Associations between childhood maltreatment and physiological dysregulation in adulthood: Methodological decisions and implications.

BACKGROUND: Childhood maltreatment is linked with health problems in adulthood. Theoretical models suggest that maltreatment leads to dysregulation in several bodily systems, and this has been corroborated using measures of physiological function (i.e., biomarkers). Methodological decisions involving the measurement of maltreatment and dimension reduction with respect to biomarkers (i.e., combining information across multiple measures) may influence research findings. OBJECTIVE: The present study compares associations between childhood maltreatment and adult physiological dysregulation using multiple dimension reduction approaches and measures of maltreatment. PARTICIPANTS AND SETTING: Participants were recruited, as children, to a prospective study of the correlates and consequences of childhood maltreatment. 253 participants were retained and provided biomarker data at midlife. Physiological dysregulation was operationalized with a conventional allostatic load approach and a novel statistical distance approach. METHODS: Regression models were employed with allostatic load or statistical distance as the outcome and prospectively or retrospectively measured child maltreatment as the primary predictor. RESULTS: When using allostatic load as the outcome, prospectively measured childhood maltreatment was positively associated with physiological dysregulation (b = 0.70, SE = 0.31, p = 0.02). When using statistical distance as the outcome, retrospectively measured childhood maltreatment was positively associated with physiological dysregulation (b = 0.69, SE = 0.19 p < 0.001). CONCLUSIONS: We report a positive association between childhood maltreatment and physiological dysregulation at midlife. However, the significance and magnitude of effects varied with different maltreatment and physiological dysregulation measures. Further review of the methods used to study adult health conditions and their relation to childhood maltreatment is needed.

Space-time modeling of child mortality at the Admin-2 level in a low and middle income countries context.

The Sustainable Development Goals call for a total reduction of preventable child mortality before 2030. Further, the goals state the desirability to have subnational mortality estimates. Estimates at this level are required for health interventions at the subnational level. In a low and middle income countries context, the data on mortality typically consist of household surveys, which are carried out with a stratified, cluster design, and census microsamples. Most household surveys collect full birth history (FBH) data on birth and death dates of a mother's children, but censuses collect summary birth history (SBH) data which consist only of the number of children born and the number that died. In previous work, direct (survey-weighted) estimates with associated variances were derived from FBH data and smoothed in space and time. Unfortunately, the FBH data from household surveys are usually not sufficiently abundant to obtain yearly estimates at the Admin-2 level (at which interventions are often made). In this paper we describe four extensions to previous work: (i) combining SBH data with FBH data, (ii) modeling on a yearly scale, to combine data on a yearly scale with data at coarser time scales, (iii) adjusting direct estimates in Admin-2 areas where we do not observe any deaths due to small sample sizes, (iv) acknowledge differences in data sources by modeling potential bias arising from the various data sources. The methods are illustrated using household survey and census data from Kenya and Malawi, to produce mortality estimates from 1980 to the time of the most recent survey, and predictions to 2020.

Changes in the spatial distribution of the under-five mortality rate: Small-area analysis of 122 DHS surveys in 262 subregions of 35 countries in Africa.

The under-five mortality rate (U5MR) is a critical and widely available population health indicator. Both the MDGs and SDGs define targets for improvement in the U5MR, and the SDGs require spatial disaggregation of indicators. We estimate trends in the U5MR for Admin-1 subnational areas using 122 DHS surveys in 35 countries in Africa and assess progress toward the MDG target reductions for each subnational region and each country as a whole. In each country, direct weighted estimates of the U5MR from each survey are calculated and combined into a single estimate for each Admin-1 region across five-year periods. Our method fully accounts for the sample design of each survey. The region-time-specific estimates are smoothed using a Bayesian, space-time model that produces more precise estimates (when compared to the direct estimates) at a one-year scale that are consistent with each other in both space and time. The resulting estimated distributions of the U5MR are summarized and used to assess subnational progress toward the MDG 4 target of two-thirds reduction in the U5MR during 1990-2015. Our space-time modeling approach is tractable and can be readily applied to a large collection of sample survey data. Subnational, regional spatial heterogeneity in the levels and trends in the U5MR vary considerably across Africa. There is no generalizable pattern between spatial heterogeneity and levels or trends in the U5MR. Subnational, small-area estimates of the U5MR: (i) identify subnational regions where interventions are still necessary and those where improvement is well under way; and (ii) countries where there is very little spatial variation and others where there are important differences between subregions in both levels and trends. More work is necessary to improve both the data sources and methods necessary to adequately measure subnational progress toward the SDG child survival targets.

Estimating under-five mortality in space and time in a developing world context.

Accurate estimates of the under-five mortality rate in a developing world context are a key barometer of the health of a nation. This paper describes a new model to analyze survey data on mortality in this context. We are interested in both spatial and temporal description, that is wishing to estimate under-five mortality rate across regions and years and to investigate the association between the under-five mortality rate and spatially varying covariate surfaces. We illustrate the methodology by producing yearly estimates for subnational areas in Kenya over the period 1980-2014 using data from the Demographic and Health Surveys, which use stratified cluster sampling. We use a binomial likelihood with fixed effects for the urban/rural strata and random effects for the clustering to account for the complex survey design. Smoothing is carried out using Bayesian hierarchical models with continuous spatial and temporally discrete components. A key component of the model is an offset to adjust for bias due to the effects of HIV epidemics. Substantively, there has been a sharp decline in Kenya in the under-five mortality rate in the period 1980-2014, but large variability in estimated subnational rates remains. A priority for future research is understanding this variability. In exploratory work, we examine whether a variety of spatial covariate surfaces can explain the variability in under-five mortality rate. Temperature, precipitation, a measure of malaria infection prevalence, and a measure of nearness to cities were candidates for inclusion in the covariate model, but the interplay between space, time, and covariates is complex.

Probabilistic population projections for countries with generalized HIV/AIDS epidemics.

In 2015, the United Nations (UN) issued probabilistic population projections for all countries up to 2100, by simulating future levels of total fertility and life expectancy and combining the results using a standard cohort component projection method. For the 40 countries with generalized HIV/AIDS epidemics, the mortality projections used the Spectrum/Estimation and Projection Package (EPP) model, a complex, multistate model designed for short-term projections of policy-relevant quantities for the epidemic. We propose a simpler approach that is more compatible with existing UN projection methods for other countries. Changes in life expectancy are projected probabilistically using a simple time series regression and then converted to age- and sex-specific mortality rates using model life tables designed for countries with HIV/AIDS epidemics. These are then input to the cohort component method, as for other countries. The method performed well in an out-of-sample cross-validation experiment. It gives similar short-run projections to Spectrum/EPP, while being simpler and avoiding multistate modelling.

Bayesian projection of life expectancy accounting for the HIV/AIDS epidemic.

BACKGROUND: While probabilistic projection methods for projecting life expectancy exist, few account for covariates related to life expectancy. Generalized HIV/AIDS epidemics have a large, immediate negative impact on the life expectancy in a country, but this impact can be mitigated by widespread use of antiretroviral therapy (ART). Thus, projection methods for countries with generalized HIV/AIDS epidemics could be improved by accounting for HIV prevalence, the future course of the epidemic, and ART coverage. METHODS: We extend the current Bayesian probabilistic life expectancy projection methods of Raftery et al. (2013) to account for HIV prevalence and adult ART coverage in countries with generalized HIV/AIDS epidemics. RESULTS: We evaluate our method using out-of-sample validation. We find that the proposed method performs better than the method that does not account for HIV prevalence or ART coverage for projections of life expectancy in countries with a generalized epidemic, while projections for countries without an epidemic remain essentially unchanged. CONCLUSIONS: In general, our projections show rapid recovery to pre-epidemic life expectancy levels in the presence of widespread ART coverage. After the initial life expectancy recovery, we project a steady rise in life expectancy until the end of the century. CONTRIBUTION: We develop a simple Bayesian hierarchical model for long-term projections of life expectancy while accounting for HIV/AIDS prevalence and coverage of ART. The method produces well-calibrated projections for countries with generalized HIV/AIDS epidemics up to 2100 while having limited data demands.