Sub-national Surveys Research Articles

A spatial regression model for the disaggregation of areal unit based data to high-resolution grids with application to vaccination coverage mapping

The growing demand for spatially detailed data to advance the Sustainable Development Goals agenda of ‘leaving no one behind’ has resulted in a shift in focus from aggregate national and province-based metrics to small areas and high-resolution grids in the health and development arena. Vaccination coverage is customarily measured through aggregate-level statistics, which mask fine-scale heterogeneities and ‘coldspots’ of low coverage. This paper develops a methodology for high-resolution mapping of vaccination coverage using areal data in settings where point-referenced survey data are inaccessible. The proposed methodology is a binomial spatial regression model with a logit link and a combination of covariate data and random effects modelling two levels of spatial autocorrelation in the linear predictor. The principal aspect of the model is the melding of the misaligned areal data and the prediction grid points using the regression component and each of the conditional autoregressive and the Gaussian spatial process random effects. The Bayesian model is fitted using the INLA-SPDE approach. We demonstrate the predictive ability of the model using simulated data sets. The results obtained indicate a good predictive performance by the model, with correlations of between 0.66 and 0.98 obtained at the grid level between true and predicted values. The methodology is applied to predicting the coverage of measles and diphtheria-tetanus-pertussis vaccinations at 5 × 5 km2 in Afghanistan and Pakistan using subnational Demographic and Health Surveys data. The predicted maps are used to highlight vaccination coldspots and assess progress towards coverage targets to facilitate the implementation of more geographically precise interventions. The proposed methodology can be readily applied to wider disaggregation problems in related contexts, including mapping other health and development indicators.

A systematic review of sub-national food insecurity research in South Africa: Missed opportunities for policy insights.

Food insecurity is an intractable problem in South Africa. The country has a tradition of evidence-based decision making, grounded in the findings of national surveys. However, the rich insights from sub-national surveys remain a largely untapped resource for understandings of the contextual experience of food insecurity. A web-based search identified 169 sub-national food insecurity studies conducted in the post-apartheid period between 1994 and 2014. The systematic review found that the studies used 27 different measures of food insecurity, confounding the comparative analysis of food insecurity at this level. While social grants have brought a measure of poverty relief at household level, unaffordable diets were the root cause of food insecurity. The increasing consumption of cheaper, more available and preferred ‘globalised’ foods with high energy content and low nutritional value lead to overweight and obesity alongside child stunting. Unless a comparable set of indicators is used in such surveys, they are not able to provide comparable information on the scope and scale of the problem. Policy makers should be engaging with researchers to learn from these studies, while researchers need to share this wealth of sub-national study findings with government to strengthen food security planning, monitoring, and evaluation at all levels.

Do anti-malarials in Africa meet quality standards? The market penetration of non quality-assured artemisinin combination therapy in eight African countries

BackgroundQuality of artemisinin-based combination therapy (ACT) is important for ensuring malaria parasite clearance and protecting the efficacy of artemisinin-based therapies. The extent to which non quality-assured ACT (non-QAACT), or those not granted global regulatory approval, are available and used to treat malaria in endemic countries is poorly documented. This paper uses national and sub-national medicine outlet surveys conducted in eight study countries (Benin, Kinshasa and Kantanga [Democratic Republic of the Congo, DRC], Kenya, Madagascar, Nigeria, Tanzania, Uganda and Zambia) between 2009 and 2015 to describe the non-QAACT market and to document trends in availability and distribution of non-QAACT in the public and private sector.ResultsIn 2014/15, non-QAACT were most commonly available in Kinshasa (83%), followed by Katanga (53%), Nigeria (48%), Kenya (42%), and Uganda (33%). Non-QAACT accounted for 20% of the market share in the private sector in Kenya, followed by Benin and Uganda (19%), Nigeria (12%) and Zambia (8%); this figure was 27% in Katanga and 40% in Kinshasa. Public sector non-QAACT availability and distribution was much lower, with the exception of Zambia (availability, 85%; market share, 32%). Diverse generics and formulations were available, but non-QAACT were most commonly artemether–lumefantrine (AL) or dihydroartemisinin-piperaquine (DHA PPQ), in tablet formulation, imported, and distributed in urban areas at either pharmacies or drug stores. The number of unique manufacturers supplying non-QAACT to each country ranged from 9 in Uganda to 92 in Nigeria.ConclusionsAddressing the availability and distribution of non-QAACT will require effective private sector engagement and evidence-based strategies to address provider and consumer demand for these products. Given the variation in non-QAACT markets observed across the eight study countries, active efforts to limit registration, importation and distribution of non-QAACT must be tailored to the country context, and will involve addressing complex and challenging aspects of medicine registration, private sector pharmaceutical regulation, local manufacturing and drug importation. These efforts may be critical not only to patient health and safety, but also to effective malaria control and protection of artemisinin drug efficacy in the face of spreading resistance.

Girl child marriage as a risk factor for early childhood development and stunting

This paper quantitatively examines the intergenerational effects of girl child marriage, or the developmental and health outcomes of children born to women who marry before age 18. The overall objective is to understand the mechanisms through which girl child marriage affects the health and well-being of children in sub-Saharan Africa, as well as the relative magnitude and impact of these mechanisms. We used data from 37,558 mother-child pairs identified through 16 national and sub-national cross-sectional surveys across sub-Saharan Africa conducted between 2010 and 2014 by the UNICEF Multiple Indicator Clusters Survey program. The Early Childhood Development Index was used to measure child development, and stunting was used to measure health. Using logistic regression, we found that the odds of being off-track for development and being stunted were 25% and 29% higher, respectively, for children born to women who married before age 18 compared to those whose mothers married later (p < 0.001). Geographic location and primary education, which were conceptualized as contextual factors, explained most of this relationship, controlling for country fixed-effects. In adjusted models, we found that early childbearing was not the sole pathway through which girl child marriage affected child development and health. Our final models revealed that disparities in advanced maternal education and wealth explained child development and stunting. We conclude that there are intergenerational consequences of girl child marriage on her child's well-being, and that through association with other contextual, socioeconomic, and biological factors, marrying early does matter for child development and health. Our findings resonate with existing literature and point toward important policy considerations for improving early childhood outcomes.

Mobile Phone Surveys for Collecting Population-Level Estimates in Low- and Middle-Income Countries: A Literature Review.

BackgroundNational and subnational level surveys are important for monitoring disease burden, prioritizing resource allocation, and evaluating public health policies. As mobile phone access and ownership become more common globally, mobile phone surveys (MPSs) offer an opportunity to supplement traditional public health household surveys.ObjectiveThe objective of this study was to systematically review the current landscape of MPSs to collect population-level estimates in low- and middle-income countries (LMICs).MethodsPrimary and gray literature from 7 online databases were systematically searched for studies that deployed MPSs to collect population-level estimates. Titles and abstracts were screened on primary inclusion and exclusion criteria by two research assistants. Articles that met primary screening requirements were read in full and screened for secondary eligibility criteria. Articles included in review were grouped into the following three categories by their survey modality: (1) interactive voice response (IVR), (2) short message service (SMS), and (3) human operator or computer-assisted telephone interviews (CATI). Data were abstracted by two research assistants. The conduct and reporting of the review conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.ResultsA total of 6625 articles were identified through the literature review. Overall, 11 articles were identified that contained 19 MPS (CATI, IVR, or SMS) surveys to collect population-level estimates across a range of topics. MPSs were used in Latin America (n=8), the Middle East (n=1), South Asia (n=2), and sub-Saharan Africa (n=8). Nine articles presented results for 10 CATI surveys (10/19, 53%). Two articles discussed the findings of 6 IVR surveys (6/19, 32%). Three SMS surveys were identified from 2 articles (3/19, 16%). Approximately 63% (12/19) of MPS were delivered to mobile phone numbers collected from previously administered household surveys. The majority of MPS (11/19, 58%) were panel surveys where a cohort of participants, who often were provided a mobile phone upon a face-to-face enrollment, were surveyed multiple times.ConclusionsVery few reports of population-level MPS were identified. Of the MPS that were identified, the majority of surveys were conducted using CATI. Due to the limited number of identified IVR and SMS surveys, the relative advantages and disadvantages among the three survey modalities cannot be adequately assessed. The majority of MPS were sent to mobile phone numbers that were collected from a previously administered household survey. There is limited evidence on whether a random digit dialing (RDD) approach or a simple random sample of mobile network provided list of numbers can produce a population representative survey.

A global database of food and nutrient consumption.

In every region of the world, poor diet is a leading cause of both malnutrition and chronic diseases including diabetes, cardiovascular diseases and specific cancers. (1-3) In 2013, 38.3 million deaths occurred due to chronic diseases globally (70% of all deaths), with most of these deaths occurring in developing countries. (4) Anecdotal evidence and more formal evaluations in a limited number of countries suggest that changes in traditional eating patterns and a growing reliance on new types of foods are major drivers of these transitions. However, data on global patterns of dietary habits, as well as differences by population characteristics are not well established. An empirical assessment of dietary intakes is needed for evidence-based policy-making to address global health challenges. In most nations worldwide, assessment of dietary habits has been limited by the absence of robust data on individual dietary intakes that can be used in comparative studies. Up to now, most global analyses have evaluated only single dietary factors or have used data on crude household expenditure or national food supply estimates that do not adequately capture individuals' actual consumption levels. (5,6) Moreover, types of foods consumed and diet-related diseases are often unevenly distributed within populations and it is therefore essential to collect data on specific demographic groups to understand the impact of diets on diseases. Furthermore, even when individual dietary intakes are available, these are rarely standardized or comparable across countries or time, due to differences in the data collection instruments and their intended use, in the design and administration of surveys, and in data processing and analysis. As part of our efforts for the 2010 Global Burden of Diseases study, we systematically identified the available data from national and subnational surveys of individual-based dietary intakes of key foods and nutrients worldwide, by age, sex, country and time (1980-2010). Our preliminary methods have been reported (7) and further details are available from the corresponding author on request. Briefly, we searched multiple electronic databases and used extensive personal communications with researchers and government authorities worldwide to identify and obtain nationally representative dietary intake surveys or, if these were unavailable, large subnational surveys. For countries without identified national or subnational individual-level dietary surveys, we searched for individual-level surveys from large cohort studies as well as other data sources on diet such as the World Health Organization (WHO) Global Infobase, the WHO STEPS database and household expenditure surveys. For trans-unsaturated fatty acids (trans-fats) and dietary sodium, we also searched for biomarker surveys measuring circulating or adipose trans-fat concentrations or 24-hour urinary sodium excretion. Finally, we used the comprehensive United Nations Food and Agricultural Organization (FAO) food balance sheets, (8) which provide country-level data on per capita food availability for major food groups in 187 countries and across the entire time period studied. For trans-fat, we also included industry estimates of nation-specific availability of partially hydrogenated oil, total oils/ fats and total packaged foods per capita from both retail and food-service establishments in 79 countries (Mark Stavro, Bunge LLC, personal communication, 23 May 2012). Due to the limited amount of relevant published data, most survey data were obtained by direct contacts with researchers and officials. By combining all these sources of information, including adjusted FAO data and industry estimates, our final estimates were derived from dietary information drawn from 187 countries. We included data from 325 dietary surveys and 145 urinary sample surveys. The total number of individuals sampled in each surveyed country ranged from several hundred to more than 10000. …

How effective is tobacco control enforcement to protect minors: Results from subnational surveys across four districts in India

Context: On analogy with the WHO's Framework Convention on Tobacco Control, Indian tobacco control legislation, namely, Cigarette and Other Tobacco Products Act (COTPA), prohibits the sale of tobacco products to minors and near an educational institution. Aims: The objectives are to measure the compliance to the provisions of COTPA which bans the tobacco sale to and by the minors, prohibits sale within 100 yards distance of an educational institution, and an overall compliance to guidelines of Tobacco-free educational institutions. Methods: Using a pretested observational checklist, a cross-sectional survey was conducted between January and March 2013 across 1227 point-of-sale and 1408 educational institutions in four districts in India in 2013. Requisite ethical and administrative approvals were taken. Results: The study found moderate to low compliance to the provisions of COTPA regarding the ban on sale of tobacco products, to and by the minors, and around educational institutions. Tobacco products were easily accessible to minors in 57.7% of tobacco shops. The mandatory signages under Section-6 (b) of COTPA were not displayed in less than half of the educational institutions. In nearly one-fifth, tobacco products were being sold in and around 100 yards of institute's boundary. More violations pertaining to Section-6 (a) and 6 (b) were reported in district Jhunjhunu (representing Western India) and district Dhar (representing Central India), respectively, as compared to other jurisdictions under study. The tobacco-free institution guidelines were being followed by most educational institutions of Ernakulam district (representing South India). Conclusions: The present study observed a low compliance with enforcement of Indian tobacco control legislation. Thus, monitoring for compliance of policies and advocacy with policymakers is important for ensuring proper enforcement and preventing youth from initiating into tobacco use.

Burden of Hemoglobinopathies (Thalassemia, Sickle Cell Disorders and G6PD Deficiency) in Iran, 1990-2010: findings from the Global Burden of Disease Study 2010.

Hemoglobinopathies are known as the most common genetic disorders in Iran. The paper aims to provide global estimates of deaths and disability adjusted life years (DALYs) due to hemoglobinopathies in Iran by sex and age during 1990 to 2010 and describe the challenges due to limitations of the Global Burden of Disease Study 2010 (GBD 2010). GBD 2010 estimates of the numbers of deaths and years of life lost (YLLs) due to premature mortality were calculated using the Cause of Death Ensemble model (CODEm). Years of life lost due to disability (YLDs) were computed by multiplication of prevalence, the disability weight for occurrence of sequelae, and the duration of symptoms. Prevalence was estimated through a systematic search of published and available unpublished data sources, with a Bayesian meta-regression model developed for GBD 2010. Disability weights were produced using collected data from population-based surveys. Uncertainty from all inputs was incorporated into the computations of DALYs using simulation methods. We aim to prepare and criticize the results of GBD 2010 and provide some recommendations for reaching better conclusions about the burden of hemoglobinopathies in Iran. Between 1990 and 2010, the overall deaths attributed to hemoglobinopathies decreased from 0.51% to 0.36% of total deaths, with the corresponding burden declining from 1% to 0.82% of total DALYs. There was a reduction in deaths and DALYs rates for all ages and the rates attributed to all ages followed the same pattern in Iranian men and women. The highest DALYs for hemoglobinopathies, thalassemia, sickle cell disorder, and glucose-6-phosphate dehydrogenase deficiency (G6PD-D) were found in those aged less than 5 years. The collective burden of all of these hemoglobin disorder was lower in 2010 than in 1990. Although the screening programs in Iran have been very successful in reducing the number of thalassemia patients between 1990 to 2010, in order to provide a better estimation of the burden of hemoglobin disorders, it is necessary to perform a national and sub-national study of hemoglobinopathies using multiple national and sub-national surveys.

Global rain-fed, irrigated, and paddy croplands: A new high resolution map derived from remote sensing, crop inventories and climate data

Irrigation accounts for 70% of global water use by humans and 33–40% of global food production comes from irrigated croplands. Accurate and timely information related to global irrigation is therefore needed to manage increasingly scarce water resources and to improve food security in the face of yield gaps, climate change and extreme events such as droughts, floods, and heat waves. Unfortunately, this information is not available for many regions of the world. This study aims to improve characterization of global rain-fed, irrigated and paddy croplands by integrating information from national and sub-national surveys, remote sensing, and gridded climate data sets. To achieve this goal, we used supervised classification of remote sensing, climate, and agricultural inventory data to generate a global map of irrigated, rain-fed, and paddy croplands. We estimate that 314 million hectares (Mha) worldwide were irrigated circa 2005. This includes 66Mha of irrigated paddy cropland and 249Mha of irrigated non-paddy cropland. Additionally, we estimate that 1047Mha of cropland are managed under rain-fed conditions, including 63Mha of rain-fed paddy cropland and 985Mha of rain-fed non-paddy cropland. More generally, our results show that global mapping of irrigated, rain-fed, and paddy croplands is possible by combining information from multiple data sources. However, regions with rapidly changing irrigation or complex mixtures of irrigated and non-irrigated crops present significant challenges and require more and better data to support high quality mapping of irrigation.

What happens to lost nets: a multi-country analysis of reasons for LLIN attrition using 14 household surveys in four countries.

BackgroundWhile significant focus has been given to net distribution, little is known about what is done with nets that leave a household, either to be used by others or when they are discarded. To better understand the magnitude of sharing LLIN between households and patterns of discarding LLIN, the present study pools data from 14 post-campaign surveys to draw larger conclusions about the fate of nets that leave households.MethodsData from 14 sub-national post-campaign surveys conducted in Ghana, Senegal, Nigeria (10 states), and Uganda between 2009 and 2012 were pooled. Survey design and data collection methods were similar across surveys. The timing of surveys ranged from 2–16 months following their respective mass LLIN distributions.ResultsAmong the 14 surveys a total of 14,196 households reported owning 25,447 nets of any kind, of which 23,955 (94%) were LLINs. In addition, a total of 4,102 nets were reported to have left the households in the sample: 63% were discarded, and 34% were given away. Only 255 of the discarded nets were reported used for other purposes, representing less than 1% of the total sample of nets. The majority (62.5%) of nets given away were given to or taken by relatives, while 31.1% were given to non-relatives. Campaign nets were almost six times (OR 5.95, 4.25-8.32, p < 0.0001) more likely to be given away than non-campaign nets lost during the same period. Nets were primarily given away within the first few months after distribution. The overall rate of net redistribution was 5% of all nets.Discussion and conclusionIntra-household re-allocation of nets does occur, but was sensitive to current household net ownership and the time elapsed since mass distribution. These factors can be addressed programmatically to further facilitate reallocation within a given community. Secondly, the overwhelming majority of nets were used for malaria prevention. Of the repurposed nets (<1% overall), the majority were already considered too torn, indicating they had already served out their useful life for malaria prevention. National programmes and donor agencies should remain confident that overall, their investments in LLIN are being appropriately used.

How good is compliance with smoke-free legislation in India? Results of 38 subnational surveys.

India has been implementing smoke-free legislation since 2008 prohibiting smoking in public places. This study aimed to assess the level of compliance with smoke-free legislation (defined as the presence of no-smoking signage and the absence of active smoking, smoking aids, cigarette butts/bidi ends and smoking smell) and the role of enforcement systems in Indian jurisdictions. This was a cross-sectional, retrospective review of reports and primary data sheets of surveys conducted in 38 selected jurisdictions across India in 2012-2013. Of 20 455 public places (in 38 jurisdictions), 10 377 (51%) demonstrated full compliance with smoke-free law. Educational institutions and healthcare facilities performed well at 65% and 62%, respectively, while eateries and frequently visited other public places (such as bus stands, railway stations, shopping malls, stadia, cinema halls etc.) performed poorly at 37% and 27%, respectively. Absence of no-smoking signage was the largest contributor to non-compliance across all types of public places. Enforcement systems were present in all jurisdictions, but no associations could be demonstrated between these and smoke-free compliance. Smoke-free compliance in public places in India was suboptimal and was mainly related to the absence of no-smoking signage. This warrants further pragmatic and innovative ways to improve the situation.

Abstract MP76: The Impact of Low Consumption of Fruits and Vegetables on Mortality from Cardiovascular Diseases in 187 Countries

Background: Consumption of fruits and of vegetables each influence CVD risk. Yet, the global CVD mortality attributable to low intakes of each, by country, age, and sex, are not established. Objectives: To quantify the burdens of CVD attributable to low fruit consumption and low vegetable consumption by age and sex in 187 countries in 2010. Methods: We characterized consumption of fruits and vegetables by age, sex, and country based on 204 national and subnational surveys from 109 countries representing 85.2% of the world’s adult population complemented by bayesian hierarchical imputation for missing data. Etiologic effects of fruit and vegetable intake on CHD and stroke were quantified based on meta-analyses of prospective observational studies, supported by effects on CVD risk factors in intervention studies. Cause-specific mortality rates were obtained from the 2010 Global Burden of Diseases Study. CHD and stroke mortality attributable to low intakes of fruits [&lt;300g/d] and vegetables (including legumes) [&lt;400g/d] were estimated using comparative risk assessment, by country, age, and sex. Results: In 2010, 2,814,850 CVD deaths [95%UI: 2,652,230-2,977,471] were attributable to low fruit intake [36% CHD, 17% ischemic stroke, 47% hemorrhagic and other nonischemic stroke] and 1,922,582 CVD deaths [1,839,270-2,005,894] were attributable to low vegetable intake [42% CHD, 21% ischemic stroke, 37% hemorrhagic other nonischemic stroke]. Burdens were similar by sex: 55% and 54% of these deaths, respectively, occurred in men. Nearly 1 in 2 CVD deaths attributable to fruits and 2 in 5 attributable to vegetables occurred prematurely, before age 70 y. Substantial heterogeneity was evident across nations (Figure). Conclusions: These results highlight the substantial burdens as well as disparities in CVD attributable to insufficient consumption of fruits and vegetables around the world, informing prevention strategies and priorities.

National and sub-national burden of chronic diseases attributable to lifestyle risk factors in Iran 1990 - 2013; study protocol.

Non-communicable diseases, as the major public health problem, are caused by different risk factors. The main leading lifestyle risk factors for most diseases burden in Iran are unhealthy diet, physical inactivity, and smoking. The aim of this study is to provide data collection and methodology processes for estimating the trends of exposures to the selected lifestyle risk factors and their attributed burden at national and sub-national levels. Systematic review will be performed through PubMed/MEDLINE, Scopus and ISI/Web of Science as well as Iranian databases such as IranMedex, Irandoc and Scientific Information Database (SID). In addition, hand searching of unpublished data sources will be used to identify relevant population-based studies. The searched studies will be included only if it is reasonably population-based and representative, and exposure data has been reported or could be plausibly obtained from the study. For risk factors with no surveys identified, other sources of potential data will be considered. The target population is healthy Iranian adult population living within Iran from 1990 to 2013. Other data sources include national censuses, national registration systems, and national and sub-national surveys. Spatio-temporal Bayesian hierarchical model and Bayesian multilevel autoregressive model will be used to overcome the problem of data gaps in provinces, and in some age or sex groups or in urban/rural areas. The problem of misaligned areal units will be also addressed in these models. National and sub-national assessment of major lifestyle risk factors such as unhealthy diet, physical inactivity, and smoking is necessary for priority setting and policy making in different regions of Iran.

The trend of national and subnational burden of maternal conditions in Iran from 1990 to 2013: the study protocol.

It is widely accepted that maternal mortality is a proxy for maternal health status. Maternal deaths only represent the top of the iceberg; morbidity due to maternal causes apart from maternal mortality, poses a huge burden on women's families. There is an excessive need to widen the research on maternal morbidity. Here, we explain the framework of our study on maternal conditions and their burden in Iran as a part of the National and Sub-national Burden of Diseases (NASBOD) study. A systematic search will be carried out for both published and unpublished data on maternal mortality and morbidity reported between 1985 and 2013. Data collected through systematic review and those obtained from national and sub-national surveys will be extracted in a data set. Two statistical models will be applied: Bayesian Autoregressive Multi-level models and Spatio-Temporal Regression models. Models will be used to overcome the problem of data gaps across provinces, years and age groups. In order to control and manage maternal conditions and to make more efficient and cost-effective policies, there is an excessive need for data on the burden of such diseases. There are a few sub-national analyses of the burden of disease. In the current study, burden of maternal conditions will be assessed at national and sub-national levels in Iran between 1990 and 2013. The results of this study are undoubtedly required to provide comprehensive information at the national and provincial levels to administer interventions more effectively, since the priority based policies need regional assessments and comparisons.

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<i>Circulation</i> Editors’ Picks

Recent forest expansion in Thailand: a methodological artifact?

Several Asian developing countries recently reported a net increase in forest cover. In Thailand, such reports have been vehemently rejected by forest officials, researchers, politicians, and international organizations alike. According to the dominant interpretation, the apparent forest regrowth derives from a methodological artifact. While the determination of the true evolution of forest cover has important implications, this interpretation has never been subject to scrutiny. This article presents a broad range of data and analyses suggesting important flaws in this interpretation. Based notably on (1) a critical review of available forest statistics and the methodology used to produce these statistics, (2) case study material from northern Phetchabun Province, and (3) an analysis of recent sub-national remote-sensing surveys, we reject the dominant interpretation of official statistics and suggest that reforestation has increased in Thailand and plausibly became the overall trend in the late 1990s.

Availability of data for monitoring noncommunicable disease risk factors in India

To examine the availability of data measuring noncommunicable disease (NCD) risk factor indicators from household surveys conducted in India from 2000 to 2009. Questionnaires and publications used in household surveys were identified through internet and PubMed searches and examined to determine which core NCD risk factor indicators recommended by the World Health Organization (WHO) for NCD monitoring were being measured. Surveys with a sample size of 5000 or more were included to ensure a certain level of precision. The completeness of core indicator measurement and the geographical representativeness of the surveys were assessed. Twenty six surveys met the inclusion criteria. Among the WHO-recommended core behavioural risk factor indicators, those monitoring tobacco use were measured completely in national and subnational surveys; those assessing dietary intake and physical inactivity were measured only in subnational surveys, and those assessing alcohol use were not measured at all. Among WHO-recommended core biological risk factors, only body mass index was measured in national and subnational surveys, whereas blood pressure, fasting blood glucose and blood cholesterol were measured only in subnational surveys. Due to the use of non-standard indicator definitions, measurement of core indicators in some of the national and subnational surveys was incomplete. The availability of data on core risk factor indicators to monitor the increasing burden of NCDs is inadequate in India. These indicators using standardized definitions should be included in the periodic national household health surveys to provide data at the national and disaggregated levels.

Combination prevention: a deeper understanding of effective HIV prevention

Evidence-informed and human rights-based combination prevention combines behavioural, biomedical, and structural interventions to address both the immediate risks and underlying causes of vulnerability to HIV infection, and the pathways that link them. Because these are context-specific, no single prescription or standard package will apply universally. Anchored in 'know your epidemic' estimates of where the next 1000 infections will occur and 'know your response' analyses of resource allocation and programming gaps, combination prevention strategies seek to realign programme priorities for maximum effect to reduce epidemic reproductive rates at local, regional, and national levels. Effective prevention means tailoring programmes to local epidemics and ensuring that components are delivered with the intensity, quality, and scale necessary to achieve intended effects. Structural interventions, addressing the social, economic, cultural, and legal constraints that create HIV risk environments and undermine the agency of individuals to protect themselves and others, are also public goods in their own right. Applying the principles of combination prevention systematically and consistently in HIV programme planning, with due attention to context, can increase HIV programme effectiveness. Better outcome and impact measurement using multiple methods and data triangulation can build the evidence base on synergies between the components of combination prevention at individual, group, and societal levels, facilitating iterative knowledge translation within and among programmes.

Medicine prices, availability, and affordability in 36 developing and middle-income countries: a secondary analysis

WHO and Health Action International (HAI) have developed a standardised method for surveying medicine prices, availability, affordability, and price components in low-income and middle-income countries. Here, we present a secondary analysis of medicine availability in 45 national and subnational surveys done using the WHO/HAI methodology. Data from 45 WHO/HAI surveys in 36 countries were adjusted for inflation or deflation and purchasing power parity. International reference prices from open international procurements for generic products were used as comparators. Results are presented for 15 medicines included in at least 80% of surveys and four individual medicines. Average public sector availability of generic medicines ranged from 29.4% to 54.4% across WHO regions. Median government procurement prices for 15 generic medicines were 1.11 times corresponding international reference prices, although purchasing efficiency ranged from 0.09 to 5.37 times international reference prices. Low procurement prices did not always translate into low patient prices. Private sector patients paid 9-25 times international reference prices for lowest-priced generic products and over 20 times international reference prices for originator products across WHO regions. Treatments for acute and chronic illness were largely unaffordable in many countries. In the private sector, wholesale mark-ups ranged from 2% to 380%, whereas retail mark-ups ranged from 10% to 552%. In countries where value added tax was applied to medicines, the amount charged varied from 4% to 15%. Overall, public and private sector prices for originator and generic medicines were substantially higher than would be expected if purchasing and distribution were efficient and mark-ups were reasonable. Policy options such as promoting generic medicines and alternative financing mechanisms are needed to increase availability, reduce prices, and improve affordability.

AIDS, drought, and child malnutrition in southern Africa

To investigate trends in child malnutrition in six countries in southern Africa, in relation to the HIV epidemic and drought in crop years 2001/2 and 2002/3. Epidemiological analysis of sub-national and national surveys with related data. Data from Lesotho, Malawi, Mozambique, Swaziland, Zambia and Zimbabwe, compiled and analysed under UNICEF auspices. Secondary data: children 0-5 years for weight-for-age; HIV prevalence data from various sources especially antenatal clinic surveillance. Child nutritional status as measured by prevalence of underweight deteriorated from 2001 onwards in all countries except Lesotho, with very substantial increases in some provinces/districts (e.g. from 5 to 20% in Maputo (Mozambique, 1997-2002), 17 to 32% in Copperbelt (Zambia, 1999-2001/2) and 11 to 26% in Midlands province (Zimbabwe, 1999-2002)). Greater deterioration in underweight occurred in better-off areas. Areas with higher HIV/AIDS prevalences had (so far) lower malnutrition rates (and infant mortality rates), presumably because more modern areas--with greater reliance on trade and wage employment--have more HIV/AIDS. Areas with higher HIV/AIDS showed more deterioration in child nutrition. A significant area-level interaction was found of HIV/AIDS with the drought period, associated with particularly rapid deterioration in nutritional status. First, the most vulnerable may be households in more modern areas, nearer towns, to whom resources need to be directed. Second, the causes of this vulnerability need to be investigated. Third, HIV/AIDS amplifies the effect of drought on nutrition, so rapid and effective response will be crucial if drought strikes again. Fourth, expanded nutritional surveillance is now needed to monitor and respond to deteriorating trends. Finally, with or without drought, new means are needed of bringing help, comfort and assistance to the child population.