The prevalence of cardiovascular disease risk factors among adults living in extreme poverty.

Evidence on cardiovascular disease (CVD) risk factor prevalence among adults living below the World Bank's international line for extreme poverty (those with income <$1.90 per day) globally is sparse. Here we pooled individual-level data from 105 nationally representative household surveys across 78 countries, representing 85% of people living in extreme poverty globally, and sorted individuals by country-specific measures of household income or wealth to identify those in extreme poverty. CVD risk factors (hypertension, diabetes, smoking, obesity and dyslipidaemia) were present among 17.5% (95% confidence interval (CI) 16.7-18.3%), 4.0% (95% CI 3.6-4.5%), 10.6% (95% CI 9.0-12.3%), 3.1% (95% CI 2.8-3.3%) and 1.4% (95% CI 0.9-1.9%) of adults in extreme poverty, respectively. Most were not treated for CVD-related conditions (for example, among those with hypertension earning <$1.90 per day, 15.2% (95% CI 13.3-17.1%) reported taking blood pressure-lowering medication). The main limitation of the study is likely measurement error of poverty level and CVD risk factors that could have led to an overestimation of CVD risk factor prevalence among adults in extreme poverty. Nonetheless, our results could inform equity discussions for resource allocation and design of effective interventions.

Economic Growth and Childhood Malnutrition in Low- and Middle-Income Countries.

Importance: Economic growth may reduce childhood malnutrition through improvements of several contributing factors, but the empirical evidence is mixed. Identifying the most important factors that contribute to child malnutrition and their associations with economic growth can inform decision-making about targeted investments to improve children's health. Objective: To assess the associations between economic growth and malnutrition, contributing factors and malnutrition, and economic growth and contributing factors of malnutrition in low- and middle-income countries (LMICs). Design, Setting, and Participants: This cross-sectional study used data from 239 Demographic and Health Surveys from January 1, 1990, to December 31, 2021. Observations included 1 138 568 children aged 0 to 35 months with valid anthropometric measures and information on contributing factors of malnutrition from 58 LMICs. Data were analyzed from May 20, 2022, to February 16, 2023. Exposure: National per-capita gross domestic product (GDP) was used as a proxy for economic growth. Main Outcomes and Measures: Six measures of childhood malnutrition were constructed: stunting (height-for-age z score <-2), underweight (weight-for-age z score <-2), wasting (weight-for-height z score <-2), overweight (weight-for-height z score >2), obesity (weight-for-height z score >3), and dietary diversity failure (consumption of less than 5 of 8 different food groups in the past 24 hours). Eighteen contributing factors of malnutrition were constructed, of which 10 were underlying determinants (eg, access to improved sanitation) and 8 were immediate determinants (eg, breastfeeding initiation). Results: A total of 1 138 568 children (mean [SD] age, 17.14 [10.26] months; 579 589 [50.9%] boys and 558 979 [49.1%] girls) were included in the analysis. Of these, 27.3% (95% CI, 27.2%-27.4%) had stunting; 25.7% (95% CI, 25.6%-25.8%), underweight; 11.2% (95% CI, 11.1%-11.2%), wasting; 3.8% (95% CI, 3.7%-3.8%), overweight; 1.1% (95% CI, 1.1%-1.1%), obesity; and 79.8% (95% CI, 79.7%-79.9%), dietary diversity failure. Per-capita GDP was weakly associated with childhood malnutrition. The odds ratios associated with a 5% increase in per-capita GDP were 0.99 (95% CI, 0.99-1.00) for stunting, 1.01 (95% CI, 1.00-1.01) for wasting, 1.00 (95% CI, 1.00-1.00) for underweight, 0.98 (95% CI, 0.98-0.98) for overweight, 0.98 (95% CI, 0.97-0.98) for obesity, and 1.03 (95% CI, 1.01-1.04) for dietary diversity failure. Although strong associations were found between many contributing factors and most outcomes for malnutrition, associations identified between per-capita GDP and these contributing factors themselves were ambiguous. Conclusions and Relevance: In this multicountry cross-sectional study, economic growth was weakly associated with childhood malnutrition and several contributing factors. To reduce child malnutrition, economic growth may need to be accompanied by more targeted investments to improve contributing factors that are strongly associated with child malnutrition, such as maternal health and education.

Quasi-experimental evaluation of a nationwide diabetes prevention programme.

Diabetes is a leading cause of morbidity, mortality and cost of illness1,2. Health behaviours, particularly those related to nutrition and physical activity, play a key role in the development of type 2 diabetes mellitus3. Whereas behaviour change programmes (also known as lifestyle interventions or similar) have been found efficacious in controlled clinical trials4,5, there remains controversy about whether targeting health behaviours at the individual level is an effective preventive strategy for type 2 diabetes mellitus6 and doubt among clinicians that lifestyle advice and counselling provided in the routine health system can achieve improvements in health7-9. Here we show that being referred to the largest behaviour change programme for prediabetes globally (the English Diabetes Prevention Programme) is effective in improving key cardiovascular risk factors, including glycated haemoglobin (HbA1c), excess body weight and serum lipid levels. We do so by using a regression discontinuity design10, which uses the eligibility threshold in HbA1c for referral to the behaviour change programme, in electronic health data from about one-fifth of all primary care practices in England. We confirm our main finding, the improvement of HbA1c, using two other quasi-experimental approaches: difference-in-differences analysis exploiting the phased roll-out of the programme and instrumental variable estimation exploiting regional variation in programme coverage. This analysis provides causal, rather than associational, evidence that lifestyle advice and counselling implemented at scale in a national health system can achieve important health improvements.

Aspirin for Secondary Prevention of Cardiovascular Disease in 51 Low-, Middle-, and High-Income Countries.

Importance: Aspirin is an effective and low-cost option for reducing atherosclerotic cardiovascular disease (CVD) events and improving mortality rates among individuals with established CVD. To guide efforts to mitigate the global CVD burden, there is a need to understand current levels of aspirin use for secondary prevention of CVD. Objective: To report and evaluate aspirin use for secondary prevention of CVD across low-, middle-, and high-income countries. Design, Setting, and Participants: Cross-sectional analysis using pooled, individual participant data from nationally representative health surveys conducted between 2013 and 2020 in 51 low-, middle-, and high-income countries. Included surveys contained data on self-reported history of CVD and aspirin use. The sample of participants included nonpregnant adults aged 40 to 69 years. Exposures: Countries' per capita income levels and world region; individuals' socioeconomic demographics. Main Outcomes and Measures: Self-reported use of aspirin for secondary prevention of CVD. Results: The overall pooled sample included 124 505 individuals. The median age was 52 (IQR, 45-59) years, and 50.5% (95% CI, 49.9%-51.1%) were women. A total of 10 589 individuals had a self-reported history of CVD (8.1% [95% CI, 7.6%-8.6%]). Among individuals with a history of CVD, aspirin use for secondary prevention in the overall pooled sample was 40.3% (95% CI, 37.6%-43.0%). By income group, estimates were 16.6% (95% CI, 12.4%-21.9%) in low-income countries, 24.5% (95% CI, 20.8%-28.6%) in lower-middle-income countries, 51.1% (95% CI, 48.2%-54.0%) in upper-middle-income countries, and 65.0% (95% CI, 59.1%-70.4%) in high-income countries. Conclusion and Relevance: Worldwide, aspirin is underused in secondary prevention, particularly in low-income countries. National health policies and health systems must develop, implement, and evaluate strategies to promote aspirin therapy.

The socioeconomic gradient of alcohol use: an analysis of nationally representative survey data from 55 low-income and middle-income countries.

BACKGROUND: Alcohol is a leading risk factor for over 200 conditions and an important contributor to socioeconomic health inequalities. However, little is known about the associations between individuals' socioeconomic circumstances and alcohol consumption, especially heavy episodic drinking (HED; ≥5 drinks on one occasion) in low-income or middle-income countries. We investigated the association between individual and household level socioeconomic status, and alcohol drinking habits in these settings. METHODS: In this pooled analysis of individual-level data, we used available nationally representative surveys-mainly WHO Stepwise Approach to Surveillance surveys-conducted in 55 low-income and middle-income countries between 2005 and 2017 reporting on alcohol use. Surveys from participants aged 15 years or older were included. Logistic regression models controlling for age, country, and survey year stratified by sex and country income groups were used to investigate associations between two indicators of socioeconomic status (individual educational attainment and household wealth) and alcohol use (current drinking and HED amongst current drinkers). FINDINGS: Surveys from 336 287 participants were included in the analysis. Among males, the highest prevalence of both current drinking and HED was found in lower-middle-income countries (L-MICs; current drinking 49·9% [95% CI 48·7-51·2] and HED 63·3% [61·0-65·7]). Among females, the prevalence of current drinking was highest in upper-middle-income countries (U-MIC; 29·5% [26·1-33·2]), and the prevalence of HED was highest in low-income countries (LICs; 36·8% [33·6-40·2]). Clear gradients in the prevalence of current drinking were observed across all country income groups, with a higher prevalence among participants with high socioeconomic status. However, in U-MICs, current drinkers with low socioeconomic status were more likely to engage in HED than participants with high socioeconomic status; the opposite was observed in LICs, and no association between socioeconomic status and HED was found in L-MICs. INTERPRETATION: The findings call for urgent alcohol control policies and interventions in LICs and L-MICs to reduce harmful HED. Moreover, alcohol control policies need to be targeted at socially disadvantaged groups in U-MICs. FUNDING: Deutsche Forschungsgemeinschaft and the National Center for Advancing Translational Sciences of the US National Institutes of Health.

Global economic burden of unmet surgical need for appendicitis.

BACKGROUND: There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. METHODS: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. RESULTS: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and $73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and $75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. CONCLUSION: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially.

Predictors of patients' choice of hospitals under universal health coverage: a case study of the Nicaraguan capital.

BACKGROUND: This study looks at the factors that can shape patients' choice of healthcare providers. Understanding this process can help with making high quality healthcare more accessible for all. We focus on distance, patient's health status, (perceived) quality of healthcare facility, and referrals to investigate how these factors compete in shaping patients' choice of hospitals. METHODS: This study was carried out in Managua, the capital of Nicaragua. Utilizing an exit-survey, patients were interviewed across five public hospitals in 2017 and then six in 2019 when a new highly-equipped hospital was added to the system. We used a multinomial logit model to investigate patients' preference of a specific hospital over the rest within each wave. RESULTS: Our results show that being referred to a hospital is the strongest predictor and in some cases, it can increase the relative risk ratio of choosing a facility by a factor of 49 (p < 0.01; 95% CI: 27.39-87.17). For the remaining factors, the hierarchy of importance was less clear-cut yet all these factors remained significantly important at various levels. CONCLUSIONS: Overall, our results highlight the importance of referral systems in making quality healthcare more equitable. Moreover, with distance also being a key predictor and in the absence of an organized referral system, those with low-income would either be further deprived by having to settle with locally available healthcare (regardless of its quality) or face high amounts of out-of-pocket expenditure when seeking help from the private sector.

Socio-economic predictors of adolescent marriage and maternity in West and Central Africa between 1986 and 2017.

BACKGROUND: Early marriage and maternity prevalence rates among adolescent girls remain alarmingly high in West and Central Africa (WCA). This study aims to explore the associations between socio-economic factors and the prevalence of early marriage and maternity, thus contributing to the identification of girls at risk of early pregnancy or marriage. METHODS: We pooled data from national representative surveys (1986 - 2017) for 23 countries in WCA to examine associations between wealth, educational attainment, religious affiliation, and place of residence with adolescent marriage and maternity. We decomposed the wealth and education gradients for individual countries, while controlling for common characteristics of the local environment via the use of primary sampling unit fixed-effects. The pooled sample provides information on 262 721 girls (age 15-19 years). Survey weights and population share weights were used in the estimations. RESULTS: The prevalence of adolescent maternity and marriage exhibited a wealth and education gradient. Prevalence of marriage in the poorest wealth quintile was 41.1% (95% confidence interval (CI) = 38.8%-43.5%) and 10.5% (95% CI = 9.5%-11.6%) in the richest. For maternity it was 38.3% (95% CI = 36.4%-40.3%) in the poorest quintile and 12.7% (95% CI = 11.5%-13.9%) in the richest. Marriage/maternity is three/two times more likely to occur among girls with incomplete primary or no formal education than in those with at least primary. Maternity and marriage among adolescents exhibit a geographical pattern and differences between religious groups. Adolescent marriage prevalence was 34.4% (95% CI = 32.9%-35.8%) in rural areas compared to 13.3% (95% CI = 12.3%-14.2%) in urban areas. Adolescent maternity prevalence was 32.8% (95% CI = 31.7%-33.9%) in rural compared to 16.3% (95% CI = 15.3%-17.3%) in urban areas. Finally, the prevalence of adolescent marriage was substantially higher among Muslims compared to all other religious groups. CONCLUSIONS: Our results highlight the disparities in the prevalence of adolescent marriage and maternity and confirm the existence of wealth and education gradients. These findings can help to improve targeting of vulnerable adolescents and to identify areas for policy implementation.

Does early childbearing affect utilization of antenatal care services and infant birth weight: Evidence from West and Central African Region.

BACKGROUND: Adequate antenatal care (ANC) utilization is recognized as one of the important drivers of safe childbirth and positive birth outcomes. The usage of ANC services fluctuates with various personal, socio-economic, and cultural characteristics and in resource-poor settings, adolescent mothers are at a particularly high risk of insufficient ANC utilization. OBJECTIVES: This paper investigates whether the usage of ANC services and institutional delivery as well as newborn birth weight differ systematically between adolescent and adult mothers in West and Central Africa. Moreover, we explore to what extent differences in birth weight are explained by ANC usage, adolescence, and select socio-economic characteristics of the mother. METHODS: We pooled cross-sectional data from all Demographic and Health Surveys (DHS) and Multi Indicator Cluster Surveys (MICS) conducted in countries in West and Central Africa region between 1986 and 2017 to estimate measures of ANC usage and qualified delivery assistance (along with a combined measure of "adequate maternal healthcare" aggregating these two factors) and newborn birth weight by maternal age group. We estimated various regression models to analyze a) the association between adolescence and adequate prenatal and maternal health care controlling for select socio-economic maternal characteristics as well as the local environment and b) between adolescence, adequate maternal health care, and newborn birth weight outcomes, also controlling for maternal characteristics and the local environment. All regressions were linear probability models for binary outcomes and simple linear models for continuous outcomes. RESULTS: Adequate maternal health care provision was lowest among adolescent mothers: 23.0% among adolescents vs an average of 29.2% across all other age groups. Moreover, we found maternal education and wealth to be positively and significantly associated with receiving adequate maternal health care. Adolescent mothers had the highest risk of low infantile birth weight with 14.5% (95% confidence interval (CI) = 13.6%-15.5%), which is roughly 1.5-2 times higher than in older mothers. We found that adolescence is still strongly associated with low birth weight even when adequate maternal health care and various socio-economic factors as well as the local environment are controlled for. CONCLUSIONS: Our findings suggest that ANC supply in resource-poor settings should be particularly tailored to adolescent mothers' needs and that further research is necessary to explore what individual maternal characteristics beyond socio-economic and physical (eg, BMI) factors drive the prevalence of low birth weight. Moreover, the currently used measures of maternal care quality are heavily dependent on pure quantitative measures (number of ANC visits). New indicators incorporating measures of factual quality and scope ought to be developed and incorporated into large routine household surveys such as DHS and MICS.

Long-term consequences of early marriage and maternity in West and Central Africa: Wealth, education, and fertility.

OBJECTIVE: Early marriage and childbearing have substantial detrimental effects on both, the affected girls and women at the micro level, as well as entire economies on the macro level. West and Central African countries have some of the highest prevalence rates of early marriage and maternity worldwide. This work attempts to quantify the long-term economic, societal, and fertility effects of marriage and pregnancy in early and late adolescence in West and Central Africa. METHODS: We used pooled cross-sectional data collected between 1986 and 2017 in 21 West and Central African countries within the DHS and MICS programs to estimate the associations of marriage and maternity during early (10-14) and late (15-19) adolescence retrospectively on wealth accumulation, educational attainment, as well as the woman's lifetime fertility. RESULTS: Descriptively, women who married or gave birth as young or very young adolescents are overrepresented among the poorest and least educated quintiles of the adult population and underrepresented among the richest and most educated. These gradients were confirmed within a regression analysis which additionally controlled for current age of the woman and PSU fixed effects. Marrying in early/late adolescence was associated with a 12%/6% higher likelihood of being in the poorest wealth quintile in later life and 29%/20% increased likelihood of not completing primary education, as compared to women who married as adults. Maternity in early/late adolescence was associated with a 7%/4% higher likelihood of belonging to the poorest quintile and 17%/10% higher likelihood of being uneducated. Moreover, women who married/gave birth during early or late adolescence, on average, have 2.2/2.3 or 1.4/1.5 more children than those who have married/become mothers as adults. CONCLUSIONS: Our findings suggest that the dire consequences of early marriage and maternity hit youngest girls the hardest - both immediately and long-term. Hence, it is not only worthwhile to prevent adolescent marriage and pregnancy in general, but also specifically target very young girls below age 15 to attempt to at least delay such far-reaching demographic life events.

Socio-economic predictors of undernutrition and anaemia in adolescent mothers in West and Central Africa.

BACKGROUND: Adolescence is a formative period when an individual acquires physical, cognitive, emotional, and social resources that are the foundation for later life, health, and well-being [1]. However, in West and Central African region, this trajectory is curtailed by early childbearing associated with an increased risk of undernutrition and anemia. Evidence on socio-economic determinants of anemia and undernutrition in adolescent mothers is limited. This paper aims to shed some light on this issue and, more specifically, assess the socio-economic determinants of anemia among childbearing adolescents in the region. METHODS: For this observational study, we pooled data from all Demographic and Health Surveys (DHS) conducted in countries in West and Central Africa region between 1986 and 2017. Outcomes were undernutrition and anemia in adolescent mothers. Predictors were education, wealth, place of residence (rural/urban), and religion. Descriptive statistics were calculated using survey weights for individual surveys and in the pooled sample each country was additionally weighted with its population share. We estimated multiple regression models with and without primary sampling unit fixed effects for both outcomes. All regressions were linear probability models. RESULTS: Having no formal education was the strongest predictor for both anemia and undernutrition. Belonging to the richest asset quintile was also associated with lower anemia and undernutrition prevalence in some specifications. While urban location of the mother was positively associated with anemia, there was no association with undernutrition. CONCLUSIONS: Overall, having any formal education emerged as a sole strong predictor of reduced adolescent maternal undernutrition and anemia. Promotion of female education can potentially serve as a high-impact intervention to improve adolescent girls' health in the region. However, we cannot make conclusions about its causal impact based on this study alone.

Assessment of Undernutrition Among Children in 55 Low- and Middle-Income Countries Using Dietary and Anthropometric Measures.

Importance: Evidence on the suitability of anthropometric failure (ie, stunting, underweight, and wasting) as a stand-alone measure of child undernutrition can inform global and national nutrition and health agendas. Objective: To provide a comprehensive estimate of the prevalence of child undernutrition by evaluating both dietary and anthropometric measures simultaneously across 55 low- and middle-income countries. Design, Setting, and Participants: This was a cross-sectional study that used Demographic and Health Surveys program data from July 2009 to January 2019, to allocate children into dietary and anthropometric failure categories. Nationally representative household surveys were conducted in 55 low- and middle-income countries. Participants included children aged 6 to 23 months who were born singleton and had valid anthropometric measures as well as available 24-hour food intake recollection. Data analysis was conducted from August 23 to October 22, 2020. Exposures: Two factors were considered to allocate children into the respective categories. Dietary failure was based on the World Health Organization standards for minimum dietary diversity. Anthropometric failure was constructed using the World Health Organization child growth reference standard z score for stunted growth, muscle wasting, and less than average weight for age. Main Outcomes and Measures: Dietary and anthropometric failures were cross-tabulated, which yielded 4 potential outcomes: dietary failure only, anthropometric failure only, both failures, and neither failure. Total child populations for each category were extrapolated from United Nations population estimates. Results: Of the 162 589 children (median age [range], 14 months [6-23 months]; 83 467 boys [51.3%]; 78 894 Asian children [48.5%]) in our sample, 42.9% of children had dietary failure according to the standard World Health Organization definition without being identified as having anthropometric failures. In all, 34.7% had both failures, 42.9% had dietary failure only, 8.3% had anthropometric failure only, and 14.1% had neither failure. Dietary and anthropometric measures were discordant for 51.2% of children; these children had nutritional needs identified by only 1 of the 2 measures. Dietary failure doubled the proportion of children in need of dietary interventions compared with anthropometry alone (43%). A total of 45.3 million additional children who experienced undernutrition in these 55 countries were not captured through the evaluation of anthropometric failures only. These results were consistent across geographic regions. Conclusions and Relevance: The results of this cross-sectional study suggest that the current standard of measuring child undernutrition by estimating the prevalence of anthropometric failure should be complemented with dietary and food-based measures. Anthropometry alone may fail to identify many children who have insufficient dietary intake.

Targeting Hypertension Screening in Low- and Middle-Income Countries: A Cross-Sectional Analysis of 1.2 Million Adults in 56 Countries.

Background As screening programs in low- and middle-income countries (LMICs) often do not have the resources to screen the entire population, there is frequently a need to target such efforts to easily identifiable priority groups. This study aimed to determine (1) how hypertension prevalence in LMICs varies by age, sex, body mass index, and smoking status, and (2) the ability of different combinations of these variables to accurately predict hypertension. Methods and Results We analyzed individual-level, nationally representative data from 1 170 629 participants in 56 LMICs, of whom 220 636 (18.8%) had hypertension. Hypertension was defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or reporting to be taking blood pressure-lowering medication. The shape of the positive association of hypertension with age and body mass index varied across world regions. We used logistic regression and random forest models to compute the area under the receiver operating characteristic curve in each country for different combinations of age, body mass index, sex, and smoking status. The area under the receiver operating characteristic curve for the model with all 4 predictors ranged from 0.64 to 0.85 between countries, with a country-level mean of 0.76 across LMICs globally. The mean absolute increase in the area under the receiver operating characteristic curve from the model including only age to the model including all 4 predictors was 0.05. Conclusions Adding body mass index, sex, and smoking status to age led to only a minor increase in the ability to distinguish between adults with and without hypertension compared with using age alone. Hypertension screening programs in LMICs could use age as the primary variable to target their efforts.

The Impact of Immediate Initiation of Antiretroviral Therapy on Patients' Healthcare Expenditures: A Stepped-Wedge Randomized Trial in Eswatini.

Immediate initiation of antiretroviral therapy (ART) for all people living with HIV has important health benefits but implications for the economic aspects of patients' lives are still largely unknown. This stepped-wedge cluster-randomized controlled trial aimed to determine the causal impact of immediate ART initiation on patients' healthcare expenditures in Eswatini. Fourteen healthcare facilities were randomly assigned to transition at one of seven time points from the standard of care (ART eligibility below a CD4 count threshold) to the immediate ART for all intervention (EAAA). 2261 patients living with HIV were interviewed over the study period to capture their past-year out-of-pocket healthcare expenditures. In mixed-effects regression models, we found a 49% decrease (RR 0.51, 95% CI 0.36, 0.72, p < 0.001) in past-year total healthcare expenditures in the EAAA group compared to the standard of care, and a 98% (RR 0.02, 95% CI 0.00, 0.02, p < 0.001) decrease in spending on private and traditional healthcare. Despite a higher frequency of HIV care visits for newly initiated ART patients, immediate ART initiation appears to have lowered patients' healthcare expenditures because they sought less care from alternative healthcare providers. This study adds an important economic argument to the World Health Organization's recommendation to abolish CD4-count-based eligibility thresholds for ART.

RESUMEN: El inicio inmediato de la terapia antirretroviral (TAR) para todas las personas que viven con VIH tiene importantes beneficios para la salud, pero aún se desconocen las implicaciones en el aspecto económico. Este ensayo controlado aleatorizado por clústers (CRT por sus siglas en inglés) por grupos en distintas etapas pretende determinar el impacto del inicio inmediato de la TAR en los gastos sanitarios de los pacientes en Eswatini. Catorce centros sanitarios fueron asignados aleatoriamente a la transición en uno de los siete periodos de la asistencia estándar (elegibilidad para la TAR en niveles definidos de recuento de CD4) a la intervención de TAR inmediato para todos (EAAA). Se entrevistó a 2.261 pacientes con VIH a lo largo del estudio para conocer sus gastos sanitarios del año anterior. Según los modelos de regresión de efectos mixtos, se observó un descenso del 49% (RR: 0,51; IC del 95%: 0,36, 0,72; p<0,001) en el gasto sanitario total del año anterior en el grupo de la EAAA, y un descenso del 98% (RR 0,02; IC del 95%: 0,00, 0,02; p<0,001) en el gasto en asistencia sanitaria privada y tradicional. A pesar de una mayor frecuencia de visitas deatención de VIH para los pacientes que recién comenzaron laTAR, la aplicación inmediata de laTAR redujo los gastos sanitarios de los pacientes dado que buscaron menos atención de proveedores de asistencia sanitaria alternativos. Este estudio añade un importante argumento económico a la recomendación de la Organización Mundial de la Salud de abolir las restricciones de elegibilidad para la terapia antirretroviral basados en el recuento de CD4.

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

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.

Association between country preparedness indicators and quality clinical care for cardiovascular disease risk factors in 44 lower- and middle-income countries: A multicountry analysis of survey data.

BACKGROUND: Cardiovascular diseases are leading causes of death, globally, and health systems that deliver quality clinical care are needed to manage an increasing number of people with risk factors for these diseases. Indicators of preparedness of countries to manage cardiovascular disease risk factors (CVDRFs) are regularly collected by ministries of health and global health agencies. We aimed to assess whether these indicators are associated with patient receipt of quality clinical care. METHODS AND FINDINGS: We did a secondary analysis of cross-sectional, nationally representative, individual-patient data from 187,552 people with hypertension (mean age 48.1 years, 53.5% female) living in 43 low- and middle-income countries (LMICs) and 40,795 people with diabetes (mean age 52.2 years, 57.7% female) living in 28 LMICs on progress through cascades of care (condition diagnosed, treated, or controlled) for diabetes or hypertension, to indicate outcomes of provision of quality clinical care. Data were extracted from national-level World Health Organization (WHO) Stepwise Approach to Surveillance (STEPS), or other similar household surveys, conducted between July 2005 and November 2016. We used mixed-effects logistic regression to estimate associations between each quality clinical care outcome and indicators of country development (gross domestic product [GDP] per capita or Human Development Index [HDI]); national capacity for the prevention and control of noncommunicable diseases ('NCD readiness indicators' from surveys done by WHO); health system finance (domestic government expenditure on health [as percentage of GDP], private, and out-of-pocket expenditure on health [both as percentage of current]); and health service readiness (number of physicians, nurses, or hospital beds per 1,000 people) and performance (neonatal mortality rate). All models were adjusted for individual-level predictors including age, sex, and education. In an exploratory analysis, we tested whether national-level data on facility preparedness for diabetes were positively associated with outcomes. Associations were inconsistent between indicators and quality clinical care outcomes. For hypertension, GDP and HDI were both positively associated with each outcome. Of the 33 relationships tested between NCD readiness indicators and outcomes, only two showed a significant positive association: presence of guidelines with being diagnosed (odds ratio [OR], 1.86 [95% CI 1.08-3.21], p = 0.03) and availability of funding with being controlled (OR, 2.26 [95% CI 1.09-4.69], p = 0.03). Hospital beds (OR, 1.14 [95% CI 1.02-1.27], p = 0.02), nurses/midwives (OR, 1.24 [95% CI 1.06-1.44], p = 0.006), and physicians (OR, 1.21 [95% CI 1.11-1.32], p < 0.001) per 1,000 people were positively associated with being diagnosed and, similarly, with being treated; and the number of physicians was additionally associated with being controlled (OR, 1.12 [95% CI 1.01-1.23], p = 0.03). For diabetes, no positive associations were seen between NCD readiness indicators and outcomes. There was no association between country development, health service finance, or health service performance and readiness indicators and any outcome, apart from GDP (OR, 1.70 [95% CI 1.12-2.59], p = 0.01), HDI (OR, 1.21 [95% CI 1.01-1.44], p = 0.04), and number of physicians per 1,000 people (OR, 1.28 [95% CI 1.09-1.51], p = 0.003), which were associated with being diagnosed. Six countries had data on cascades of care and nationwide-level data on facility preparedness. Of the 27 associations tested between facility preparedness indicators and outcomes, the only association that was significant was having metformin available, which was positively associated with treatment (OR, 1.35 [95% CI 1.01-1.81], p = 0.04). The main limitation was use of blood pressure measurement on a single occasion to diagnose hypertension and a single blood glucose measurement to diagnose diabetes. CONCLUSION: In this study, we observed that indicators of country preparedness to deal with CVDRFs are poor proxies for quality clinical care received by patients for hypertension and diabetes. The major implication is that assessments of countries' preparedness to manage CVDRFs should not rely on proxies; rather, it should involve direct assessment of quality clinical care.

A stepped-wedge randomised trial on the impact of early ART initiation on HIV-patients' economic outcomes in Eswatini.

Background: Since 2015, the World Health Organisation (WHO) recommends immediate initiation of antiretroviral therapy (ART) for all HIV-positive patients. Epidemiological evidence points to important health benefits of immediate ART initiation; however, the policy's impact on the economic aspects of patients' lives remains unknown. Methods: We conducted a stepped-wedge cluster-randomised controlled trial in Eswatini to determine the causal impact of immediate ART initiation on patients' individual- and household-level economic outcomes. Fourteen healthcare facilities were non-randomly matched into pairs and then randomly allocated to transition from the standard of care (ART eligibility at CD4 counts of <350 cells/mm3 until September 2016 and <500 cells/mm3 thereafter) to the 'Early Initiation of ART for All' (EAAA) intervention at one of seven timepoints. Patients, healthcare personnel, and outcome assessors remained unblinded. Data were collected via standardised paper-based surveys with HIV-positive adults who were neither pregnant nor breastfeeding. Outcomes were patients' time use, employment status, household expenditures, and household living standards. Results: A total sample of 3019 participants were interviewed over the duration of the study. The mean number of participants approached at each facility per time step varied from 4 to 112 participants. Using mixed-effects negative binomial regressions accounting for time trends and clustering at the level of the healthcare facility, we found no significant difference between study arms for any economic outcome. Specifically, the EAAA intervention had no significant effect on non-resting time use (RR = 1.00 [CI: 0.96, 1.05, p=0.93]) or income-generating time use (RR = 0.94, [CI: 0.73,1.20, p=0.61]). Employment and household expenditures decreased slightly but not significantly in the EAAA group, with risk ratios of 0.93 [CI: 0.82, 1.04, p=0.21] and 0.92 [CI: 0.79, 1.06, p=0.26], respectively. We also found no significant treatment effect on households' asset ownership and living standards (RR = 0.96, [CI 0.92, 1.00, p=0.253]). Lastly, there was no evidence of heterogeneity in effect estimates by patients' sex, age, education, timing of HIV diagnosis and ART initiation. Conclusions: Our findings do not provide evidence that should discourage further investments into scaling up immediate ART for all HIV patients. Funding: Funded by the Dutch Postcode Lottery in the Netherlands, Alexander von Humboldt-Stiftung (Humboldt-Stiftung), the Embassy of the Kingdom of the Netherlands in South Africa/Mozambique, British Columbia Centre of Excellence in Canada, Doctors Without Borders (MSF USA), National Center for Advancing Translational Sciences of the National Institutes of Health and Joachim Herz Foundation. Clinical trial number: NCT02909218 and NCT03789448.

Human immunodeficiency virus (HIV) is an incurable virus that attacks the immune system and affects around 39 million people worldwide. Once diagnosed, HIV can be treated with antiretroviral therapy (ART) to limit its effects and stop it spreading to other people. HIV rates vary across the world, but the African country of Eswatini has the highest prevalence with more than one in four (27%) people classed as HIV-positive. Until 2015, people living with HIV were typically only treated with ART once their immune system weakened. Recent studies found that starting treatment earlier enhances the positive effects of ART. This caused the World Health Organization (WHO) to change their guidelines and advise people living with HIV to begin ART as soon as they are diagnosed. While antiretroviral drugs are usually provided to patients free of charge, accessing care can be expensive for patients because of high transport costs or lost time from income-generating activities. This means starting treatment earlier and, thus, having more frequent healthcare visits, may result in a greater cost to the patient. The economic impact of this change is unclear, and for patients living in poverty, these added costs can affect their decision on whether to continue treatment. Steinert et al. interviewed 3,019 HIV-patients from 14 health facilities in Eswatini who began treatment with ART either immediately after diagnosis or after their immune system became suppressed. Patients were asked about their time spent being active to generate income, employment status, monthly household expenditures, and household living standards. On average, beginning ART earlier appears to have had no large negative effects on the economic wellbeing of patients. The same results were found for patient groups defined by sex, education, age, and time spent taking ART. These findings suggest that starting ART for HIV as soon as possible offers medical benefits and seems to have no large economic consequences for patients in the short term, even for poorer communities. This adds weight to the WHO advice on HIV treatment and supports the need to continue to deliver effective treatments to countries like Eswatini that have a high rate of HIV infection.

Diabetes Prevalence and Its Relationship With Education, Wealth, and BMI in 29 Low- and Middle-Income Countries.

OBJECTIVE: Diabetes is a rapidly growing health problem in low- and middle-income countries (LMICs), but empirical data on its prevalence and relationship to socioeconomic status are scarce. We estimated diabetes prevalence and the subset with undiagnosed diabetes in 29 LMICs and evaluated the relationship of education, household wealth, and BMI with diabetes risk. RESEARCH DESIGN AND METHODS: We pooled individual-level data from 29 nationally representative surveys conducted between 2008 and 2016, totaling 588,574 participants aged ≥25 years. Diabetes prevalence and the subset with undiagnosed diabetes was calculated overall and by country, World Bank income group (WBIG), and geographic region. Multivariable Poisson regression models were used to estimate relative risk (RR). RESULTS: Overall, prevalence of diabetes in 29 LMICs was 7.5% (95% CI 7.1-8.0) and of undiagnosed diabetes 4.9% (4.6-5.3). Diabetes prevalence increased with increasing WBIG: countries with low-income economies (LICs) 6.7% (5.5-8.1), lower-middle-income economies (LMIs) 7.1% (6.6-7.6), and upper-middle-income economies (UMIs) 8.2% (7.5-9.0). Compared with no formal education, greater educational attainment was associated with an increased risk of diabetes across WBIGs, after adjusting for BMI (LICs RR 1.47 [95% CI 1.22-1.78], LMIs 1.14 [1.06-1.23], and UMIs 1.28 [1.02-1.61]). CONCLUSIONS: Among 29 LMICs, diabetes prevalence was substantial and increased with increasing WBIG. In contrast to the association seen in high-income countries, diabetes risk was highest among those with greater educational attainment, independent of BMI. LMICs included in this analysis may be at an advanced stage in the nutrition transition but with no reversal in the socioeconomic gradient of diabetes risk.

The Double Burden of Malnutrition in Bangalore, India.

The double burden of malnutrition (DBM), i.e., coexistence of under- and overnutrition, is an emerging issue in most of the low- and middle-income countries of the world. Using field survey data conducted in and around the city of Bangalore, India in 2018, we examine the patterns of DBM among women, young children (0-6 years), older children (7-18 years), and intrahousehold DBM between mothers and children. A unique aspect of the survey is that it is conducted in an area undergoing rapid urbanization, which is one of the factors responsible for DBM and can inform on the future of DBM in India. Compared to undernutrition, the prevalence of overnutrition is much higher in our study area. We find that, like other developing countries, the socioeconomic distance in prevalence of under- and overnutrition among women has decreased over time. Additionally, overnutrition among women is no longer an urban phenomenon. Similar trends were observed for older children. For younger children, on the other hand, the socioeconomic and locational differences persist, suggesting that this age group is not witnessing nutrition transition yet. The intrahousehold burden of DBM has also increased over time and the risk increases with maternal education. Although under- and overnutrition are opposite in nature, both have several common drivers, suggesting that an integrated approach might work better in tackling DBM. Several existing programs in India, such as ICDS, PDS, and the school meal program, provide excellent infrastructure to roll out policies and interventions, especially diet-based programs, aimed at both under- and overnutrition.