PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-25 (804281)

Clipboard (0)
None

Related Articles

1.  A role for INDEPTH Asian sites in translating research to action for non-communicable disease prevention and control: a case study from Ballabgarh, India 
Global Health Action  2009;2:10.3402/gha.v2i0.1990.
Background
The International Network of field sites with continuous Demographic Evaluation of Populations and Their Health (INDEPTH) has 34 Health and Demographic Surveillance System (HDSS) in 17 different low and middle-income countries. Of these, 23 sites are in Africa, 10 sites are in Asia, and one in Oceania. The INDEPTH HDSS sites in Asia identified chronic non-communicable diseases (NCDs) as a neglected area of attention. As a first step, they conducted NCD risk factor surveys within nine sites in five countries. These sites are now looking to broaden the agenda of research on NCDs using the baseline data to inform policy and practice.
Methods
A conceptual framework for translating research into action for NCDs at INDEPTH sites was developed. This had five steps – assess the problem, understand the nature of the problem, evaluate different interventions in research mode, implement evidence-based interventions in programme mode, and finally, share knowledge and provide leadership to communities and countries. Ballabgarh HDSS site in India has successfully adopted these steps and is used as a case study to demonstrate how this progress was achieved and what factors were responsible for a successful outcome.
Results
Most of the HDSS sites are in the second step of the process of translating research to action (understand the problem). The conduct of NCD risk factor surveys has enabled an assessment of the burden of NCD risk together with determinants in order to understand the burden at the population level. The experience from Ballabgarh HDSS exemplifies that the following steps – pilot testing the interventions, implementing activities in programme mode, and finally, share knowledge and provide leadership – are also possible in rural settings in low-income countries. The critical success factors identified were involvement of a premier medical institution, pre-existing links to policy makers and programme managers, strong commitment of the HDSS team and adequate human resource capacity.
Conclusion
All INDEPTH HDSS sites now need to strengthen their links to health systems at different levels and enhance their capacity to engage different stakeholders in their respective country settings so as to translate the current knowledge into actions that can benefit the health of the population they serve and beyond.
doi:10.3402/gha.v2i0.1990
PMCID: PMC2785101  PMID: 20027258
non-communicable diseases; surveillance; policy; translational research
2.  Using the INDEPTH HDSS to build capacity for chronic non-communicable disease risk factor surveillance in low and middle-income countries 
Global Health Action  2009;2:10.3402/gha.v2i0.1984.
Background
Chronic non-communicable diseases (NCDs) are the leading cause of morbidity, mortality, and disability worldwide. More than 80% of chronic disease deaths occur in low-income and middle-income countries. Epidemiological data on the burden of chronic NCD and the risk factors which predict them are lacking in most low-income countries. The INDEPTH Network (http://www.indepth-network.org) which includes the Health and Demographic Surveillance System (HDSS) with many surveillance sites in low-middle income countries provided an opportunity to establish surveillance of the major chronic NCD risk factors in 2005 using a standardised approach.
Objective
This paper presents the conceptual framework and research design of the chronic NCD risk factor surveillance within nine rural INDEPTH HDSS settings in Asia.
Methods
This multi-site study was designed as a baseline cross-sectional survey with sufficient sample size to measure trends over time. In each of nine HDSS sites in five Asian countries, a sample of 2,000 men and women aged 25–64 years, using the WHO STEPwise approach to Surveillance (http://who.int/chp/steps), was selected using stratified random sampling (in each 10-year interval) from the HDSS sampling frame.
Results
A total of 18,494 men and women from the nine sites were interviewed with an overall response rate of 98%. The major NCDs risk factors included self-reported information on tobacco and alcohol consumption, fruit and vegetable intake, physical activity patterns, and measured body weight, height, waist circumference, and blood pressure. A series of training sessions were conducted for research scientists, supervisors, and surveyors in each site. Data quality was ensured through spot check, re-check, and data validation procedures, including accuracy and completeness of data obtained. Standardised data entry programme, created using the EPIDATA software, was used to ensure uniform database structure across sites. The data merging and analysis were done using STATA Version 10.
Conclusion
This multi-site study confirmed the feasibility of conducting chronic NCD risk factor surveillance in the low and middle-income settings by integrating the chronic NCDs risk factor surveillance into an existing HDSS data collection and management setting. This collaborative work has provided reliable epidemiological data as a basis for developing chronic NCD prevention and control activities.
doi:10.3402/gha.v2i0.1984
PMCID: PMC2785135  PMID: 20027262
chronic non-communicable diseases; risk factor surveillance; INDEPTH Network; low-middle income countries; WHO STEPS
3.  Perceived risks and benefits of cigarette smoking among Nepalese adolescents: a population-based cross-sectional study 
BMC Public Health  2013;13:187.
Background
The perceived risks and benefits of smoking may play an important role in determining adolescents’ susceptibility to initiating smoking. Our study examined the perceived risks and benefits of smoking among adolescents who demonstrated susceptibility or non susceptibility to smoking initiation.
Methods
In October–November 2011, we conducted a population-based cross-sectional study in Jhaukhel and Duwakot Villages in Nepal. Located in the mid-hills of Bhaktapur District, 13 kilometers east of Kathmandu, Jhaukhel and Duwakot represent the prototypical urbanizing villages that surround Nepal’s major urban centers, where young people have easy access to tobacco products and are influenced by advertising. Jhaukhel and Duwakot had a total population of 13,669, of which 15% were smokers. Trained enumerators used a semi-structured questionnaire to interview 352 randomly selected 14- to 16-year-old adolescents. The enumerators asked the adolescents to estimate their likelihood (0%–100%) of experiencing various smoking-related risks and benefits in a hypothetical scenario.
Results
Principal component analysis extracted four perceived risk and benefit components, excluding addiction risk: (i) physical risk I (lung cancer, heart disease, wrinkles, bad colds); (ii) physical risk II (bad cough, bad breath, trouble breathing); (iii) social risk (getting into trouble, smelling like an ashtray); and (iv) social benefit (looking cool, feeling relaxed, becoming popular, and feeling grown-up). The adjusted odds ratio of susceptibility increased 1.20-fold with each increased quartile in perception of physical Risk I. Susceptibility to smoking was 0.27- and 0.90-fold less among adolescents who provided the highest estimates of physical Risk II and social risk, respectively. Similarly, susceptibility was 2.16-fold greater among adolescents who provided the highest estimates of addiction risk. Physical risk I, addiction risk, and social benefits of cigarette smoking related positively, and physical risk II and social risk related negatively, with susceptibility to smoking.
Conclusion
To discourage or prevent adolescents from initiating smoking, future intervention programs should focus on communicating not only the health risks but also the social and addiction risks as well as counteract the social benefits of smoking.
doi:10.1186/1471-2458-13-187
PMCID: PMC3599383  PMID: 23452549
Susceptibility to smoking; Physical risks; Social risks; Addiction risk; Social benefits
4.  Ageing and adult health status in eight lower-income countries: the INDEPTH WHO-SAGE collaboration 
Global Health Action  2010;3:10.3402/gha.v3i0.5302.
Background
Globally, ageing impacts all countries, with a majority of older persons residing in lower- and middle-income countries now and into the future. An understanding of the health and well-being of these ageing populations is important for policy and planning; however, research on ageing and adult health that informs policy predominantly comes from higher-income countries. A collaboration between the WHO Study on global AGEing and adult health (SAGE) and International Network for the Demographic Evaluation of Populations and Their Health in developing countries (INDEPTH), with support from the US National Institute on Aging (NIA) and the Swedish Council for Working Life and Social Research (FAS), has resulted in valuable health, disability and well-being information through a first wave of data collection in 2006–2007 from field sites in South Africa, Tanzania, Kenya, Ghana, Viet Nam, Bangladesh, Indonesia and India.
Objective
To provide an overview of the demographic and health characteristics of participating countries, describe the research collaboration and introduce the first dataset and outputs.
Methods
Data from two SAGE survey modules implemented in eight Health and Demographic Surveillance Systems (HDSS) were merged with core HDSS data to produce a summary dataset for the site-specific and cross-site analyses described in this supplement. Each participating HDSS site used standardised training materials and survey instruments. Face-to-face interviews were conducted. Ethical clearance was obtained from WHO and the local ethical authority for each participating HDSS site.
Results
People aged 50 years and over in the eight participating countries represent over 15% of the current global older population, and is projected to reach 23% by 2030. The Asian HDSS sites have a larger proportion of burden of disease from non-communicable diseases and injuries relative to their African counterparts. A pooled sample of over 46,000 persons aged 50 and over from these eight HDSS sites was produced. The SAGE modules resulted in self-reported health, health status, functioning (from the WHO Disability Assessment Scale (WHODAS-II)) and well-being (from the WHO Quality of Life instrument (WHOQoL) variables). The HDSS databases contributed age, sex, marital status, education, socio-economic status and household size variables.
Conclusion
The INDEPTH WHO–SAGE collaboration demonstrates the value and future possibilities for this type of research in informing policy and planning for a number of countries. This INDEPTH WHO–SAGE dataset will be placed in the public domain together with this open-access supplement and will be available through the GHA website (www.globalhealthaction.net) and other repositories. An improved dataset is being developed containing supplementary HDSS variables and vignette-adjusted health variables. This living collaboration is now preparing for a next wave of data collection.
doi:10.3402/gha.v3i0.5302
PMCID: PMC2957285  PMID: 20959878
ageing; survey methods; public health; burden of disease; demographic transition; disability; well-being; health status; INDEPTH WHO-SAGE
5.  Health and Demographic Surveillance System in the Western and Coastal Areas of Kenya: An Infrastructure for Epidemiologic Studies in Africa 
Journal of Epidemiology  2012;22(3):276-285.
Background
The Health and Demographic Surveillance System (HDSS) is a longitudinal data collection process that systematically and continuously monitors population dynamics for a specified population in a geographically defined area that lacks an effective system for registering demographic information and vital events.
Methods
HDSS programs have been run in 2 regions in Kenya: in Mbita district in Nyanza province and Kwale district in Coast Province. The 2 areas have different disease burdens and cultures. Vital events were obtained by using personal digital assistants and global positioning system devices. Additional health-related surveys have been conducted bimonthly using various PDA-assisted survey software.
Results
The Mbita HDSS covers 55 929 individuals, and the Kwale HDSS covers 42 585 individuals. In the Mbita HDSS, the life expectancy was 61.0 years for females and 57.5 years for males. Under-5 mortality was 91.5 per 1000 live births, and infant mortality was 47.0 per 1000 live births. The total fertility rate was 3.7 per woman. Data from the Kwale HDSS were not available because it has been running for less than 1 year at the time of this report.
Conclusions
Our HDSS programs are based on a computer-assisted survey system that provides a rapid and flexible data collection platform in areas that lack an effective basic resident registration system. Although the HDSS areas are not representative of the entire country, they provide a base for several epidemiologic and social study programs, and for practical community support programs that seek to improve the health of the people in these areas.
doi:10.2188/jea.JE20110078
PMCID: PMC3798630  PMID: 22374366
health and demographic surveillance system; Kenya; cohort profile; INDEPTH Network
6.  Understanding and living with glaucoma and non-communicable diseases like hypertension and diabetes in the Jhaukhel-Duwakot Health Demographic Surveillance Site: a qualitative study from Nepal 
Global Health Action  2014;7:10.3402/gha.v7.25358.
Background
Primary open-angle glaucoma (POAG) is one of the most common causes of irreversible blindness. A possible association between POAG and non-communicable diseases such as hypertension and diabetes suggests that the incidence of POAG may increase. People with POAG in Nepal usually present late to hospital and have poor knowledge of glaucoma.
Objectives
Anticipating a knowledge gap regarding these diseases, this study aimed to explore the knowledge of POAG, hypertension, and diabetes in the community and barriers to health care.
Design
We conducted this qualitative study in the Jhaukhel-Duwakot Health Demographic Surveillance Site (JD-HDSS), a peri-urban community near Kathmandu, a capital city of Nepal. To study how disease influences knowledge, we conducted focus group discussions separately for men and women with and without pre-existing POAG, hypertension, and diabetes. Data were analyzed using the framework analysis approach.
Results
Although people suffering from POAG, hypertension, and/or diabetes exhibited adequate knowledge of hypertension and diabetes, they lacked in-depth knowledge of POAG. People believed mostly in internal health locus of control. Perception of disease consequences and impact of disease on daily life was influenced by pre-existing POAG, hypertension, and/or diabetes but only in men. Gender disparity was observed regarding health literacy, health perception, and health barriers, which put women in a more difficult situation to tackle their health. We also revealed a gap between knowledge, attitude, and practice of health among women and healthy men.
Conclusion
Although people in JD-HDSS exhibited adequate knowledge regarding hypertension and diabetes, they lacked in-depth knowledge about POAG. This study demonstrated gender difference in health literacy and access to health care, making women more vulnerable towards disease. We also demonstrated a gap between knowledge, attitude, and practice of health. However, tailored health literacy programs may bring changes in the health status in the community.
doi:10.3402/gha.v7.25358
PMCID: PMC4212074  PMID: 25361727
barriers to health care; diabetes; health literacy; hypertension; non-communicable disease; primary open-angle glaucoma
7.  Correlates of smoking susceptibility among adolescents in a peri-urban area of Nepal: a population-based cross-sectional study in the Jhaukhel-Duwakot Health Demographic Surveillance Site 
Global Health Action  2014;7:10.3402/gha.v7.24488.
Background
Susceptibility to smoking is defined as an absence of firm commitment not to smoke in the future or when offered a cigarette by best friends. Susceptibility begins in adolescence and is the first step in the transition to becoming an established smoker. Many scholars have hypothesized and studied whether psychosocial risk factors play a crucial role in preventing adolescent susceptibility to smoking or discourage susceptible adolescents from becoming established smokers. Our study examined sociodemographic and family and childhood environmental factors associated with smoking susceptibility among adolescents in a peri-urban area of Nepal.
Design
We conducted a population-based cross-sectional study during October–November 2011 in the Jhaukhel-Duwakot Health Demographic Surveillance Site (JD-HDSS) located in a peri-urban area near Kathmandu, the capital city of Nepal, where tobacco products are easily available. Trained local enumerators conducted face-to-face interviews with 352 respondents aged 14–16. We used stepwise logistic regression to assess sociodemographic and family and childhood environmental factors associated with smoking susceptibility.
Results
The percentage of smoking susceptibility among respondents was 49.70% (95% CI: 44.49; 54.93). Multivariable analysis demonstrated that smoking susceptibility was associated with smoking by exposure of adolescents to pro-tobacco advertisements (AOR [adjusted odds ratio] =2.49; 95% CI: 1.46–4.24), the teacher (2.45; 1.28–4.68), adolescents attending concerts/picnics (2.14; 1.13–4.04), and smoking by other family members/relatives (1.76; 1.05–2.95).
Conclusions
Smoking susceptible adolescents are prevalent in the JD-HDSS, a peri-urban community of Nepal. Several family and childhood environmental factors increased susceptibility to smoking among Nepalese non-smoking adolescents. Therefore, intervention efforts need to be focused on family and childhood environmental factors with emphasis on impact of role models smoking, refusal skills in social gatherings, and discussing harmful effects of smoking with family members and during gatherings with friends.
doi:10.3402/gha.v7.24488
PMCID: PMC4102834  PMID: 25034345
adolescents; peri-urban; susceptibility to smoking; sociodemographic factors; environmental factors
8.  Clustering of chronic non-communicable disease risk factors among selected Asian populations: levels and determinants 
Global Health Action  2009;2:10.3402/gha.v2i0.1986.
Background
The major chronic non-communicable diseases (NCDs) operate through a cluster of common risk factors, whose presence or absence determines not only the occurrence and severity of the disease, but also informs treatment approaches. Primary prevention based on mitigation of these common risk factors through population-based programmes is the most cost-effective approach to contain the emerging epidemic of chronic NCDs.
Objectives
This study was conducted to explore the extent of risk factors clustering for the major chronic NCDs and its determinants in nine INDEPTH Health and Demographic Surveillance System (HDSS) sites of five Asian countries.
Design
Data originated from a multi-site chronic NCD risk factor prevalence survey conducted in 2005. This cross-sectional survey used a standardised questionnaire developed by the WHO to collect core data on common risk factors such as tobacco use, intake of fruits and vegetables, physical inactivity, blood pressure levels, and body mass index. Respondents included randomly selected sample of adults (25–64 years) living in nine rural HDSS sites in Bangladesh, India, Indonesia, Thailand, and Vietnam.
Results
Findings revealed a substantial proportion (>70%) of these largely rural populations having three or more risk factors for chronic NCDs. Chronic NCD risk factors clustering was associated with increasing age, being male, and higher educational achievements. Differences were noted among the different sites, both between and within country.
Conclusions
Since there is an extensive clustering of risk factors for the chronic NCDs in the populations studied, the interventions also need to be based on a comprehensive approach rather than on a single factor to forestall its cumulative effects which occur over time. This can work best if it is integrated within the primary health care system and the HDSS can be an invaluable epidemiological resource in this endeavor.
doi:10.3402/gha.v2i0.1986
PMCID: PMC2785214  PMID: 20027260
chronic NCDs; risk factors surveillance; clustering; INDEPTH; Asia; WHO STEPS
9.  Physical activity level and its sociodemographic correlates in a peri-urban Nepalese population: a cross-sectional study from the Jhaukhel-Duwakot health demographic surveillance site 
Background
Physical inactivity is a leading risk factor for cardiovascular and other noncommunicable diseases in high-, low- and middle-income countries. Nepal, a low-income country in South Asia, is undergoing an epidemiological transition. Although the reported national prevalence of physical inactivity is relatively low, studies in urban and peri-urban localities have always shown higher prevalence. Therefore, this study aimed to measure physical activity in three domains—work, travel and leisure—in a peri-urban community and assess its variations across different sociodemographic correlates.
Methods
Adult participants (n = 640) from six randomly selected wards of the Jhaukhel-Duwakot Health Demographic Surveillance Site (JD-HDSS) near Kathmandu responded to the Global Physical Activity Questionnaire. To determine total physical activity, we calculated the metabolic equivalent of task in minutes/week for each domain and combined the results. Respondents were categorized into high, moderate or low physical activity. We also calculated the odds ratio for low physical activity in various sociodemographic variables and self-reported cardiometabolic states.
Results
The urbanizing JD-HDSS community showed a high prevalence of low physical activity (43.3%; 95% CI 39.4–47.1). Work-related activity contributed most to total physical activity. Furthermore, women and housewives and older, more educated and self-or government-employed respondents showed a greater prevalence of physical inactivity. Respondents with hypertension, diabetes or overweight/obesity reported less physical activity than individuals without those conditions. Only 5% of respondents identified physical inactivity as a cardiovascular risk factor.
Conclusions
Our findings reveal a high burden of physical inactivity in a peri-urban community of Nepal. Improving the level of physical activity involves sensitizing people to its importance through appropriate multi-sector strategies that provide encouragement across all sociodemographic groups.
doi:10.1186/1479-5868-11-39
PMCID: PMC3984675  PMID: 24628997
Cardiovascular disease; Ethnicity; Occupation; Smoking; Hypertension; Diabetes
10.  Do Health and Demographic Surveillance Systems benefit local populations? Maternal care utilisation in Butajira HDSS, Ethiopia 
Global Health Action  2014;7:10.3402/gha.v7.24228.
Background
The benefits of Health and Demographic Surveillance sites for local populations have been the topic of discussion as countries such as Ethiopia take efforts to achieve their Millennium Development Goal targets, on which they lag behind. Ethiopia's maternal mortality ratio is very high, and in the 2011 Ethiopia Demographic and Health Survey (2011 EDHS) it was estimated to be 676/100,000 live births. Recent Global Burden of Disease (GBD) and estimates based on the United Nations model reported better, but still unacceptably high, figures of 497/100,000 and 420/100,000 live births for 2013. In the 2011 EDHS, antenatal care (ANC) utilization was estimated at 34%, and delivery in health facilities was only 10%.
Objectives
To compare maternal health service utilization among populations in a Health and Demographic Surveillance System (HDSS) to non-HDSS populations in Butajira district, south central Ethiopia.
Design
A community-based comparative cross-sectional study was conducted in January and February 2012 among women who had delivered in the 2 years before the survey.
Results
A total of 2,296 women were included in the study. One thousand eight hundred and sixty two (81.1%) had attended ANC at least once, and 37% of the women had attended ANC at least four times. A quarter of the women delivered their last child in a health facility. Of the women living outside the HDSS areas, 715 (75.3%) attended ANC at least once compared to 85.1% of women living in the HDSS areas [adjusted odds ratio (AOR) 0.59; 95% CI 0.46, 0.74]. Of the women living outside the HDSS areas, only 170 (17.9%) delivered in health facilities and were assisted by skilled attendants during delivery, whereas 30.0% of those living in HDSS areas delivered in health facilities (AOR 0.66; 95% CI 0.48, 0.91).
Conclusion
This paper provides possible evidence that living in an HDSS site has a positive influence on maternal health. In addition, there may be a positive influence on those living nearby or in the same district where an HDSS is located even when not included in the surveillance system.
doi:10.3402/gha.v7.24228
PMCID: PMC4083147  PMID: 24998383
demographic; surveillance; Ethiopia; antenatal care; skilled attendance; facility delivery
11.  The Tanzania Connect Project: a cluster-randomized trial of the child survival impact of adding paid community health workers to an existing facility-focused health system 
BMC Health Services Research  2013;13(Suppl 2):S6.
Background
Tanzania has been a pioneer in establishing community-level services, yet challenges remain in sustaining these systems and ensuring adequate human resource strategies. In particular, the added value of a cadre of professional community health workers is under debate. While Tanzania has the highest density of primary health care facilities in Africa, equitable access and quality of care remain a challenge. Utilization for many services proven to reduce child and maternal mortality is unacceptably low. Tanzanian policy initiatives have sought to address these problems by proposing expansion of community-based providers, but the Ministry of Health and Social Welfare (MoHSW ) lacks evidence that this merits national implementation. The Tanzania Connect Project is a randomized cluster trial located in three rural districts with a population of roughly 360,000 ( Kilombero, Rufiji, and Ulanga).
Description of intervention
Connect aims to test whether introducing a community health worker into a general program of health systems strengthening and referral improvement will reduce child mortality, improve access to services, expand utilization, and alter reproductive, maternal, newborn and child health seeking behavior; thereby accelerating progress towards Millennium Development Goals 4 and 5. Connect has introduced a new cadre — Community Health Agents (CHA) — who were recruited from and work in their communities. To support the CHA, Connect developed supervisory systems, launched information and monitoring operations, and implemented logistics support for integration with existing district and village operations. In addition, Connect’s district-wide emergency referral strengthening intervention includes clinical and operational improvements.
Evaluation design
Designed as a community-based cluster-randomized trial, CHA were randomly assigned to 50 of the 101 villages within the Health and Demographic Surveillance System (HDSS) in the three study districts. To garner detailed information on household characteristics, behaviors, and service exposure, a random sub-sample survey of 3,300 women of reproductive age will be conducted at the baseline and endline. The referral system intervention will use baseline, midline, and endline facility-based data to assess systemic changes. Implementation and impact research of Connect will assess whether and how the presence of the CHA at village level provides added life-saving value to the health system.
Discussion
Global commitment to launching community-based primary health care has accelerated in recent years, with much of the implementation focused on Africa. Despite extensive investment, no program has been guided by a truly experimental study. Connect will not only address Tanzania’s need for policy and operational research, it will bridge a critical international knowledge gap concerning the added value of salaried professional community health workers in the context of a high density of fixed facilities.
Trial registration: ISRCTN96819844
doi:10.1186/1472-6963-13-S2-S6
PMCID: PMC3668255  PMID: 23819587
12.  Health inequalities among older men and women in Africa and Asia: evidence from eight Health and Demographic Surveillance System sites in the INDEPTH WHO-SAGE Study 
Global Health Action  2010;3:10.3402/gha.v3i0.5420.
Background
Declining rates of fertility and mortality are driving demographic transition in all regions of the world, leading to global population ageing and consequently changing patterns of global morbidity and mortality. Understanding sex-related health differences, recognising groups at risk of poor health and identifying determinants of poor health are therefore very important for both improving health trajectories and planning for the health needs of ageing populations.
Objectives
To determine the extent to which demographic and socio-economic factors impact upon measures of health in older populations in Africa and Asia; to examine sex differences in health and further explain how these differences can be attributed to demographic and socio-economic determinants.
Methods
A total of 46,269 individuals aged 50 years and over in eight Health and Demographic Surveillance System (HDSS) sites within the INDEPTH Network were studied during 2006–2007 using an abbreviated version of the WHO Study on global AGEing and adult health (SAGE) Wave I instrument. The survey data were then linked to longitudinal HDSS background information. A health score was calculated based on self-reported health derived from eight health domains. Multivariable regression and post-regression decomposition provide ways of measuring and explaining the health score gap between men and women.
Results
Older men have better self-reported health than older women. Differences in household socio-economic levels, age, education levels, marital status and living arrangements explained from about 82% and 71% of the gaps in health score observed between men and women in South Africa and Kenya, respectively, to almost nothing in Bangladesh. Different health domains contributed differently to the overall health scores for men and women in each country.
Conclusion
This study confirmed the existence of sex differences in self-reported health in low- and middle-income countries even after adjustments for differences in demographic and socio-economic factors. A decomposition analysis suggested that sex differences in health differed across the HDSS sites, with the greatest level of inequality found in Bangladesh. The analysis showed considerable variation in how differences in socio-demographic and economic characteristics explained the gaps in self-reported health observed between older men and women in African and Asian settings. The overall health score was a robust indicator of health, with two domains, pain and sleep/energy, contributing consistently across the HDSS sites. Further studies are warranted to understand other significant individual and contextual determinants to which these sex differences in health can be attributed. This will lay a foundation for a more evidence-based approach to resource allocation, and to developing health promotion programmes for older men and women in these settings.
doi:10.3402/gha.v3i0.5420
PMCID: PMC2958198  PMID: 20967141
ageing; survey methods; public health; burden of disease; demographic transition; disability; well-being; health status; INDEPTH WHO-SAGE
13.  Profile: The Niakhar Health and Demographic Surveillance System 
The Health and Demographic Surveillance System (HDSS) in Niakhar, a rural area of Senegal, is located 135 km east of Dakar. The HDSS was established in 1962 by the Institut de Recherche pour le Développement (IRD) of Senegal to face the shortcomings of the civil registration system and provide demographic indicators.
Some 65 villages in the Niakhar area were followed annually by the HDSS from 1962–1969. The study zone was reduced to 8 villages from 1969–1983, and from then on the HDSS was extended to include 22 other villages, covering a total of 30 villages for a population estimated at 43 000 in January 2012. Thus, 8 villages in the Niakhar area have been under demographic surveillance for almost 50 years and 30 villages for 30 years.
Vital events, migrations, marital changes, pregnancies, and immunizations are routinely recorded every 4 months. The HDSS data base also includes epidemiological, economic, and environmental information obtained from specific surveys. Data were collected through annual rounds from 1962 to 1987. The rounds became weekly from 1987–1997, followed by routine visits conducted every 3 months between 1997 and 2007 and every 4 months since then. The data collected in the HDSS are not open to access, but can be fairly shared under conditions of collaboration and endowment.
doi:10.1093/ije/dyt100
PMCID: PMC3781002  PMID: 24062286
14.  Access to artemisinin-based anti-malarial treatment and its related factors in rural Tanzania 
Malaria Journal  2013;12:155.
Background
Artemisinin-based combination treatment (ACT) has been widely adopted as one of the main malaria control strategies. However, its promise to save thousands of lives in sub-Saharan Africa depends on how effective the use of ACT is within the routine health system. The INESS platform evaluated effective coverage of ACT in several African countries. Timely access within 24 hours to an authorized ACT outlet is one of the determinants of effective coverage and was assessed for artemether-lumefantrine (Alu), in two district health systems in rural Tanzania.
Methods
From October 2009 to June 2011we conducted continuous rolling household surveys in the Kilombero-Ulanga and the Rufiji Health and Demographic Surveillance Sites (HDSS). Surveys were linked to the routine HDSS update rounds. Members of randomly pre-selected households that had experienced a fever episode in the previous two weeks were eligible for a structured interview. Data on individual treatment seeking, access to treatment, timing, source of treatment and household costs per episode were collected. Data are presented on timely access from a total of 2,112 interviews in relation to demographics, seasonality, and socio economic status.
Results
In Kilombero-Ulanga, 41.8% (CI: 36.6–45.1) and in Rufiji 36.8% (33.7–40.1) of fever cases had access to an authorized ACT provider within 24 hours of fever onset. In neither of the HDSS site was age, sex, socio-economic status or seasonality of malaria found to be significantly correlated with timely access.
Conclusion
Timely access to authorized ACT providers is below 50% despite interventions intended to improve access such as social marketing and accreditation of private dispensing outlets. To improve prompt diagnosis and treatment, access remains a major bottle neck and new more innovative interventions are needed to raise effective coverage of malaria treatment in Tanzania.
doi:10.1186/1475-2875-12-155
PMCID: PMC3651283  PMID: 23651521
15.  Prevalence of physical inactivity in nine rural INDEPTH Health and Demographic Surveillance Systems in five Asian countries 
Global Health Action  2009;2:10.3402/gha.v2i0.1985.
Background
Physical inactivity leads to higher morbidity and mortality from chronic non-communicable diseases (NCDs) such as stroke and heart disease. In high income countries, studies have measured the population level of physical activity, but comparable data are lacking from most low and middle-income countries.
Objective
To assess the level of physical inactivity and its associated factors in selected rural sites in five Asian countries.
Methods
The multi-site cross-sectional study was conducted in nine rural Health and Demographic Surveillance System (HDSS) sites within the INDEPTH Network in Bangladesh, India, Indonesia, Thailand, and Vietnam. Using the methodology from the WHO STEPwise approach to Surveillance (STEPS), about 2,000 men and women aged 25–64 years were selected randomly from each HDSS sampling frame. Physical activity at work and during leisure time, and on travel to and from places, was measured using the Global Physical Activity Questionnaire version 2 (GPAQ2). The total activity was calculated as the sum of the time spent in each domain of activities in metabolic equivalent-minutes per week, and was used to determine the level of physical activity. Multivariable logistic regression was used to assess demographic factors associated with a low level of physical activity.
Results
The prevalence of physical inactivity ranged from 13% in Chililab HDSS in Vietnam to 58% in Filabavi HDSS in Vietnam. The majority of men were physically active, except in the two sites in Vietnam. Most of the respondents walked or cycled for at least 10 minutes to get from place to place, with some exceptions in the HDSSs in Indonesia and Thailand. The majority of respondents, both men and women, were inactive during their leisure time. Women, older age, and high level of education were significantly associated with physical inactivity.
Conclusion
This study showed that over 1/4 men and 1/3 women in Asian HDSSs within the INDEPTH Network are physically inactive. The wide fluctuations between the two HDSS in Vietnam offer an opportunity to explore further urbanisation and environmental impacts on physical activity. Considering the importance of physical activity in improving health and preventing chronic NCDs, efforts need to be made to promote physical activity particularly among women, older people, and high education groups in these settings.
doi:10.3402/gha.v2i0.1985
PMCID: PMC2785136  PMID: 20027261
chronic non-communicable diseases; risk factors surveillance; physical inactivity; low and middle-income countries; Asia; WHO STEPS
16.  Deaths Ascribed to Non-Communicable Diseases among Rural Kenyan Adults Are Proportionately Increasing: Evidence from a Health and Demographic Surveillance System, 2003–2010 
PLoS ONE  2014;9(11):e114010.
Background
Non-communicable diseases (NCDs) result in more deaths globally than other causes. Monitoring systems require strengthening to attribute the NCD burden and deaths in low and middle-income countries (LMICs). Data from health and demographic surveillance systems (HDSS) can contribute towards this goal.
Methods and Findings
Between 2003 and 2010, 15,228 deaths in adults aged 15 years (y) and older were identified retrospectively using the HDSS census and verbal autopsy in rural western Kenya, attributed into broad categories using InterVA-4 computer algorithms; 37% were ascribed to NCDs, 60% to communicable diseases (CDs), 3% to injuries, and <1% maternal causes. Median age at death for NCDs was 66y and 71y for females and males, respectively, with 43% (39% male, 48% female) of NCD deaths occurring prematurely among adults aged below 65y. NCD deaths were mainly attributed to cancers (35%) and cardio-vascular diseases (CVDs; 29%). The proportionate mortality from NCDs rose from 35% in 2003 to 45% in 2010 (χ2 linear trend 93.4; p<0.001). While overall annual mortality rates (MRs) for NCDs fell, cancer-specific MRs rose from 200 to 262 per 100,000 population, mainly due to increasing deaths in adults aged 65y and older, and to respiratory neoplasms in all age groups. The substantial fall in CD MRs resulted in similar MRs for CDs and NCDs among all adult females by 2010. NCD MRs for adults aged 15y to <65y fell from 409 to 183 per 100,000 among females and from 517 to 283 per 100,000 population among males. NCD MRs were higher among males than females aged both below, and at or above, 65y.
Conclusions
NCDs constitute a significant proportion of deaths in rural western Kenya. Evidence of the increasing contribution of NCDs to overall mortality supports international recommendations to introduce or enhance prevention, screening, diagnosis and treatment programmes in LMICs.
doi:10.1371/journal.pone.0114010
PMCID: PMC4245262  PMID: 25426945
17.  Blood pressure in adult rural INDEPTH population in Asia 
Global Health Action  2009;2:10.3402/gha.v2i0.2010.
Introduction
High blood pressure (BP) is a well-known major risk factor for cardiovascular diseases and is a leading contributor to cardiovascular mortality and morbidity worldwide. Reliable population-based BP data from low–middle income countries are sparse.
Objective
This paper reports BP distributions among adults in nine rural populations in five Asian countries and examines the association between high BP and associated risk factors, including gender, age, education, and body mass index.
Methods
A multi-site cross-sectional study of the major non-communicable disease risk factors (tobacco and alcohol use, fruit and vegetable intake, physical activity patterns) was conducted in 2005 in nine Health and Demographic Surveillance System (HDSS) sites in five Asian countries, all part of the INDEPTH Network. In addition to the self-report questions on risk factors, height and weight, and BP were measured during household visits using standard protocols of the WHO STEPwise approach to Surveillance.
Results
In all the study sites (except among men and women in WATCH and among women in Chililab), the mean levels of systolic BP were greater than the optimal threshold (115 mmHg). A considerable proportion of the study populations – especially those in the HDSS in India, Indonesia, and Thailand – had high BP (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg or on treatment with BP medications). A more conservative definition of high BP (systolic BP ≥ 160 mmHg or diastolic BP ≥ 100 mmHg) substantially reduced the prevalence rate. The marked differences in the proportion of the populations on high BP medication (range between 0.6 and 10.8%) raised problems in comparing the prevalence of high BP across sites when using the commonly used definition of high BP as in this study. In the four HDSS in Bangladesh, women had a higher prevalence of high BP than men; the reverse was true in the other sites (Chililab, Filabavi in Vietnam; Kanchanaburi, Thailand; and Vadu, India) where men experienced higher prevalence than women. Overweight and obesity were significantly associated with high BP, with odds ratio ranging from two in Chililab to five in Filabavi (both in Vietnam HDSS).
Conclusion
The patterns of BP in these nine cross-sectional surveys were complex, reflecting the fact that the Asian countries are at different stages of the epidemiological transition. Actions to prevent the rise of BP levels are urgently required. An emphasis should be placed on cost-effective interventions to reduce salt consumption in the population as an immediate priority.
doi:10.3402/gha.v2i0.2010
PMCID: PMC2785103  PMID: 20027254
high blood pressure; hypertension; risk factor surveillance; socioeconomic; INDEPTH; WHO STEPS
18.  Birth weight and delivery practice in a Vietnamese rural district during 12 year of rapid economic development 
Background
Since the Doi Moi reform 1986 economic conditions in Vietnam have changed significantly and positive health and health care developments have been observed. International experience shows that improved economic conditions in a country can reduce the risk of perinatal mortality, decrease the risk of low birth weight and increase the mean birth weight in newborns. The Health and Demographic Surveillance Site (HDSS) FilaBavi in Bavi district outside Hanoi city has been operational since 1999. An open cohort of more than 12,000 households (52,000 persons) has been followed primarily with respect to demography, economy and education. The aim of this research is to study trends in birth weight as well as birth and delivery practices over the time period 1999–2010 in FilaBavi in relation to the social and economic development.
Methods
Information about birth weight, sex, place and method of delivery, mother’s age and education as well as household economy of 10,114 children, born from 1999 to 2010, was obtained from the routine data collection in the HDSS.
Results
Over the study period the mean birth weight remained at the same level, about 3,100 g, in spite of increased economic resources and technology development. At the individual child level we found associations between birth weight and household economy as well as the education of the mother. Hospital delivery increased from about 35% to 65% and the use of Caesarian section increased from 2.6% to 10.1%.
Conclusion
During the twelve years studied, household income as well as the use of modern technology increased rapidly. In spite of that, the mean and variation of birth weight did not change systematically. It is suggested that increasing gaps in economic conditions and misallocation of resources, possibly to overuse of technology, are partly responsible.
doi:10.1186/1471-2393-13-41
PMCID: PMC3599374  PMID: 23418725
Birth weight; Social and economic development; Sex ratio at birth; Rural Vietnam
19.  Health and demographic surveillance systems: a step towards full civil registration and vital statistics system in sub-Sahara Africa? 
BMC Public Health  2012;12:741.
Background
In the developed world, information on vital events is routinely collected nationally to inform population and health policies. However, in many low-and middle-income countries, especially those in sub-Saharan Africa (SSA), there is a lack of effective and comprehensive national civil registration and vital statistics system. In the past decades, the number of Health and Demographic Surveillance Systems (HDSSs) has increased throughout SSA. An HDSS monitors births, deaths, causes of death, migration, and other health and socio-economic indicators within a defined population over time. Currently, the International Network for the Continuous Demographic Evaluation of Populations and Their Health (INDEPTH) brings together 38 member research centers which run 44 HDSS sites from 20 countries in Africa, Asia and Oceana. Thirty two of these HDSS sites are in SSA.
Discussion
This paper argues that, in the absence of an adequate national CRVS, HDSSs should be more effectively utilised to generate relevant public health data, and also to create local capacity for longitudinal data collection and management systems in SSA. If HDSSs get strategically located to cover different geographical regions in a country, data from these sites could be used to provide a more complete national picture of the health of the population. They provide useful data that can be extrapolated for national estimates if their regional coverage is well planned. HDSSs are however resource-intensive. Efforts are being put towards getting them linked to local or national policy contexts and to reduce their dependence on external funding. Increasing their number in SSA to cover a critical proportion of the population, especially urban populations, must be carefully planned. Strategic planning is needed at national levels to geographically locate HDSS sites and to support these through national funding mechanisms.
Summary
The paper does not suggest that HDSSs should be seen as a replacement for civil registration systems. Rather, they should serve as a short- to medium-term measure to provide data for health and population planning at regional levels with possible extrapolation to national levels. HDSSs can also provide useful lessons for countries that intend to set up nationally representative sample vital registration systems in the long term.
doi:10.1186/1471-2458-12-741
PMCID: PMC3509035  PMID: 22950896
20.  Measuring Adult Mortality Using Sibling Survival: A New Analytical Method and New Results for 44 Countries, 1974–2006 
PLoS Medicine  2010;7(4):e1000260.
Julie Rajaratnam and colleagues describe a novel method, called the Corrected Sibling Survival method, to measure adult mortality in countries without good vital registration by use of histories taken from surviving siblings.
Background
For several decades, global public health efforts have focused on the development and application of disease control programs to improve child survival in developing populations. The need to reliably monitor the impact of such intervention programs in countries has led to significant advances in demographic methods and data sources, particularly with large-scale, cross-national survey programs such as the Demographic and Health Surveys (DHS). Although no comparable effort has been undertaken for adult mortality, the availability of large datasets with information on adult survival from censuses and household surveys offers an important opportunity to dramatically improve our knowledge about levels and trends in adult mortality in countries without good vital registration. To date, attempts to measure adult mortality from questions in censuses and surveys have generally led to implausibly low levels of adult mortality owing to biases inherent in survey data such as survival and recall bias. Recent methodological developments and the increasing availability of large surveys with information on sibling survival suggest that it may well be timely to reassess the pessimism that has prevailed around the use of sibling histories to measure adult mortality.
Methods and Findings
We present the Corrected Sibling Survival (CSS) method, which addresses both the survival and recall biases that have plagued the use of survey data to estimate adult mortality. Using logistic regression, our method directly estimates the probability of dying in a given country, by age, sex, and time period from sibling history data. The logistic regression framework borrows strength across surveys and time periods for the estimation of the age patterns of mortality, and facilitates the implementation of solutions for the underrepresentation of high-mortality families and recall bias. We apply the method to generate estimates of and trends in adult mortality, using the summary measure 45q15—the probability of a 15-y old dying before his or her 60th birthday—for 44 countries with DHS sibling survival data. Our findings suggest that levels of adult mortality prevailing in many developing countries are substantially higher than previously suggested by other analyses of sibling history data. Generally, our estimates show the risk of adult death between ages 15 and 60 y to be about 20%–35% for females and 25%–45% for males in sub-Saharan African populations largely unaffected by HIV. In countries of Southern Africa, where the HIV epidemic has been most pronounced, as many as eight out of ten men alive at age 15 y will be dead by age 60, as will six out of ten women. Adult mortality levels in populations of Asia and Latin America are generally lower than in Africa, particularly for women. The exceptions are Haiti and Cambodia, where mortality risks are comparable to many countries in Africa. In all other countries with data, the probability of dying between ages 15 and 60 y was typically around 10% for women and 20% for men, not much higher than the levels prevailing in several more developed countries.
Conclusions
Our results represent an expansion of direct knowledge of levels and trends in adult mortality in the developing world. The CSS method provides grounds for renewed optimism in collecting sibling survival data. We suggest that all nationally representative survey programs with adequate sample size ought to implement this critical module for tracking adult mortality in order to more reliably understand the levels and patterns of adult mortality, and how they are changing.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Governments and international health agencies need accurate information on births and deaths in populations to help them plan health care policies and monitor the effectiveness of public-health programs designed, for example, to prevent premature deaths from preventable causes such as tobacco smoking. In developed countries, full information on births and deaths is recorded in “vital registration systems.” Unfortunately, very few developing countries have complete vital registration systems. In most African countries, for example, less than one-quarter of deaths are counted through vital registration systems. To fill this information gap, scientists have developed several methods to estimate mortality levels (the proportion of deaths in populations) and trends in mortality (how the proportion of deaths in populations changes over time) from data collected in household surveys and censuses. A household survey collects data about family members (for example, number, age, and sex) for a national sample of households randomly selected from a list of households collected in a census (a periodic count of a population).
Why Was This Study Done?
To date, global public-health efforts have concentrated on improving child survival. Consequently, methods for calculating child mortality levels and trends from surveys are well-developed and generally yield accurate estimates. By contrast, although attempts have been made to measure adult mortality using sibling survival histories (records of the sex, age if alive, or age at death, if dead, of all the children born to survey respondents' mothers that are collected in many household surveys), these attempts have often produced implausibly low estimates of adult mortality. These low estimates arise because people do not always recall deaths accurately when questioned (recall bias) and because families that have fallen apart, possibly because of family deaths, are underrepresented in household surveys (selection bias). In this study, the researchers develop a corrected sibling survival (CSS) method that addresses the problems of selection and recall bias and use their method to estimate mortality levels and trends in 44 developing countries between 1974 and 2006.
What Did the Researchers Do and Find?
The researchers used a statistical approach called logistic regression to develop the CSS method. They then used the method to estimate the probability of a 15-year-old dying before his or her 60th birthday from sibling survival data collected by the Demographic and Health Surveys program (DHS, a project started in 1984 to help developing countries collect data on population and health trends). Levels of adult mortality estimated in this way were considerably higher than those suggested by previous analyses of sibling history data. For example, the risk of adult death between the ages of 15 and 60 years was 20%–35% for women and 25%–45% for men living in sub-Saharan African countries largely unaffected by HIV and 60% for women and 80% for men living in countries in Southern Africa where the HIV epidemic is worst. Importantly, the researchers show that their mortality level estimates compare well to those obtained from vital registration data and other data sources where available. So, for example, in the Philippines, adult mortality levels estimated using the CSS method were similar to those obtained from vital registration data. Finally, the researchers used the CSS method to estimate mortality trends. These calculations reveal, for example, that there has been a 3–4-fold increase in adult mortality since the late 1980s in Zimbabwe, a country badly affected by the HIV epidemic.
What Do These Findings Mean?
These findings suggest that the CSS method, which applies a correction for both selection and recall bias, yields more accurate estimates of adult mortality in developing countries from sibling survival data than previous methods. Given their findings, the researchers suggest that sibling survival histories should be routinely collected in all future household survey programs and, if possible, these surveys should be expanded so that all respondents are asked about sibling histories—currently the DHS only collects sibling histories from women aged 15–49 years. Widespread collection of such data and their analysis using the CSS method, the researchers conclude, would help governments and international agencies track trends in adult mortality and progress toward major health and development targets.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000260.
This study and two related PLoS Medicine Research Articles by Rajaratnam et al. and by Murray et al. are further discussed in a PLoS Medicine Perspective by Mathers and Boerma
Information is available about the Demographic and Health Surveys
The Institute for Health Metrics and Evaluation makes available high-quality information on population health, its determinants, and the performance of health systems
Grand Challenges in Global Health provides information on research into better ways for developing countries to measure their health status
The World Health Organization Statistical Information System (WHOSIS) is an interactive database that brings together core health statistics for WHO member states, including information on vital registration of deaths; the WHO Health Metrics Network is a global collaboration focused on improving sources of vital statistics
doi:10.1371/journal.pmed.1000260
PMCID: PMC2854132  PMID: 20405004
21.  Profile: Agincourt Health and Socio-demographic Surveillance System 
The Agincourt health and socio-demographic surveillance system (HDSS), located in rural northeast South Africa close to the Mozambique border, was established in 1992 to support district health systems development led by the post-apartheid ministry of health. The HDSS (90 000 people), based on an annual update of resident status and vital events, now supports multiple investigations into the causes and consequences of complex health, population and social transitions. Observational work includes cohorts focusing on different stages along the life course, evaluation of national policy at population, household and individual levels and examination of household responses to shocks and stresses and the resulting pathways influencing health and well-being. Trials target children and adolescents, including promoting psycho-social well-being, preventing HIV transmission and reducing metabolic disease risk. Efforts to enhance the research platform include using automated measurement techniques to estimate cause of death by verbal autopsy, full ‘reconciliation’ of in- and out-migrations, follow-up of migrants departing the study area, recording of extra-household social connections and linkage of individual HDSS records with those from sub-district clinics. Fostering effective collaborations (including INDEPTH multi-centre work in adult health and ageing and migration and urbanization), ensuring cross-site compatibility of common variables and optimizing public access to HDSS data are priorities.
doi:10.1093/ije/dys115
PMCID: PMC3429877  PMID: 22933647
Sub-Saharan Africa; population pyramids; health transition; mortality; morbidity; cause of death; fertility; migration; census; HIV; tuberculosis; non-communicable diseases; households
22.  Distribution of cause of death in rural Bangladesh during 2003–2010: evidence from two rural areas within Matlab Health and Demographic Surveillance site 
Global Health Action  2014;7:10.3402/gha.v7.25510.
Objective
This study used the InterVA-4 computerised model to assign probable cause of death (CoD) to verbal autopsies (VAs) generated from two rural areas, with a difference in health service provision, within the Matlab Health and Demographic Surveillance site (HDSS). This study aimed to compare CoD by gender, as well as discussing possible factors which could influence differences in the distribution of CoD between the two areas.
Design
Data for this study came from the Matlab the HDSS maintained by the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) since 1966. In late 1977, icddr,b divided HDSS and implemented a high-quality maternal, newborn and child health and family planning (MNCH-FP) services project in one half, called the icddr,b service area (SA), in addition to the usual public and private MNCH-FP services that serve the other half, called the government SA. HDSS field workers registered 12,144 deaths during 2003–2010, and trained interviewers obtained VA for 98.9% of them. The probabilistic model InterVA-4 probabilistic model (version 4.02) was used to derive probable CoD from VA symptoms. Cause-specific mortality rates and fractions were compared across gender and areas. Appropriate statistical tests were applied for significance testing.
Results
Mortality rates due to neonatal causes and communicable diseases (CDs) were lower in the icddr,b SA than in the government SA, where mortality rates due to non-communicable diseases (NCDs) were lower. Cause-specific mortality fractions (CSMFs) due to CDs (23.2% versus 18.8%) and neonatal causes (7.4% versus 6%) were higher in the government SA, whereas CSMFs due to NCDs were higher (58.2% versus 50.7%) in the icddr,b SA. The rank-order of CSMFs by age group showed marked variations, the largest category being acute respiratory infection/pneumonia in infancy, injury in 1–4 and 5–14 years, neoplasms in 15–49 and 50–64 years, and stroke in 65+ years.
Conclusions
Automated InterVA-4 coding of VA to determine probable CoD revealed the difference in the structure of CoD between areas with prominence of NCDs in both areas. Such information can help local planning of health services for prevention and management of disease burden.
doi:10.3402/gha.v7.25510
PMCID: PMC4220145  PMID: 25377333
InterVA; verbal autopsy; cause of death; Matlab; Bangladesh
23.  Drivers of Inequality in Millennium Development Goal Progress: A Statistical Analysis 
PLoS Medicine  2010;7(3):e1000241.
David Stuckler and colleagues examine the impact of the HIV and noncommunicable disease epidemics on low-income countries' progress toward the Millennium Development Goals for health.
Background
Many low- and middle-income countries are not on track to reach the public health targets set out in the Millennium Development Goals (MDGs). We evaluated whether differential progress towards health MDGs was associated with economic development, public health funding (both overall and as percentage of available domestic funds), or health system infrastructure. We also examined the impact of joint epidemics of HIV/AIDS and noncommunicable diseases (NCDs), which may limit the ability of households to address child mortality and increase risks of infectious diseases.
Methods and Findings
We calculated each country's distance from its MDG goals for HIV/AIDS, tuberculosis, and infant and child mortality targets for the year 2005 using the United Nations MDG database for 227 countries from 1990 to the present. We studied the association of economic development (gross domestic product [GDP] per capita in purchasing-power-parity), the relative priority placed on health (health spending as a percentage of GDP), real health spending (health system expenditures in purchasing-power-parity), HIV/AIDS burden (prevalence rates among ages 15–49 y), and NCD burden (age-standardised chronic disease mortality rates), with measures of distance from attainment of health MDGs. To avoid spurious correlations that may exist simply because countries with high disease burdens would be expected to have low MDG progress, and to adjust for potential confounding arising from differences in countries' initial disease burdens, we analysed the variations in rates of change in MDG progress versus expected rates for each country. While economic development, health priority, health spending, and health infrastructure did not explain more than one-fifth of the differences in progress to health MDGs among countries, burdens of HIV and NCDs explained more than half of between-country inequalities in child mortality progress (R2-infant mortality  = 0.57, R2-under 5 mortality  = 0.54). HIV/AIDS and NCD burdens were also the strongest correlates of unequal progress towards tuberculosis goals (R2 = 0.57), with NCDs having an effect independent of HIV/AIDS, consistent with micro-level studies of the influence of tobacco and diabetes on tuberculosis risks. Even after correcting for health system variables, initial child mortality, and tuberculosis diseases, we found that lower burdens of HIV/AIDS and NCDs were associated with much greater progress towards attainment of child mortality and tuberculosis MDGs than were gains in GDP. An estimated 1% lower HIV prevalence or 10% lower mortality rate from NCDs would have a similar impact on progress towards the tuberculosis MDG as an 80% or greater rise in GDP, corresponding to at least a decade of economic growth in low-income countries.
Conclusions
Unequal progress in health MDGs in low-income countries appears significantly related to burdens of HIV and NCDs in a population, after correcting for potentially confounding socioeconomic, disease burden, political, and health system variables. The common separation between NCDs, child mortality, and infectious syndromes among development programs may obscure interrelationships of illness affecting those living in poor households—whether economic (e.g., as money spent on tobacco is lost from child health expenditures) or biological (e.g., as diabetes or HIV enhance the risk of tuberculosis).
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In 2000, 189 countries adopted the United Nations (UN) Millennium Declaration, which commits the world to the eradication of extreme poverty by 2015. The Declaration lists eight Millennium Development Goals (MDGs), 21 quantifiable targets, and 60 indicators of progress. So, for example, MDG 4 aims to reduce child mortality (deaths). The target for this goal is to reduce the number of children who die each year before they are five years old (the under-five mortality rate) to two-thirds of its 1990 value by 2015. Indicators of progress toward this goal include the under-five mortality rate and the infant mortality rate. Because poverty and ill health are inextricably linked—ill health limits the ability of individuals and nations to improve their economic status, and poverty contributes to the development of many illnesses—two other MDGs also tackle public health issues. MDG 5 sets a target of reducing maternal mortality by three-quarters of its 1990 level by 2015. MDG 6 aims to halt and begin to reverse the spread of HIV/AIDS, malaria, and other major diseases such as tuberculosis by 2015.
Why Was This Study Done?
Although progress has been made toward achieving the MDGs, few if any of the targets are likely to be met by 2015. Worryingly, low-income countries are falling furthest behind their MDG targets. For example, although child mortality has been declining globally, in many poor countries there has been little or no progress. What is the explanation for this and other inequalities in progress toward the health MDGs? Some countries may simply lack the financial resources needed to combat epidemics or may allocate only a low proportion of their gross domestic product (GDP) to health. Alternatively, money allocated to health may not always reach the people who need it most because of an inadequate health infrastructure. Finally, coexisting epidemics may be hindering progress toward the MDG health targets. Thus, the spread of HIV/AIDS may be hindering attempts to limit the spread of tuberculosis because HIV infection increases the risk of active tuberculosis, and ongoing epidemics of diabetes and other noncommunicable diseases (NCDs) may be affecting the attainment of health MDGs by diverting scarce resources. In this study, the researchers investigate whether any of these possibilities is driving the inequalities in MDG progress.
What Did the Researchers Do and Find?
The researchers calculated how far 227 countries were from their MDG targets for HIV, tuberculosis, and infant and child mortality in 2005 using information collected by the UN. They then used statistical methods to study the relationship between this distance and economic development (GDP per person), health spending as a proportion of GDP (health priority), actual health system expenditures, health infrastructure, HIV burden, and NCD burden in each country. Economic development, health priority, health spending, and health infrastructure explained no more than one-fifth of the inequalities in progress toward health MDGs. By contrast, the HIV and NCD burdens explained more than half of inequalities in child mortality progress and were strongly associated with unequal progress toward tuberculosis goals. Furthermore, the researchers calculated that a 1% reduction in the number of people infected with HIV or a 10% reduction in rate of deaths from NCDs in a population would have a similar impact on progress toward the tuberculosis MDG target as a rise in GDP corresponding to at least a decade of growth in low-income countries.
What Do These Findings Mean?
These findings are limited by the quality of the available data on health indicators in low-income countries and, because the researchers used country-wide data, their findings only reveal possible drivers of inequalities in progress toward MDGs in whole countries and may mask drivers of within-country inequalities. Nevertheless, as one of the first attempts to analyze the determinants of global inequalities in progress toward the health MDGs, these findings have important implications for global health policy. Most importantly, the finding that unequal progress is related to the burdens of HIV and NCDs in populations suggests that programs designed to achieve health MDGs must consider all the diseases and factors that can trap households in vicious cycles of illness and poverty, especially since the achievement of feasible reductions in NCDs in low-income countries could greatly enhance progress towards health MDGs.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000241.
The United Nations Millennium Development Goals website provides detailed information about the Millennium Declaration, the MDGs, their targets and their indicators
The Millennium Development Goals Report 2009 and its progress chart provide an up-to-date assessment of progress towards the MDGs
The World Health Organization provides information about poverty and health and health and development
doi:10.1371/journal.pmed.1000241
PMCID: PMC2830449  PMID: 20209000
24.  Patterns of alcohol consumption in diverse rural populations in the Asian region 
Global Health Action  2009;2:10.3402/gha.v2i0.2017.
Background
Alcohol abuse, together with tobacco use, is a major determinant of health and social well-being, and is one of the most important of 26 risk factors comparatively assessed in low and middle income countries, surpassed only by high blood pressure and tobacco.
Objectives
The alcohol consumption patterns and the associations between consumption of alcohol and socio-demographic and cultural factors have been investigated in nine rural Health and Demographic Surveillance System (HDSS) located in five Asian countries.
Methods
The information was collected from multiple study sites, with sample sizes of sufficient size to measure trends in age and sex groups over time. Adopting the WHO STEPwise approach to Surveillance (WHO STEPS), stratified random sampling (in each 10-year interval) from the HDSS sampling frame was undertaken. Information regarding alcohol consumption and demographic indicators were collected using the WHO STEPwise standard surveillance form. The data from the nine HDSS sites were merged and analysed using STATA software version 10.
Results
Alcohol was rarely consumed in five of the HDSS (four in Bangladesh, and one in Indonesia). In the two HDSS in Vietnam (Chililab, Filabavi) and one in Thailand (Kanchanaburi), alcohol consumption was common in men. The mean number of drinks per day during the last seven days, and prevalence of at-risk drinker were found to be highest in Filabavi. The prevalence of female alcohol consumption was much smaller in comparison with men. In Chililab, people who did not go to school or did not complete primary education were more likely to drink in comparison to people who graduated from high school or university.
Conclusions
Although uncommon in some countries because of religious and cultural practices, alcohol consumption patterns in some sites were cause for concern. In addition, qualitative studies may be necessary to understand the factors influencing alcohol consumption levels between the two sites in Vietnam and the site in Thailand in order to design appropriate interventions.
doi:10.3402/gha.v2i0.2017
PMCID: PMC2785538  PMID: 20027253
alcohol consumption; risk factor surveillance; INDEPTH; Asia; WHO STEPS
25.  Is Self-Rated Health an Independent Index for Mortality among Older People in Indonesia? 
PLoS ONE  2012;7(4):e35308.
Background
Empirical studies on the association between self-rated health (SRH) and subsequent mortality are generally lacking in low- and middle-income countries. The evidence on whether socio-economic status and education modify this association is inconsistent. This study aims to fill these gaps using longitudinal data from a Health and Demographic Surveillance System (HDSS) site in Indonesia.
Methods
In 2010, we assessed the mortality status of 11,753 men and women aged 50+ who lived in Purworejo HDSS and participated in the INDEPTH WHO SAGE baseline in 2007. Information on self-rated health, socio-demographic indicators, disability and chronic disease were collected through face-to-face interview at baseline. We used Cox-proportional hazards regression for mortality and included all variables measured at baseline, including interaction terms between SRH and both education and socio-economic status (SES).
Results
During an average of 36 months follow-up, 11% of men and 9.5% of women died, resulting in death rates of 3.1 and 2.6 per 1,000 person-months, respectively. The age-adjusted Hazard Ratio (HR) for mortality was 17% higher in men than women (HR = 1.17; 95% CI = 1.04–1.31). After adjustment for covariates, the hazard ratios for mortality in men and women reporting bad health were 3.0 (95% CI = 2.0–4.4) and 4.9 (95% CI = 3.2–7.4), respectively. Education and SES did not modify this association for either sex.
Conclusions
This study supports the predictive power of bad self-rated health for subsequent mortality in rural Indonesian men and women 50 years old and over. In these analyses, education and household socio-economic status do not modify the relationship between SRH and mortality. This means that older people who rate their own health poorly should be an important target group for health service interventions.
doi:10.1371/journal.pone.0035308
PMCID: PMC3327655  PMID: 22523584

Results 1-25 (804281)