Publications by authors named "Pascal Geldsetzer"

101 Publications

Estimated effect of increased diagnosis, treatment, and control of diabetes and its associated cardiovascular risk factors among low-income and middle-income countries: a microsimulation model.

Lancet Glob Health 2021 Sep 22. Epub 2021 Sep 22.

Institute for Applied Health Research, University of Birmingham, Birmingham, UK; Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa; Medical Research Council-Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.

Background: Given the increasing prevalence of diabetes in low-income and middle-income countries (LMICs), we aimed to estimate the health and cost implications of achieving different targets for diagnosis, treatment, and control of diabetes and its associated cardiovascular risk factors among LMICs.

Methods: We constructed a microsimulation model to estimate disability-adjusted life-years (DALYs) lost and health-care costs of diagnosis, treatment, and control of blood pressure, dyslipidaemia, and glycaemia among people with diabetes in LMICs. We used individual participant data-specifically from the subset of people who were defined as having any type of diabetes by WHO standards-from nationally representative, cross-sectional surveys (2006-18) spanning 15 world regions to estimate the baseline 10-year risk of atherosclerotic cardiovascular disease (defined as fatal and non-fatal myocardial infarction and stroke), heart failure (ejection fraction of <40%, with New York Heart Association class III or IV functional limitations), end-stage renal disease (defined as an estimated glomerular filtration rate <15 mL/min per 1·73 m or needing dialysis or transplant), retinopathy with severe vision loss (<20/200 visual acuity as measured by the Snellen chart), and neuropathy with pressure sensation loss (assessed by the Semmes-Weinstein 5·07/10 g monofilament exam). We then used data from meta-analyses of randomised controlled trials to estimate the reduction in risk and the WHO OneHealth tool to estimate costs in reaching either 60% or 80% of diagnosis, treatment initiation, and control targets for blood pressure, dyslipidaemia, and glycaemia recommended by WHO guidelines. Costs were updated to 2020 International Dollars, and both costs and DALYs were computed over a 10-year policy planning time horizon at a 3% annual discount rate.

Findings: We obtained data from 23 678 people with diabetes from 67 countries. The median estimated 10-year risk was 10·0% (IQR 4·0-18·0) for cardiovascular events, 7·8% (5·1-11·8) for neuropathy with pressure sensation loss, 7·2% (5·6-9·4) for end-stage renal disease, 6·0% (4·2-8·6) for retinopathy with severe vision loss, and 2·6% (1·2-5·3) for congestive heart failure. A target of 80% diagnosis, 80% treatment, and 80% control would be expected to reduce DALYs lost from diabetes complications from a median population-weighted loss to 1097 DALYs per 1000 population over 10 years (IQR 1051-1155), relative to a baseline of 1161 DALYs, primarily from reduced cardiovascular events (down from a median of 143 to 117 DALYs per 1000 population) due to blood pressure and statin treatment, with comparatively little effect from glycaemic control. The target of 80% diagnosis, 80% treatment, and 80% control would be expected to produce an overall incremental cost-effectiveness ratio of US$1362 per DALY averted (IQR 1304-1409), with the majority of decreased costs from reduced cardiovascular event management, counterbalanced by increased costs for blood pressure and statin treatment, producing an overall incremental cost-effectiveness ratio of $1362 per DALY averted (IQR 1304-1409).

Interpretation: Reducing complications from diabetes in LMICs is likely to require a focus on scaling up blood pressure and statin medication treatment initiation and blood pressure medication titration rather than focusing on increasing screening to increase diabetes diagnosis, or a glycaemic treatment and control among people with diabetes.

Funding: None.
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http://dx.doi.org/10.1016/S2214-109X(21)00340-5DOI Listing
September 2021

The effect of bearing and rearing a child on blood pressure: a nationally representative instrumental variable analysis of 444611 mothers in India.

Int J Epidemiol 2021 Jul 19. Epub 2021 Jul 19.

Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany.

Background: At the individual level, it is well known that pregnancies have a short-term effect on a woman's cardiovascular system and blood pressure. The long-term effect of having children on maternal blood pressure, however, is unknown. We thus estimated the causal effect of having children on blood pressure among mothers in India, a country with a history of high fertility rates.

Methods: We used nationally representative cross-sectional data from the 2015-16 India National Family and Health Survey (NFHS-4). The study population comprised 444 611 mothers aged 15-49 years. We used the sex of the first-born child as an instrumental variable (IV) for the total number of a woman's children. We estimated the effect of an additional child on systolic and diastolic blood pressure in IV (two-stage least squares) regressions. In additional analyses, we stratified the IV regressions by time since a mother last gave birth. Furthermore, we repeated our analyses using mothers' husbands and partners as the regression sample.

Results: On average, mothers had 2.7 children [standard deviation (SD): 1.5], a systolic blood pressure of 116.4 mmHg (SD: 14.4) and diastolic blood pressure of 78.5 mmHg (SD: 9.4). One in seven mothers was hypertensive. In conventional ordinary least squares regression, each child was associated with 0.42 mmHg lower systolic [95% confidence interval (CI): -0.46 to -0.39, P < 0.001] and 0.13 mmHg lower diastolic (95% CI: -0.15 to -0.11, P < 0.001) blood pressure. In the IV regressions, each child decreased a mother's systolic blood pressure by an average of 1.00 mmHg (95% CI: -1.26 to -0.74, P < 0.001) and diastolic blood pressure by an average of 0.35 mmHg (95% CI: -0.52 to -0.17, P < 0.001). These decreases were sustained over more than a decade after childbirth, with effect sizes slightly declining as the time since last birth increased. Having children did not influence blood pressure in men.

Conclusions: Bearing and rearing a child decreases blood pressure among mothers in India.
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http://dx.doi.org/10.1093/ije/dyab058DOI Listing
July 2021

The effect of eligibility for antiretroviral therapy on body mass index and blood pressure in KwaZulu-Natal, South Africa.

Sci Rep 2021 07 19;11(1):14718. Epub 2021 Jul 19.

Department of Economics, University of Goettingen, Göttingen, Germany.

We use a regression discontinuity design to estimate the causal effect of antiretroviral therapy (ART) eligibility according to national treatment guidelines of South Africa on two risk factors for cardiovascular disease, body mass index (BMI) and blood pressure. We combine survey data collected in 2010 in KwaZulu-Natal, South Africa, with clinical data on ART. We find that early ART eligibility significantly reduces systolic and diastolic blood pressure. We do not find any significant effects on BMI. The effect on blood pressure can be detected up to three years after becoming eligible for ART.
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http://dx.doi.org/10.1038/s41598-021-94057-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8289961PMC
July 2021

Body-mass index and diabetes risk in 57 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data in 685 616 adults.

Lancet 2021 07;398(10296):238-248

Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.

Background: The prevalence of overweight, obesity, and diabetes is rising rapidly in low-income and middle-income countries (LMICs), but there are scant empirical data on the association between body-mass index (BMI) and diabetes in these settings.

Methods: In this cross-sectional study, we pooled individual-level data from nationally representative surveys across 57 LMICs. We identified all countries in which a WHO Stepwise Approach to Surveillance (STEPS) survey had been done during a year in which the country fell into an eligible World Bank income group category. For LMICs that did not have a STEPS survey, did not have valid contact information, or declined our request for data, we did a systematic search for survey datasets. Eligible surveys were done during or after 2008; had individual-level data; were done in a low-income, lower-middle-income, or upper-middle-income country; were nationally representative; had a response rate of 50% or higher; contained a diabetes biomarker (either a blood glucose measurement or glycated haemoglobin [HbA]); and contained data on height and weight. Diabetes was defined biologically as a fasting plasma glucose concentration of 7·0 mmol/L (126·0 mg/dL) or higher; a random plasma glucose concentration of 11·1 mmol/L (200·0 mg/dL) or higher; or a HbA of 6·5% (48·0 mmol/mol) or higher, or by self-reported use of diabetes medication. We included individuals aged 25 years or older with complete data on diabetes status, BMI (defined as normal [18·5-22·9 kg/m], upper-normal [23·0-24·9 kg/m], overweight [25·0-29·9 kg/m], or obese [≥30·0 kg/m]), sex, and age. Countries were categorised into six geographical regions: Latin America and the Caribbean, Europe and central Asia, east, south, and southeast Asia, sub-Saharan Africa, Middle East and north Africa, and Oceania. We estimated the association between BMI and diabetes risk by multivariable Poisson regression and receiver operating curve analyses, stratified by sex and geographical region.

Findings: Our pooled dataset from 58 nationally representative surveys in 57 LMICs included 685 616 individuals. The overall prevalence of overweight was 27·2% (95% CI 26·6-27·8), of obesity was 21·0% (19·6-22·5), and of diabetes was 9·3% (8·4-10·2). In the pooled analysis, a higher risk of diabetes was observed at a BMI of 23 kg/m or higher, with a 43% greater risk of diabetes for men and a 41% greater risk for women compared with a BMI of 18·5-22·9 kg/m. Diabetes risk also increased steeply in individuals aged 35-44 years and in men aged 25-34 years in sub-Saharan Africa. In the stratified analyses, there was considerable regional variability in this association. Optimal BMI thresholds for diabetes screening ranged from 23·8 kg/m among men in east, south, and southeast Asia to 28·3 kg/m among women in the Middle East and north Africa and in Latin America and the Caribbean.

Interpretation: The association between BMI and diabetes risk in LMICs is subject to substantial regional variability. Diabetes risk is greater at lower BMI thresholds and at younger ages than reflected in currently used BMI cutoffs for assessing diabetes risk. These findings offer an important insight to inform context-specific diabetes screening guidelines.

Funding: Harvard T H Chan School of Public Health McLennan Fund: Dean's Challenge Grant Program.
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http://dx.doi.org/10.1016/S0140-6736(21)00844-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8336025PMC
July 2021

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

J Am Heart Assoc 2021 07 2;10(13):e021063. Epub 2021 Jul 2.

Heidelberg Institute of Global Health Medical Faculty and University Hospital University of Heidelberg Germany.

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.
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http://dx.doi.org/10.1161/JAHA.121.021063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8403275PMC
July 2021

Mapping physical access to health care for older adults in sub-Saharan Africa and implications for the COVID-19 response: a cross-sectional analysis.

Lancet Healthy Longev 2020 Oct 20;1(1):e32-e42. Epub 2020 Oct 20.

Institute of Geography, Heidelberg University, Heidelberg, Germany.

Background: Severe acute respiratory syndrome coronavirus 2, the virus causing COVID-19, is rapidly spreading across sub-Saharan Africa. Hospital-based care for COVID-19 is often needed, particularly among older adults. However, a key barrier to accessing hospital care in sub-Saharan Africa is travel time to the nearest health-care facility. To inform the geographical targeting of additional health-care resources, we aimed to estimate travel time at a 1 km × 1 km resolution to the nearest hospital and to the nearest health-care facility of any type for adults aged 60 years and older in sub-Saharan Africa.

Methods: We assembled a dataset on the geolocation of health-care facilities, separately for hospitals and any type of health-care facility and including both private-sector and public-sector facilities, using data from the OpenStreetMap project and the Kenya Medical Research Institute-Wellcome Trust Programme. Population data at a 1 km × 1 km resolution were obtained from WorldPop. We estimated travel time to the nearest health-care facility for each 1 km × 1 km grid using a cost-distance algorithm.

Findings: 9·6% (95% CI 5·2-16·9) of adults aged 60 years or older across sub-Saharan Africa had an estimated travel time to the nearest hospital of 6 h or longer, varying from 0·0% (0·0-3·7) in Burundi and The Gambia to 40·9% (31·8-50·7) in Sudan. For the nearest health-care facility of any type (whether primary, secondary, or tertiary care), 15·9% (95% CI 10·1-24·4) of adults aged 60 years or older across sub-Saharan Africa had an estimated travel time of 2 h or longer, ranging from 0·4% (0·0-4·4) in Burundi to 59·4% (50·1-69·0) in Sudan. Most countries in sub-Saharan Africa contained populated areas in which adults aged 60 years and older had a travel time to the nearest hospital of 12 h or longer and to the nearest health-care facility of any type of 6 h or longer. The median travel time to the nearest hospital for the fifth of adults aged 60 years or older with the longest travel times was 348 min (IQR 240-576; equal to 5·8 h) for the entire population of sub-Saharan Africa, ranging from 41 min (34-54) in Burundi to 1655 min (1065-2440; equal to 27·6 h) in Gabon.

Interpretation: Our high-resolution maps of estimated travel times to both hospitals and health-care facilities of any type can be used by policy makers and non-governmental organisations to help target additional health-care resources, such as makeshift hospitals or transport programmes to existing health-care facilities, to older adults with the least physical access to care. In addition, this analysis shows the locations of population groups most likely to under-report COVID-19 symptoms because of low physical access to health-care facilities. Beyond the COVID-19 response, this study can inform the efforts of countries to improve physical access to care for conditions that are common among older adults in the region, such as chronic non-communicable diseases.

Funding: Bill & Melinda Gates Foundation.
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http://dx.doi.org/10.1016/S2666-7568(20)30010-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7574846PMC
October 2020

Correction: Knowledge About COVID-19 Among Adults in China: Cross-sectional Online Survey.

J Med Internet Res 2021 May 12;23(5):e30100. Epub 2021 May 12.

Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany.

[This corrects the article DOI: 10.2196/26940.].
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http://dx.doi.org/10.2196/30100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8156116PMC
May 2021

Trends in Mail-Order Pharmacy Use in the U.S. From 1996 to 2018: An Analysis of the Medical Expenditure Panel Survey.

Am J Prev Med 2021 08 3;61(2):e63-e72. Epub 2021 May 3.

Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford University, Palo Alto, California; Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany.

Introduction: The use of mail-order pharmacies is generally associated with lower healthcare costs and improved medication adherence. To promote the use of mail-order pharmacies, it is important to understand the time trends in their use and whether these trends vary by population subgroups.

Methods: This study used the 1996-2018 Medical Expenditure Panel Survey to determine the annual prevalence of mail-order pharmacy use (defined as purchasing ≥1 prescription from a mail-order or online pharmacy) among U.S. adult prescription users and its variation by population characteristics. Logistic regression was used to determine the correlates of mail-order pharmacy use. Results were presented for medications and therapeutic classes most commonly purchased by mail-order pharmacy exclusive users. Analyses were conducted in December 2020.

Results: The annual prevalence of mail-order pharmacy use among U.S. adult prescription users increased from 10.2% (95% CI=9.3, 11.1) in 1996 to 17.0% (95% CI=15.9, 18.1) in 2005 and then declined to 15.7% (95% CI=14.9, 16.6) by 2018. Absolute differences in the prevalence of use by race/ethnicity, education, and health insurance coverage widened over time, whereas they remained stable when stratifying by sex, age, marital status, region, limitations in daily activities, pain interference, health status, number of chronic conditions, and access to medical care. Among mail-order pharmacy exclusive users, the 3 most commonly purchased medications were atorvastatin (16.7%), levothyroxine (13.6%), and lisinopril (13.1%); the 3 most commonly purchased therapeutic classes were cardiovascular agents (57.9%), metabolic agents (52.1%), and central nervous system agents (29.6%).

Conclusions: The prevalence of mail-order pharmacy use has declined in recent years and has shown significant variation across population subgroups. Future research should examine whether the declining trends and variation in use may influence the management of chronic conditions and the disparities in health and healthcare costs.
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http://dx.doi.org/10.1016/j.amepre.2021.02.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8319048PMC
August 2021

Climate and the spread of COVID-19.

Sci Rep 2021 04 27;11(1):9042. Epub 2021 Apr 27.

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

Visual inspection of world maps shows that coronavirus disease 2019 (COVID-19) is less prevalent in countries closer to the equator, where heat and humidity tend to be higher. Scientists disagree how to interpret this observation because the relationship between COVID-19 and climatic conditions may be confounded by many factors. We regress the logarithm of confirmed COVID-19 cases per million inhabitants in a country against the country's distance from the equator, controlling for key confounding factors: air travel, vehicle concentration, urbanization, COVID-19 testing intensity, cell phone usage, income, old-age dependency ratio, and health expenditure. A one-degree increase in absolute latitude is associated with a 4.3% increase in cases per million inhabitants as of January 9, 2021 (p value < 0.001). Our results imply that a country, which is located 1000 km closer to the equator, could expect 33% fewer cases per million inhabitants. Since the change in Earth's angle towards the sun between equinox and solstice is about 23.5°, one could expect a difference in cases per million inhabitants of 64% between two hypothetical countries whose climates differ to a similar extent as two adjacent seasons. According to our results, countries are expected to see a decline in new COVID-19 cases during summer and a resurgence during winter. However, our results do not imply that the disease will vanish during summer or will not affect countries close to the equator. Rather, the higher temperatures and more intense UV radiation in summer are likely to support public health measures to contain SARS-CoV-2.
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http://dx.doi.org/10.1038/s41598-021-87692-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8079387PMC
April 2021

Knowledge About COVID-19 Among Adults in China: Cross-sectional Online Survey.

J Med Internet Res 2021 04 29;23(4):e26940. Epub 2021 Apr 29.

Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany.

Background: A detailed understanding of the public's knowledge and perceptions of COVID-19 could inform governments' public health actions in response to the pandemic.

Objective: The aim of this study was to determine the knowledge and perceptions of COVID-19 among adults in China and its variation among provinces and by sociodemographic characteristics.

Methods: Between May 8 and June 8, 2020, we conducted a cross-sectional online survey among adults in China who were registered with the private survey company KuRunData. We set a target sample size of 10,000 adults, aiming to sample 300-360 adults from each province in China. Participants were asked 25 questions that tested their knowledge about COVID-19, including measures to prevent infection, common symptoms, and recommended care-seeking behavior. We disaggregated responses by age; sex; education; province; household income; rural-urban residency; and whether or not a participant had a family member, friend, or acquaintance who they know to have been infected with SARS-CoV-2. All analyses used survey sampling weights.

Results: There were 5079 men and 4921 women who completed the questionnaire and were included in the analysis. Out of 25 knowledge questions, participants answered a mean and median of 21.4 (95% CI 21.3-21.4) and 22 (IQR 20-23) questions correctly, respectively. A total of 83.4% (95% CI 82.7%-84.1%) of participants answered four-fifths or more of the questions correctly. For at least one of four ineffective prevention measures (using a hand dryer, regular nasal irrigation, gargling mouthwash, and taking antibiotics), 68.9% (95% CI 68.0%-69.8%) of participants answered that it was an effective method to prevent a SARS-CoV-2 infection. Although knowledge overall was similar across provinces, the percent of participants who answered the question on recommended care-seeking behavior correctly varied from 47.0% (95% CI 41.4%-52.7%) in Tibet to 87.5% (95% CI 84.1%-91.0%) in Beijing. Within provinces, participants who were male, were middle-aged, were residing in urban areas, and had higher household income tended to answer a higher proportion of the knowledge questions correctly.

Conclusions: This online study of individuals across China suggests that the majority of the population has good knowledge of COVID-19. However, a substantial proportion still holds misconceptions or incorrect beliefs about prevention methods and recommended health care-seeking behaviors, especially in rural areas and some less wealthy provinces in Western China. This study can inform the development of tailored public health policies and promotion campaigns by identifying knowledge areas for which misconceptions are comparatively common and provinces that have relatively low knowledge.
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http://dx.doi.org/10.2196/26940DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8086781PMC
April 2021

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

AIDS Behav 2021 Oct 8;25(10):3194-3205. Epub 2021 Apr 8.

Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany.

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.
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http://dx.doi.org/10.1007/s10461-021-03241-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8416844PMC
October 2021

Cardiovascular disease risk profile and management practices in 45 low-income and middle-income countries: A cross-sectional study of nationally representative individual-level survey data.

PLoS Med 2021 03 4;18(3):e1003485. Epub 2021 Mar 4.

Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom.

Background: Global cardiovascular disease (CVD) burden is high and rising, especially in low-income and middle-income countries (LMICs). Focussing on 45 LMICs, we aimed to determine (1) the adult population's median 10-year predicted CVD risk, including its variation within countries by socio-demographic characteristics, and (2) the prevalence of self-reported blood pressure (BP) medication use among those with and without an indication for such medication as per World Health Organization (WHO) guidelines.

Methods And Findings: We conducted a cross-sectional analysis of nationally representative household surveys from 45 LMICs carried out between 2005 and 2017, with 32 surveys being WHO Stepwise Approach to Surveillance (STEPS) surveys. Country-specific median 10-year CVD risk was calculated using the 2019 WHO CVD Risk Chart Working Group non-laboratory-based equations. BP medication indications were based on the WHO Package of Essential Noncommunicable Disease Interventions guidelines. Regression models examined associations between CVD risk, BP medication use, and socio-demographic characteristics. Our complete case analysis included 600,484 adults from 45 countries. Median 10-year CVD risk (interquartile range [IQR]) for males and females was 2.7% (2.3%-4.2%) and 1.6% (1.3%-2.1%), respectively, with estimates indicating the lowest risk in sub-Saharan Africa and highest in Europe and the Eastern Mediterranean. Higher educational attainment and current employment were associated with lower CVD risk in most countries. Of those indicated for BP medication, the median (IQR) percentage taking medication was 24.2% (15.4%-37.2%) for males and 41.6% (23.9%-53.8%) for females. Conversely, a median (IQR) 47.1% (36.1%-58.6%) of all people taking a BP medication were not indicated for such based on CVD risk status. There was no association between BP medication use and socio-demographic characteristics in most of the 45 study countries. Study limitations include variation in country survey methods, most notably the sample age range and year of data collection, insufficient data to use the laboratory-based CVD risk equations, and an inability to determine past history of a CVD diagnosis.

Conclusions: This study found underuse of guideline-indicated BP medication in people with elevated CVD risk and overuse by people with lower CVD risk. Country-specific targeted policies are needed to help improve the identification and management of those at highest CVD risk.
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http://dx.doi.org/10.1371/journal.pmed.1003485DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7932723PMC
March 2021

Cervical Cancer Screening in Low- and Middle-Income Countries-Reply.

JAMA 2021 02;325(8):790-791

Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany.

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http://dx.doi.org/10.1001/jama.2020.25217DOI Listing
February 2021

Variation in the Proportion of Adults in Need of Blood Pressure-Lowering Medications by Hypertension Care Guideline in Low- and Middle-Income Countries: A Cross-Sectional Study of 1 037 215 Individuals From 50 Nationally Representative Surveys.

Circulation 2021 03 8;143(10):991-1001. Epub 2021 Feb 8.

Division of Primary Care and Population Health, Department of Medicine, Stanford University, CA (P.G.).

Background: Current hypertension guidelines vary substantially in their definition of who should be offered blood pressure-lowering medications. Understanding the effect of guideline choice on the proportion of adults who require treatment is crucial for planning and scaling up hypertension care in low- and middle-income countries.

Methods: We extracted cross-sectional data on age, sex, blood pressure, hypertension treatment and diagnosis status, smoking, and body mass index for adults 30 to 70 years of age from nationally representative surveys in 50 low- and middle-income countries (N = 1 037 215). We aimed to determine the effect of hypertension guideline choice on the proportion of adults in need of blood pressure-lowering medications. We considered 4 hypertension guidelines: the 2017 American College of Cardiology/American Heart Association guideline, the commonly used 140/90 mm Hg threshold, the 2016 World Health Organization HEARTS guideline, and the 2019 UK National Institute for Health and Care Excellence guideline.

Results: The proportion of adults in need of blood pressure-lowering medications was highest under the American College of Cardiology/American Heart Association, followed by the 140/90 mm Hg, National Institute for Health and Care Excellence, and World Health Organization guidelines (American College of Cardiology/American Heart Association: women, 27.7% [95% CI, 27.2-28.2], men, 35.0% [95% CI, 34.4-35.7]; 140/90 mm Hg: women, 26.1% [95% CI, 25.5-26.6], men, 31.2% [95% CI, 30.6-31.9]; National Institute for Health and Care Excellence: women, 11.8% [95% CI, 11.4-12.1], men, 15.7% [95% CI, 15.3-16.2]; World Health Organization: women, 9.2% [95% CI, 8.9-9.5], men, 11.0% [95% CI, 10.6-11.4]). Individuals who were unaware that they have hypertension were the primary contributor to differences in the proportion needing treatment under different guideline criteria. Differences in the proportion needing blood pressure-lowering medications were largest in the oldest (65-69 years) age group (American College of Cardiology/American Heart Association: women, 60.2% [95% CI, 58.8-61.6], men, 70.1% [95% CI, 68.8-71.3]; World Health Organization: women, 20.1% [95% CI, 18.8-21.3], men, 24.1.0% [95% CI, 22.3-25.9]). For both women and men and across all guidelines, countries in the European and Eastern Mediterranean regions had the highest proportion of adults in need of blood pressure-lowering medicines, whereas the South and Central Americas had the lowest.

Conclusions: There was substantial variation in the proportion of adults in need of blood pressure-lowering medications depending on which hypertension guideline was used. Given the great implications of this choice for health system capacity, policy makers will need to carefully consider which guideline they should adopt when scaling up hypertension care in their country.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.051620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7940589PMC
March 2021

Curbing the COVID-19 pandemic with facility-based isolation of mild cases: a mathematical modeling study.

J Travel Med 2021 02;28(2)

Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany, 69120.

Background: In many countries, patients with mild coronavirus disease 2019 (COVID-19) are told to self-isolate at home, but imperfect compliance and shared living space with uninfected people limit the effectiveness of home-based isolation. We examine the impact of facility-based isolation compared to self-isolation at home on the continuing epidemic in the USA.

Methods: We developed a compartment model to simulate the dynamic transmission of COVID-19 and calibrated it to key epidemic measures in the USA from March to September 2020. We simulated facility-based isolation strategies with various capacities and starting times under different diagnosis rates. Our primary model outcomes are new infections and deaths over 2 months from October 2020 onwards. In addition to national-level estimations, we explored the effects of facility-based isolation under different epidemic burdens in major US Census Regions. We performed sensitivity analyses by varying key model assumptions and parameters.

Results: We find that facility-based isolation with moderate capacity of 5 beds per 10 000 total population could avert 4.17 (95% credible interval 1.65-7.11) million new infections and 16 000 (8000-23 000) deaths in 2 months compared with home-based isolation. These results are equivalent to relative reductions of 57% (44-61%) in new infections and 37% (27-40%) in deaths. Facility-based isolation with high capacity of 10 beds per 10 000 population could achieve reductions of 76% (62-84%) in new infections and 52% (37-64%) in deaths when supported by expanded testing with an additional 20% daily diagnosis rate. Delays in implementation would substantially reduce the impact of facility-based isolation. The effective capacity and the impact of facility-based isolation varied by epidemic stage across regions.

Conclusion: Timely facility-based isolation for mild COVID-19 cases could substantially reduce the number of new infections and effectively curb the continuing epidemic in the USA. Local epidemic burdens should determine the scale of facility-based isolation strategies.
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http://dx.doi.org/10.1093/jtm/taaa226DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7799023PMC
February 2021

Revisiting the association between temperature and COVID-19 transmissibility across 117 countries.

ERJ Open Res 2020 Oct 2;6(4). Epub 2020 Nov 2.

Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.

https://bit.ly/32OTBiS.
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http://dx.doi.org/10.1183/23120541.00550-2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7682714PMC
October 2020

A cross-sectional study of cardiovascular disease risk clustering at different socio-geographic levels in India.

Nat Commun 2020 11 18;11(1):5891. Epub 2020 Nov 18.

Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany.

Despite its importance for the targeting of interventions, little is known about the degree to which cardiovascular disease (CVD) risk factors cluster within different socio-geographic levels in South Asia. Using two jointly nationally representative household surveys, which sampled 1,082,100 adults across India, we compute the intra-cluster correlation coefficients (ICCs) of five major CVD risk factors (raised blood glucose, raised blood pressure, smoking, overweight, and obesity) at the household, community, district, and state level. Here we show that except for smoking, the level of clustering is generally highest for households, followed by communities, districts, and then states. On average, more economically developed districts have a higher household ICC in rural areas. These findings provide critical information for sample size calculations of cluster-randomized trials and household surveys, and inform the targeting of policies and prevention programming aimed at reducing CVD in India.
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http://dx.doi.org/10.1038/s41467-020-19647-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7674456PMC
November 2020

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.

PLoS Med 2020 11 10;17(11):e1003268. Epub 2020 Nov 10.

Institut Africain de Santé publique (IASP), Ouagadougou, Burkina Faso.

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.
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http://dx.doi.org/10.1371/journal.pmed.1003268DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7654799PMC
November 2020

Healthcare worker attendance during the early stages of the COVID-19 pandemic: A longitudinal analysis of fingerprint-verified data from all public-sector secondary and tertiary care facilities in Bangladesh.

J Glob Health 2020 Dec;10(2):020509

Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany.

Background: The COVID-19 pandemic has overwhelmed hospitals in several areas in high-income countries. An effective response to this pandemic requires health care workers (HCWs) to be present at work, particularly in low- and middle-income countries (LMICs) where they are already in critically low supply. To inform whether and to what degree policymakers in Bangladesh, and LMICs more broadly, should expect a drop in HCW attendance as COVID-19 continues to spread, this study aims to determine how HCW attendance has changed during the early stages of the COVID-19 pandemic in Bangladesh.

Methods: This study analyzed daily fingerprint-verified attendance data from all 527 public-sector secondary and tertiary care facilities in Bangladesh to describe HCW attendance from January 26, 2019 to March 22, 2020, by cadre, hospital type, and geographic division. We then regressed HCW attendance onto fixed effects for day-of-week, month, and hospital, as well as indicators for each of three pandemic periods: a China-focused period (January 11, 2020 (first confirmed COVID-19 death in China) until January 29, 2020), international-spread period (January 30, 2020 (World Health Organization's declaration of a global emergency) until March 6, 2020), and local-spread period (March 7, 2020 (first confirmed COVID-19 case in Bangladesh) until the end of the study period).

Findings: On average between January 26, 2019 and March 22, 2020, 34.1% of doctors, 64.6% of nurses, and 70.6% of other health care staff were present for their scheduled shift. HCWs' attendance rate increased with time in 2019 among all cadres. Nurses' attendance level dropped by 2.5% points (95% confidence interval (CI) = -3.2% to -1.8%) and 3.5% points (95% CI = -4.5% to -2.5%) during the international-spread and the local-spread periods of the COVID-19 pandemic, relative to the China-focused period. Similarly, the attendance level of other health care staff declined by 0.3% points (95% CI = -0.8% to 0.2%) and 2.3% points (95% CI = -3.0% to -1.6%) during the international-spread and local-spread periods, respectively. Among doctors, however, the international-spread and local-spread periods were associated with a statistically significant increase in attendance by 3.7% points (95% CI = 2.5% to 4.8%) and 4.9% points (95% CI = 3.5% to 6.4%), respectively. The reduction in attendance levels across all HCWs during the local-spread period was much greater at large hospitals, where the majority of COVID-19 testing and treatment took place, than that at small hospitals.

Conclusions: After a year of significant improvements, HCWs' attendance levels among nurses and other health care staff (who form the majority of Bangladesh's health care workforce) have declined during the early stages of the COVID-19 pandemic. This finding may portend an even greater decrease in attendance if COVID-19 continues to spread in Bangladesh. Policymakers in Bangladesh and similar LMICs should undertake major efforts to achieve high attendance levels among HCWs, particularly nurses, such as by providing sufficient personal protective equipment as well as monetary and non-monetary incentives.
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http://dx.doi.org/10.7189/jogh.10.020509DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7568346PMC
December 2020

Willingness to pay for community delivery of antiretroviral treatment in urban Tanzania: a cross-sectional survey.

Health Policy Plan 2021 Feb;35(10):1300-1308

Heidelberg Institute of Global Health (HIGH), Heidelberg University, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany.

Community health worker (CHW)-led community delivery of HIV antiretroviral therapy (ART) could increase ART coverage and decongest healthcare facilities. It is unknown how much patients would be willing to pay to receive ART at home and, thus, whether ART community delivery could be self-financing. Set in Dar es Salaam, this study aimed to determine patients' willingness to pay (WTP) for CHW-led ART community delivery. We sampled ART patients living in the neighbourhoods surrounding each of 48 public-sector healthcare facilities in Dar es Salaam. We asked participants (N = 1799) whether they (1) preferred ART community delivery over standard facility-based care, (2) would be willing to pay for ART community delivery and (3) would be willing to pay each of an incrementally increasing range of prices for the service. 45.0% (810/1799; 95% CI: 42.7-47.3) of participants preferred ART community delivery over standard facility-based care and 51.5% (417/810; 95% CI: 48.1-55.0) of these respondents were willing to pay for ART community delivery. Among those willing to pay, the mean and median amount that participants were willing to pay for one ART community delivery that provides a 2-months' supply of antiretroviral drugs was 3.61 purchasing-power-parity-adjusted dollars (PPP$) (95% CI: 2.96-4.26) and 1.27 PPP$ (IQR: 1.27-2.12), respectively. An important limitation of this study is that participants all resided in neighbourhoods within the catchment area of the healthcare facility at which they were interviewed and, thus, may incur less costs to attend standard facility-based ART care than other ART patients in Dar es Salaam. While there appears to be a substantial WTP, patient payments would only constitute a minority of the costs of implementing ART community delivery. Thus, major co-financing from governments or donors would likely be required.
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http://dx.doi.org/10.1093/heapol/czaa088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7886440PMC
February 2021

Lifetime Prevalence of Cervical Cancer Screening in 55 Low- and Middle-Income Countries.

JAMA 2020 10;324(15):1532-1542

Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany.

Importance: The World Health Organization is developing a global strategy to eliminate cervical cancer, with goals for screening prevalence among women aged 30 through 49 years. However, evidence on prevalence levels of cervical cancer screening in low- and middle-income countries (LMICs) is sparse.

Objective: To determine lifetime cervical cancer screening prevalence in LMICs and its variation across and within world regions and countries.

Design, Setting, And Participants: Analysis of cross-sectional nationally representative household surveys carried out in 55 LMICs from 2005 through 2018. The median response rate across surveys was 93.8% (range, 64.0%-99.3%). The population-based sample consisted of 1 136 289 women aged 15 years or older, of whom 6885 (0.6%) had missing information for the survey question on cervical cancer screening.

Exposures: World region, country; countries' economic, social, and health system characteristics; and individuals' sociodemographic characteristics.

Main Outcomes And Measures: Self-report of having ever had a screening test for cervical cancer.

Results: Of the 1 129 404 women included in the analysis, 542 475 were aged 30 through 49 years. A country-level median of 43.6% (interquartile range [IQR], 13.9%-77.3%; range, 0.3%-97.4%) of women aged 30 through 49 years self-reported to have ever been screened, with countries in Latin America and the Caribbean having the highest prevalence (country-level median, 84.6%; IQR, 65.7%-91.1%; range, 11.7%-97.4%) and those in sub-Saharan Africa the lowest prevalence (country-level median, 16.9%; IQR, 3.7%-31.0%; range, 0.9%-50.8%). There was large variation in the self-reported lifetime prevalence of cervical cancer screening among countries within regions and among countries with similar levels of per capita gross domestic product and total health expenditure. Within countries, women who lived in rural areas, had low educational attainment, or had low household wealth were generally least likely to self-report ever having been screened.

Conclusions And Relevance: In this cross-sectional study of data collected in 55 low- and middle-income countries from 2005 through 2018, there was wide variation between countries in the self-reported lifetime prevalence of cervical cancer screening. However, the median prevalence was only 44%, supporting the need to increase the rate of screening.
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http://dx.doi.org/10.1001/jama.2020.16244DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7576410PMC
October 2020

The impact of continuous quality improvement on coverage of antenatal HIV care tests in rural South Africa: Results of a stepped-wedge cluster-randomised controlled implementation trial.

PLoS Med 2020 10 7;17(10):e1003150. Epub 2020 Oct 7.

Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa.

Background: Evidence for the effectiveness of continuous quality improvement (CQI) in resource-poor settings is very limited. We aimed to establish the effects of CQI on quality of antenatal HIV care in primary care clinics in rural South Africa.

Methods And Findings: We conducted a stepped-wedge cluster-randomised controlled trial (RCT) comparing CQI to usual standard of antenatal care (ANC) in 7 nurse-led, public-sector primary care clinics-combined into 6 clusters-over 8 steps and 19 months. Clusters randomly switched from comparator to intervention on pre-specified dates until all had rolled over to the CQI intervention. Investigators and clusters were blinded to randomisation until 2 weeks prior to each step. The intervention was delivered by trained CQI mentors and included standard CQI tools (process maps, fishbone diagrams, run charts, Plan-Do-Study-Act [PDSA] cycles, and action learning sessions). CQI mentors worked with health workers, including nurses and HIV lay counsellors. The mentors used the standard CQI tools flexibly, tailored to local clinic needs. Health workers were the direct recipients of the intervention, whereas the ultimate beneficiaries were pregnant women attending ANC. Our 2 registered primary endpoints were viral load (VL) monitoring (which is critical for elimination of mother-to-child transmission of HIV [eMTCT] and the health of pregnant women living with HIV) and repeat HIV testing (which is necessary to identify and treat women who seroconvert during pregnancy). All pregnant women who attended their first antenatal visit at one of the 7 study clinics and were ≥18 years old at delivery were eligible for endpoint assessment. We performed intention-to-treat (ITT) analyses using modified Poisson generalised linear mixed effects models. We estimated effect sizes with time-step fixed effects and clinic random effects (Model 1). In separate models, we added a nested random clinic-time step interaction term (Model 2) or individual random effects (Model 3). Between 15 July 2015 and 30 January 2017, 2,160 participants with 13,212 ANC visits (intervention n = 6,877, control n = 6,335) were eligible for ITT analysis. No adverse events were reported. Median age at first booking was 25 years (interquartile range [IQR] 21 to 30), and median parity was 1 (IQR 0 to 2). HIV prevalence was 47% (95% CI 42% to 53%). In Model 1, CQI significantly increased VL monitoring (relative risk [RR] 1.38, 95% CI 1.21 to 1.57, p < 0.001) but did not improve repeat HIV testing (RR 1.00, 95% CI 0.88 to 1.13, p = 0.958). These results remained essentially the same in both Model 2 and Model 3. Limitations of our study include that we did not establish impact beyond the duration of the relatively short study period of 19 months, and that transition steps may have been too short to achieve the full potential impact of the CQI intervention.

Conclusions: We found that CQI can be effective at increasing quality of primary care in rural Africa. Policy makers should consider CQI as a routine intervention to boost quality of primary care in rural African communities. Implementation research should accompany future CQI use to elucidate mechanisms of action and to identify factors supporting long-term success.

Trial Registration: This trial is registered at ClinicalTrials.gov under registration number NCT02626351.
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http://dx.doi.org/10.1371/journal.pmed.1003150DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7540892PMC
October 2020

Change in clinical knowledge of diabetes among primary healthcare providers in Indonesia: repeated cross-sectional survey of 5105 primary healthcare facilities.

BMJ Open Diabetes Res Care 2020 10;8(1)

Institute of Global Health, Heidelberg University, Heidelberg, Baden-Württemberg, Germany.

Introduction: Indonesia is experiencing a rapid rise in the number of people with diabetes. There is limited evidence on how well primary care providers are equipped to deal with this growing epidemic. This study aimed to determine the level of primary healthcare providers' knowledge of diabetes, change in knowledge from 2007 to 2014/2015 and the extent to which changes in the diabetes workforce composition, geographical distribution of providers, and provider characteristics explained the change in diabetes knowledge.

Research Design And Methods: In 2007 and 2014/2015, a random sample of public and private primary healthcare providers who reported providing diabetes care across 13 provinces in Indonesia completed a diabetes clinical case vignette. A provider's diabetes vignette score represents the percentage of all correct clinical actions for a hypothetical diabetes patient that were spontaneously mentioned by the provider. We used standardization and fixed-effects linear regression models to determine the extent to which changes in diabetes workforce composition, geographical distribution of providers, and provider characteristics explained any change in diabetes knowledge between survey rounds, and how knowledge varied among provinces.

Results: The mean unadjusted vignette score decreased from 37.1% (95% CI 36.4% to 37.9%) in 2007 to 29.1% (95% CI 28.4% to 29.8%, p<0.001) in 2014/2015. Vignette scores were, on average, 6.9 (95% CI -8.2 to 5.6, p<0.001) percentage points lower in 2014/2015 than in 2007 after adjusting for provider cadre, geographical distribution, and provider experience and training. Physicians and providers with postgraduate diabetes training had the highest vignette scores.

Conclusions: Diabetes knowledge among primary healthcare providers in Indonesia decreased, from an already low level, between 2007 and 2014/2015. Policies that improve preservice training, particularly at newer schools, and investment in on-the-job training in diabetes might halt and reverse the decline in diabetes knowledge among Indonesia's primary healthcare workforce.
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http://dx.doi.org/10.1136/bmjdrc-2020-001415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7536835PMC
October 2020

Trends in Mail-Order Prescription Use among U.S. Adults from 1996 to 2018: A Nationally Representative Repeated Cross-Sectional Study.

medRxiv 2020 Sep 23. Epub 2020 Sep 23.

Stanford School of Medicine, Stanford University, Heidelberg Institute of Global Health, University of Heidelberg, Germany, 291 Campus Drive, Stanford, CA 94305, United States.

Background: Mail-order prescriptions are popular in the U.S., but the recent mail delays due to operational changes at the United States Postal Services (USPS) may postpone the delivery of vital medications. Despite growing recognition of the health and economic effects of a postal crisis on mail-order pharmacy consumers, little is known about the extent of mail-order prescription use, and most importantly, the population groups and types of medications that will likely be most affected by these postal delays.

Methods: The prevalence of mail-order prescription use was assessed using a nationally representative repeated cross-sectional survey (the Medical Expenditure Panel Survey) carried out among adults aged 18 and older in each year from 1996 to 2018. We stratified use of mail-order prescription by socio-demographic and health characteristics. Additionally, we calculated which prescription medications were most prevalent among all mailed medications, and for which medications users were most likely to opt for mail-order prescription.

Findings: 500,217 adults participated in the survey. Between 1996 and 2018, the prevalence of using at least one mail-order prescription in a year among U.S. adults was 9.8% (95% CI, 9.5%-10.0%). Each user purchased a mean of 19.4 (95% CI, 19.0-19.8) mail-order prescriptions annually. The prevalence of use increased from 6.9% (95% CI, 6.4%-7.5%) in 1996 to 10.3% (95% CI, 9.7%-10.9%) in 2018, and the mean annual number of mail-order prescriptions per user increased from 10.7 (95% CI, 9.8-11.7) to 20.5 (95% CI, 19.3-21.7) over the same period. Use of mail-order prescription in 2018 was common among adults aged 65 and older (23.9% [95% CI, 22.3%-25.4%]), non-Hispanic whites (13.6% [95% CI, 12.8%-14.5%]), married adults (12.7% [95% CI, 11.8%-13.6%]), college graduates (12.2% [95% CI, 11.3%-13.1%]), high-income adults (12.6%, [95% CI, 11.6%-13.6%]), disabled adults (19.3% [95% CI, 17.9%-20.7%]), adults with poor health status (15.6% [95% CI, 11.6%-19.6%]), adults with three or more chronic conditions (24.2% [95% CI, 22.2%-26.2%]), Medicare beneficiaries (22.8% [95% CI, 21.4%-24.3%]), and military-insured adults (13.9% [95% CI, 10.8%-17.1%]). Mail-order prescriptions were commonly filled for analgesics, levothyroxine, cardiovascular agents, antibiotics, and diabetes medications.

Interpretation: The use of mail-order prescription, including for critical medications such as insulin, is increasingly common among U.S. adults and displays substantial variation between population groups. A national slowdown of mail delivery could have important health consequences for a considerable proportion of the U.S. population, particularly during the current Coronavirus disease 2019 epidemic.
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http://dx.doi.org/10.1101/2020.09.22.20199505DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523158PMC
September 2020

A stepped-wedge randomized trial and qualitative survey of HIV pre-exposure prophylaxis uptake in the Eswatini population.

Sci Transl Med 2020 09;12(562)

Heidelberg Institute of Global Health (HIGH), Heidelberg University, 69120 Heidelberg, Germany.

Clinical trials have shown that antiretroviral drugs used as pre-exposure prophylaxis (PrEP) are highly effective for preventing HIV acquisition. PrEP efforts, including in sub-Saharan Africa, have almost exclusively focused on certain priority groups, particularly female sex workers, men having sex with men, pregnant women, serodiscordant couples, and young women. As part of a PrEP demonstration project involving the general population at six primary health care facilities in Eswatini (formerly Swaziland), we conducted a randomized trial of a health care facility-based PrEP promotion package designed to increase PrEP uptake. Over the 18-month study duration, 33.6% (517 of 1538) of adults identified by health care workers as being at risk of acquiring HIV took up PrEP, and 30.0% of these individuals attended all scheduled appointments during the first 6 months after initiation of PrEP. The PrEP promotion package was associated with a 55% (95% confidence interval, 15 to 110%; = 0.036) relative increase in the number of individuals taking up PrEP, with an absolute increase of 2.2 individuals per month per health care facility. When asked how PrEP uptake could be improved in 217 accompanying in-depth qualitative interviews, interviewees recommended an expansion of PrEP promotion activities beyond health care facilities to communities. Although a health care facility-based promotion package improved PrEP uptake, both uptake and retention remained low. Expanding promotion activities to the community is needed to achieve greater PrEP coverage among adults at risk of HIV infection in Eswatini and similar settings.
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http://dx.doi.org/10.1126/scitranslmed.aba4487DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8023147PMC
September 2020

"It's hard for us men to go to the clinic. We naturally have a fear of hospitals." Men's risk perceptions, experiences and program preferences for PrEP: A mixed methods study in Eswatini.

PLoS One 2020 23;15(9):e0237427. Epub 2020 Sep 23.

Institute of Global Health, Ruprecht-Karls-Universität, Heidelberg, Germany.

Few studies on HIV Pre-Exposure Prophylaxis (PrEP) have focused on men who have sex with women. We present findings from a mixed-methods study in Eswatini, the country with the highest HIV prevalence in the world (27%). Our findings are based on risk assessments, in-depth interviews and focus-group discussions which describe men's motivations for taking up or declining PrEP. Quantitatively, men self-reported starting PrEP because they had multiple or sero-discordant partners or did not know the partner's HIV-status. Men's self-perception of risk was echoed in the qualitative data, which revealed that the hope of facilitated sexual performance or relations, a preference for pills over condoms and the desire to protect themselves and others also played a role for men to initiate PrEP. Trust and mistrust and being able or unable to speak about PrEP with partner(s) were further considerations for initiating or declining PrEP. Once on PrEP, men's sexual behavior varied in terms of number of partners and condom use. Men viewed daily pill-taking as an obstacle to starting PrEP. Side-effects were a major reason for men to discontinue PrEP. Men also worried that taking anti-retroviral drugs daily might leave them mistaken for a person living with HIV, and viewed clinic-based PrEP education and initiation processes as a further obstacle. Given that men comprise only 29% of all PrEP users in Eswatini, barriers to men's uptake of PrEP will need to be addressed, in terms of more male-friendly services as well as trialing community-based PrEP education and service delivery.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0237427PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7510987PMC
October 2020

Healthcare Worker Attendance During the Early Stages of the COVID-19 Pandemic: A Longitudinal Analysis of Daily Fingerprint-Verified Data from All Public-Sector Secondary and Tertiary Care Facilities in Bangladesh.

medRxiv 2020 Sep 3. Epub 2020 Sep 3.

Heidelberg Institute of Global Health, University of Heidelberg. Im Neuenheimer Feld 130.3 69120 Heidelberg, Germany.

Background: The COVID-19 pandemic has overwhelmed hospitals in several areas in high-income countries. An effective response to this pandemic requires healthcare workers (HCWs) to be present at work, particularly in low- and middle-income countries (LMICs) where they are already in critically low supply. To inform whether and to what degree policymakers in Bangladesh, and LMICs more broadly, should expect a drop in HCW attendance as COVID-19 continues to spread, this study aims to determine how HCW attendance has changed during the early stages of the COVID-19 pandemic in Bangladesh.

Methods: This study analyzed daily fingerprint-verified attendance data from all 527 public-sector secondary and tertiary care facilities in Bangladesh to describe HCW attendance from January 26, 2019 to March 22, 2020, by cadre, hospital type, and geographic division. We then regressed HCW attendance onto fixed effects for day-of-week, month, and hospital, as well as indicators for each of three pandemic periods: a China-focused period (January 11, 2020 [first confirmed COVID-19 death in China] until January 29, 2020), international-spread period (January 30, 2020 [World Health Organization declared a global emergency] until March 6, 2020), and local-spread period (March 7, 2020 [first confirmed COVID-19 case in Bangladesh] until the end of the study period).

Findings: On average between January 26, 2019 and March 22, 2020, 34.1% of doctors, 64.6% of nurses, and 70.6% of other healthcare staff were present for their scheduled shift. Attendance rate increased with time in 2019 among all cadres. Attendance level of nurses dropped by 2.5% points (95% CI; -3.2% to -1.8%) and 3.5% points (95% CI; -4.5% to -2.5%) during the international-spread and the local-spread periods of the COVID-19 pandemic, relative to the China-focused period. Similarly, the attendance level of other healthcare staff declined by 0.3% points (95% CI; -0.8% to 0.2%) and 2.3% points (95% CI; -3.0% to -1.6%) during the international-spread and local-spread periods, respectively. Among doctors, however, the international-spread and local-spread periods were associated with a statistically significant increase in attendance by 3.7% points (95% CI; 2.5% to 4.8%) and 4.9% points (95% CI; 3.5% to 6.4%), respectively. The reduction in attendance levels across all HCWs during the local-spread period was much greater at large hospitals, where the majority of COVID-19 testing and treatment took place, than that at small hospitals.

Conclusions: After a year of significant improvements, attendance levels among nurses and other healthcare staff (who form the majority of the healthcare workforce in Bangladesh) have declined during the early stages of the COVID-19 pandemic. This finding may portend an even greater decrease in attendance if COVID-19 continues to spread in Bangladesh. Policymakers in Bangladesh and similar LMICs should undertake major efforts to achieve high attendance levels among HCWs, particularly nurses, such as by providing sufficient personal protective equipment as well as monetary and non-monetary incentives.
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http://dx.doi.org/10.1101/2020.09.01.20186445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7480043PMC
September 2020

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

Elife 2020 08 24;9. Epub 2020 Aug 24.

Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany.

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.
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http://dx.doi.org/10.7554/eLife.58487DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7529454PMC
August 2020

Analysis of Attained Height and Diabetes Among 554,122 Adults Across 25 Low- and Middle-Income Countries.

Diabetes Care 2020 10 6;43(10):2403-2410. Epub 2020 Aug 6.

Department of Economics and Centre for Modern Indian Studies, Georg-August-Universität Göttingen, Göttingen, Germany.

Objective: The prevalence of type 2 diabetes is rising rapidly in low-income and middle-income countries (LMICs), but the factors driving this rapid increase are not well understood. Adult height, in particular shorter height, has been suggested to contribute to the pathophysiology and epidemiology of diabetes and may inform how adverse environmental conditions in early life affect diabetes risk. We therefore systematically analyzed the association of adult height and diabetes across LMICs, where such conditions are prominent.

Research Design And Methods: We pooled individual-level data from nationally representative surveys in LMICs that included anthropometric measurements and diabetes biomarkers. We calculated odds ratios (ORs) for the relationship between attained adult height and diabetes using multilevel mixed-effects logistic regression models. We estimated ORs for the pooled sample, major world regions, and individual countries, in addition to stratifying all analyses by sex. We examined heterogeneity by individual-level characteristics.

Results: Our sample included 554,122 individuals across 25 population-based surveys. Average height was 161.7 cm (95% CI 161.2-162.3), and the crude prevalence of diabetes was 7.5% (95% CI 6.9-8.2). We found no relationship between adult height and diabetes across LMICs globally or in most world regions. When stratifying our sample by country and sex, we found an inverse association between adult height and diabetes in 5% of analyses (2 out of 50). Results were robust to alternative model specifications.

Conclusions: Adult height is not associated with diabetes across LMICs. Environmental factors in early life reflected in attained adult height likely differ from those predisposing individuals for diabetes.
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http://dx.doi.org/10.2337/dc20-0019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646204PMC
October 2020

Mapping physical access to healthcare for older adults in sub-Saharan Africa: A cross-sectional analysis with implications for the COVID-19 response.

medRxiv 2020 Aug 26. Epub 2020 Aug 26.

Institute of Geography, Heidelberg University, Heidelberg, Germany.

Background: SARS-CoV-2, the virus causing coronavirus disease 2019 (COVID-19), is rapidly spreading across sub-Saharan Africa (SSA). Hospital-based care for COVID-19 is particularly often needed among older adults. However, a key barrier to accessing hospital care in SSA is travel time to the healthcare facility. To inform the geographic targeting of additional healthcare resources, this study aimed to determine the estimated travel time at a 1km × 1km resolution to the nearest hospital and to the nearest healthcare facility of any type for adults aged 60 years and older in SSA.

Methods: We assembled a unique dataset on healthcare facilities' geolocation, separately for hospitals and any type of healthcare facility (including primary care facilities) and including both private- and public-sector facilities, using data from the OpenStreetMap project and the KEMRI Wellcome Trust Programme. Population data at a 1km × 1km resolution was obtained from WorldPop. We estimated travel time to the nearest healthcare facility for each 1km × 1km grid using a cost-distance algorithm.

Findings: 9.6% (95% CI: 5.2% - 16.9%) of adults aged ≥60 years had an estimated travel time to the nearest hospital of longer than six hours, varying from 0.0% (95% CI: 0.0% - 3.7%) in Burundi and The Gambia, to 40.9% (95% CI: 31.8% - 50.7%) in Sudan. 11.2% (95% CI: 6.4% - 18.9%) of adults aged ≥60 years had an estimated travel time to the nearest healthcare facility of any type (whether primary or secondary/tertiary care) of longer than three hours, with a range of 0.1% (95% CI: 0.0% - 3.8%) in Burundi to 55.5% (95% CI: 52.8% - 64.9%) in Sudan. Most countries in SSA contained populated areas in which adults aged 60 years and older had a travel time to the nearest hospital of more than 12 hours and to the nearest healthcare facility of any type of more than six hours. The median travel time to the nearest hospital for the fifth of adults aged ≥60 years with the longest travel times was 348 minutes (equal to 5.8 hours; IQR: 240 - 576 minutes) for the entire SSA population, ranging from 41 minutes (IQR: 34 - 54 minutes) in Burundi to 1,655 minutes (equal to 27.6 hours; IQR: 1065 - 2440 minutes) in Gabon.

Interpretation: Our high-resolution maps of estimated travel times to both hospitals and healthcare facilities of any type can be used by policymakers and non-governmental organizations to help target additional healthcare resources, such as new make-shift hospitals or transport programs to existing healthcare facilities, to older adults with the least physical access to care. In addition, this analysis shows precisely where population groups are located that are particularly likely to under-report COVID-19 symptoms because of low physical access to healthcare facilities. Beyond the COVID-19 response, this study can inform countries' efforts to improve care for conditions that are common among older adults, such as chronic non-communicable diseases.
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http://dx.doi.org/10.1101/2020.07.17.20152389DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7386521PMC
August 2020
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