal; Manne-Goehler, Jennifer; Theilmann, Michaela; Davies, Justine I.; Awasthi, Ashish; Danaei, Goodarz; Gaziano, Thomas A.; Vollmer, Sebastian; Jaacks, Lindsay M.; Bärnighausen, Till; et al.
      Atun, Rifat
      PLOS Medicine 2018; 15(6) p.1-23: Art. e1002581
      Background Cardiovascular disease (CVD) is the leading cause of mortality in India. Yet, evidence on the CVD risk of India’s population is limited. To inform health system planning and effective targeting of interventions, this study aimed to determine how CVD risk—and the factors that determine risk—varies among states in India, by rural–urban location, and by individual-level sociodemographic characteristics. Methods and findings We used 2 large household surveys carried out between 2012 and 2014, which included a sample of 797,540 adults aged 30 to 74 years across India. The main outcome variable was the predicted 10-year risk of a CVD event as calculated with the Framingham risk score. The Harvard–NHANES, Globorisk, and WHO–ISH scores were used in secondary analyses. CVD risk and the prevalence of CVD risk factors were examined by state, rural–urban residence, age, sex, household wealth, and education. Mean CVD risk varied from 13.2% (95% CI: 12.7%–13.6%) in Jharkhand to 19.5% (95% CI: 19.1%–19.9%) in Kerala. CVD risk tended to be highest in North, Northeast, and South India. District-level wealth quintile (based on median household wealth in a district) and urbanization were both positively associated with CVD risk. Similarly, household wealth quintile and living in an urban area were positively associated with CVD risk among both sexes, but the associations were stronger among women than men. Smoking was more prevalent in poorer household wealth quintiles and in rural areas, whereas body mass index, high blood glucose, and systolic blood pressure were positively associated with household wealth and urban location. Men had a substantially higher (age-standardized) smoking prevalence (26.2% [95% CI: 25.7%–26.7%] versus 1.8% [95% CI: 1.7%–1.9%]) and mean systolic blood pressure (126.9 mm Hg [95% CI: 126.7–127.1] versus 124.3 mm Hg [95% CI: 124.1–124.5]) than women. Important limitations of this analysis are the high proportion of missing values (27.1%) in the main outcome variable, assessment of diabetes through a 1-time capillary blood glucose measurement, and the inability to exclude participants with a current or previous CVD event. Conclusions This study identified substantial variation in CVD risk among states and sociodemographic groups in India—findings that can facilitate effective targeting of CVD programs to those most at risk and most in need. While the CVD risk scores used have not been validated in South Asian populations, the patterns of variation in CVD risk among the Indian population were similar across all 4 risk scoring systems.
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      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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