Journal Articles (2019)
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Item Mapping disparities in education across low- and middle-income countries(Nature, 12/25/2019) Local Burden of Disease Educational Attainment CollaboratorsEducational attainment is an important social determinant of maternal, newborn, and child health1–3 . As a tool for promoting gender equity, it has gained increasing traction in popular media, international aid strategies, and global agenda-setting4–6 . The global health agenda is increasingly focused on evidence of precision public health, which illustrates the subnational distribution of disease and illness7,8 ; however, an agenda focused on future equity must integrate comparable evidence on the distribution of social determinants of health9–11. Here we expand on the available precision SDG evidence by estimating the subnational distribution of educational attainment, including the proportions of individuals who have completed key levels of schooling, across all low- and middle-income countries from 2000 to 2017. Previous analyses have focused on geographical disparities in average attainment across Africa or for specifc countries, but—to our knowledge—no analysis has examined the subnational proportions of individuals who completed specifc levels of education across all low- and middle-income countries12–14. By geolocating subnational data for more than 184 million person-years across 528 data sources, we precisely identify inequalities across geography as well as within populations.Item Determinants of health seeking behavior for chronic non-communicable diseases and related out-of-pocket expenditure: results from a cross-sectional survey in northern Bangladesh(BMC, 12/23/2019) Binte Rasul, Fatema; Kalmus, Olivier; Sarker, Malabika; Adib, Hossain Ishrath; Hossain, Md Shahadath; Hasan, Md Zabir; Brenner, Stephan; Nazneen, Shaila; Islam, Muhammed Nazmul; De Allegri, ManuelaBackground: In spite of high prevalence rates, little is known about health seeking and related expenditure for chronic non-communicable diseases in low-income countries. We assessed relevant patterns of health seeking and related out-of-pocket expenditure in Bangladesh. Methods: We used data from a household survey of 2500 households conducted in 2013 in Rangpur district. We employed multinomial logistic regression to assess factors associated with health seeking choices (no care or selfcare, semi-qualified professional care, and qualified professional care). We used descriptive statistics (5% trimmed mean and range, median) to assess related patterns of out-of-pocket expenditure (including only direct costs). Results: Eight hundred sixty-six (12.5%) out of 6958 individuals reported at least one chronic non-communicable disease. Of these 866 individuals, 139 (16%) sought no care or self-care, 364 (42%) sought semi-qualified care, and 363 (42%) sought qualified care. Multivariate analysis confirmed that the following factors increased the likelihood of seeking qualified care: a higher education, a major chronic non-communicable disease, a higher socio-economic status, a lower proportion of chronic household patients, and a shorter distance between a household and a subdistrict public referral health facility. Seven hundred fifty-four (87 %) individuals reported out-of-pocket expenditure, with drugs absorbing the largest portion (85%) of total expenditure. On average, qualified care seekers encountered the highest out-of-pocket expenditure, followed by those who sought semi-qualified care and no care, or self-care. Conclusion: Our study reveals insufficiencies in health provision for chronic conditions, with more than half of all affected people still not seeking qualified care, and the majority still encountering considerable out-of-pocket expenditure. This calls for urgent measures to secure better access to care and financial protection.Item Estimated societal costs of stroke in the UK based on a discrete event simulation(Oxford Academic, 12/17/2019) Patel, Anita; Berdunov, Vladislav; Quayyum, Zahidul; King, Derek; Knapp, Martin; Wittenberg, RaphaelBackground: there are around 100,000 new stroke cases and over a million people living with its consequences annually in the UK. This has large impacts on health and social care, unpaid carers and lost productivity. We aimed to estimate associated costs. Methods: we estimated 2014/2015 annual mean cost per person and aggregate UK cost of stroke for individuals aged ≥40 from a societal perspective. Health and social care costs in the first and subsequent years after stroke were estimated from discrete event simulation modelling, with probability of progression and length of receipt of different health and social care services obtained from routine registry and audit data. Unpaid care hours and lost productivity were obtained from trial data. UK unit costs were applied to estimate mean costs. Epidemiological estimates of stroke incidence and prevalence were then applied to estimate aggregate costs for the UK. Results: mean cost of new-onset stroke is £45,409 (95% CI 42,054-48,763) in the first year after stroke and £24,778 (20,234– 29,322) in subsequent years. Aggregate societal cost of stroke is £26 billion per year, including £8.6 billion for NHS and social care. The largest component of total cost was unpaid care (61%) and, given high survival, £20.6 billion related to ongoing care. Conclusion: the estimated aggregate cost of stroke substantially exceeds previous UK estimates. Since most of the cost is attributed to unpaid care, interventions aimed at rehabilitation and reducing new and recurrent stroke are likely to yield substantial benefits to carers and cost savings to societyItem Prevalence of multimorbidity among Bangladeshi adult population: A nationwide cross-sectional study(BMJ Journals, 11/28/2018) Khan, Nusrat; Rahman, Mahfuzar; Mitra, Dipak; Afsana, KaosarObjective This study aimed to report prevalence and evaluate the association between multimorbidity and associated risk factors in the adult population of Bangladesh. Design A cross-sectional study was conducted using a multistage clustered random sampling strategy. Setting The study was conducted among the general population of 58 districts in Bangladesh. Participants A total of 12 338 male and female individuals aged ≥35 were included for analysis in this study. Identified through a household listing conducted prior to the study, from 15 297 individuals meeting the inclusion criteria, 12 338 participants were included based on availability during data collection, consent and health condition. Outcome measures Multimorbidity in terms of hypertension, diabetes, cancer, cardiovascular diseases, stroke and chronic obstructive pulmonary disease. Results Approximately 8.4% (95% CI 7.0 to 9.7) of individuals suffer from multimorbidity, of which hypertension accounted for (30.1%) followed by diabetes (10.6%). The mean age of the population was 58.6 (SD ±9.2) years. The prevalence of multimorbidity was lower among men (7.7%) compared with women (8.9%). The likelihood of having multimorbidity among obese individuals were more than double than people with normal body mass index (BMI). Physical activity protected individuals from developing multimorbidity: however, the physical activity adjusted OR was 0.5 (95% CI 0.2 to 1.2). After adjusting for all covariates, higher age, higher educational status, economic status, and higher BMI were found to be significantly associated with the odds of developing multimorbidity, with an overall adjusted OR of 0.02 (95% CI 0.01 to 0.02). Conclusion This study reported a high prevalence of multimorbidity in Bangladesh, although it explored the burden and identified risk factors considering only six chronic diseases. Further detailed exploration through longitudinal studies considering a wider range of diseases is needed to document the actual burden, develop effective preventive measures and clinical guidelines to improve the quality of life of the population.Item Association between height and hypertension in the adult Nepalese population: Findings from a nationally representative survey(Wiley, 11/7/2019) Gupta, Rajat Das; Haider, Shams Shabab; Hashan, Mohammad Rashidul; Rahman, Muhammad Aziz; Sarker, MalabikaBackground and aims The burden of hypertension is increasing in Nepal. Different studies have evaluated the relationship between height and blood pressure in different regions, with mixed results. The relationship between height and hypertension has not yet been explored in the Nepalese context. Given this knowledge gap, this study aims to determine the relationship between height and hypertension among Nepalese adults (aged ≥18 years). Methods This study utilized the dataset from the Nepal Demographic and Health Survey (NDHS) 2016. Hypertension was defined as systolic blood pressure ≥ 140 mmHg and/or a diastolic blood pressure ≥ 90 mmHg. Height, measured in centimeters (cm), was analyzed as a continuous variable. Based on previous evidence, the following covariates were considered: age, sex, presence of overweight or obesity, educational status, household wealth status, and place, province, and ecological zone of residence. Multilevel multivariable logistic regression was done to evaluate the association between height and hypertension. Both crude odds ratio (COR) and adjusted odds ratio (AOR) are reported, along with a 95% confidence interval (CI). Sample weight of NDHS was adjusted during analysis. Results Among 13 393 weighted individuals over the age of 18 years, the prevalence of hypertension in Nepal was found to be 21.1% (95% CI, 19.9%‐22.4%). In the final multivariable model, after adjusting for relevant covariates, it was found that height was inversely associated with hypertension. For a Nepalese adult, the odds of hypertension decreased by 10% with each 10‐cm increase in height (AOR 0.9; 95% CI 0.8‐0.9; P = 0.003). Conclusion Awareness should be raised among people with low stature for prevention of hypertension. Longitudinal studies are recommended to include genetic and social/environmental determinants of stature in the analyses.Item Health shock and preference instability: Assessing health-state dependency of willingness-to-pay for corrective eyeglasses(BMC, 11/7/2019) Islam, Muhammed Nazmul; Rabbani, Atonu; Sarker, MalabikaBackground: Differences in contingent valuation (CV) estimates for identical healthcare goods can cast considerable doubt on the true economic measures of consumer preferences. Hypothetical nature of CV methods can potentially depend on the salience, context and perceived relevance of the good or service under consideration. Thus, the high demand elasticity for healthcare goods warrants careful selection of study population as the contexts of valuation significantly changes after experiencing health shock. Methods: In this study, using triple-bounded dichotomous choice (TBDC) experiments, we test how negative health shock (namely, being diagnosed with refractive errors), can alter preference over a common health good (namely, corrective eyeglasses). We compared elicited WTP of diagnosed patients with a synthetically constructed comparable cohort without the same health shock, controlling for the possible self-selection using a number of matching techniques based on the observable socio-demographic characteristics. Results: The consumers diagnosed with vision problems exhibit a rightward shift in their demand curve compared to observationally identical consumers without such problems resulting in about 17% higher consumer surplus. The consumers without the health shock are willing to pay about BDT 762.4 [95% CI: BDT 709.9 - BDT 814.9] for corrective eyeglasses, which gets 15–30% higher for the matched with-health-shock consumers. Multivariable analyses suggest more educated and wealthier individuals are willing to pay respectively BDT 208 and BDT 119 more for corrective eyeglasses. We have tested the models for different matching protocols. Our results are fairly robust to alternate specifications and various matching techniques. Conclusion: The preferences for healthcare goods, such as eyeglasses, can significantly depend upon the respondent being diagnosed with refractive errors. Our findings have implications for general cost-benefit analyses often relying on WTP, which can vary depending on the contexts. There are also increasing interests in cost recovery models, which require understanding the demand for healthcare goods and services. We find eliciting the demand needs to consider the health status of the population from which the respondents are sampled.Item Study protocol to assess the impact of an integrated nutrition intervention on the growth and development of children under two in rural Bangladesh(BMC, 11/1/2019) Ara, Gulshan; Sanin, Kazi Istiaque; Khanam, Mansura; Sarker, Shafiqul Alam; Khan, Sihan Sadat; Rifat, Mahfuza; Chowdhury, Imran Ahmed; Askari, Sufia; Afsana, Kaosar; Ahmed, TahmeedBackground: The period from birth to two years is the “critical window” for achieving optimal growth and development. An inadequate quality and quantities of complementary foods, poor child-feeding practices and infection negatively impact the growth of under-twos. Approximately one-third of under-fives in developing countries are stunted; many are also micronutrient deficient. An estimated 6% of mortalities among under-fives can be prevented by ensuring optimal complementary feeding. The objective of the study was to assess the ability of a 12-month integrated nutrition intervention to improve the nutritional status (length-for-age Z-score) of 6 to 12- month-old children in rural Bangladesh. Methods: In this community-based randomized controlled trial, the intervention group received a package of interventions that includes, food vouchers; to prepare egg-based nutritious snacks (suji firni for < 1-year-olds, suji halwa for > 1-year-olds), micronutrient powder to fortify children’s food at home, child feeding counselling and water, sanitation and hygiene (WASH), behaviour change communication. The control group received routine health messages provided by the government. Baseline and endline surveys were conducted; Data collection was performed monthly on children’s growth, food voucher utilization, child feeding and morbidity. In addition, we assessed the cognitive development of the children after 12 months of intervention. Conclusion: This trial aims to explore whether an integrated nutrition intervention can mitigate childhood stunting during the critical window of opportunity in rural Bangladesh. The results may provide robust evidence to improve the linear growth of children in developing countries.Item Putting health equity at heart of universal coverage—the need for national programmes of action(BMJ, 10/25/2019) Friedman, Eric A; Gostin, Lawrence O; Kavanagh, Matthew M; Periago, Mirta Roses; Marmot, Michael; Coates, Anna; Binagwaho, Agnes; Mukherjee, Joia; Chowdhury, Mushtaque; Robinson, Tracy; Veloso, Valdiléa G; Wang, Chenguang; Were, MiriamIncome inequality is growing,1 fuelling both right wing populism2 and demands for progressive, inclusive policies. Global disquiet over inequality prompted the United Nations to pledge in the sustainable development goals (SDGs) that “no one will be left behind.”3 Health inequities present a defining challenge of our time,4 and governments need to adopt and rigorously implement national programmes of action to respond across multiple dimensions so that economic and social status no longer determine human health and wellbeing. Most of the data collected on health has been at national and global levels. Such aggregated data may mask deep unfairness in the distribution of good health, much as a growing gross domestic product can mask highly unequal distribution of wealth. For example, a baby born in a largely white, wealthy suburb of St Louis in the US can expect to live 35 more years than one born in a mostly black, lower income suburb a few miles away; the average life expectancy in Saint Louis County is close to 79 years, but ranges from 56 to 91across neighbourhoods.56 Globally, life expectancy is 72 years but people in the United Kingdom live an average of 81 years while those in Sierra Leone average only 54.7 There have been few actionable, inclusive national initiatives expressly designed to achieve health equity—a missed opportunity as countries create national development strategies and develop health plans that include precise national health targets. Despite some important work on health equity, international institutions have not brought equity to the centre through concrete, actionable strategies. The political declaration on universal health coverage agreed at the 2019 UN high level meeting on universal health coverage, for example, reiterated the pledge to leave no one behind. but set out neither specific targets on, nor specific strategies to achieve, health equity.60 We examine the reasons and suggest how to put health inequalities sat the centre of the agenda and fulfil the SDGs’ central promise.Item Newborn physical condition and breastfeeding behaviours: Secondary outcomes of a cluster-randomized trial of prenatal lipid-based nutrient supplements in Bangladesh(Wiley, 2019-10) Ullah, Md Barkat; Mridha, Malay K; Arnold, Charles D; Matias, Susana L; A Khan, Md Showkat; Siddiqui, Zakia; Hossain, Mokbul; Paul, Rina Rani; Dewey, Kathryn GPrenatal nutritional supplements may improve birth outcomes. This study aims to examine the effect of prenatal lipid-based nutrient supplements (LNS), compared with iron and folic acid (IFA), on general newborn physical condition and feeding behaviours. We conducted a cluster-randomized effectiveness trial that enrolled 4,011 pregnant women at ≤20 gestational weeks. LNS and IFA were provided to women in 48 and 16 clusters, respectively, for daily consumption until delivery. We collected data on household socio-economic, food insecurity, and maternal characteristics during early pregnancy and on newborn condition and feeding within 72 hr of delivery. We analysed intervention effects on these secondary outcomes using mixed models with analysis of covariance for continuous outcomes and logistic regression for dichotomous outcomes. Among 3,664 live births, intervention groups did not differ in newborn response, mother's rating of the general condition of her newborn, early initiation of breastfeeding (EIBF), suckling ability, or frequency and exclusivity of breastfeeding in the first 24 hr. If the mother perceived her infant to be healthy, EIBF was more likely (OR [95% CI]: 2.08 [1.46, 2.97]) and frequency of breastfeeding in the first 24 hr was greater (mean difference [95% CI]: 3.0 [1.91, 4.01]), but there was no difference in exclusive breastfeeding in the first 24 hr. Newborn condition and early breastfeeding practices were not affected by giving mothers prenatal LNS versus IFA. However, early breastfeeding practices were related to maternal perception of her newborn's condition. Thus, interventions to improve breastfeeding practices for newborns with poorer perceived health status may be useful.Item Gestational weight gain and newborn anthropometric outcomes in rural Bangladesh(Wiley Online Library, 2019-10) Kac, Gilberto; Arnold, Charles D.; Matias, Susana L.; Mridha, Malay K.; Dewey, Kathryn G.Low gestational weight gain (GWG) is a known predictor of fetal growth restriction in higher income countries, but there is little information on this association in lower income countries. Our objective is to describe the association between GWG and birth outcomes among pregnant women in rural Bangladesh. Pregnant women were identified in a community-based programme and enrolled into the study at an average of 13 weeks' gestation (n = 4,011). Maternal weight and height were measured at enrolment, maternal weight was measured at 36 weeks' gestation, and newborns were measured after birth. Rate of GWG (g/weeks) was calculated, and women were categorized as having adequate or inadequate GWG (Institute of Medicine recommendations). Newborn anthropometric outcomes included weight-for-age z score (WAZ), length-for-age z score (LAZ), head-circumference-for-age z score (HCZ), body mass index (BMI)-for-age z score (BMIZ), low birthweight (LBW < 2,500 g), WAZ < −2, LAZ < −2, HCZ < −2, BMIZ < −2, and small for gestational age (SGA: <10th percentile). Multivariate models were adjusted for confounders. Only 26% of the 2,562 women in these analyses had adequate GWG. Compared with newborns of women with inadequate GWG, infants of women with adequate GWG had a lower risk of adverse anthropometric outcomes (relative risk [95% confidence interval]: LBW = 0.68 [0.59, 0.80], LAZ < −2 = 0.64 [0.51, 0.80], HCZ < −2 = 0.75 [0.60, 0.93], BMIZ < −2 = 0.70 [0.59, 0.83], and SGA = 0.80 [0.73, 0.86]), but there was no significant difference in mean (SE) duration of gestation, 39.7 (0.08) versus 39.7 (0.05) weeks. In this population, GWG rate is a strong predictor of newborn anthropometric outcomes, but not duration of gestation.