Gary L. Darmstadt, MD, MS, is Associate Dean for Maternal and Child Health, and Professor of Neonatal and Developmental Pediatrics in the Department of Pediatrics at the Stanford University School of Medicine. Previously Dr. Darmstadt was Senior Fellow in the Global Development Program at the Bill & Melinda Gates Foundation (BMGF), where he led a cross-foundation initiative on Women, Girls and Gender, assessing how addressing gender inequalities and empowering women and girls leads to improved gender equality as well as improved health and development outcomes. Prior to this role, he served as BMGF Director of Family Health, leading strategy development and implementation across nutrition, family planning and maternal, newborn and child health.

Darmstadt was formerly Associate Professor and Founding Director of the International Center for Advancing Neonatal Health in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health. He has trained in Pediatrics at Johns Hopkins University, in Dermatology at Stanford University, and in Pediatric Infectious Disease as a fellow at the University of Washington, Seattle, where he was Assistant Professor in the Departments of Pediatrics and Medicine. Dr. Darmstadt left the University of Washington to serve as Senior Research Advisor for the Saving Newborn Lives program of Save the Children-US, where he led the development and implementation of the global research strategy for newborn health and survival, before joining Johns Hopkins.

Administrative Appointments

  • Affiliated Faculty Member, Woods Institute for the Environment (2015 - Present)
  • Associate Dean for Maternal and Child Health, Stanford University School of Medicine (2015 - Present)
  • Faculty Affiliate, King Center on Global Development (2015 - Present)
  • Faculty Affiliate, Stanford Program on Water, Health, & Development (2015 - Present)
  • Faculty Fellow, Center for Innovation in Global Health (CIGH) at Stanford University School of Medicine (2015 - Present)
  • Member, Center for Population Health Sciences (2015 - Present)
  • Member, Stanford Medicine Teaching and Mentoring Academy, Stanford University (2015 - Present)
  • Professor and Co-Director of Global Pediatric Research, Department of Pediatrics, Stanford University School of Medicine (2015 - Present)
  • Senior Fellow, Freeman Spogli Institute for International Studies (2015 - Present)
  • Senior Fellow, Global Development Division, Bill & Melinda Gates Foundation, Seattle, WA (2013 - 2014)
  • Director, Family Health Programs, Global Development Division, Bill & Melinda Gates Foundation, Seattle, WA (2010 - 2013)
  • Interim Deputy Director, Strategic Project Team Lead, Maternal, MNCH, IHSD, Global Health Program, Bill and Melinda Gates Foundation, Seattle, WA (2008 - 2010)
  • Senior Program Officer, Newborn Health, MNCH Team Member, IHSD, Global Health Program, Bill and Melinda Gates Foundation, Seattle, WA (2008 - 2008)
  • Associate Professor, Department of International Health, Bloomberg School of Public Health, The Johns Hopkins University (2005 - 2008)
  • Founding Director, International Center for Advancing Neonatal Health, Bloomberg School of Public Health, The Johns Hopkins University (2005 - 2008)
  • Assistant Professor, Department of International Health, Bloomberg School of Public Health, The Johns Hopkins University (2002 - 2004)
  • Senior Research Advisor, Saving Newborn Lives Initiative, Office of Health, Save the Children Federation-US, Washington, DC (2000 - 2005)
  • Assistant Professor, Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA (1999 - 2000)
  • Assistant Professor, Division of Dermatology, Department of Pediatrics, Children's Hospital & Regional Medical Center (1999 - 2000)
  • Assistant Professor, Division of Infectious Disease, Rheumatology & Immunology, Department of Pediatrics, Children's Hospital & Regional Medical Center (1999 - 2000)
  • Adjunct Assistant Professor, Division of Community Health and Health Systems, Department of International Health, Bloomberg School of Public Health, The Johns Hopkins University (1998 - 2002)
  • Acting Assistant Professor, Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA (1998 - 1999)
  • Acting Assistant Professor, Division of Dermatology, Department of Pediatrics, Children's Hospital & Regional Medical Center (1998 - 1999)
  • Acting Assistant Professor, Division of Infectious Disease, Rheumatology & Immunology, Department of Pediatrics, Children's Hospital & Regional Medical Center (1998 - 1999)
  • Staff Pediatrician, Department of Pediatrics, Kaiser Permanente Medical Group, Hayward and Redwood City, CA (1992 - 1994)

Honors & Awards

  • Faculty Research Fellow, Clayman Institute for Gender Research, Stanford University (2017-2018)
  • 2017 Outstanding Alumnus, University of California, San Diego (2017)
  • Society of Scholars, Johns Hopkins University (2016)
  • Sidney Hurwitz Visiting Professor, Society for Pediatric Dermatology (2015)
  • Top 10 Global Health Milestones of 2012, First Place, LondonSummit on Family Planning Ignites $2.6 billion in Commitment (2012)
  • Holy Cow Award (for extraordinary contribution in Social and Behavioral Change initiatives), Bill & Melinda Gates Foundation (2011)
  • BRAVO Award (for most outstanding cross-program), India Project Team, Bill & Melinda Gates Foundation (2010)
  • Paper of the Year nomination, British Medical Journal (for article in Pediatrics 2007) (2009)
  • Paper of the Year, The Lancet (2008)
  • Best Poster, Countdown to 2015, Tracking Progress in Child Survival (2005)
  • Best Communication, The skin and nutritional problems of the newborn, International Congress of Neonatal Dermatology (1998)
  • First Place, San Francisco Dermatologic Society Resident Forum (1994)
  • Johns Hopkins Francis F. Schwentker Research Award, Department of Pediatrics, JHU (1992)
  • Johns Hopkins Francis F. Schwentker Research Award, Department of Pediatrics, JHU, Dermatitis as a presenting sign of cystic fibrosis (1991)
  • Secretary's Award for Innovations in Health Promotion and Disease Prevention, Honorable Mention, Establishment of community-based child abuse prevention services in North San Diego County (1988)
  • Highest Honors, California Polytechnic State University (CPSU) Graduation (1979)
  • Honors, Gamma Sigma Delta (Agricultural) Honor Society (1979)
  • President's Honor List, California Polytechnic State University (1979)
  • Phi Kappa Phi, Honor Society (1978)

Boards, Advisory Committees, Professional Organizations

  • Advisory Board, The 2030 Collaborative (2019 - Present)
  • Inclusion & Diversity Advisory Board, Elsevier (2019 - Present)
  • Scientific Advisory Team, Avadim Health (2019 - Present)
  • Advisory Group, Research prioritization of maternal, newborn, child and adolescent health (MNCAH) in humanitarian emergencies, World Health Organization (2018 - Present)
  • Advisory Group, World Health Organization Global Scales of Early Development Project (2018 - Present)
  • Global Mental Health External Advisory Board, University of Washington (2018 - Present)
  • UNICEF Specialist Advisor, Children with Developmental Delays and Disabilities (2018 - Present)
  • Member, Global Hygiene Council (2016 - Present)
  • Advisory Board, Maternal Child Health, World Health Organization, South East Asia Region (2015 - Present)
  • Advisory Group, Lancet Stillbirth Series (2015 - Present)
  • Steering Committee Chair, Gender in Health and Development Lancet Series (2015 - Present)
  • Board member, Autism Speaks, Global Action Committee of the Board (2014 - Present)
  • Board of Directors, Project Mercy (2013 - Present)
  • Executive Committee, Forum on Investing in Young Children Globally, Institute of Medicine (2013 - Present)
  • R&D Advisory Board, GlaxoSmithKline - Save the Children (2013 - Present)
  • Steering Committee, Early Child Development Lancet Series (2013 - Present)
  • Strategic Advisory Group, Saving Newborn Lives, Save the Children (2013 - Present)
  • Advisory Group, Every Newborn Action Plan (2013 - 2014)
  • Chair, Evaluation Committee, Partnership for Maternal, Newborn and Child Health (PMNCH) (2013 - 2014)
  • Steering Committee, Every Newborn Lancet Series (2013 - 2014)
  • Global Health Advisory Board, Institute of Medicine (2011 - Present)
  • Global Action Council on Population Growth, World Economic Forum (2011 - 2013)
  • Board of Directors, Agros International (2010 - Present)
  • Board of Directors Co-Chair and Member, Global Alliance for Improved Nutrition (2010 - 2013)
  • Steering Committee, Saving Lives at Birth, A Grand Challenge for Development (2010 - 2013)
  • Technical Advisory Group, Saving Newborn Lives Program (2008 - 2010)
  • Member, Society for Pediatric Research (2002 - Present)
  • Member, American Academy of Dermatology (1998 - Present)
  • Member, Pediatrics Infectious Disease Society (1995 - Present)
  • Fellow, American Academy of Pediatrics (1993 - Present)
  • Member, American Academy of Pediatrics (1993 - Present)
  • Fellow, American Academy of Dermatology (1992 - Present)

Professional Education

  • Exectutive Education, Harvard Kennedy School, Boston, MA, Leadership for the 21st Century (2013)
  • Gear Up Program, Bill & Melinda Gates Foundation, Seattle, WA, Manager effectiveness training (2013)
  • Executive Education, Harvard Kennedy School, Boston, MA, Leadership Decision Making: Optimizing Organizational Performance (2012)
  • Fellow, Children's Hospital & Medical Center, University of Washington School of Medicine, Seattle, WA, Division of Infectious Disease (1997)
  • Resident, Stanford University School of Medicine, Stanford, CA, Department of Dermatology (1994)
  • Resident, Johns Hopkins University School of Medicine, Baltimore, MD, Pediatrics (1992)
  • B.S., California Polytechnic State University (CPSU), San Luis Obispo (graduated with Highest Honors), Crop Science (1979)
  • M.S., University of Wisconsin, Madison, Agronomy (Plant Physiology) (1982)
  • M.D., University of California, San Diego (UCSD), Dermatology (1989)

Community and International Work

  • Impact of Pneumococcal Vaccine Introduction in Bangladesh, Bangladesh


    Childhood Vaccination

    Partnering Organization(s)

    Child Health Research Foundation

    Populations Served

    Children in Bangladesh



    Ongoing Project


    Opportunities for Student Involvement


  • Etiology and Incidence of Neonatal Infections in South Asia, Bangladesh, Pakistan, & India


    Neonatal Infections

    Partnering Organization(s)

    Child Health Research Foundation

    Populations Served

    Newborns in Bangladesh, Pakistan, & India



    Ongoing Project


    Opportunities for Student Involvement


  • Establishment of Child Development Centers in Bangladesh, Bangladesh


    Child Developmental Assessment and Management

    Partnering Organization(s)

    Dhaka Shishu Hospital

    Populations Served

    Children in Bangladesh



    Ongoing Project


    Opportunities for Student Involvement


  • Development and validation of a Rapid Neurodevelopmental Assessment tool, Dhaka, Bangladesh


    child development assessment

    Partnering Organization(s)

    Dhaka Shishu Hospital

    Populations Served

    Children in Bangladesh



    Ongoing Project


    Opportunities for Student Involvement


  • Topical emollient therapy in the management of severe acute malnutrition, Dhaka, Bangladesh


    Treatment of Severe Acute Malnutition

    Partnering Organization(s)

    icddr,b, GlaxoSmithKline

    Populations Served

    Under-2 Children in Bangladesh



    Ongoing Project


    Opportunities for Student Involvement


Research & Scholarship


  • Lancet Series on the Next Generation of Gender Equality, Stanford University (11/1/2015 - 12/2019)

    Major new visibility on the importance of investing in women and girls has created new opportunities to accelerate advances in health and development of nations around the world. A more intentional approach to addressing gender norms and gender inequalities in policies, programs and research is critical to this effort. We are working with the Lancet to develop a series of papers on the following topics:

    1. Unlocking human potential through shaping gender norms
    2. Unlocking gender norm data
    3. Unlocking gender norm change to achieve health and development impact at scale
    4. Unlocking gender norm change in systems to ensure sustainability of health and development impact
    5. Unlocking global action to shape gender norms and optimize health and development across the life course

    Through these papers, we hope to i) propose a conceptual framework for associations between gender norms, gender inequalities and health and development, ii) place the development and shaping of gender norms and gender equality in historical perspective, iii) define the global scope and size of issues of unhealthy gender norms and gender inequalities across the life course (with a focus on early childhood, adolescence, and early and late adulthood), including costs of inaction, in high, middle and low-income countries, iv) synthesize the existing evidence for approaches to shape gender norms, v) quantify the benefits of addressing unhealthy gender norms and gender inequalities for women, girls, men and boys, vi) calculate the cost to implement these solutions at scale, vii) define global metrics, and viii) develop a concrete action plan to advance healthy gender norms as well as health and development of women, men, girls and boys, and of societies worldwide.


    Stanford, CA

  • Topical emollient Therapy in the Management of Severe Acute Malnutrition: A Randomized Controlled Clinical Trial in Bangladesh, icddr,b, GlaxoSmithKline (4/2015 - 12/2017)

    Topical emollient therapy in the management of severe acute malnutrition: A randomized controlled clinical trial in Bangladesh to test whether rehabilitation from severe acute malnutrition can be accelerated through topical applications of sunflower seed oil.




    • Rachel Gibson, Senior Discovery Medicine Scientist, Maternal and Neonatal Health Unit, GlaxoSmithKline, London, UK
    • Pauline Williams, Vice President, Health of Global Health R&D, GlaxoSmithKline, London, UK
    • KM Shahuuja, Clinical Researcher, icddr,b, Dhaka, Bangladesh
    • Tahmeed Ahmed, Director, Centre for Nutrition and Food Security, icddrb, Dhaka, Bangladesh
    • Md Igbal Hossain, Senior Scientist, icddr,b, Dhaka, Bangladesh
  • Reducing infectious disease exposure among school-aged children in developing countries: The WaSH Up! Alliance, Stanford University (July 1, 2016 - 2/2021)

    WaSH Up! is a partnership between Sesame Street, World Vision, and Stanford University to reduce child disease and death by ensuring children have access to safe water and sanitation by practice healthy behaviors relators to water, sanitation and hygiene (WaSH). Sesame Workshop has worked to created a new Muppet character named Raya, a girl ambassador who promotes safe WaSH practices. Sesame Workshop with World Vision announces a commitment to roll out WaSH Up! across 15 countries in the next six years. The team at Stanford University will be the primary evaluator and research partner, investigating school- and community-based interventions. Stanford will contribute a strong theoretical grounding leading to improvements
    in program design and impact, to design a rigorous evaluation of the program’s impacts, and to
    identify and pursue complementary research opportunities.


    Lusaka, Zambia


    • Jenna Davis, Professor of Civil and Environmental Engineering and Senior Fellow at the Woods Institute for the Environment, Stanford University
  • Creating a Scalable Model to End Poverty: Delivery of an Integrated Childhood Development Strategy in Rural China

    To building on existing programs and collaborations between the Rural Education and Action Program (REAP) and the Chinese government to pilot, deliver, and evaluate an integrated, community-based program for children 0-3 years in existing parenting center in rural China.


    Shaanxi, China


    • Scott Rozelle, Helen C. Farnsworth Professor in International Agricultural Policy and Senior Fellow at the Stanford Institute for Economic Policy Research, Stanford University
  • The Lancet Series: Advancing Early Childhood Development: from Science to Scale, The Lancet

    The 2016 Lancet Early Childhood Development Series highlights early childhood development at a time when it has been universally endorsed in the 2030 Sustainable Development Goals. This Series considers new scientific evidence for interventions, building on the findings and recommendations of previous Lancet Series on child development (2007, 2011), and proposes pathways for implementation of early childhood development at scale. The Series emphasises 'nurturing care', especially of children below three years of age, and multi-sectoral interventions starting with health, which can have wide reach to families and young children through health and nutrition.



  • Learning from Ananya - Scaling Up Improved Family Health, Stanford University (12/2016 - 12/2019)

    The Stanford University (SU) School of Medicine “Co-Creation” group will employ a mixed quantitative and qualitative methods approach to analyze/mine existing data sets, dialogue with implementers and evaluators, and share the knowledge and data gained from the Bill and Melinda Gates Foundation (BMGF)-funded Ananya program in Bihar, India. SU will conduct this analysis to disseminate learning from Ananya to inform the scale-up of national and global family health (reproductive, maternal, newborn and child health and nutrition, RMNCHN) interventions. In close collaboration with the BMGF India Country Office (ICO), and Ananya implementation and evaluation partners, SU will analyze and synthesize a range of existing data sources, which – together with the primary qualitative data we will collect – will inform the development of core peer-reviewed articles and additional papers and policy briefs. These insights will help the BMGF Program Strategy Teams (PSTs), the government of Bihar, Ananya grantees, and the broader global health community make evidence-informed decisions to optimize the coverage, quality and impact of their investments in improving maternal and child health outcomes.


    Bihar, India


    • Mark Cullen, Professor, Stanford University School of Medicine
    • Wolfgang Munar, Research Professor, Department of Global Health, George Washington University
  • Uncovering gender inequalities in East Africa: Using artificial intelligence to gain insights from media data, Stanford Human-centered Artificial Intelligence Institute (5/2019 - 4/2020)

    Major goals: 1) Create word embeddings for gendered terms utilizing East-African corpora of media data to gain insights into the ways different gender groups may be perceived and labelled in the region; 2) create a database of word embeddings trained on publicly available sources, focusing on Kenya; 3) overlay relevant country-level statistics to assess how gender stereotypes identified through word embeddings reflect gender-inequitable behavior in the region, and 4) measure bias contained in embeddings of words related to women and men separately as they compare to embeddings containing neutral words



  • Women’s Empowerment Collectives (WEC) Research Consortium Global Data and Learning Partnership, American Institutes for Research (though a grant from the Bill and Melinda Gates Foundation) (11/2018 - 10/2022)

    Major goals: Consolidate and strengthen the evidence base on the impact and cost-effectiveness of WECs, through three streams of work: (a) design and implement a portfolio evaluation, (b) serve as an evaluation anchor to provide technical assistance to BMGF and evaluation teams supported by BMGF, and (c) contribute to the global evidence base through synthesizing existing research and producing research based on primary data.



  • Landscaping women’s economic empowerment (WEE) in East Africa, Bill and Melinda Gates Foundation (11/2018 - 12/2019)

    Major goals: Landscape WEE in East Africa, including a mapping of gender equality researchers, policies, programs, practitioners, data, publications, media coverage and funders.



  • Gender integration strategy support and product development, Bill and Melinda Gates Foundation (11/2018 - 12/2020)

    Major goals: Support expansion of the BMGF’s gender integration work through development of an on-demand model for technical assistance and learning on gender integration. Support program teams to become gender intentional; develop customized gender integration tools, disseminate key lessons learned, and provide strategic support to leadership to set appropriate targets, measures and accountability mechanisms.



  • Determination of gestational age and preterm birth rates in low resource settings using newborn metabolic profiles, Bill and Melinda Gates Foundation (11/2017 - 12/2020)

    Major goals: Investigate approaches to improve the methodology, and demonstrate the feasibility of using newborn blood spots, cord blood and/or maternal blood to estimate gestational age of newborns in Africa and Asia through metabolic and computational analysis in collaboration with the Ottawa Hospital Research Initiative and the Ontario Newborn Screening Program.


    Africa and Asia

  • Reducing hospital-acquired infections (HAIs) in Bangladesh, Centers for Disease Control and Prevention (9/2016 - 9/2021)

    Majors goals: 1) Identify a potential set of evidence-based interventions for reducing HAIs in neonates in low- and middle-income countries; 2) Perform a pilot study to test interventions at three facilities in Bangladesh to assess their acceptance, feasibility, and cost; and select interventions to bundle for implementation; 3) Conduct a baseline evaluation to assess current incidence of HAIs and identify current newborn care practices, and then evaluate the efficacy of the selected bundle of interventions to reduce HAIs and mortality in neonatal wards and NICUs at three hospitals in Bangladesh; 4) Engage frontline hospital staff across the three facilities in a collaborative effort to integrate a sustainable culture of quality improvement into neonatal wards/NICUs at all three hospitals.



  • Creating a scalable model to end poverty: Delivery of an integrated childhood development strategy in rural China, The Enlight Foundation Fund (9/2016 - 8/2024)

    Major goals: To build on existing programs and collaborations between the Rural Education and Action Program (REAP) and the Chinese government to pilot, deliver, and evaluate an integrated, community-based health, nutrition and child stimulation program for children 0-3 years in rural China.



  • Bringing it Home: Driving School-based WASH Messaging into the Household Environment, USAID (4/2019 - 9/2021)




    • Jenna Davis, Professor of Civil and Environmental Engineering and Senior Fellow at the Woods Institute for the Environment, Stanford University
  • Using existing data to investigate relationships between social norms and adolescent health behaviors and outcomes, Bill and Melinda Gates Foundation (2016 - 2019)



  • Emollient therapy for severe acute malnutrition (SAM): Randomized controlled clinical trial in Bangladesh, Thrasher Research Fund (2015 - 2018)



  • Ethiopia Gender Transformational Leadership (12/2019 - 3/2021)



  • Gender integration work with Echidna Giving (1/2020 - 12/2020)



  • Bihar data repository and analysis (5/2020 - 12/2020)


    Bihar, India

  • Gender equality mainstreaming philanthropy resources & workshops #GESI (6/2020 - 11/2021)



  • Analysis and dissemination of learning from Aetiology of Neonatal Infection in South Asia, New Venture Fund (6/2020 - 6/2021)



  • Risk factors for an emerging threat: patterns of antibiotic-resistant Campylobacter in households in rural Sitapur, India, Stanford Center for Innovation in Global Health Seed Award (3/2020 - 2/2021)


    Sitapur, India


    • Alexandria Boehm, Professor of Civil and Environmental Engineering and Senior Fellow at the Woods Institute for the Environment, Stanford University
  • Thematic research on National Rural Livelihoods project in India, International Initiative for Impact Evaluation (3ie) (11/2020 - 6/2021)



  • Skin barrier repair therapy for prevention of serious infections and atopic diseases in young children in Bangladesh, Islamic Development Bank Transform Fund (1/2021)



  • A Mobile Autism Risk Initiative (AMARI) to detect Autism Spectrum Disorder in Bangladeshi children under the age of 4, Islamic Development Bank Transform Fund (1/2021)




Stanford Advisees

  • Med Scholar Project Advisor
    Tasnim Ahmed
  • Doctoral Dissertation Reader (AC)
    James Winter


All Publications

  • Impact of emollient therapy for preterm infants in the neonatal period on child neurodevelopment in Bangladesh: an observational cohort study. Journal of health, population, and nutrition Darmstadt, G. L., Khan, N. Z., Rosenstock, S., Muslima, H., Parveen, M., Mahmood, W., Ahmed, A. S., Chowdhury, M. A., Zeger, S., Saha, S. K. 2021; 40 (1): 24


    BACKGROUND: Topical treatment with sunflower seed oil (SSO) or Aquaphor reduced sepsis and neonatal mortality in hospitalized preterm infants <33 weeks' gestational age in Bangladesh. We sought to determine whether the emollient treatments improved neurodevelopmental outcomes during early childhood.METHODS: 497 infants were randomized to receive SSO, Aquaphor, or neither through the neonatal period or hospital discharge. 159 infant survivors were enrolled in the longitudinal follow-up study using a validated Rapid Neurodevelopmental Assessment tool and the Bayley Scales of Infant Development II (BSID II) administered at three-monthly intervals for the first year and thereafter at six-monthly intervals. Lowess smoothing was used to display neurodevelopmental status across multiple domains by age and treatment group, and Generalized Estimating Equations (GEE) were used to compare treatment groups across age points.RESULTS: 123 children completed at least one follow-up visit. Lowess graphs suggest that lower proportions of children who received massage with either SSO or Aquaphor had neurodevelopmental delays than control infants in a composite outcome of disabilities. In GEE analysis, infants receiving SSO showed a significant protective effect on the development of fine motor skills [odds ratio (OR) 0.92, 95% confidence interval (CI) 0.86-0.98, p=0.006]. The Psychomotor Development Index (PDI) in the BSID II showed significantly lower disability rates in the Aquaphor group (23.6%) compared to the control (55.2%) (OR 0.21, 95% CI 0.06-0.72, p=0.004).CONCLUSIONS: Emollient massage of very preterm, hospitalized newborn infants improved some child neurodevelopmental outcomes over the first 2 years of follow-up. Findings warrant further confirmatory research.TRIAL REGISTRATION: (98-04-21-03-2) under weblink

    View details for DOI 10.1186/s41043-021-00248-9

    View details for PubMedID 34039435

  • Levels and potential drivers of under-five mortality sex ratios in low- and middle-income countries PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Costa, J., Weber, A. M., Abdalla, S., Darmstadt, G. L., Victora, C. G. 2021

    View details for DOI 10.1111/ppe.12763

    View details for Web of Science ID 000654436400001

  • Gendered effects of COVID-19 on young girls in regions of conflict. Lancet (London, England) Nesamoney, S. N., Darmstadt, G. L., Wise, P. H. 2021; 397 (10288): 1880-1881

    View details for DOI 10.1016/S0140-6736(21)00936-3

    View details for PubMedID 34022981

  • Addressing the impacts of COVID-19 on gender equality and global health security in regions of violent conflict. Journal of global health Nesamoney, S. N., Darmstadt, G. L., Wise, P. H. 2021; 11: 03074

    View details for DOI 10.7189/jogh.11.03074

    View details for PubMedID 34055324

  • Integrated trajectories of the maternal metabolome, proteome, and immunome predict labor onset. Science translational medicine Stelzer, I. A., Ghaemi, M. S., Han, X., Ando, K., Hedou, J. J., Feyaerts, D., Peterson, L. S., Rumer, K. K., Tsai, E. S., Ganio, E. A., Gaudilliere, D. K., Tsai, A. S., Choisy, B., Gaigne, L. P., Verdonk, F., Jacobsen, D., Gavasso, S., Traber, G. M., Ellenberger, M., Stanley, N., Becker, M., Culos, A., Fallahzadeh, R., Wong, R. J., Darmstadt, G. L., Druzin, M. L., Winn, V. D., Gibbs, R. S., Ling, X. B., Sylvester, K., Carvalho, B., Snyder, M. P., Shaw, G. M., Stevenson, D. K., Contrepois, K., Angst, M. S., Aghaeepour, N., Gaudilliere, B. 2021; 13 (592)


    Estimating the time of delivery is of high clinical importance because pre- and postterm deviations are associated with complications for the mother and her offspring. However, current estimations are inaccurate. As pregnancy progresses toward labor, major transitions occur in fetomaternal immune, metabolic, and endocrine systems that culminate in birth. The comprehensive characterization of maternal biology that precedes labor is key to understanding these physiological transitions and identifying predictive biomarkers of delivery. Here, a longitudinal study was conducted in 63 women who went into labor spontaneously. More than 7000 plasma analytes and peripheral immune cell responses were analyzed using untargeted mass spectrometry, aptamer-based proteomic technology, and single-cell mass cytometry in serial blood samples collected during the last 100 days of pregnancy. The high-dimensional dataset was integrated into a multiomic model that predicted the time to spontaneous labor [R = 0.85, 95% confidence interval (CI) [0.79 to 0.89], P = 1.2 * 10-40, N = 53, training set; R = 0.81, 95% CI [0.61 to 0.91], P = 3.9 * 10-7, N = 10, independent test set]. Coordinated alterations in maternal metabolome, proteome, and immunome marked a molecular shift from pregnancy maintenance to prelabor biology 2 to 4 weeks before delivery. A surge in steroid hormone metabolites and interleukin-1 receptor type 4 that preceded labor coincided with a switch from immune activation to regulation of inflammatory responses. Our study lays the groundwork for developing blood-based methods for predicting the day of labor, anchored in mechanisms shared in preterm and term pregnancies.

    View details for DOI 10.1126/scitranslmed.abd9898

    View details for PubMedID 33952678

  • Setting research priorities for sexual, reproductive, maternal, newborn, child and adolescent health in humanitarian settings. Conflict and health Kobeissi, L., Nair, M., Evers, E. S., Han, M. D., Aboubaker, S., Say, L., Rollins, N., Darmstadt, G. L., Blanchet, K., Garcia, D. M., Hagon, O., Ashorn, P., Members of the WHO research prioritization group for SRMNCAH promotion in humanitarian settings, Abbas, D., Abdi, H., Al-Nsour, M., Baingana, F. K., Bashour, H. N., Casey, S., Chi, P. C., Dakkak, H., Devakumar, D., Hynes, M., Garry, S., Ippe, J., Mitu, N. J., Jojan, S. A., Kozuki, N., Mahmood, Q., Mann, P., Mates, E., Mangen, P. O., Ozmert, E., Petrucci, R., Tappis, H., Wood, G. 2021; 15 (1): 16


    BACKGROUND: An estimated 70.8 million people are forcibly displaced worldwide, 75% of whom are women and children. Prioritizing a global research agenda to inform guidance, service delivery, access to and quality of services is essential to improve the survival and health of women, children and adolescents in humanitarian settings.METHOD: A mixed-methods design was adapted from the Child Health and Nutrition Research Initiative (CHNRI) methodology to solicit priority research questions across the sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) domains in humanitarian settings. The first step (CHNRI) involved data collection and scoring of perceived priority questions, using a web-based survey over two rounds (first, to generate the questions and secondly, to score them). Over 1000 stakeholders from across the globe were approached; 177 took part in the first survey and 69 took part in the second. These research questions were prioritized by generating a research prioritization score (RPP) across four dimensions: answerability, program feasibility, public health relevance and equity. A Delphi process of 29 experts followed, where the 50 scored and prioritized CHRNI research questions were shortlisted. The top five questions from the CHNRI scored list for each SRMNCAH domain were voted on, rendering a final list per domain.RESULTS: A total of 280 questions were generated. Generated questions covered sexual and reproductive health (SRH) (n=90, 32.1%), maternal health (n=75, 26.8%), newborn health (n=42, 15.0%), child health (n=43, 15.4%), and non-SRH aspects of adolescent health (n=31, 11.1%). A shortlist of the top ten prioritized questions for each domain were generated on the basis of the computed RPPs. During the Delphi process, the prioritized questions, based on the CHNRI process, were further refined. Five questions from the shortlist of each of the SRMNCAH domain were formulated, resulting in 25 priority questions across SRMNCAH. For example, one of the prioritized SRH shortlisted and prioritized research question included: "What are effective strategies to implement good quality comprehensive contraceptive services (long-acting, short-acting and EC) for women and girls in humanitarian settings?"CONCLUSION: Data needs, effective intervention strategies and approaches, as well as greater efficiency and quality during delivery of care in humanitarian settings were prioritized. The findings from this research provide guidance for researchers, program implementers, as well as donor agencies on SRMNCAH research priorities in humanitarian settings. A global research agenda could save the lives of those who are at greatest risk and vulnerability as well as increase opportunities for translation and innovation for SRMNCAH in humanitarian settings.

    View details for DOI 10.1186/s13031-021-00353-w

    View details for PubMedID 33771212

  • Understanding how biologic and social determinants affect disparities in preterm birth and outcomes of preterm infants in the NICU. Seminars in perinatology Stevenson, D. K., Aghaeepour, N., Maric, I., Angst, M. S., Darmstadt, G. L., Druzin, M. L., Gaudilliere, B., Ling, X. B., Moufarrej, M. N., Peterson, L. S., Quake, S. R., Relman, D. A., Snyder, M. P., Sylvester, K. G., Shaw, G. M., Wong, R. J. 2021: 151408


    To understand the disparities in spontaneous preterm birth (sPTB) and/or its outcomes, biologic and social determinants as well as healthcare practice (such as those in neonatal intensive care units) should be considered. They have been largely intractable and remain obscure in most cases, despite a myriad of identified risk factors for and causes of sPTB. We still do not know how they might actually affect and lead to the different outcomes at different gestational ages and if they are independent of NICU practices. Here we describe an integrated approach to study the interplay between the genome and exposome, which may drive biochemistry and physiology, with health disparities.

    View details for DOI 10.1016/j.semperi.2021.151408

    View details for PubMedID 33875265

  • Gender and the impact of COVID-19 on demand for and access to health care: analysis of data from Kenya, Nigeria, and South Africa Abdalla, S., Katz, E. G., Darmstadt, G. L. ELSEVIER SCI LTD. 2021: 7
  • The role of piped water supplies in advancing health, economic development, and gender equality in rural communities. Social science & medicine (1982) Winter, J. C., Darmstadt, G. L., Davis, J. 2021: 113599


    In rural areas of sub-Saharan Africa, one in eight households obtain drinking water from a piped system; the rest fetch water from improved and unimproved sources located at some distance from their homes. This task falls primarily to women and girls, creating time poverty and risks to safety and health. In this paper, we present a conceptual model that elaborates the mechanisms linking access to piped water with food security and long-term economic impacts. These hypotheses were tested in a quasi-experimental study of four villages in rural Zambia using a combination of household surveys, Global Positioning System transponders, and water meters to measure time spent fetching water, water consumption, and how water was being utilized for domestic and productive activities. Households receiving the piped water intervention spent a median of 3.8h per week less fetching water, savings that accrued primarily to women and girls. Household water consumption increased 32%, which was used for both domestic and productive uses. Increases in the frequency of gardening and the size of garden plots in treatment households were observed. Households receiving piped water reported being happier, healthier, and having more time to participate in work inside or outside the home. We find that piped water supplies can promote the economic development and well-being of rural households, with particular benefits to women and girls, conditional upon pricing and management models that ensure sustainable service.

    View details for DOI 10.1016/j.socscimed.2020.113599

    View details for PubMedID 33485713

  • Prevalence and psychosocial impact of atopic dermatitis in Bangladeshi children and families. PloS one Pedersen, C. J., Uddin, M. J., Saha, S. K., Darmstadt, G. L. 2021; 16 (4): e0249824


    Skin conditions are the fourth leading cause of nonfatal disease globally, with atopic dermatitis (AD) a major and rising contributor. Though atopic dermatitis (AD) is rising in prevalence, little is known about its psychosocial effects on children and families in low- and middle-income countries (LMICs).We conducted a community-based, cross-sectional survey of 2242 under-5 children in rural Bangladesh using the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire to measure AD prevalence and severity, the Patient-Oriented Eczema Measure (POEM) to measure severity, and the Infants' Dermatitis Quality of Life index (IDQoL) and Dermatitis Family Index (DFI) to measure quality of life.Overall AD prevalence in under-five children was 11.9% [95% confidence interval (CI) 10.6-13.3%]. Prevalence was highest in children age 30-35 months [16.2% (95% CI 11.4-21.0)]. IDQoL was significantly higher in males (2.67) vs. females (1.95, p = 0.015), the lowest (3.06) vs. highest (1.63) wealth quintile (p<0.001), and among mothers with < primary (2.41) vs. > secondary (1.43) education (p = 0.039). POEM severity was correlated with IDQoL (r = 0.77, p<0.001) and DFI (r = 0.56, p<0.001). Severe disease as rated by caretakers was correlated with POEM (r = 0.73, p<0.001), IDQoL (r = 0.82, p<0.001) and DFI (r = 0.57, p<0.001).Severe AD significantly affects quality of life for children and families in Bangladesh. As access to healthcare expands in LMICs, identification and treatment of both the medical and psychosocial morbidities associated with the disease are needed.

    View details for DOI 10.1371/journal.pone.0249824

    View details for PubMedID 33861780

  • Prevalence and Stigma of Postpartum Common Mental Disorders in the Gurage Region of Ethiopia: A Mixed-Methods Observational Cohort Study. Frontiers in psychology Monaghan, S., Akale, M. A., Demeke, B., Darmstadt, G. L. 2021; 12: 626797


    Objectives: Mental disorders are vastly underdiagnosed in low-income countries that disproportionately affect women. We aimed to evaluate the prevalence of common mental disorders in newly postpartum women, and stigma associated with mental health reporting in an Ethiopian community using a validated World Health Organization survey. Methods: The Self Reporting Questionnaire (SRQ) for psychological distress was administered in Amharic by nurses to 118 women aged 18-37 years who had given birth in the prior 3 months in the Glenn C. Olsen Memorial Primary Hospital in Yetebon. Mental health stigma among the four nursing staff was assessed using Link and Phelan's Components of Stigma. Results: Among 118 women surveyed, 18% had a probable common mental disorder using the SRQ 4/5 cutoff and 2% admitted to suicidal thoughts. Presence of stigma in the healthcare staff was verified, including labeling, stereotyping, separating, and status loss and discrimination. Conclusion: Postpartum mental health disorders as well as stigma against such diagnoses are common in the Yetebon community. There is an urgent need for increased availability of properly trained and supervised healthcare staff in the identification and referral of postpartum women with common mental disorders.

    View details for DOI 10.3389/fpsyg.2021.626797

    View details for PubMedID 33897534

  • Best practices in global health evaluation: Reflections on learning from an independent program analysis in Bihar, India. Journal of global health Mehta, K. M., Ward, V. C., Darmstadt, G. L. 2020; 10 (2): 020395

    View details for DOI 10.7189/jogh.10.020395

    View details for PubMedID 33403103

  • Statewide implementation of a quality improvement initiative for reproductive, maternal, newborn and child health and nutritionin Bihar, India. Journal of global health Creanga, A. A., Srikantiah, S., Mahapatra, T., Das, A., Sonthalia, S., Moharana, P. R., Gore, A., Daulatrao, S., Durbha, R., Kaul, S., Galavotti, C., Laterra, A., Pepper, K. T., Darmstadt, G. L., Shah, H. 2020; 10 (2): 021008


    Background: CARE India designed and implemented a comprehensive, statewide quality improvement (QI) initiative to improve reproductive, maternal, newborn, and child health and nutrition (RMNCHN) services in public facilities in Bihar. We provide a description of this initiative and its key results during 2014-2017.Methods: We reviewed program documents to identify QI strategies employed and ascertain their coverage. We analysed data from: a) two public facility assessments to ascertain the availability of essential equipment and supplies and the distribution of human resources by facility level; b) a four-phase provider mentoring and training intervention covering 319 facilities to examine changes in emergency obstetric and newborn care (EmONC) practices; and c) four state-representative household surveys to explore changes in selected RMNCHN service utilisation by health sector. Associations of interest were ascertained using chi2 tests.Results: Thirty-eight District Quality Assurance Committees and QI teams in 98% of facilities were formed to develop an implementation plan for the QI initiative and oversee its execution. QI strategies were to strengthen facilities' infrastructure; build the state's contracting, procurement, and inventory management capacities; rationalise human resources; improve providers' skills; and modernise data systems. Implementation led to facility infrastructure upgrades, improved clinical staff distribution, and higher availability of equipment and supplies over time, especially in higher-level facilities. Following the mentoring and training intervention in facilities offering both basic and comprehensive EmONC, performance of key practices (eg, adequate administration of uterotonics <1 minute after birth, initiation of skin-to-skin care <5 minutes after birth) improved significantly (P<0.05). CARE India collected program data and assisted with modernising data systems for tracking human resources, supplies, and program progress statewide. Of women seeking antenatal care, the proportion obtaining key screenings (eg, weight, blood pressure measurements) in public facilities increased over time (P<0.05). A 6-percentage point decline in home deliveries during 2016-2017 was accompanied by a higher increase of deliveries in public than private facilities (5- vs 1-percentage point; P<0.05).Conclusion: Substantial advances were made in improving RMNCHN service quality in Bihar. Continued improvement building on the established QI platform is expected and should be guided by data from now functional data systems.

    View details for DOI 10.7189/jogh.10.021008

    View details for PubMedID 33425332

  • Geospatial variations in trends of reproductive, maternal, newborn and child health and nutrition indicators at block level in Bihar, India, during scale-up of Ananya program interventions. Journal of global health Abdalla, S., Pair, E., Mehta, K. M., Ward, V. C., Darmstadt, G. L. 2020; 10 (2): 021004


    Background: Geographical variations in the levels and trajectory of health indicators at local level can inform the adaptation of interventions and development of targeted approaches for efficient scale-up of intervention impact. We examined the hypothesis that time trends of a set of reproductive, maternal, newborn, and child health and nutrition (RMNCHN) indicators varied at block-level during the statewide scale-up phase of the Ananya program in Bihar, India.Methods: We used data on 22 selected indicators from four rounds of the Community-based Household Survey carried out between 2014 and 2017. Indicator levels at each round were estimated for each block. We used hierarchical Bayesian spatiotemporal modelling to smooth the raw estimates for each block with the estimates from its neighbouring blocks, and to examine space-time interaction models for evidence of variations in trends of indicators across blocks. We expressed the uncertainty around the smoothed levels and the trends with 95% credible intervals.Results: There was evidence of variations in trends at block level in all but three indicators: facility delivery, public facility delivery, and age-appropriate initiation of complementary feeding. Fifteen indicators showed trends in opposite directions (increases in some blocks and declines in others). All blocks had at least 97.5% probability of a rise in immediate breastfeeding, early pregnancy registration, and having at least four antenatal care visits. All blocks had at least 97.5% probability of a decline in seeking care for pregnancy complications.Conclusions: The findings underscore the value of monitoring and evaluation at local level for targeted implementation of RMNCHN interventions. There is a need for identifying systematic factors leading to universal trends, or variable contextual or implementation factors leading to variable trends, in order to optimise primary health care program impact.Study registration: number NCT02726230.

    View details for DOI 10.7189/jogh.10.021004

    View details for PubMedID 33425328

  • Time poverty: Obstacle to women's human rights, health and sustainable development JOURNAL OF GLOBAL HEALTH Hyde, E., Greene, M. E., Darmstadt, G. L. 2020; 10 (2): 020313

    View details for DOI 10.7189/jogh.10.020313

    View details for Web of Science ID 000612476300028

    View details for PubMedID 33282212

    View details for PubMedCentralID PMC7688061

  • Health layering of self-help groups: impacts on reproductive, maternal, newborn and child health and nutrition in Bihar, India. Journal of global health Mehta, K. M., Irani, L., Chaudhuri, I., Mahapatra, T., Schooley, J., Srikantiah, S., Abdalla, S., Ward, V., Carmichael, S. L., Bentley, J., Creanga, A., Wilhelm, J., Tarigopula, U. K., Bhattacharya, D., Atmavilas, Y., Nanda, P., Weng, Y., Pepper, K. T., Darmstadt, G. L., Ananya Study Group, Atmavilas, Y., Bhattacharya, D., Bentley, J., Borkum, E., Carmichael, S., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W. A., Nanda, P., Pepper, K. T., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Shah, H., Srikantiah, S., Tarigopula, U. K., Ward, V., Weng, Y., Walker, D., Wilhelm, J. 2020; 10 (2): 021007


    Background: Self-help group (SHG) interventions have been widely studied in low and middle income countries. However, there is little data on specific impacts of health layering, or adding health education modules upon existing SHGs which were formed primarily for economic empowerment. We examined three SHG interventions from 2012-2017 in Bihar, India to test the hypothesis that health-layering of SHGs would lead to improved health-related behaviours of women in SHGs.Methods: A model for health layering of SHGs - Parivartan - was developed by the non-governmental organisation (NGO), Project Concern International, in 64 blocks of eight districts. Layering included health modules, community events and review mechanisms. The health layering model was adapted for use with government-led SHGs, called JEEViKA+HL, in 37 other blocks of Bihar. Scale-up of government-led SHGs without health layering (JEEViKA) occurred contemporaneously in 433 other blocks, providing a natural comparison group. Using Community-based Household Surveys (CHS, rounds 6-9) by CARE India, 62 reproductive, maternal, newborn and child health and nutrition (RMNCHN) and sanitation indicators were examined for SHGs with health layering (Pavivartan SHGs and JEEViKA+HL SHGs) compared to those without. We calculated mean, standard deviation and odds ratios of indicators using surveymeans and survey logistic regression.Results: In 2014, 64% of indicators were significantly higher in Parivartan members compared to non-members residing in the same blocks. During scale up, from 2015-17, half (50%) of indicators had significantly higher odds in health layered SHG members (Parivartan or JEEViKA+HL) in 101 blocks compared to SHG members without health layering (JEEViKA) in 433 blocks.Conclusions: Health layering of SHGs was demonstrated by an NGO-led model (Parivartan), adapted and scaled up by a government model (JEEViKA+HL), and associated with significant improvements in health compared to non-health-layered SHGs (JEEViKA). These results strengthen the evidence base for further layering of health onto the SHG platform for scale-level health change.Study registration: number NCT02726230.

    View details for DOI 10.7189/jogh.10.021007

    View details for PubMedID 33425331

  • Health impact of self-help groups scaled-up statewide in Bihar, India. Journal of global health Mehta, K. M., Irani, L., Chaudhuri, I., Mahapatra, T., Schooley, J., Srikantiah, S., Abdalla, S., Ward, V. C., Carmichael, S. L., Bentley, J., Creanga, A., Wilhelm, J., Tarigopula, U. K., Bhattacharya, D., Atmavilas, Y., Nanda, P., Weng, Y., Pepper, K. T., Darmstadt, G. L., Ananya Study Group, Atmavilas, Y., Bhattacharya, D., Bentley, J., Borkum, E., Carmichael, S., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W. A., Nanda, P., Pepper, K. T., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Shah, H., Srikantiah, S., Ward, V., Weng, Y., Walker, D., Wilhelm, J. 2020; 10 (2): 021006


    Background: The objective of this study was to assess the impact of self-help groups (SHGs) and subsequent scale-up on reproductive, maternal, newborn, child health, and nutrition (RMNCHN) and sanitation outcomes among marginalised women in Bihar, India from 2014-2017.Methods: We examined RMNCHN and sanitation behaviors in women who were members of any SHGs compared to non-members, without differentiating between types of SHGs. We analysed annual surveys across 38 districts of Bihar covering 62690 women who had a live birth in the past 12 months. All analyses utilised data from Community-based Household Surveys (CHS) rounds 6-9 collected in 2014-2017 by CARE India as part of the Bihar Technical Support Program funded by the Bill & Melinda Gates Foundation. We examined 66 RMNCHN and sanitation indicators using survey logistic regression; the comparison group in all cases was age-comparable women from the geographic contexts of the SHG members but who did not belong to SHGs. We also examined links between discussion topics in SHGs and changes in relevant behaviours, and stratification of effects by parity and mother's age.Results: SHG members had higher odds compared to non-SHG members for 60% of antenatal care indicators, 22% of delivery indicators, 70% of postnatal care indicators, 50% of nutrition indicators, 100% of family planning and sanitation indicators and no immunisation indicators measured. According to delivery platform, most FLW performance indicators (80%) had increased odds, followed by maternal behaviours (57%) and facility care and outreach service delivery (22%) compared to non-SHG members. Self-report of discussions within SHGs on specific topics was associated with increased related maternal behaviours. Younger SHG members (<25 years) had attenuated health indicators compared to older group members (≥25 years), and women with more children had more positive indicators compared to women with fewer children.Conclusions: SHG membership was associated with improved RMNCHN and sanitation indicators at scale in Bihar, India. Further work is needed to understand the specific impacts of health layering upon SHGs. Working through SHGs is a promising vehicle for improving primary health care.Study registration: number NCT02726230.

    View details for DOI 10.7189/jogh.10.021006

    View details for PubMedID 33425330

  • Impact of mHealth interventions for reproductive, maternal, newborn and child health and nutrition at scale: BBC Media Action and the Ananya program in Bihar, India. Journal of global health Ward, V. C., Raheel, H., Weng, Y., Mehta, K. M., Dutt, P., Mitra, R., Sastry, P., Godfrey, A., Shannon, M., Chamberlain, S., Kaimal, R., Carmichael, S. L., Bentley, J., Abdalla, S., Pepper, K. T., Mahapatra, T., Srikantiah, S., Borkum, E., Rangarajan, A., Sridharan, S., Rotz, D., Nanda, P., Tarigopula, U. K., Atmavilas, Y., Bhattacharya, D., Darmstadt, G. L., Ananya Study Group, Atmavilas, Y., Bhattacharya, D., Bentley, J., Borkum, E., Carmichael, S., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W. A., Nanda, P., Pepper, K. T., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Shah, H., Srikantiah, S., Tarigopula, U. K., Ward, V., Weng, Y., Walker, D., Wilhelm, J. 2020; 10 (2): 021005


    Background: Mobile health (mHealth) tools have potential for improving the reach and quality of health information and services through community health workers in low- and middle-income countries. This study evaluates the impact of an mHealth tool implemented at scale as part of the statewide reproductive,maternal, newborn and child health and nutrition (RMNCHN) program in Bihar, India.Methods: Three survey-based data sets were analysed to compare the health-related knowledge, attitudes and behaviours amongst childbearing women exposed to the Mobile Kunji and Dr. Anita mHealth tools during their visits with frontline workers compared with those who were unexposed.Results: An evaluation by Mathematica (2014) revealed that exposure to Mobile Kunji and Dr. Anita recordings were associated with significantly higher odds of consuming iron-folic acid tablets (odds ratio (OR)=2.3, 95% confidence interval (CI)=1.8-3.1) as well as taking a set of three measures for delivery preparedness (OR=2.8, 95% CI=1.9-4.2) and appropriate infant complementary feeding (OR=1.9, 95% CI=1.0-3.5). CARE India's Community-based Household Surveys (2012-2017) demonstrated significant improvements in early breastfeeding (OR=1.64, 95% CI=1.5-1.78) and exclusive breastfeeding (OR=1.46, 95% CI=1.33-1.62) in addition to birth preparedness practices. BBC Media Action's Usage & Engagement Survey (2014) demonstrated a positive association between exposure to Mobile Kunji and Dr. Anita and exclusive breastfeeding (58% exposed vs 43% unexposed, P<0.01) as well as maternal respondents' trust in their frontline worker.Conclusions: Significant improvements in RMNCHN-related knowledge and behaviours were observed for Bihari women who were exposed to Mobile Kunji and Dr. Anita. This analysis is unique in its rigorous evaluation across multiple data sets of mHealth interventions implemented at scale. These results can help inform global understanding of how best to use mHealth tools, for whom, and in what contexts.Study registration: number NCT02726230.

    View details for DOI 10.7189/jogh.10.021005

    View details for PubMedID 33425329

  • Evaluation of a large-scale reproductive, maternal, newborn and child health and nutrition program in Bihar, India, through an equity lens. Journal of global health Ward, V. C., Weng, Y., Bentley, J., Carmichael, S. L., Mehta, K. M., Mahmood, W., Pepper, K. T., Abdalla, S., Atmavilas, Y., Mahapatra, T., Srikantiah, S., Borkum, E., Rangarajan, A., Sridharan, S., Rotz, D., Bhattacharya, D., Nanda, P., Tarigopula, U. K., Shah, H., Darmstadt, G. L., Ananya Study Group, Atmavilas, Y., Bhattacharya, D., Bentley, J., Borkum, E., Carmichael, S., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W. A., Nanda, P., Pepper, K. T., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Shah, H., Srikantiah, S., Tarigopula, U. K., Ward, V., Weng, Y., Walker, D., Wilhelm, J. 2020; 10 (2): 021011


    Background: Despite increasing focus on health inequities in low- and middle income countries, significant disparities persist. We analysed impacts of a statewide maternal and child health program among the most compared to the least marginalised women in Bihar, India.Methods: Utilising survey-weighted logistic regression, we estimated programmatic impact using difference-in-difference estimators from Mathematica data collected at the beginning (2012, n=10174) and after two years of program implementation (2014, n=9611). We also examined changes in disparities over time using eight rounds of Community-based Household Surveys (CHS) (2012-2017, n=48349) collected by CARE India.Results: At baseline for the Mathematica data, least marginalised women generally performed desired health-related behaviours more frequently than the most marginalised. After two years, most disparities persisted. Disparities increased for skilled birth attendant identification [+16.2% (most marginalised) vs +32.6% (least marginalized), P<0.01) and skin-to-skin care (+14.8% vs +20.4%, P<0.05), and decreased for immediate breastfeeding (+10.4 vs -4.9, P<0.01). For the CHS data, odds ratios compared the most to the least marginalised women as referent. Results demonstrated that disparities were most significant for indicators reliant on access to care such as delivery in a facility (OR range: 0.15 to 0.48) or by a qualified doctor (OR range: 0.08 to 0.25), and seeking care for complications (OR range: 0.26 to 0.64).Conclusions: Disparities observed at baseline generally persisted throughout program implementation. The most significant disparities were observed amongst behaviours dependent upon access to care. Changes in disparities largely were due to improvements for the least marginalised women without improvements for the most marginalised. Equity-based assessments of programmatic impacts, including those of universal health approaches, must be undertaken to monitor disparities and to ensure equitable and sustainable benefits for all.Study registration: number NCT02726230.

    View details for DOI 10.7189/jogh.10.021011

    View details for PubMedID 33425335

  • Impact of the Ananya program on reproductive, maternal, newborn and child health and nutrition in Bihar, India: early results from a quasi-experimental study. Journal of global health Darmstadt, G. L., Weng, Y., Pepper, K. T., Ward, V. C., Mehta, K. M., Borkum, E., Bentley, J., Raheel, H., Rangarajan, A., Bhattacharya, D., Tarigopula, U. K., Nanda, P., Sridharan, S., Rotz, D., Carmichael, S. L., Abdalla, S., Munar, W., Ananya Study Group, Atmavilas, Y., Bhattacharya, D., Bentley, J., Borkum, E., Carmichael, S., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W. A., Nanda, P., Pepper, K. T., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Delhi, N., Shah, H., Srikantiah, S., Tarigopula, U. K., Ward, V., Weng, Y., Walker, D., Wilhelm, J. 2020; 10 (2): 021002


    Background: The Government of Bihar (GoB) in India, the Bill and Melinda Gates Foundation and several non-governmental organisations launched the Ananya program aimed to support the GoB to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) statewide. Here we summarise changes in indicators attained during the initial two-year pilot phase (2012-2013) of implementation in eight focus districts of approximately 28 million population, aimed to inform subsequent scale-up.Methods: The quasi-experimental impact evaluation included statewide household surveys at two time points during the pilot phase: January-April 2012 ("baseline") including an initial cohort of beneficiaries and January-April 2014 ("midline") with a new cohort. The two arms were: 1) eight intervention districts, and 2) a comparison arm comprised of the remaining 30 districts in Bihar where Ananya interventions were not implemented. We analysed changes in indicators across the RMNCHN continuum of care from baseline to midline in intervention and comparison districts using a difference-in-difference analysis.Results: Indicators in the two arms were similar at baseline. Overall, 40% of indicators (20 of 51) changed significantly from baseline to midline in the comparison districts unrelated to Ananya; two-thirds (n=13) of secular indicator changes were in a direction expected to promote health. Statistically significant impact attributable to the Ananya program was found for 10% (five of 51) of RMNCHN indicators. Positive impacts were most prominent for mother's behaviours in contraceptive utilisation.Conclusions: The Ananya program had limited impact in improving health-related outcomes during the first two-year period covered by this evaluation. The program's theories of change and action were not powered to observe statistically significant differences in RMNCHN indicators within two years, but rather aimed to help inform program improvements and scale-up. Evaluation of large-scale programs such as Ananya using theory-informed, equity-sensitive (including gender), mixed-methods approaches can help elucidate causality and better explain pathways through which supply- and demand-side interventions contribute to changes in behaviour among the actors involved in the production of population-level health outcomes. Evidence from Bihar indicates that deep structural constraints in health system organisation and delivery of interventions pose substantial limitations on behaviour change among health care providers and beneficiaries.Study registration: number NCT02726230.

    View details for DOI 10.7189/jogh.10.021002

    View details for PubMedID 33427822

  • Trends in reproductive, maternal, newborn and child health and nutrition indicators during five years of piloting and scaling-up of Ananya interventions in Bihar, India. Journal of global health Abdalla, S., Weng, Y., Mehta, K. M., Mahapatra, T., Srikantiah, S., Shah, H., Ward, V. C., Pepper, K. T., Bentley, J., Carmichael, S. L., Creanga, A., Wilhelm, J., Tarigopula, U. K., Nanda, P., Bhattacharya, D., Atmavilas, Y., Darmstadt, G. L., Ananya Study Group, Atmavilas, Y., Bentley, J., Bhattacharya, D., Borkum, E., Carmichael, S. L., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Delhi, N., Irani, L., Delhi, N., Krishnan, S., Mahapatra, T., Mehta, K. M., Francisco, S., Mitra, R., Munar, W., Nanda, P., Pepper, K. T., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Schooley, J., Shah, H., Srikantiah, S., Tarigopula, U. K., Ward, V. C., Walker, D., Weng, Y., Wilhelm, J. 2020; 10 (2): 021003


    Background: The Ananya program in Bihar implemented household and community-level interventions to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) in two phases: a first phase of intensive ancillary support to governmental implementation and innovation testing by non-government organisation (NGO) partners in eight focus districts (2012-2014), followed by a second phase of state-wide government-led implementation with techno-managerial assistance from NGOs (2014 onwards). This paper examines trends in RMNCHN indicators in the program's implementation districts from 2012-2017.Methods: Eight consecutive rounds of cross-sectional Community-based Household Surveys conducted by CARE India in 2012-2017 provided comparable data on a large number of indicators of frontline worker (FLW) performance, mothers' behaviours, and facility-based care and outreach service delivery across the continuum of maternal and child care. Logistic regression, considering the complex survey design and sample weights generated by that design, was used to estimate trends using survey rounds 2-5 for the first phase in the eight focus districts and rounds 6-9 for the second phase in all 38 districts statewide, as well as the overall change from round 2-9 in focus districts. To aid in contextualising the results, indicators were also compared amongst the formerly focus and the non-focus districts at the beginning of the second phase.Results: In the first phase, the levels of 34 out of 52 indicators increased significantly in the focus districts, including almost all indicators of FLW performance in antenatal and postnatal care, along with mother's birth preparedness, some breastfeeding practices, and immunisations. Between the two phases, 33 of 52 indicators declined significantly. In the second phase, the formerly focus districts experienced a rise in the levels of 14 of 50 indicators and a decline in the levels of 14 other indicators. There was a rise in the levels of 22 out of 50 indicators in the non-focus districts in the second phase, with a decline in the levels of 13 other indicators.Conclusions: Improvements in indicators were conditional on implementation support to program activities at a level of intensity that was higher than what could be achieved at scale so far. Successes during the pilot phase of intensive support suggests that RMNCHN can be improved statewide in Bihar with sufficient investments in systems performance improvements.Study registration: number NCT02726230.

    View details for DOI 10.7189/jogh.10.021003

    View details for PubMedID 33427818

  • Learning from Ananya: Lessons for primary health care performance improvement. Journal of global health Darmstadt, G. L., Ananya Study Group 2020; 10 (2): 020356

    View details for DOI 10.7189/jogh.10.020356

    View details for PubMedID 33110552

  • Prevalence and perceptions of infant massage in India: study from Maharashtra and Madhya Pradesh states. BMC pediatrics Chaturvedi, S., Randive, B., Pathak, A., Agarkhedkar, S., Tillu, G., Darmstadt, G. L., Patwardhan, B. 2020; 20 (1): 512


    BACKGROUND: Knowledge of the prevailing infant care practices and their effects is important to inform practice and public programs. Infant massage is a traditional practice in India but remains less studied. This study was conducted to study the prevalence and perceptions of infant massage practices in two states of India.METHODS: A total of 1497 caretakers of children under 18months of age were interviewed in a cross-sectional study at immunisation units of medical schools in Maharashtra (MH) and Madhya Pradesh (MP) states and through home visits in villages in MH during March through August 2018.RESULTS: Infant massage was a prevalent practice (93.8% [95%CI: 92.4,94.9]) in both study states - 97.9%[95%CI:96.9,98.8] in MH and 85.3%[95%CI: 81.9,88.3] in MP - and the prevalence did not vary between male (94.5%) and female (93.5%) infants (p=0.44). Massage was mostly initiated in the first week of life (82%); it is widely viewed as a traditional practice. It was common to massage the baby once daily (77%), before bathing (77%), and after feeding (57%). Massage was mostly conducted using oils (97%). In MH, preferred oils were a sesame oil-based proprietary traditional medicine oil (36%) and coconut oil (18%) while olive (29%) and mustard (20%) oils were most popular in MP. Commonly reported application techniques included gentle massage with minimal pressure, pressing (30%) and manually stretching certain joints (60%). Commonly reported perceived benefits of infant massage included increased bone strength, better sleep and growth, while no harm was perceived (95%).CONCLUSION: Infant oil massage is a highly prevalent traditional practice in MH and MP. Clear guidance on the use of massage, choice of oil, and techniques for application is required to optimize benefits and minimize risks of this popular traditional practice.

    View details for DOI 10.1186/s12887-020-02416-y

    View details for PubMedID 33167905

  • Prevalence of atopic dermatitis, asthma and rhinitis from infancy through adulthood in rural Bangladesh: a population-based, cross-sectional survey. BMJ open Pedersen, C. J., Uddin, M. J., Saha, S. K., Darmstadt, G. L. 2020; 10 (11): e042380


    OBJECTIVE: Describe the pattern of atopic disease prevalence from infancy to adulthood.DESIGN: Cross-sectional household survey.SETTING: Community-based demographic surveillance site, Mirzapur, Bangladesh.PARTICIPANTS: 7275 individuals in randomly selected clusters within 156 villages.PRIMARY AND SECONDARY OUTCOME MEASURES: The 12-month prevalence of atopic dermatitis (by UK Working Party Criteria (UK criteria) and International Study of Asthma and Allergies in Childhood (ISAAC)), asthma and rhinitis (by ISAAC); disease severity (by ISAAC); history of ever receiving a medical diagnosis.RESULTS: Children aged 2 years had the highest prevalence of atopic dermatitis-18.8% (95% CI 15.2% to 22.4%) by UK criteria and 14.9% (95% CI 11.6% to 18.1%) by ISAAC- and asthma (20.1%, 95%CI 16.4% to 23.8%). Prevalence of rhinitis was highest among 25-29year olds (6.0%, (95% CI% 4.5 to 7.4%). History of a medical diagnosis was lowest for atopic dermatitis (4.0%) and highest for rhinitis (27.3%) and was significantly associated with severe disease compared with those without severe disease for all three conditions (atopic dermatitis: 30.0% vs 11.7%, p=0.015; asthma; 85.0% vs 60.4%, p<0.001; rhinitis: 34.2% vs 7.3%, p<0.001) and having a higher asset-based wealth score for asthma (29.7% (highest quintile) vs 7.5% (lowest quintile), p<0.001) and rhinitis (39.8% vs 12.5%, p=0.003). Prevalence of having >1 condition was highest (36.2%) at 2 years and decreased with age. Having atopic dermatitis (ISAAC) was associated with significantly increased odds ratios (OR) for comorbid asthma (OR 5.56 (95% CI 4.26 to 7.26)] and rhinitis (3.68 (95% CI 2.73 to 4.96)). Asthma and rhinitis were also strongly associated with each other (OR 8.39 (95% CI 6.48 to 10.86)).CONCLUSIONS: Atopic disease burden was high in this rural Bangladeshi population. Having one atopic condition was significantly associated with the presence of another. Low incidence of ever obtaining a medical diagnosis highlights an important opportunity to increase availability of affordable diagnosis and treatment options for all age groups.

    View details for DOI 10.1136/bmjopen-2020-042380

    View details for PubMedID 33148768

  • Associations Among Early Stimulation, Stunting, and Child Development in Four Countries in the East Asia-Pacific INTERNATIONAL JOURNAL OF EARLY CHILDHOOD Rao, N., Richards, B., Lau, C., Weber, A. M., Sun, J., Darmstadt, G. L., Sincovich, A., Bacon-Shone, J., Ip, P. 2020
  • Applying a gender lens to global health and well-being: Framing a Journal of Global Health special collection JOURNAL OF GLOBAL HEALTH Stark, L., Seff, I., Weber, A., Darmstadt, G. L. 2020; 10 (1)
  • Towards personalized medicine in maternal and child health: integrating biologic and social determinants. Pediatric research Stevenson, D. K., Wong, R. J., Aghaeepour, N., Maric, I., Angst, M. S., Contrepois, K., Darmstadt, G. L., Druzin, M. L., Eisenberg, M. L., Gaudilliere, B., Gibbs, R. S., Gotlib, I. H., Gould, J. B., Lee, H. C., Ling, X. B., Mayo, J. A., Moufarrej, M. N., Quaintance, C. C., Quake, S. R., Relman, D. A., Sirota, M., Snyder, M. P., Sylvester, K. G., Hao, S., Wise, P. H., Shaw, G. M., Katz, M. 2020

    View details for DOI 10.1038/s41390-020-0981-8

    View details for PubMedID 32454518

  • Gender discrimination and depressive symptoms among child-bearing women: ELSPAC-CZ cohort study. EClinicalMedicine Stepanikova, I., Acharya, S., Abdalla, S., Baker, E., Klanova, J., Darmstadt, G. L. 2020; 20: 100297


    Background: Depression is approximately two-fold more prevalent among women than men. Social theories suggest that discrimination is a pathway through which gender inequalities affect women's lives, but data are lacking. This cohort study evaluates whether perceived gender discrimination is linked to depressive symptoms among child-bearing women.Methods: Data were obtained from 4,688 participants enrolled in pregnancy in 1991-92 in the European Longitudinal Cohort Study of Pregnancy and Childhood, Czech Republic. Perceived gender discrimination was assessed in mid-pregnancy, year seven, and year eleven. Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale at eight time-points between mid-pregnancy and year eleven post-delivery. Linear mixederror-component models of depressive symptoms were estimated.Findings: Perceived gender discrimination, reported by 10.7% of women, was related to higher depressive symptoms, both in the unadjusted analysis (b=0.15 [95% confidence interval (CI): 0.12, 0.19], p<0.001) and in the fully adjusted model (b=0.12 [95% CI: 0.09, 0.16], p<0.001). Covariates linked to higher depressive symptoms included financial hardship (b=0.12 [95% CI: 0.10, 0.14], p<0.001), childhood emotional/physical neglect (b=0.18 [95% CI: 0.14, 0.22], p<0.001), and childhood sexual abuse (b=0.04 [95% CI: 0.03, 0.06], p<0.001); an inverse relationship was evident for social support (-0.05 [95% CI: -0.07, -0.04], p<0.001) and having a partner who performs female-stereotypical household tasks (b=-0.03 [95% CI: -0.05, -0.01], p=0.001).Interpretation: The findings provide the first evidence that perceived gender discrimination is associated with depressive symptoms among child-bearing women. Social intervention programs aimed at reducing gender discrimination can potentially contribute to better mental health of women.Funding: Bill and Melinda Gates Foundation.

    View details for DOI 10.1016/j.eclinm.2020.100297

    View details for PubMedID 32300743

  • Gender equality: Framing a special collection of evidence for all. EClinicalMedicine Darmstadt, G. L. 2020; 20: 100307

    View details for DOI 10.1016/j.eclinm.2020.100307

    View details for PubMedID 32300751

  • The Influence of Schooling on the Stability and Mutability of Gender Attitudes: Findings From a Longitudinal Study of Adolescent Girls in Zambia. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Chae, S., Haberland, N., McCarthy, K. J., Weber, A. M., Darmstadt, G. L., Ngo, T. D. 2020; 66 (1S): S25–S33


    PURPOSE: Inequitable gender norms are thought to harm lifelong health and well-being. We explore the process of gender attitude change and the role of schooling in shifting or reinforcing gender norms among adolescent girls in Zambia.METHODS: We used longitudinal data collected from unmarried, vulnerable girls (aged 10-19years) as part of the Adolescent Girls Empowerment Program. We conducted random effects multinomial logistic regression to determine whether schooling-related factors were associated with shifts in adolescent girls' gender attitudes across three survey rounds and explored whether these relationships varied by age.RESULTS: Mean gender attitude scores at the aggregate level remained stable over time among rural girls and improved slightly for urban girls. At the individual level, about half the girls had relatively unchanged scores, whereas the other half shifted to higher or lower scores between rounds. Rural and urban girls currently attending school were more likely to have relatively stable equitable attitudes than stable, inequitable attitudes, or attitudes that shifted to inequitable. Educational attainment was not associated with shifts in gender attitudes among rural girls. Urban girls with higher educational attainment were more likely to have relatively stable equitable attitudes than stable, inequitable attitudes, or attitudes that shifted to inequitable or more equitable.CONCLUSIONS: Patterns of gender attitude stability and change differed more for urban girls than rural girls and varied by age and schooling-related factors. In general, schooling appears to be an institutional lever that holds promise for shifting gender attitudes toward greater equality. Our study highlights the importance of looking longitudinally at the effects of social context and reinforces calls for targeted, context-specific interventions for this age group.

    View details for DOI 10.1016/j.jadohealth.2019.08.031

    View details for PubMedID 31866034

  • Applying a gender lens to global health and well-being: Framing a Journal of Global Health special collection. Journal of global health Stark, L. n., Seff, I. n., Weber, A. n., Darmstadt, G. L. 2020; 10 (1): 010103

    View details for DOI 10.7189/jogh.10.01013

    View details for PubMedID 32257130

    View details for PubMedCentralID PMC7125946

  • Gender equality and global health: intersecting political challenges. Journal of global health Cislaghi, B. n., Weber, A. M., Gupta, G. R., Darmstadt, G. L. 2020; 10 (1): 010701


    Women's and men's health outcomes are different. Some differences are biological, related to male and female sex, while others are related to their gender. Sex- and gender-related issues require different solutions, but policy makers lack straightforward heuristic strategies to identify gender-related health inequities.Using 169 causes of disability-adjusted life years (DALYs) from the 2017 Global Burden of Disease, we calculated the female-to-male (f:m) and male-to-female (m:f) ratios of global DALYs, rank-ordered the ratios by size and calculated the proportion of all-cause DALYs that each cause explained, separately for males and females 15-49 years old. Gender-related vs sex-related causes were categorised using literature on the drivers for the 15 causes with highest f:m and m:f ratios.Causes of DALYs with high m:f ratios appear to be gendered and include: road injuries, interpersonal violence, and drowning - totaling 12.4% of men's (15-49 years) all-cause DALYs. However, causes of DALYs with high f:m ratios are more likely a mix of sex-related and gender-related factors - including headache disorders, depressive disorders, and dietary iron deficiency - totaling 13.4% of women's (15-49 years) all-cause DALYs. Ratios vary by age, geography and Socio-demographic Index.Gender-related vs sex-related causes were categorised using available literature on the drivers for selected causes, illustrating that sex-disaggregated data represents a mix of social and biological influences. This analysis offers a model that policy makers can use to uncover potential gender inequalities in health, including intersections with other social factors. From it, new challenges emerge for global health policy makers and practitioners willing to address them. Global health actors will need to achieve a balance between the two agendas of global health and gender equality.

    View details for DOI 10.7189/jogh.10.010701

    View details for PubMedID 32257161

    View details for PubMedCentralID PMC7101083

  • Perpetration of intimate partner violence and mental health outcomes: sex- and gender-disaggregated associations among adolescents and young adults in Nigeria. Journal of global health Stark, L. n., Seff, I. n., Weber, A. M., Cislaghi, B. n., Meinhart, M. n., Bermudez, L. G., Atuchukwu, V. n., Onotu, D. n., Darmstadt, G. L. 2020; 10 (1): 010708


    The association between intimate partner violence (IPV) victimisation and poor mental health outcomes is well established. Less is known about the correlation between IPV perpetration and mental health, particularly among adolescents and young adults. Using data from the nationally representative Violence Against Children Survey, this analysis examines the association between IPV perpetration and mental health for male and female adolescents and young adults in Nigeria.Multivariate logistic regression models were used to examine associations between ever-perpetration of IPV and four self-reported mental health variables: severe sadness, feelings of worthlessness, suicide ideation, and alcohol use. Models were sex-disaggregated, controlled for age, marital status, and schooling, and tested with and without past exposure to violence. Standard errors were adjusted for sampling stratification and clustering. Observations were weighted to be representative of 13-24 year-olds in Nigeria.Males were nearly twice as likely as females to perpetrate IPV (9% v. 5%, respectively; P < 0.001), while odds of perpetration for both sexes were higher for those ever experiencing IPV (adjusted odds ratio (aOR) = 4.60 for males; aOR = 2.71 for females). Female perpetrators had 2.73 higher odds of reporting severe sadness (95% confidence interval CI = 1.44, 5.17; P = 0.002) and 2.72 times greater odds of reporting suicide ideation (1.28, 5.79; P = 0.010) than non-perpetrating females, even when controlling for past-year violence victimisation. In contrast, male perpetrators had 2.65 times greater odds of feeling worthless (1.09, 6.43; P = 0.031), and 2.36 times greater odds of reporting alcohol use in the last 30 days (1.50, 3.73; P < 0.001), as compared to non-perpetrating males.Among adolescents and young adults in Nigeria, IPV perpetration and negative mental health outcomes are associated but differ for males and females. Mindful of the cross-sectional nature of the data, it is possible that socially determined gender norms may shape the ways in which distress from IPV perpetration is understood and expressed. Additional research is needed to clarify these associations and inform violence prevention efforts.

    View details for DOI 10.7189/jogh.10.010708

    View details for PubMedID 32257165

    View details for PubMedCentralID PMC7101086

  • Association of collective attitudes and contraceptive practice in nine sub-Saharan African countries. Journal of global health Mejía-Guevara, I. n., Cislaghi, B. n., Weber, A. n., Hallgren, E. n., Meausoone, V. n., Cullen, M. R., Darmstadt, G. L. 2020; 10 (1): 010705


    There is ample evidence that gender norms affect contraceptive practice; however, data are mostly qualitative with limited geographical scope. We investigated that association quantitatively using collective community-level attitudes towards premarital sex and wife-beating as proxies for gender norms.Data came from nationally representative Demographic and Health Surveys (2005-2009) for women of reproductive age (15-49 years) in nine sub-Saharan African countries. Using multilevel logistic models, controlling for individual covariates and community-level indicators of women's empowerment, we assessed the community-level association of gender norms regarding premarital sex and wife-beating with individual contraception uptake and demand satisfied among fecund sexually active women. Norms were approximated as 'collective attitudinal norms' from female/male residents (aged 15-49 years) from the same community. We assessed the magnitude and significance of the community-level effects and attributed variance across communities. The same analysis was replicated for each country.In a fully-adjusted model with a pooled sample of 24 404 adolescent women, the odds of contraception use increased with a 1 standard deviation (SD) increase in the variation of collective permissive attitudes towards premarital sex of female (odds ratio (OR) = 1.08, 95% confidence interval (CI) = 1.02-1.15) and male (OR = 1.11, 95% CI = 1.05-1.17) peers (15-24 years), while odds of contraceptive use declined by 10% (OR = 0.90, 95% CI = 0.85-0.96) with collective accepting attitudes towards wife-beating of women aged 15-49 years. Similar results were found in separate models that controlled for adults' permissive attitudes towards premarital sex. The community-level attributed variance (V2 = 1.62, 95% CI = 1.45-1.80) represented 33% (intra-class correlation (ICC) = 33.0, 95% CI = 30.0-35.4) of the total variation of contraception use, and attitudes towards premarital sex and violence jointly explained nearly 26% of that V2 variance. The community-level shared of attributed variation of contraceptive use varied significantly across countries, from 3.5% in Swaziland (ICC = 3.5, 95% CI = 0.8-13.7) to 60.2% in Nigeria (OR = 60.2, 95% CI = 56.0-64.2).Overall, significant positive associations of collective permissive attitudes of both adolescent and adult women towards premarital sex were found for use of, and demand for, contraception, whereas collective accepting attitudes towards wife-beating were negatively associated with the use and demand for contraception. Ours is the first study to define quantitatively the influence of proxies for gender norms at the community level on women's family planning decisions. These findings offer new insights for understanding the role of sex-related attitudes and norms as important factors in shaping contraceptive practices and improving the effectiveness of family planning policies by targeting individuals as well as their groups of influence.

    View details for DOI 10.7189/jogh.10.010705

    View details for PubMedID 32257163

    View details for PubMedCentralID PMC7101087

  • Association of collective attitudes and contraceptive practice in nine sub-Saharan African countries Journal of Global Health Mejía-Guevara, I., Cislaghi, ., Weber, A., Hallgren, E., Meausoone, V., Cullen, M. R., Darmstadt, G. L. 2020; 10 (1)

    View details for DOI 10.7189/jogh.10.010705

  • Metabolic gestational age assessment in low resource settings: a validation protocol. Gates open research Bota, A. B., Ward, V., Hawken, S., Wilson, L. A., Lamoureux, M., Ducharme, R., Murphy, M. S., Denize, K. M., Henderson, M., Saha, S. K., Akther, S., Otieno, N. A., Munga, S., Atito, R. O., Stringer, J. S., Mwape, H., Price, J. T., Mujuru, H. A., Chimhini, G., Magwali, T., Mudawarima, L., Chakraborty, P., Darmstadt, G. L., Wilson, K. 2020; 4: 150


    Preterm birth is the leading global cause of neonatal morbidity and mortality. Reliable gestational age estimates are useful for quantifying population burdens of preterm birth and informing allocation of resources to address the problem. However, evaluating gestational age in low-resource settings can be challenging, particularly in places where access to ultrasound is limited. Our group has developed an algorithm using newborn screening analyte values derived from dried blood spots from newborns born in Ontario, Canada for estimating gestational age within one to two weeks. The primary objective of this study is to validate a program that derives gestational age estimates from dried blood spot samples (heel-prick or cord blood) collected from health and demographic surveillance sites and population representative health facilities in low-resource settings in Zambia, Kenya, Bangladesh and Zimbabwe. We will also pilot the use of an algorithm to identify birth percentiles based on gestational age estimates and weight to identify small for gestational age infants. Once collected from local sites, samples will be tested by the Newborn Screening Ontario laboratory at the Children's Hospital of Eastern Ontario (CHEO) in Ottawa, Canada. Analyte values will be obtained through laboratory analysis for estimation of gestational age as well as screening for other diseases routinely conducted at Ontario's newborn screening program. For select conditions, abnormal screening results will be reported back to the sites in real time to facilitate counseling and future clinical management. We will determine the accuracy of our existing algorithm for estimation of gestational age in these newborn samples. Results from this research hold the potential to create a feasible method to assess gestational age at birth in low- and middle-income countries where reliable estimation may be otherwise unavailable.

    View details for DOI 10.12688/gatesopenres.13155.1

    View details for PubMedID 33501414

  • Multiomics Characterization of Preterm Birth in Low- and Middle-Income Countries. JAMA network open Jehan, F. n., Sazawal, S. n., Baqui, A. H., Nisar, M. I., Dhingra, U. n., Khanam, R. n., Ilyas, M. n., Dutta, A. n., Mitra, D. K., Mehmood, U. n., Deb, S. n., Mahmud, A. n., Hotwani, A. n., Ali, S. M., Rahman, S. n., Nizar, A. n., Ame, S. M., Moin, M. I., Muhammad, S. n., Chauhan, A. n., Begum, N. n., Khan, W. n., Das, S. n., Ahmed, S. n., Hasan, T. n., Khalid, J. n., Rizvi, S. J., Juma, M. H., Chowdhury, N. H., Kabir, F. n., Aftab, F. n., Quaiyum, A. n., Manu, A. n., Yoshida, S. n., Bahl, R. n., Rahman, A. n., Pervin, J. n., Winston, J. n., Musonda, P. n., Stringer, J. S., Litch, J. A., Ghaemi, M. S., Moufarrej, M. N., Contrepois, K. n., Chen, S. n., Stelzer, I. A., Stanley, N. n., Chang, A. L., Hammad, G. B., Wong, R. J., Liu, C. n., Quaintance, C. C., Culos, A. n., Espinosa, C. n., Xenochristou, M. n., Becker, M. n., Fallahzadeh, R. n., Ganio, E. n., Tsai, A. S., Gaudilliere, D. n., Tsai, E. S., Han, X. n., Ando, K. n., Tingle, M. n., Maric, I. n., Wise, P. H., Winn, V. D., Druzin, M. L., Gibbs, R. S., Darmstadt, G. L., Murray, J. C., Shaw, G. M., Stevenson, D. K., Snyder, M. P., Quake, S. R., Angst, M. S., Gaudilliere, B. n., Aghaeepour, N. n. 2020; 3 (12): e2029655


    Worldwide, preterm birth (PTB) is the single largest cause of deaths in the perinatal and neonatal period and is associated with increased morbidity in young children. The cause of PTB is multifactorial, and the development of generalizable biological models may enable early detection and guide therapeutic studies.To investigate the ability of transcriptomics and proteomics profiling of plasma and metabolomics analysis of urine to identify early biological measurements associated with PTB.This diagnostic/prognostic study analyzed plasma and urine samples collected from May 2014 to June 2017 from pregnant women in 5 biorepository cohorts in low- and middle-income countries (LMICs; ie, Matlab, Bangladesh; Lusaka, Zambia; Sylhet, Bangladesh; Karachi, Pakistan; and Pemba, Tanzania). These cohorts were established to study maternal and fetal outcomes and were supported by the Alliance for Maternal and Newborn Health Improvement and the Global Alliance to Prevent Prematurity and Stillbirth biorepositories. Data were analyzed from December 2018 to July 2019.Blood and urine specimens that were collected early during pregnancy (median sampling time of 13.6 weeks of gestation, according to ultrasonography) were processed, stored, and shipped to the laboratories under uniform protocols. Plasma samples were assayed for targeted measurement of proteins and untargeted cell-free ribonucleic acid profiling; urine samples were assayed for metabolites.The PTB phenotype was defined as the delivery of a live infant before completing 37 weeks of gestation.Of the 81 pregnant women included in this study, 39 had PTBs (48.1%) and 42 had term pregnancies (51.9%) (mean [SD] age of 24.8 [5.3] years). Univariate analysis demonstrated functional biological differences across the 5 cohorts. A cohort-adjusted machine learning algorithm was applied to each biological data set, and then a higher-level machine learning modeling combined the results into a final integrative model. The integrated model was more accurate, with an area under the receiver operating characteristic curve (AUROC) of 0.83 (95% CI, 0.72-0.91) compared with the models derived for each independent biological modality (transcriptomics AUROC, 0.73 [95% CI, 0.61-0.83]; metabolomics AUROC, 0.59 [95% CI, 0.47-0.72]; and proteomics AUROC, 0.75 [95% CI, 0.64-0.85]). Primary features associated with PTB included an inflammatory module as well as a metabolomic module measured in urine associated with the glutamine and glutamate metabolism and valine, leucine, and isoleucine biosynthesis pathways.This study found that, in LMICs and high PTB settings, major biological adaptations during term pregnancy follow a generalizable model and the predictive accuracy for PTB was augmented by combining various omics data sets, suggesting that PTB is a condition that manifests within multiple biological systems. These data sets, with machine learning partnerships, may be a key step in developing valuable predictive tests and intervention candidates for preventing PTB.

    View details for DOI 10.1001/jamanetworkopen.2020.29655

    View details for PubMedID 33337494

  • Topical emollient therapy in the management of severe acute malnutrition in children under two: A randomized controlled clinical trial in Bangladesh. Journal of global health Shahunja, K. M., Ahmed, T. n., Hossain, M. I., Mahfuz, M. n., Kendall, L. n., Zhu, X. n., Singh, K. n., Crowther, J. M., Singh, S. n., Gibson, R. A., Darmstadt, G. L. 2020; 10 (1): 010414


    Topical emollient therapy can improve neonatal health and growth and potentially provides an additional avenue for augmenting the provision of nutrition to children with severe acute malnutrition (SAM). We hypothesised that topical treatment of hospitalised children with SAM using sunflower seed oil (SSO), in addition to standard-of-care for SAM, would improve skin barrier function and weight gain, reduce risk of infection, and accelerate clinical recovery.We conducted a randomised, two-arm, controlled, unblinded clinical trial in 212 subjects aged 2 to 24 months who were admitted for care of SAM at the 'Dhaka Hospital' of icddr,b during January 2016 to November 2017. Enrollment was age-stratified into 2 to <6 months and 6 to 24 months age groups in a 1:2 ratio. All children received SAM standard-of-care, and the SSO group was also treated with 3 g of SSO per kg body weight three times daily for 10 days. Primary outcome was rate of weight gain over the 10-day study period. Secondary endpoints included rate of nosocomial infection, time to recovery from acute illness, skin condition score, rate of transepidermal water loss (TEWL) and C-reactive protein (CRP) level.Rate of weight gain was higher in the SSO than the control group (adjusted mean difference, AMD = 0.90 g/kg/d, 95% confidence interval (CI) = -1.22 to 3.03 in the younger age stratum), but did not reach statistical significance. Nosocomial infection rate was significantly lower in the SSO group in the older age stratum (adjusted odds ratio (OR) = 0.41, 95% CI = 0.19 to 0.85; P = 0.017), but was comparable in the younger age stratum and overall. Skin condition score improved (AMD = -14.88, 95% CI = -24.12 to -5.65, P = 0.002) and TEWL was reduced overall (AMD = -2.59, 95% CI = -3.86 to -1.31, P < 0.001) in the SSO group. Reduction in CRP level was significantly greater in the SSO group (median: -0.28) than the control group (median 0.00) (P = 0.019) in the younger age stratum.Topical therapy with SSO was beneficial for children with SAM when applied as adjunctive therapy. A community-based trial with a longer intervention period is recommended to validate these NCT02616289.

    View details for DOI 10.7189/jogh.10.010414

    View details for PubMedID 32509290

    View details for PubMedCentralID PMC7243074

  • "So Why Should I Call Them?": Survivor Support Service Characteristics as Drivers of Help-Seeking in India. Journal of interpersonal violence Newberry, J. A., Kaur, J. n., Gurrapu, S. n., Behl, R. n., Darmstadt, G. L., Halpern-Felsher, B. n., Rao, G. V., Mahadevan, S. V., Strehlow, M. C. 2020: 886260520970306


    Women in South Asia face the highest lifetime prevalence of intimate partner violence in the world, which is just one form of violence against women (VAW). In India, few women seek help after experiencing violence, particularly from formal resources, such as physicians or the police. While many studies have investigated the impact of survivor characteristics and patterns of violence on help-seeking behaviors, there is scant research on support service characteristics and their impact on help-seeking. The introduction of a novel crisis helpline in Gujarat, India provided an opportunity to better understand how successful help-seeking can be driven by the perceived and experienced characteristics of the helpline. We conducted in-depth interviews with helpline users to identify factors and pathways that promoted or discouraged help-seeking in general, help-seeking from a formal source, and help-seeking from this particular helpline. We analyzed 32 interviews of women who used the helpline. Participants were from eight districts across the state, representing a diverse range of sociodemographic backgrounds. After conducting a thematic analysis, we found that action-oriented service, timeliness, and women-focused staff influenced (positively and negatively) participants' feelings of safety, empowerment, and trust in the helpline, which ultimately impacted their decision to seek help from the helpline or even to seek help at all. This study illuminates how service characteristics, in and of themselves, can influence the likelihood that survivors will seek help, emphasizing the need for survivors to have a voice in the growth and refinement of VAW support services. Consequently, these areas must be a focus of future research and initiatives to improve help-seeking by VAW survivors.

    View details for DOI 10.1177/0886260520970306

    View details for PubMedID 33150827

  • Social normative and social network factors associated with adolescent pregnancy: a cross-sectional study of 176 villages in rural Honduras. Journal of global health Shakya, H. B., Darmstadt, G. L., Barker, K. M., Weeks, J. n., Christakis, N. A. 2020; 10 (1): 010706


    Adolescent pregnancy and childbirth are common throughout Central America. While gendered beliefs promoting motherhood are a known risk factor, their association with adolescent childbirth within the social networks of Central American communities is unknown.This was a cross-sectional study looking at adolescent childbirth amongst women ages 15-20 years (N = 2990) in rural Honduras, using reproductive health data on all individuals ≥15 years of age (N = 24 937 of 31 300 population) including social network contacts, all of whom were interviewed as part of the study. The outcome, adolescent childbirth, was defined as having had a child < age 20 years. Predictors included whether a woman's social contact had an adolescent childbirth and the social contact's reported perception of community support for adolescent childbirth.While girls who identified a father in the village as a social contact had a lower likelihood of adolescent childbirth regardless of whether or not they reported being in a partnership, this finding did not hold for girls who identified mothers. There was an association between a social contact's report of norms supporting adolescent childbirth and a girl's risk of adolescent childbirth; however, village-level aggregate norms attenuated that relationship. Independent significant associations were found between a girl's risk of adolescent childbirth and both a social contact's adolescent childbirth and the village proportion of women who had had an adolescent childbirth. The association between social contacts' adolescent childbirth and a girl's risk of adolescent childbirth across relationships was more robust for stronger relationships and when the social contact was closer in age to the girl.If, as this evidence suggests, a strong driver of adolescent childbirth is the frequency of the occurrence of adolescent childbirth both within the greater community and within a girl's proximal social network, the challenge for intervention strategies is to encourage norms that prevent adolescent childbirth without stigmatising those who have had an adolescent childbirth. Programmatic efforts to counter prevailing norms that limit a woman's role to motherhood, and that support and encourage strong norms for girls' education may play an important role in addressing this situation.

    View details for DOI 10.7189/jogh.10.010706

    View details for PubMedID 32373336

    View details for PubMedCentralID PMC7182389

  • Improving primary health care delivery in Bihar, India: Learning from piloting and statewide scale-up of Ananya. Journal of global health Darmstadt, G. L., Pepper, K. T., Ward, V. C., Srikantiah, S. n., Mahapatra, T. n., Tarigopula, U. K., Bhattacharya, D. n., Irani, L. n., Schooley, J. n., Chaudhuri, I. n., Dutt, P. n., Sastry, P. n., Mitra, R. n., Chamberlain, S. n., Monaghan, S. n., Nanda, P. n., Atmavilas, Y. n., Saggurti, N. n., Borkum, E. n., Rangarajan, A. n., Mehta, K. M., Abdalla, S. n., Wilhelm, J. n., Weng, Y. n., Carmichael, S. L., Raheel, H. n., Bentley, J. n., Munar, W. A., Creanga, A. n., Trehan, S. n., Walker, D. n., Shah, H. n. 2020; 10 (2): 021001


    In 2010, the Bill and Melinda Gates Foundation (BMGF) partnered with the Government of Bihar (GoB), India to launch the Ananya program to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) outcomes. The program sought to address supply- and demand-side barriers to the adoption, coverage, quality, equity and health impact of select RMNCHN interventions. Approaches included strengthening frontline worker service delivery; social and behavior change communications; layering of health, nutrition and sanitation into women's self-help groups (SHGs); and quality improvement in maternal and newborn care at primary health care facilities. Ananya program interventions were piloted in approximately 28 million population in eight innovation districts from 2011-2013, and then beginning in 2014, were scaled up by the GoB across the rest of the state's population of 104 million. A Bihar Technical Support Program provided techno-managerial support to governmental Health as well as Integrated Child Development Services, and the JEEViKA Technical Support Program supported health layering and scale-up of the GoB's SHG program. The level of support at the block level during statewide scale-up in 2014 onwards was approximately one-fourth that provided in the pilot phase of Ananya in 2011-2013. This paper - the first manuscript in an 11-manuscript and 2-viewpoint collection on Learning from Ananya: Lessons for primary health care performance improvement - seeks to provide a broad description of Ananya and subsequent statewide adaptation and scale-up, and capture the background and context, key objectives, interventions, delivery approaches and evaluation methods of this expansive program. Subsequent papers in this collection focus on specific intervention delivery platforms. For the analyses in this series, Stanford University held key informant interviews and worked with the technical support and evaluation grantees of the Ananya program, as well as leadership from the India Country Office of the BMGF, to analyse and synthesise data from multiple sources. Capturing lessons from the Ananya pilot program and statewide scale-up will assist program managers and policymakers to more effectively design and implement RMNCHN programs at scale through technical assistance to governments.

    View details for DOI 10.7189/jogh.10.021001

    View details for PubMedID 33414906

    View details for PubMedCentralID PMC7757841

  • Shifts in Women's Paid Employment Participation During the World War II Era and Later Life Health. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Falconi, A. M., Weber, A. M., Cullen, M. R., Stefanick, M. L., Michael, Y. L., Darmstadt, G. L. 2020; 66 (1S): S42–S50


    PURPOSE: The greatest proportional increase in female labor force participation of the 20th century occurred post-World War II (WWII) when shifts in policy and growth in service and clerical work spurred an influx of women into the labor force. Research has yet to demonstrate how variation in women's employment participation during this era related to their later life health. We examined how shifts in women's employment patterns during the WWII era influenced their disease and mortality risk.METHODS: Using data from the Women's Health Initiative Observational Study, we evaluated the employment history of a cohort of 6,158 women across the U.S. during the WWII era. We fit logistic regression models estimating the association between involvement in the workforce over 5-year intervals and health (i.e., cancer, cardiovascular disease, and mortality). We also ran models with a younger cohort (n= 12,435) of women to assess how associations between work and health varied between cohorts.RESULTS: The older cohort of women who entered the workforce before the onset of WWII showed mixed to no differences in health relative to homemakers. The younger cohort of women who entered the workforce during WWII tended to show negative relationships between work during their late/post-childbearing years and health, experiencing higher risks for mortality.CONCLUSIONS: The policies, social forces, and broader environment in which women live appear to significantly influence how involvement in the workforce over the life course influences health. Women whose entry into the workforce was initially encouraged socially but were later confronted with opposition experienced increased health risks.

    View details for DOI 10.1016/j.jadohealth.2019.10.005

    View details for PubMedID 31866037

  • Parent-Related Normative Perceptions of Adolescents and Later Weight Control Behavior: Longitudinal Analysis of Cohort Data From Brazil. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Abdalla, S., Buffarini, R., Weber, A. M., Cislaghi, B., Costa, J. C., Menezes, A. M., Goncalves, H., Wehrmeister, F. C., Meausoone, V., Victora, C. G., Darmstadt, G. L. 2020; 66 (1S): S9–S16


    PURPOSE: Body image-related norms can be imposed by parents and can shape adolescents' body satisfaction in consequential ways, yet evidence on long-term effects is scarce. Longitudinal data from a country with strong body image focus provided a unique opportunity to investigate long-term influences of normative parent-related perceptions.METHODS: Multinomial logistic regression was used on data from a 1993 birth cohort in Brazil to investigate the association of normal-body mass index (BMI) adolescents' perception of their parent's opinion of their weight at age 11years with their weight control attempts at 18years, testing a mediating role for body dissatisfaction at age 15years. All models controlled for body dissatisfaction at age 11years and BMI change between ages 11 and 15years.RESULTS: A total of 1150 boys and 1336 girls were included. Girls were more likely than boys to diet without nutritionist advice to lose weight (51.5% vs. 34.3% among boys) and use medication to gain weight (12.7% vs. 4.2%). Normal-BMI adolescents who reported at age 11years that their parents thought they were thin had higher odds of feeling thinner than ideal at age 15years (odds ratio 2.8, 95% confidence interval 1.8-3.2; and odds ratio 2.0, 95% confidence interval 1.5-2.7) among boys and girls, respectively). Feeling thinner than ideal at age 15years was associated among girls with higher odds of weight gain attempts at age 18years. Similar patterns appeared among girls reporting that their parents thought they were fat at age 11years, feeling fatter than ideal at age 15years and having higher odds of weight loss attempts at age 18years. Body dissatisfaction was a statistically significant mediator among girls but not boys.CONCLUSIONS: A long-term influence of parent-related perceptions via a likely trajectory of body dissatisfaction is evident among girls.

    View details for DOI 10.1016/j.jadohealth.2019.09.007

    View details for PubMedID 31866039

  • Relationships Between Maternal Factors and Weight Loss Attempts Among Urban Male and Female Adolescents Living in Soweto, Johannesburg, South Africa. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Cohen, E., Richter, L. M., Chidumwa, G., Abdalla, S., Weber, A. M., Darmstadt, G. L., Norris, S. A. 2020; 66 (1S): S17–S24


    PURPOSE: South Africa is undergoing rapid urban transition favoring ideals of thinness, which increases eating disorders risk for female adolescents, whereas older women continue to uphold corpulence as a female cultural value. This study aimed to assess the potential conflicting relationship between urban male and female adolescents' weight loss attempts (WLA) and maternal body image norms within households.METHODS: The study included a longitudinal sample of mother-daughter and mother-son pairs from the Birth to Twenty Plus Cohort (N= 1,613), using data collected at 13, 17, and 22years. Sociodemographic characteristics, eating attitudes, WLA, and body mass index were assessed in mothers and their offspring. Relationships between maternal factors and offspring's WLA were assessed using both logistic regression and structural equation modeling.RESULTS: More females had WLA compared with their male counterparts at 13, 17, and 22years. Multivariable models showed an independent positive association between maternal household socioeconomic status and boys' WLA at 13years, whereas independent negative associations were found between mothers' body mass index and boys' WLA at 17 and 22years. Mothers' age and sons' WLA at 22years showed an independent positive association. No association was found between maternal factors and daughters' WLA.CONCLUSIONS: Strong gender-differentiated intergenerational patterns were observed between maternal factors and offspring's WLA from early adolescence to early adulthood. The lack of relationship between maternal factors and daughters' behavior in contrast to that of sons suggests that Western acculturation may pose a greater risk for females to modern body image disturbances and eating disorders.

    View details for DOI 10.1016/j.jadohealth.2019.10.015

    View details for PubMedID 31866033

  • Attitudinal Acceptance of Intimate Partner Violence Among Adolescents and Young Adults in Nigeria and Tanzania: An Exploration Into Target Reference Groups Order and Affiliation of Authorship. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Meinhart, M., Seff, I., Darmstadt, G. L., Weber, A. M., Stark, L. 2020; 66 (1S): S3–S8


    PURPOSE: Attitudinal programming for the prevention of intimate partner violence (IPV) among adolescents and young adults often focuses on whom to target based on gender or age; yet other pivotal junctures may relate to when to intervene, such as critical events (e.g., marriage). Using data from the nationally representative Violence Against Children Survey in Nigeria and Tanzania, this study examines the gendered association of acceptance of IPV across 3 reference groups-age, marital status, and education attainment-for male and female adolescents and young adults.METHODS: Data were analyzed from a sample of 2,437 and 1,771 males in Nigeria and Tanzania, respectively, and 1,766 and 1,968 females in each respective country. Logistic regressions were used to estimate the odds of agreeing with at least one of 5 scenarios when it is acceptable for a husband to beat his wife. A second model examined how experience of IPV in the prior 12 months influences the attitudinal outcome for females.RESULTS: Age was not found to be a significant predictor for attitudinal acceptance of IPV in either country or for either gender. Level of schooling was found to be a significant predictor for decreased odds of attitudinal acceptance of IPV for males but not females in both countries. In contrast, being married was associated with IPV acceptance for females in Tanzania (adjusted odds ratio [aOR]: 1.56; confidence intervals [CIs]: 1.03-2.37) and Nigeria (aOR: 1.66; CIs: 1.19-2.30), but not for males. The significance of marriage for females in Nigeria remained (aOR: 1.67; CIs: 1.20-2.33), even adjusted for past 12-month IPV experience (aOR: 1.85; CIs: 1.11-3.07) and the interaction of IPV experience and marriage (aOR: 3.42, CIs: 1.72-6.80).CONCLUSIONS: Among adolescents and young adults in Nigeria and Tanzania, there are gendered associations for attitudinal acceptance of IPV. Marriage appears to be a strong predictor for females, even adjusted for IPV experience, thus indicating that there is something unique to marriage among female adolescents and young adults that influences acceptance of IPV.

    View details for DOI 10.1016/j.jadohealth.2019.10.006

    View details for PubMedID 31866035

  • The Intersectionality of Gender and Wealth in Adolescent Health and Behavioral Outcomes in Brazil: The 1993 Pelotas Birth Cohort. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Buffarini, R., Abdalla, S., Weber, A. M., Costa, J. C., Menezes, A. M., Goncalves, H., Wehrmeister, F. C., Meausoone, V., Darmstadt, G. L., Victora, C. G. 2020; 66 (1S): S51–S57


    PURPOSE: Brazilian society is characterized by deep socioeconomic inequalities. Using data from a population-based birth cohort, we explored how the intersectionality of family income and gender may affect adolescent health and behavioral outcomes.METHODS: Children born in 1993 in the Brazilian city of Pelotas have been followed up prospectively at the age of 15years when the follow-up rate was 85.7% of the original cohort. Participants answered standardized questionnaires, and anthropometric measures were obtained. Outcomes in five domains were studied: overweight (body mass index above+1 SD of the World Health Organization standard for age and sex), cigarette smoking (in the previous month), violence (fight in which someone was injured, in the past year), self-reported unhappiness (based on a face scale), and psychological symptoms (Strengths and Difficulties Questionnaire). Monthly family income was recoded in quintiles.RESULTS: Results were available for more than 4,101-4,334 adolescents, depending on the outcome. Overweight was more common among boys than girls (29.7% and 25.6%; p= .004) and was directly related to family income among boys (p < .001), but not among girls (p= .681). Smoking was less common among boys than girls (12.3% and 21.0%, p < .001) and showed strong inverse association with income among girls (p < .001), but not among boys (p= .099). Reported violence was twice as common among boys than girls (16.4% vs. 8.0%; p < .001); an inverse association with income was present among girls (p < .001), but not for boys (p= .925). Boys and girls were similarly likely to report being unhappy (18.4% and 20.1%; p= .176), with an inverse association with family income in girls. Psychological symptoms were slightly less common among boys than girls (25.3% and 28.3%; p= .014), with strong inverse associations with income in both sexes (p < .001). Adolescent girls from poor families were the group with the highest prevalence for three of the five outcomes: smoking, unhappiness, and psychological problems.CONCLUSIONS: Gender norms influence adolescent health and behavioral outcomes, but the direction and strength of the associations are modified by socioeconomic position. Preventive strategies must take into account the intersectionality of gender and wealth.

    View details for DOI 10.1016/j.jadohealth.2019.08.029

    View details for PubMedID 31866038

  • Gender Norms and Weight Control Behaviors in U.S. Adolescents: A Prospective Cohort Study (1994-2002). The Journal of adolescent health : official publication of the Society for Adolescent Medicine Nagata, J. M., Domingue, B. W., Darmstadt, G. L., Weber, A. M., Meausoone, V., Cislaghi, B., Shakya, H. B. 2020; 66 (1S): S34–S41


    PURPOSE: The aim of this article was to determine the relationship between gender norms and weight control behaviors in U.S. adolescents.METHODS: We analyzed prospective cohort data from the National Longitudinal Study of Adolescent to Adult Health (N= 9,861), at baseline in 1994-1995 (ages 11-18years, Wave I), 1-year follow-up (ages 12-19years, Wave II), and 7-year follow-up (ages 18-26years, Wave III). The primary exposure variable was a measure of one's gender normativity based on the degree to which males and females behave in ways that are similar to the behaviors of their same-gender peers. The outcome variable was an individual's weight control attempts (trying to lose or gain weight) and behaviors (dieting, fasting/skipping meals, vomiting, or weight-loss pills/laxatives/diuretics to lose weight or ate different/more foods than usual or taking supplements to gain weight).RESULTS: In logistic regression analyses controlling for potential confounders, a higher baseline individual gender normativity score (higher femininity in females and higher masculinity in males) was associated with weight loss attempts (beta= .10; p= .01) and weight loss behaviors (beta= .18; p<.001) in girls but was associated with weight gain attempts (beta= .18; p < .001) and behaviors (beta= .16; p < .001) in boys at 1-year follow-up. Higher individual gender normativity score was protective of weight loss attempts (beta=-.15; p < .001) and weight loss behaviors (beta=-.17; p<.001) in males but not females at 7-year follow-up. Loess plots provided visualizations of significant relationships.CONCLUSIONS: Gender norms may reinforce a thinner body ideal for girls but a larger ideal for boys.

    View details for DOI 10.1016/j.jadohealth.2019.08.020

    View details for PubMedID 31866036

  • Progress on Sustainable Development Goal 5 and improved health through better measurement SSM-POPULATION HEALTH Keats, E. C., Darmstadt, G. L., Bhutta, Z. A. 2019; 9
  • Religious affiliation and immunization coverage in 15 countries in Sub-Saharan Africa. Vaccine Costa, J. C., Weber, A. M., Darmstadt, G. L., Abdalla, S., Victora, C. G. 2019


    BACKGROUND: Although religious affiliation has been identified as a potential barrier to immunization in some African countries, there are no systematic multi-country analyses, including within-country variability, on this issue. We investigated whether immunization varied according to religious affiliation and sex of the child in sub-Saharan African (SSA) countries.METHODS: We used data from 15 nationally representative surveys from 2010 to 2016. The major religious groups were described by country in terms of wealth, residence, and education. Proportions of fully immunized and unvaccinated children were stratified by country, maternal religion, and sex of the child. Poisson regression with robust variance was used to assess whether the outcomes varied according to religion, with and without adjustment for the above cited sociodemographic confounders. Interactions between child sex and religion were investigated.RESULTS: Fifteen countries had >10% of families affiliated with Christianity and >10% affiliated with Islam, and four also had >10% practicing folk religions. In general, Christians were wealthier, more educated and more urban. Nine countries had significantly lower full immunization coverage among Muslims than Christians (pooled prevalence ratio=0.81; 95%CI: 0.79-0.83), of which seven remained significant after adjustment for confounders (pooled ratio=0.90; 0.87-0.92). Four countries had higher coverage among Muslims, of which two remained significant after adjustment. Regarding unvaccinated children, six countries showed higher proportions among Muslims, all of which remained significant after adjustment [crude pooled ratio=1.83 (1.59-2.07); adjusted=1.31 (1.14-1.48)]. Children from families practicing folk religions did not show any consistent patterns in immunization. Child sex was not consistently associated with vaccination.CONCLUSION: Muslim religion was associated with lower vaccine coverage in several SSA countries, both for boys and girls. The involvement of religious leaders is essential for increasing immunization coverage and supporting the leave no one behind agenda of the Sustainable Development Goals.

    View details for DOI 10.1016/j.vaccine.2019.11.024

    View details for PubMedID 31791811

  • Kangaroo Mother Care implementation research to develop models for accelerating scale-up in India and Ethiopia: study protocol for an adequacy evaluation. BMJ open Medhanyie, A. A., Alemu, H., Asefa, A., Beyene, S. A., Gebregizabher, F. A., Aziz, K., Bhandari, N., Beyene, H., Brune, T., Chan, G., Cranmer, J. N., Darmstadt, G., Duguma, D., Fikre, A., Andualem, B. G., Gobezayehu, A. G., Mariam, D. H., Abay, T. H., Mohan, H. L., Jadaun, A., Jayanna, K., Kajal, F. N., Kar, A., Krishna, R., Kumar, A., Kumar, V., Madhur, T. K., Belew, M. L., M, R., Martines, J., Mazumder, S., Amin, H., Mony, P. K., Muleta, M., Pileggi-Castro, C., Pn Rao, S., Estifanos, A. S., Sibley, L. M., Singhal, N., Tadele, H., Tariku, A., Lemango, E. T., Tadesse, B. T., Upadhyay, R., Worku, B., Hadush, M. Y., Bahl, R., KMC Scale-Up Study Group, Medhanyie, A. A., Alemu, H., Asefa, A., Beyene, S. A., Gebregizabher, F. A., Aziz, K., Bhandari, N., Beyene, H., Brune, T., Chan, G. J., Cranmer, J. N., Darmstadt, G. L., Duguma, D., Fikre, A., Andualem, B. G., Gobezayehu, A. G., Mariam, D. H., Abay, T. H., Mohan, H. L., Jadaun, A., Jayanna, K., Kajal, F. N., Kar, A., Krishna, R., Kumar, A., Kumar, V., Madhur, T. K., Belew, M. L., Rajini, M., Martines, J. C., Mazumder, S., Amin, H. M., Mony, P. K., Muleta, M., Pileggi-Castro, C., Rao, S., Estifanos, A. S., Sibley, L. M., Singhal, N., Tadele, H., Tariku, A., Lemango, E. T., Tadesse, B. T., Upadhyay, R. P., Worku, B., Hadush, M. Y., Bahl, R. 2019; 9 (11): e025879


    INTRODUCTION: Kangaroo Mother Care (KMC) is the practice of early, continuous and prolonged skin-to-skin contact between the mother and the baby with exclusive breastfeeding. Despite clear evidence of impact in improving survival and health outcomes among low birth weight infants, KMC coverage has remained low and implementation has been limited. Consequently, only a small fraction of newborns that could benefit from KMC receive it.METHODS AND ANALYSIS: This implementation research project aims to develop and evaluate district-level models for scaling up KMC in India and Ethiopia that can achieve high population coverage. The project includes formative research to identify barriers and contextual factors that affect implementation and utilisation of KMC and design scalable models to deliver KMC across the facility-community continuum. This will be followed by implementation and evaluation of these models in routine care settings, in an iterative fashion, with the aim of reaching a successful model for wider district, state and national-level scale-up. Implementation actions would happen at three levels: 'pre-KMC facility'-to maximise the number of newborns getting to a facility that provides KMC; 'KMC facility'-for initiation and maintenance of KMC; and 'post-KMC facility'-for continuation of KMC at home. Stable infants with birth weight<2000g and born in the catchment population of the study KMC facilities would form the eligible population. The primary outcome will be coverage of KMC in the preceding 24hours and will be measured at discharge from the KMC facility and 7days after hospital discharge.ETHICS AND DISSEMINATION: Ethics approval was obtained in all the project sites, and centrally by the Research Ethics Review Committee at the WHO. Results of the project will be submitted to a peer-reviewed journal for publication, in addition to national and global level dissemination.STUDY STATUS: WHO approved protocol: V.4-12 May 2016-Protocol ID: ERC 2716. Study implementation beginning: April 2017. Study end: expected March 2019.TRIAL REGISTRATION NUMBER: Community Empowerment Laboratory, Uttar Pradesh, India (ISRCTN12286667); St John's National Academy of Health Sciences, Bangalore, India and Karnataka Health Promotion Trust, Bangalore, India (CTRI/2017/07/008988); Society for Applied Studies, Delhi (NCT03098069); Oromia, Ethiopia (NCT03419416); Amhara, SNNPR and Tigray, Ethiopia (NCT03506698).

    View details for DOI 10.1136/bmjopen-2018-025879

    View details for PubMedID 31753865

  • Implications of gendered behaviour and contexts for social mobility in the USA: a nationally representative observational study. The Lancet. Planetary health Domingue, B. W., Cislaghi, B., Nagata, J. M., Shakya, H. B., Weber, A. M., Boardman, J. D., Darmstadt, G. L., Harris, K. M. 2019; 3 (10): e420–e428


    BACKGROUND: We constructed measures of an individual's gendered behaviour and their gendered environment to investigate the salience of gender norms during adolescence for social mobility during the next decade of life.METHODS: In this nationally representative observational study, we collected individual-level data from the National Longitudinal Study of Adolescent to Adult Health (Add Health), which enrolled a cohort of nationally representative school students aged 11-19 years from across the USA and followed them up for 14 years (ie, to age 25-33 years). We characterised gendered behaviour for adolescents in a performative sense via self-reports of behaviours and beliefs. We aggregated this individual-level measure to create a proxy measure of an individual's social context by taking averages for an individual's peers of the same sex and school year.FINDINGS: Between Jan 5, 1994, and Dec 26, 1995, Add Health collected data on a cohort of 20 745 students. 14 540 respondents were followed-up 14 years later between April 3, 2007, and Feb 1, 2009, of whom 7722 (53·1%) were female. More masculine male respondents were downwardly mobile; they were enrolled in school for fewer years and were more likely to have lower status jobs than their less masculine same-sex school peers. More masculine male respondents were also more likely to have jobs in occupational categories with larger proportions of males than their same-sex school peers. Gendered behaviour was not predictive of future educational and occupational attainment for female respondents. Male adolescents in school years with more masculine same-sex peers than male adolescents in other school years also tended to have lower educational and occupational attainment than their male peers. Educational and occupational attainment in early midlife for female respondents was not affected by their gendered environment.INTERPRETATION: Gender, when measured as a set of gender-distinct behaviours in adolescence, was associated with differential patterns of social mobility from adolescence to young adulthood. Moreover, variation in an individual's local gender norms has implications for subsequent socioeconomic attainment, especially for male adolescents. These findings have potential implications for observed health disparities.FUNDING: Bill & Melinda Gates Foundation.

    View details for DOI 10.1016/S2542-5196(19)30191-3

    View details for PubMedID 31625514

  • Implications of gendered behaviour and contexts for social mobility in the USA: a nationally representative observational study LANCET PLANETARY HEALTH Domingue, B. W., Cislaghi, B., Nagata, J. M., Shakya, H. B., Weber, A. M., Boardman, J. D., Darmstadt, G. L., Harris, K. 2019; 3 (10): E420–E428
  • Detecting Developmental Delay and Autism Through Machine Learning Models Using Home Videos of Bangladeshi Children: Development and Validation Study JOURNAL OF MEDICAL INTERNET RESEARCH Tariq, Q., Fleming, S., Schwartz, J., Dunlap, K., Corbin, C., Washington, P., Kalantarian, H., Khan, N. Z., Darmstadt, G. L., Wall, D. 2019; 21 (4)

    View details for DOI 10.2196/13822

    View details for Web of Science ID 000465558900001

  • Pregnancy intervals after stillbirth, neonatal death and spontaneous abortion and the risk of an adverse outcome in the next pregnancy in rural Bangladesh. BMC pregnancy and childbirth Nonyane, B. A., Norton, M., Begum, N., Shah, R. M., Mitra, D. K., Darmstadt, G. L., Baqui, A. H., Projahnmo Study Group in Bangladesh 2019; 19 (1): 62


    BACKGROUND: Studies have revealed associations between preceding short and long birth-to-birth or birth-to-pregnancy intervals and poor pregnancy outcomes. Most of these studies, however, have examined the effect of intervals that began with live births. Using data from Bangladesh, we examined the effect of inter-outcome intervals (IOI) starting with a non-live birth or neonatal death, on outcomes in the next pregnancy. Pregnancy spacing behaviors in rural northeast Bangladesh have changed little since 2004.METHODS: We analyzed pregnancy histories for married women aged 15-49 years who had outcomes between 2000 and 2006 in Sylhet, Bangladesh. We examined the effects of the preceding outcome and the IOI length on the risk of stillbirth, neonatal death and spontaneous abortion using multinomial logistic regression models.RESULTS: Data included 64,897 pregnancy outcomes from 33,495 mothers. Inter-outcome intervals of 27-50 months and live births were baseline comparators. Stillbirths followed by IOI's <=6 months, 7-14 months or overall <=14 months had increased risks for spontaneous abortion with adjusted relative risk ratios (aRRR) and 95% confidence intervals = 29.6 (8.09, 108.26), 1.84 (0.84, 4.02) and 2.53 (1.19, 5.36), respectively. Stillbirths followed by IOIs 7-14 months had aRRR 2.00 (1.39, 2.88) for stillbirths. Neonatal deaths followed by IOIs <=6 months had aRRR 28.2 (8.59, 92.63) for spontaneous abortion. Neonatal deaths followed by IOIs 7-14 and 15-26 months had aRRRs 3.08 (1.82, 5.22) and 2.32 (1.38, 3.91), respectively, for stillbirths; and aRRRs 2.81 (2.06, 3.84) and 1.70 (1.24, 3.84), respectively, for neonatal deaths. Spontaneous abortions followed by IOIs <=6 months and 7-14 months had, respectively, aRRRs 23.21 (10.34, 52.13) and 1.80 (0.98, 3.33) for spontaneous abortion.CONCLUSION: In rural northeast Bangladesh, short inter-outcome intervals after stillbirth, neonatal death and spontaneous abortion were associated with a high risk of a similar outcome in the next pregnancy. These findings are aligned with other studies from Bangladesh. Two studies from similar settings have found benefits of waiting six months before conceiving again, suggesting that incorporating this advice into programs should be considered. Further research is warranted to confirm these findings.

    View details for PubMedID 30738434

  • Assessing Diversity in Early Childhood Development in the East Asia-Pacific CHILD INDICATORS RESEARCH Rao, N., Sun, J., Richards, B., Weber, A., Sincovich, A., Darmstadt, G. L., Ip, P. 2019; 12 (1): 235–54
  • Use of mobile technology by frontline health workers to promote reproductive, maternal, newborn and child health and nutrition: a cluster randomized controlled Trial in Bihar, India. Journal of global health Carmichael, S. L., Mehta, K. n., Srikantiah, S. n., Mahapatra, T. n., Chaudhuri, I. n., Balakrishnan, R. n., Chaturvedi, S. n., Raheel, H. n., Borkum, E. n., Trehan, S. n., Weng, Y. n., Kaimal, R. n., Sivasankaran, A. n., Sridharan, S. n., Rotz, D. n., Tarigopula, U. K., Bhattacharya, D. n., Atmavilas, Y. n., Pepper, K. T., Rangarajan, A. n., Darmstadt, G. L. 2019; 9 (2): 0204249


    mHealth technology holds promise for improving the effectiveness of frontline health workers (FLWs), who provide most health-related primary care services, especially reproductive, maternal, newborn, child health and nutrition services (RMNCHN), in low-resource - especially hard-to-reach - settings. Data are lacking, however, from rigorous evaluations of mHealth interventions on delivery of health services or on health-related behaviors and outcomes.The Information Communication Technology-Continuum of Care Service (ICT-CCS) tool was designed for use by community-based FLWs to increase the coverage, quality and coordination of services they provide in Bihar, India. It consisted of numerous mobile phone-based job aids aimed to improve key RMNCHN-related behaviors and outcomes. ICT-CCS was implemented in Saharsa district, with cluster randomization at the health sub-center level. In total, evaluation surveys were conducted with approximately 1100 FLWs and 3000 beneficiaries who had delivered an infant in the previous year in the catchment areas of intervention and control health sub-centers, about half before implementation (mid-2012) and half two years afterward (mid-2014). Analyses included bivariate and difference-in-difference analyses across study groups.The ICT-CCS intervention was associated with more frequent coordination of AWWs with ASHAs on home visits and greater job confidence among ASHAs. The intervention resulted in an 11 percentage point increase in FLW antenatal home visits during the third trimester (P = 0.04). In the post-implementation period, postnatal home visits during the first week were increased in the intervention (72%) vs the control (60%) group (P < 0.01). The intervention also resulted in 13, 12, and 21 percentage point increases in skin-to-skin care (P < 0.01), breastfeeding immediately after delivery (P < 0.01), and age-appropriate complementary feeding (P < 0.01). FLW supervision and other RMNCHN behaviors were not significantly impacted.Important improvements in FLW home visits and RMNCHN behaviors were achieved. The ICT-CCS tool shows promise for facilitating FLW effectiveness in improving RMNCHN behaviors.

    View details for DOI 10.7189/jogh.09.020424

    View details for PubMedID 31788233

    View details for PubMedCentralID PMC6875677

  • The D-score: a metric for interpreting the early development of infants and toddlers across global settings. BMJ global health Weber, A. M., Rubio-Codina, M., Walker, S. P., van Buuren, S., Eekhout, I., Grantham-McGregor, S. M., Araujo, M. C., Chang, S. M., Fernald, L. C., Hamadani, J. D., Hanlon, C., Karam, S. M., Lozoff, B., Ratsifandrihamanana, L., Richter, L., Black, M. M., Working group members and data contributors, Attanasio, O., Darmstadt, G. L., Doove, B. M., Galasso, E., Jervis, P., Medhin, G., Menezes, A. M., Pitchik, H., Reynolds, S., Schady, N. 2019; 4 (6): e001724


    Introduction: Early childhood development can be described by an underlying latent construct. Global comparisons of children's development are hindered by the lack of a validated metric that is comparable across cultures and contexts, especially for children under age 3years. We constructed and validated a new metric, the Developmental Score (D-score), using existing data from 16 longitudinal studies.Methods: Studies had item-level developmental assessment data for children 0-48 months and longitudinal outcomes at ages >4-18 years, including measures of IQ and receptive vocabulary. Existing data from 11 low-income, middle-income and high-income countries were merged for >36000 children. Item mapping produced 95 'equate groups' of same-skill items across 12 different assessment instruments. A statistical model was built using the Rasch model with item difficulties constrained to be equal in a subset of equate groups, linking instruments to a common scale, the D-score, a continuous metric with interval-scale properties. D-score-for-age z-scores (DAZ) were evaluated for discriminant, concurrent and predictive validity to outcomes in middle childhood to adolescence.Results: Concurrent validity of DAZ with original instruments was strong (average r=0.71), with few exceptions. In approximately 70% of data rounds collected across studies, DAZ discriminated between children above/below cut-points for low birth weight (<2500g) and stunting (-2 SD below median height-for-age). DAZ increased significantly with maternal education in 55% of data rounds. Predictive correlations of DAZ with outcomes obtained 2-16 years later were generally between 0.20 and 0.40. Correlations equalled or exceeded those obtained with original instruments despite using an average of 55% fewer items to estimate the D-score.Conclusion: The D-score metric enables quantitative comparisons of early childhood development across ages and sets the stage for creating simple, low-cost, global-use instruments to facilitate valid cross-national comparisons of early childhood development.

    View details for DOI 10.1136/bmjgh-2019-001724

    View details for PubMedID 31803508

  • Characteristics of successful programmes targeting gender inequality and restrictive gender norms for the health and wellbeing of children, adolescents, and young adults: a systematic review. The Lancet. Global health Levy, J. K., Darmstadt, G. L., Ashby, C. n., Quandt, M. n., Halsey, E. n., Nagar, A. n., Greene, M. E. 2019


    In the context of the Sustainable Development Goals and the shifting global burden of disease, this systematic review analyses the evidence from rigorously evaluated programmes that seek to transform the gendered social norms undermining the health and wellbeing of children, adolescents, and young adults. The aim of this study was threefold: to describe the landscape of gender-transformative programmes that attempt to influence health-related outcomes; to identify mechanisms through which successful programmes work; and to highlight where gaps might exist in implementation and evaluation.We systematically reviewed rigorous evaluations published between Jan 1, 2000, and Nov 1, 2018 of programmes that sought to decrease gender inequalities and transform restrictive gender norms to improve the health and wellbeing of 0-24 year olds. We included rigorously evaluated health programmes that met the Interagency Gender Working Group definition of gender-transformative programming, regardless of where in the world they were implemented and what area of health they focused on.Among 22 993 articles identified by our search, 61 evaluations of 59 programmes met review criteria. Programmes were concentrated in sub-Saharan Africa (25 [42%]), south Asia (13 [22%]), and North America (13 [22%]) and mainly measured health indicators related to reproductive health (29 [48%]), violence (26 [43%]), or HIV (18 [30%]). Programmes most frequently focused on improving the individual power of the beneficiaries, rather than working on broader systems of inequality. 45 (74%) of the evaluations measured significant improvements in health-related and gender-related indicators; however, only ten (16%) showed evidence of, or potential for, broader norm change. These ten programmes worked with sectors beyond health, included multiple stakeholders, implemented diversified strategies, and fostered critical awareness and participation among affected community members.This review can accelerate efforts to improve global health by leading to more strategic investment in programmes that promote gender equality and target restrictive gender norms among young people. Such programmes can lead to a lifetime of improved health and wellbeing by challenging not only attitudes and behaviours related to gender at an early age, but also the gendered systems that surround them.Bill & Melinda Gates Foundation.

    View details for DOI 10.1016/S2214-109X(19)30495-4

    View details for PubMedID 31879212

  • 'Our village is dependent on us. That's why we can't leave our work'. Characterizing mechanisms of motivation to perform among Accredited Social Health Activists (ASHA) in Bihar. Health policy and planning Wahid, S. S., Munar, W. n., Das, S. n., Gupta, M. n., Darmstadt, G. L. 2019


    Community health workers (CHWs) play major roles in delivering primary healthcare services, linking communities to the formal health system and addressing the social determinants of health. Available evidence suggests that the performance of CHW programmes in low- and middle-income countries can be influenced by context-dependent causal mechanisms such as motivation to perform. There are gaps regarding what these mechanisms are, and what their contribution is to CHW performance. We used a theory-driven case study to characterize motivational mechanisms among Accredited Social Health Activists (ASHAs) in Bihar, India. Data were collected through semi-structured interviews with CHWs and focus group discussions with beneficiary women. Data were coded using a combined deductive and inductive approach. We found that ASHAs were motivated by a sense of autonomy and self-empowerment; a sense of competence, connection and community service; satisfaction of basic financial needs; social recognition; and feedback and answerability. Findings highlight the potential of ASHAs' intrinsic motivation to increase their commitment to communities and identification with the health system and of programme implementation and management challenges as sources of work dissatisfaction. Efforts to nurture and sustain ASHAs' intrinsic motivation while addressing these challenges are necessary for improving the performance of Bihar's ASHA programme. Further research is needed to characterize the dynamic interactions between ASHAs' motivation, commitment, job satisfaction and overall performance; also, to understand how work motivation is sustained or lost through time. This can inform policy and managerial reforms to improve ASHA programme's performance.

    View details for DOI 10.1093/heapol/czz131

    View details for PubMedID 31670772

  • Global research priorities to accelerate programming to improve early childhood development in the sustainable development era: a CHNRI exercise. Journal of global health Tomlinson, M. n., Darmstadt, G. L., Yousafzai, A. K., Daelmans, B. n., Britto, P. n., Gordon, S. L., Tablante, E. n., Dua, T. n. 2019; 9 (3): 020703


    Approximately 250 million children under the age of five in low and middle-income countries (LMICs) will not achieve their developmental potential due to poverty and stunting alone. Investments in programming to improve early childhood development (ECD) have the potential to disrupt the cycle of poverty and therefore should be prioritised. Support for ECD has increased in recent years. Nevertheless, donors and policies continue to neglect ECD, in part from lack of evidence to guide policy makers and donors about where they should focus policies and programmes. Identification and investment in research is needed to overcome these constraints and in order to achieve high quality implementation of programmes to improve ECD.The Child Health and Nutrition Research Initiative (CHNRI) priority setting methodology was applied in order to assess research priorities for improving ECD. A group of 348 global and local experts in ECD-related research were identified and invited to generate research questions. This resulted in 406 research questions which were categorised and refined by study investigators into 54 research questions across six thematic goals which were evaluated using five criteria: answerability, effectiveness, feasibility, impact, and effect on equity. Research options were ranked by their final research priority score multiplied by 100.The top three research priority options from the LMIC experts came from the third thematic goal of improving the impact of interventions, whereas the top three research priority options from high-income country experts came from different goals: improving the integration of interventions, increasing the understanding of health economics and social protection strategies, and improving the impact of interventions.The results of this process highlight that priorities for future research should focus on the need for services and support to parents to provide nurturing care, and the training of health workers and non-specialists in implementation of interventions to improve ECD. Three of the six thematic goals of the present priority setting centred on interventions (ie, improving impact, implementation of interventions and improving the integration of interventions). In order to achieve higher coverage through sustainable interventions to improve ECD with equitable reach, interventions should be integrated and not be sector driven.

    View details for DOI 10.7189/jogh.09.020703

    View details for PubMedID 31673352

    View details for PubMedCentralID PMC6815874

  • Effects of team-based goals and non-monetary incentives on front-line health worker performance and maternal health behaviours: a cluster randomised controlled trial in Bihar, India. BMJ global health Carmichael, S. L., Mehta, K., Raheel, H., Srikantiah, S., Chaudhuri, I., Trehan, S., Mohanty, S., Borkum, E., Mahapatra, T., Weng, Y., Kaimal, R., Sivasankaran, A., Sridharan, S., Rotz, D., Tarigopula, U. K., Bhattacharya, D., Atmavilas, Y., Munar, W., Rangarajan, A., Darmstadt, G. L., Ananya Study Group, Atmavilas, Y., Bhattacharya, D., Borkum, E., Carmichael, S. L., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Kaimal, R., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W., Pepper, K., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Schooley, J., Shah, H., Srikantiah, S., Kiran Tarigopula, U., Ward, V., Weng, Y., Wahid, S., Wilhelm, J. 2019; 4 (4): e001146


    Introduction: We evaluated the impact of a 'Team-Based Goals and Incentives' (TBGI) intervention in Bihar, India, designed to improve front-line (community health) worker (FLW) performance and health-promoting behaviours related to reproductive, maternal, newborn and child health and nutrition.Methods: This study used a cluster randomised controlled trial design and difference-in-difference analyses of improvements in maternal health-related behaviours related to the intervention's team-based goals (primary), and interactions of FLWs with each other and with maternal beneficiaries (secondary). Evaluation participants included approximately 1300 FLWs and 3600 mothers at baseline (May to June 2012) and after 2.5 years of implementation (November to December 2014) who had delivered an infant in the previous year.Results: The TBGI intervention resulted in significant increases in the frequency of antenatal home visits (15 absolute percentage points (PP), p=0.03) and receipt of iron-folic acid (IFA) tablets (7 PP, p=0.02), but non-significant changes in other health behaviours related to the trial's goals. Improvements were seen in selected attitudes related to coordination and teamwork among FLWs, and in the provision of advice to beneficiaries (ranging from 8 to 14 PP) related to IFA, cord care, breast feeding, complementary feeding and family planning.Conclusion: Results suggest that combining an integrated set of team-based coverage goals and targets, small non-cash incentives for teams who meet targets and team building to motivate FLWs resulted in improvements in FLW coordination and teamwork, and in the quality and quantity of FLW-beneficiary interactions. These improvements represent programmatically meaningful steps towards improving health behaviours and outcomes.Trial registration number: NCT03406221.

    View details for DOI 10.1136/bmjgh-2018-001146

    View details for PubMedID 31543982

  • Gender norms and health: insights from global survey data. Lancet (London, England) Weber, A. M., Cislaghi, B. n., Meausoone, V. n., Abdalla, S. n., Mejía-Guevara, I. n., Loftus, P. n., Hallgren, E. n., Seff, I. n., Stark, L. n., Victora, C. G., Buffarini, R. n., Barros, A. J., Domingue, B. W., Bhushan, D. n., Gupta, R. n., Nagata, J. M., Shakya, H. B., Richter, L. M., Norris, S. A., Ngo, T. D., Chae, S. n., Haberland, N. n., McCarthy, K. n., Cullen, M. R., Darmstadt, G. L. 2019


    Despite global commitments to achieving gender equality and improving health and wellbeing for all, quantitative data and methods to precisely estimate the effect of gender norms on health inequities are underdeveloped. Nonetheless, existing global, national, and subnational data provide some key opportunities for testing associations between gender norms and health. Using innovative approaches to analysing proxies for gender norms, we generated evidence that gender norms impact the health of women and men across life stages, health sectors, and world regions. Six case studies showed that: (1) gender norms are complex and can intersect with other social factors to impact health over the life course; (2) early gender-normative influences by parents and peers can have multiple and differing health consequences for girls and boys; (3) non-conformity with, and transgression of, gender norms can be harmful to health, particularly when they trigger negative sanctions; and (4) the impact of gender norms on health can be context-specific, demanding care when designing effective gender-transformative health policies and programmes. Limitations of survey-based data are described that resulted in missed opportunities for investigating certain populations and domains. Recommendations for optimising and advancing research on the health impacts of gender norms are made.

    View details for DOI 10.1016/S0140-6736(19)30765-2

    View details for PubMedID 31155273

  • Invasive Pneumococcal Infections in Children with Nephrotic Syndrome in Bangladesh. The Pediatric infectious disease journal Malaker, R. n., Saha, S. n., Hanif, M. n., Ahmed, A. n., Saha, S. n., Hasanuzzaman, M. n., Khondakar, T. n., Islam, M. n., Baqui, A. H., Santosham, M. n., Darmstadt, G. L., Whitney, C. G., Saha, S. K. 2019


    Children with nephrotic syndrome are susceptible to invasive bacterial infections. In this study, we aimed to: (1) determine the pathogens associated with infections in children with nephrotic syndrome and (2) describe antimicrobial susceptibility and serotype distribution of Streptococcus pneumoniae to guide evidence-based treatment and prevention policies.From June 2013 to March 2015, we collected blood and/or ascitic fluid from children hospitalized with nephrotic syndrome and suspected bacterial disease in the largest pediatric hospital of Bangladesh. We cultured all samples and performed polymerase chain reaction (PCR) and immunochromatographic test on ascitic fluid for detection of S. pneumoniae. Pneumococcal isolates were tested for antibiotic susceptibility using disc diffusion and serotyped using Quellung reaction and PCR.We identified 1342 children hospitalized with nephrotic syndrome. Among them, 608 children had suspected bacterial disease from whom blood and/or ascitic fluid were collected. A pathogen was identified in 8% (48/608) of cases, 94% (45/48) of which were S. pneumoniae. Most (73%, 33/45) pneumococcal infections were identified through culture of blood and ascitic fluid and 27% (12/45) through immunochromatographic test and PCR of ascitic fluid. In total, 24 different pneumococcal serotypes were detected; 51% are covered by PCV10 (+6A), 53% by PCV13 and 60% by PPSV23. All pneumococcal isolates were susceptible to penicillin.Because S. pneumoniae was the primary cause of invasive infections, pneumococcal vaccines may be considered as a preventive intervention in children with nephrotic syndrome. Additionally, penicillin can be used to prevent and treat pneumococcal infections in children with nephrotic syndrome in Bangladesh.

    View details for DOI 10.1097/INF.0000000000002386

    View details for PubMedID 31220048

  • Improving health with programmatic, legal, and policy approaches to reduce gender inequality and change restrictive gender norms. Lancet (London, England) Heymann, J. n., Levy, J. K., Bose, B. n., Ríos-Salas, V. n., Mekonen, Y. n., Swaminathan, H. n., Omidakhsh, N. n., Gadoth, A. n., Huh, K. n., Greene, M. E., Darmstadt, G. L. 2019


    Evidence that gender inequalities and restrictive norms adversely affect health is extensive; however, far less research has focused on testing solutions. We first comprehensively reviewed the peer-reviewed and grey literature for rigorously evaluated programmes that aimed to reduce gender inequality and restrictive gender norms and improve health. We identified four mutually reinforcing factors underpinning change: (1) multisectoral action, (2) multilevel, multistakeholder involvement, (3) diversified programming, and (4) social participation and empowerment. Following this review, because little research has investigated the effects of national-level law and policy reforms, we conducted original quasi-experimental studies on laws and policies related to education, work, and income, all social determinants of health in which deep gender inequalities exist. We examined whether the laws and policies significantly affected health outcomes and gender norms, and whether law-induced and policy-induced changes in gender norms mediated the health effects, in areas for which longitudinal data existed. Laws and policies that made primary education tuition-free (13 intervention countries with the law and/or policy and ten control countries without) and that provided paid maternity and parental leave (seven intervention and 15 control countries) significantly improved women's and their children's health (odds ratios [OR] of 1·16-2·10, depending on health outcome) and gender equality in household decision making (OR 1·46 for tuition-free and 1·45 for paid maternity and parental leave) as a proxy indicator of gender norms. Increased equality partially mediated the positive effects on health outcomes. We conclude by discussing examples of how improved governance can support gender-equitable laws, policies, and programmes, immediate next steps, and future research needs.

    View details for DOI 10.1016/S0140-6736(19)30656-7

    View details for PubMedID 31155271

  • Adolescent gender norms and adult health outcomes in the USA: a prospective cohort study. The Lancet. Child & adolescent health Shakya, H. B., Domingue, B. n., Nagata, J. M., Cislaghi, B. n., Weber, A. n., Darmstadt, G. L. 2019


    Previous research has documented differences in health behaviours between men and women, with differential risks and health outcomes between the sexes. Although some sex-specific differences in health outcomes are caused by biological factors, many others are socially driven through gender norms. We therefore aimed to assess whether gender expression as an adolescent, determined by the degree to which an individual's behvaiours were typical of their gender, were associated with health behaviours and outcomes in adulthood.In this prospective cohort study, we used data from the National Longitudinal Study of Adolescent to Adult Health, a nationally representative sample of US adolescents from whom data were collected during adolescence (ages 11-18 years) and adulthood (ages 24-32 years). We created a measure of gender expression that was based on the degree to which male and female adolescents and adults behave in stereotypically masculine (for men) or feminine (for women) ways relative to their same-gender peers. Adolescents were assessed for baseline sociodemographic characteristics and gender expression, and these participants were later assessed, during adulthood, for their gender expression and health behaviours and outcomes, which included depression, self-rated health, drug and alcohol use, cardiovascular risk factors, experience of sexual violence, diet, and obesity. These data were collected via surveys, except for body-mass index, cholesterol, and blood pressure, which were collected as biomarkers.Between April and December, 1995, self-reported data were collected from 10 480 female and 10 263 male adolescents; similar data were subsequently collected in several waves in this cohort, with a final collection between January, 2008, and February, 2009, when participants were aged 24-32 years. We used data from this final wave and from baseline, and our study represents a secondary analysis of these data. Of these participants, complete follow-up data from 6721 (80%) adult women and 5885 (80%) adult men were available. Gender expression was stable for men and women from adolescence to adulthood. High masculinity (vs low masculinity) in adolescent and adult men was positively associated with smoking in the past month, use of marijuana and recreational drugs, prescription drug misuse (adult gender expression only), and consumption of fast food and soda (adolescent gender expression only) in the past week. However, higher masculine gender expression in adult men was negatively associated with diagnosed depression and high cholesterol in adulthood, and masculine gender expression in adolescent and adult men was negatively associated with high blood pressure in adults. High femininity (vs low femininity) in adolescent or adult women was positively associated with high cholesterol and blood pressure (both adult gender expression only), depression, migraines (adult gender expression only), and physical limitations (ie, health problems that limited their daily activities). However, higher femininity in adolescence was negatively associated with self-rated good health in adulthood. Although feminine gender expression in adolescents was predictive of adult recreational and prescription drug and marijuana use and experience of sexual violence, feminine gender expression in adulthood was negatively associated with adult substance use and experience of sexual violence, suggesting that expressions of femininity typical of adolescents impart risks that expression of femininity as an adult does not. Individuals who are highly masculine or feminine seem to be at greatest risk of adverse health outcomes and behaviours.We found compelling evidence that adolescent gender expression is correlated with health in adulthood independently of gender expression as an adult. Although more research is needed to identify causal mechanisms, our results suggest that those designing health behaviour interventions should carefully consider integrating gender transformative components into interventions.Eunice Kennedy Shriver National Institute of Child Health and Human Development, Gender Equality, Integrated Delivery, HIV, Nutrition, Family Planning, and Water Sanitation and Hygiene Program Strategy Teams (Bill and Melinda Gates Foundation).

    View details for DOI 10.1016/S2352-4642(19)30160-9

    View details for PubMedID 31155319

  • Detecting Developmental Delay and Autism Through Machine Learning Models Using Home Videos of Bangladeshi Children: Development and Validation Study. Journal of medical Internet research Tariq, Q. n., Fleming, S. L., Schwartz, J. N., Dunlap, K. n., Corbin, C. n., Washington, P. n., Kalantarian, H. n., Khan, N. Z., Darmstadt, G. L., Wall, D. P. 2019; 21 (4): e13822


    Autism spectrum disorder (ASD) is currently diagnosed using qualitative methods that measure between 20-100 behaviors, can span multiple appointments with trained clinicians, and take several hours to complete. In our previous work, we demonstrated the efficacy of machine learning classifiers to accelerate the process by collecting home videos of US-based children, identifying a reduced subset of behavioral features that are scored by untrained raters using a machine learning classifier to determine children's "risk scores" for autism. We achieved an accuracy of 92% (95% CI 88%-97%) on US videos using a classifier built on five features.Using videos of Bangladeshi children collected from Dhaka Shishu Children's Hospital, we aim to scale our pipeline to another culture and other developmental delays, including speech and language conditions.Although our previously published and validated pipeline and set of classifiers perform reasonably well on Bangladeshi videos (75% accuracy, 95% CI 71%-78%), this work improves on that accuracy through the development and application of a powerful new technique for adaptive aggregation of crowdsourced labels. We enhance both the utility and performance of our model by building two classification layers: The first layer distinguishes between typical and atypical behavior, and the second layer distinguishes between ASD and non-ASD. In each of the layers, we use a unique rater weighting scheme to aggregate classification scores from different raters based on their expertise. We also determine Shapley values for the most important features in the classifier to understand how the classifiers' process aligns with clinical intuition.Using these techniques, we achieved an accuracy (area under the curve [AUC]) of 76% (SD 3%) and sensitivity of 76% (SD 4%) for identifying atypical children from among developmentally delayed children, and an accuracy (AUC) of 85% (SD 5%) and sensitivity of 76% (SD 6%) for identifying children with ASD from those predicted to have other developmental delays.These results show promise for using a mobile video-based and machine learning-directed approach for early and remote detection of autism in Bangladeshi children. This strategy could provide important resources for developmental health in developing countries with few clinical resources for diagnosis, helping children get access to care at an early age. Future research aimed at extending the application of this approach to identify a range of other conditions and determine the population-level burden of developmental disabilities and impairments will be of high value.

    View details for PubMedID 31017583

  • Disrupting gender norms in health systems: making the case for change. Lancet (London, England) Hay, K. n., McDougal, L. n., Percival, V. n., Henry, S. n., Klugman, J. n., Wurie, H. n., Raven, J. n., Shabalala, F. n., Fielding-Miller, R. n., Dey, A. n., Dehingia, N. n., Morgan, R. n., Atmavilas, Y. n., Saggurti, N. n., Yore, J. n., Blokhina, E. n., Huque, R. n., Barasa, E. n., Bhan, N. n., Kharel, C. n., Silverman, J. G., Raj, A. n. 2019


    Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.

    View details for DOI 10.1016/S0140-6736(19)30648-8

    View details for PubMedID 31155270

  • Why now for a Series on gender equality, norms, and health? Lancet (London, England) Darmstadt, G. L., Heise, L. n., Gupta, G. R., Henry, S. n., Cislaghi, B. n., Greene, M. E., Hawkes, S. n., Hay, K. n., Heymann, J. n., Klugman, J. n., Levy, J. K., Raj, A. n., Weber, A. M. 2019

    View details for DOI 10.1016/S0140-6736(19)30985-7

    View details for PubMedID 31155268

  • Gender equality and gender norms: framing the opportunities for health. Lancet (London, England) Gupta, G. R., Oomman, N. n., Grown, C. n., Conn, K. n., Hawkes, S. n., Shawar, Y. R., Shiffman, J. n., Buse, K. n., Mehra, R. n., Bah, C. A., Heise, L. n., Greene, M. E., Weber, A. M., Heymann, J. n., Hay, K. n., Raj, A. n., Henry, S. n., Klugman, J. n., Darmstadt, G. L. 2019


    The Sustainable Development Goals offer the global health community a strategic opportunity to promote human rights, advance gender equality, and achieve health for all. The inability of the health sector to accelerate progress on a range of health outcomes brings into sharp focus the substantial impact of gender inequalities and restrictive gender norms on health risks and behaviours. In this paper, the fifth in a Series on gender equality, norms, and health, we draw on evidence to dispel three myths on gender and health and describe persistent barriers to progress. We propose an agenda for action to reduce gender inequality and shift gender norms for improved health outcomes, calling on leaders in national governments, global health institutions, civil society organisations, academic settings, and the corporate sector to focus on health outcomes and engage actors across sectors to achieve them; reform the workplace and workforce to be more gender-equitable; fill gaps in data and eliminate gender bias in research; fund civil-society actors and social movements; and strengthen accountability mechanisms.

    View details for DOI 10.1016/S0140-6736(19)30651-8

    View details for PubMedID 31155276

  • Progress on Sustainable Development Goal 5 and improved health through better measurement. SSM - population health Keats, E. C., Darmstadt, G. L., Bhutta, Z. A. 2019; 9: 100491

    View details for DOI 10.1016/j.ssmph.2019.100491

    View details for PubMedID 31998828

    View details for PubMedCentralID PMC6978490

  • Multiomics modeling of the immunome, transcriptome, microbiome, proteome and metabolome adaptations during human pregnancy BIOINFORMATICS Ghaemi, M., DiGiulio, D. B., Contrepois, K., Callahan, B., Ngo, T. M., Lee-McMullen, B., Lehallier, B., Robaczewska, A., Mcilwain, D., Rosenberg-Hasson, Y., Wong, R. J., Quaintance, C., Culos, A., Stanley, N., Tanada, A., Tsai, A., Gaudilliere, D., Ganio, E., Han, X., Ando, K., McNeil, L., Tingle, M., Wise, P., Maric, I., Sirota, M., Wyss-Coray, T., Winn, V. D., Druzin, M. L., Gibbs, R., Darmstadt, G. L., Lewis, D. B., Nia, V., Agard, B., Tibshirani, R., Nolan, G., Snyder, M. P., Relman, D. A., Quake, S. R., Shaw, G. M., Stevenson, D. K., Angst, M. S., Gaudilliere, B., Aghaeepour, N. 2019; 35 (1): 95–103
  • Multiomics modeling of the immunome, transcriptome, microbiome, proteome and metabolome adaptations during human pregnancy. Bioinformatics (Oxford, England) Ghaemi, M. S., DiGiulio, D. B., Contrepois, K., Callahan, B., Ngo, T. T., Lee-McMullen, B., Lehallier, B., Robaczewska, A., Mcilwain, D., Rosenberg-Hasson, Y., Wong, R. J., Quaintance, C., Culos, A., Stanley, N., Tanada, A., Tsai, A., Gaudilliere, D., Ganio, E., Han, X., Ando, K., McNeil, L., Tingle, M., Wise, P., Maric, I., Sirota, M., Wyss-Coray, T., Winn, V. D., Druzin, M. L., Gibbs, R., Darmstadt, G. L., Lewis, D. B., Partovi Nia, V., Agard, B., Tibshirani, R., Nolan, G., Snyder, M. P., Relman, D. A., Quake, S. R., Shaw, G. M., Stevenson, D. K., Angst, M. S., Gaudilliere, B., Aghaeepour, N. 2019; 35 (1): 95–103


    Motivation: Multiple biological clocks govern a healthy pregnancy. These biological mechanisms produce immunologic, metabolomic, proteomic, genomic and microbiomic adaptations during the course of pregnancy. Modeling the chronology of these adaptations during full-term pregnancy provides the frameworks for future studies examining deviations implicated in pregnancy-related pathologies including preterm birth and preeclampsia.Results: We performed a multiomics analysis of 51 samples from 17 pregnant women, delivering at term. The datasets included measurements from the immunome, transcriptome, microbiome, proteome and metabolome of samples obtained simultaneously from the same patients. Multivariate predictive modeling using the Elastic Net (EN) algorithm was used to measure the ability of each dataset to predict gestational age. Using stacked generalization, these datasets were combined into a single model. This model not only significantly increased predictive power by combining all datasets, but also revealed novel interactions between different biological modalities. Future work includes expansion of the cohort to preterm-enriched populations and in vivo analysis of immune-modulating interventions based on the mechanisms identified.Availability and implementation: Datasets and scripts for reproduction of results are available through: information: Supplementary data are available at Bioinformatics online.

    View details for PubMedID 30561547

  • Achieving Gender and Social Equality: More Than Gender Parity is Needed. Academic medicine : journal of the Association of American Medical Colleges Raj, A. n., Kumra, T. n., Darmstadt, G. L., Freund, K. M. 2019


    In this Perspective, the authors review Association of American Medical Colleges data on gender parity and intersectionality, consider the literature on gender parity in academic medicine and the underlying gender norms that explain these statistics, and offer recommendations for moving past indicators of parity to achieve gender and social equality.Improvements in gender parity among medical school graduates have not translated to gender parity among practicing physicians or medical school faculty, particularly for racial/ethnic minorities. Further, gender parity does not correspond to gender equality, such that gender-based disparities in salaries and advancement persist. In addition, social norms related to traditional gender role expectations reinforce existing biases and lead to sexual harassment and the discrimination of women in the workplace.Building on their analysis of existing data and the literature, the authors offer concrete recommendations to achieve gender equality in academic medicine that not only improve parity but also support policies and practices to address the norms that further bias and discrimination. These recommendations include the collection, monitoring, and open reporting of data on salaries as well as on sex and race/ethnicity; stronger policies related to family leave and sexual discrimination and harassment; and accountability structures to ensure that policies are enforced. While these efforts alone cannot eliminate gender inequalities, academic medicine should be at the forefront of creating a climate in medicine that is supportive of gender equality as part of their larger goal of promoting social equality.

    View details for DOI 10.1097/ACM.0000000000002877

    View details for PubMedID 31335818

  • Understanding health disparities. Journal of perinatology : official journal of the California Perinatal Association Stevenson, D. K., Wong, R. J., Aghaeepour, N., Angst, M. S., Darmstadt, G. L., DiGiulio, D. B., Druzin, M. L., Gaudilliere, B., Gibbs, R. S., B Gould, J., Katz, M., Li, J., Moufarrej, M. N., Quaintance, C. C., Quake, S. R., Relman, D. A., Shaw, G. M., Snyder, M. P., Wang, X., Wise, P. H. 2018


    Based upon our recent insights into the determinants of preterm birth, which is the leading cause of death in children under five years of age worldwide, we describe potential analytic frameworks that provides both a common understanding and, ultimately the basis for effective, ameliorative action. Our research on preterm birth serves as an example that the framing of any human health condition is a result of complex interactions between the genome and the exposome. New discoveries of the basic biology of pregnancy, such as the complex immunological and signaling processes that dictate the health and length of gestation, have revealed a complexity in the interactions (current and ancestral) between genetic and environmental forces. Understanding of these relationships may help reduce disparities in preterm birth and guide productive research endeavors and ultimately, effective clinical and public health interventions.

    View details for PubMedID 30560947

  • Application of machine-learning to predict early spontaneous preterm birth among nulliparous non-Hispanic black and white women. Annals of epidemiology Weber, A., Darmstadt, G. L., Gruber, S., Foeller, M. E., Carmichael, S. L., Stevenson, D. K., Shaw, G. M. 2018


    PURPOSE: Spontaneous preterm birth is a leading cause of perinatal mortality in the United States, occurring disproportionately among non-Hispanic black women compared to other race-ethnicities. Clinicians lack tools to identify first-time mothers at risk for spontaneous preterm birth. This study assessed prediction of early (<32weeks) spontaneous preterm birth among non-Hispanic black and white women by applying state-of-the-art machine-learning to multilevel data from a large birth cohort.METHODS: Data from birth certificate and hospital discharge records for 336,214 singleton births to nulliparous women in California from 2007 to 2011 were used in cross-validated regressions, with multiple imputation for missing covariate data. Residential census tract information was overlaid for 281,733 births. Prediction was assessed with areas under the receiver operator characteristic curves (AUCs).RESULTS: Cross-validated AUCs were low (0.62 [min=0.60, max=0.63] for non-Hispanic blacks and 0.63 [min=0.61, max=0.65] for non-Hispanic whites). Combining racial-ethnic groups improved prediction (cross-validated AUC=0.67 [min=0.65, max=0.68]), approaching what others have achieved using biomarkers. Census tract-level information did not improve prediction.CONCLUSIONS: The resolution of administrative data was inadequate to precisely predict individual risk for early spontaneous preterm birth despite the use of advanced statistical methods.

    View details for PubMedID 30236415

  • Epidemiology of Otitis Media With Otorrhea Among Bangladeshi Children: Baseline Study for Future Assessment of Pneumococcal Conjugate Vaccine Impact PEDIATRIC INFECTIOUS DISEASE JOURNAL Naziat, H., Saha, S., Islam, M., Saha, S., Uddin, M. J., Hussain, M., Luby, S. P., Darmstadt, G. L., Whitney, C. G., Gessner, B. D., Saha, S. K. 2018; 37 (7): 715–21


    Otitis media (OM) poses a high disease burden on Bangladeshi children, but little is known about its etiologies. We conducted a surveillance study in the largest pediatric hospital to characterize pathogens responsible for OM.In the outpatient ear-nose-throat department of Dhaka Shishu Hospital, which serves 0 to 18-year-old children, we collected ear swabs from OM children with otorrhea from April 2014 to March 2015. We cultured all specimens for bacterial pathogens and assessed serotype and antimicrobial susceptibility of Streptococcus pneumoniae (Spn) and Haemophilus influenzae (Hi) isolates.We recorded 1111 OM episodes; 88% (981/1111) involved otorrhea, and we collected samples from 91% (891/981) of these children. Fifty-one percent (452/891) were culture positive (contaminants excluded), with Hi (21%, 187/891) and Spn (18%, 164/891) most commonly detected. Overall, 45 distinct single and mixed pathogens were revealed. Dominant pneumococcal serotypes were 19A, 19F, 3 and 14; 98% of Hi isolates were nontypeable. Pneumococcal conjugate vaccine (PCV)10 and PCV10 + 6A serotypes accounted for 8% and 9% of all OM and 46% and 49% of pneumococcus-positive cases, respectively, and were more likely to be nonsusceptible to at least 1 antibiotic (erythromycin and/or trimethoprim-sulfamethoxazole) than nonvaccine serotypes (91% vs. 77%). Staphylococcus aureus (9%, 83/891) and Pseudomonas aeruginosa (4%, 38/891) were also found.Nontypeable Hi (NTHi) and Spn are predominant causes of OM in Bangladesh. PCV10, introduced in March 2015, is likely to reduce pneumococcal and overall OM burden. Data collected post-PCV10 will provide comprehensive insight into the effects of this vaccine on these pathogens.

    View details for PubMedID 29634626

  • Reducing early infant mortality in India: results of a prospective cohort of pregnant women using emergency medical services BMJ OPEN Bills, C. B., Newberry, J. A., Darmstadt, G., Pirrotta, E. A., Rao, G., Mahadevan, S. V., Strehlow, M. C. 2018; 8 (4): e019937


    To describe the demographic characteristics and clinical outcomes of neonates born within 7 days of public ambulance transport to hospitals across five states in India.Prospective observational study.Five Indian states using a centralised emergency medical services (EMS) agency that transported 3.1 million pregnant women in 2014.Over 6 weeks in 2014, this study followed a convenience sample of 1431 neonates born to women using a public-private ambulance service for a 'pregnancy-related' problem. Initial calls were deemed 'pregnancy related' if categorised by EMS dispatchers as 'pregnancy', 'childbirth', 'miscarriage' or 'labour pains'. Interfacility transfers, patients absent on ambulance arrival, refusal of care and neonates born to women beyond 7 days of using the service were excluded.death at 2, 7 and 42 days after delivery.Among 1684 women, 1411 gave birth to 1431 newborns within 7 days of initial ambulance transport. Median maternal age at delivery was 23 years (IQR 21-25). Most mothers were from rural/tribal areas (92.5%) and lower social (79.9%) and economic status (69.9%). Follow-up rates at 2, 7 and 42 days were 99.8%, 99.3% and 94.1%, respectively. Cumulative mortality rates at 2, 7 and 42 days follow-up were 43, 53 and 62 per 1000 births, respectively. The perinatal mortality rate (PMR) was 53 per 1000. Preterm birth (OR 2.89, 95% CI 1.67 to 5.00), twin deliveries (OR 2.80, 95% CI 1.10 to 7.15) and caesarean section (OR 2.21, 95% CI 1.15 to 4.23) were the strongest predictors of mortality.The perinatal mortality rate associated with this cohort of patients with high-acuity conditions of pregnancy was nearly two times the most recent rate for India as a whole (28 per 1000 births). EMS data have the potential to provide more robust estimates of PMR, reduce inequities in timely access to healthcare and increase facility-based care through service of marginalised populations.

    View details for PubMedID 29654018

  • A Gender Lens on the Health and Well-being of Young Males JOURNAL OF ADOLESCENT HEALTH Patton, G. C., Darmstadt, G. L., Petroni, S., Sawyer, S. M. 2018; 62 (3): S6–S8

    View details for PubMedID 29455720

  • A genome-wide association study identifies only two ancestry specific variants associated with spontaneous preterm birth SCIENTIFIC REPORTS Rappoport, N., Toung, J., Hadley, D., Wong, R. J., Fujioka, K., Reuter, J., Abbott, C. W., Oh, S., Hu, D., Eng, C., Huntsman, S., Bodian, D. L., Niederhuber, J. E., Hong, X., Zhang, G., Sikora-Wohfeld, W., Gignoux, C. R., Wang, H., Oehlert, J., Jelliffe-Pawlowski, L. L., Gould, J. B., Darmstadt, G. L., Wang, X., Bustamante, C. D., Snyder, M. P., Ziv, E., Patsopoulos, N. A., Muglia, L. J., Burchard, E., Shaw, G. M., O'Brodovich, H. M., Stevenson, D. K., Butte, A. J., Sirota, M. 2018; 8: 226


    Preterm birth (PTB), or the delivery prior to 37 weeks of gestation, is a significant cause of infant morbidity and mortality. Although twin studies estimate that maternal genetic contributions account for approximately 30% of the incidence of PTB, and other studies reported fetal gene polymorphism association, to date no consistent associations have been identified. In this study, we performed the largest reported genome-wide association study analysis on 1,349 cases of PTB and 12,595 ancestry-matched controls from the focusing on genomic fetal signals. We tested over 2 million single nucleotide polymorphisms (SNPs) for associations with PTB across five subpopulations: African (AFR), the Americas (AMR), European, South Asian, and East Asian. We identified only two intergenic loci associated with PTB at a genome-wide level of significance: rs17591250 (P = 4.55E-09) on chromosome 1 in the AFR population and rs1979081 (P = 3.72E-08) on chromosome 8 in the AMR group. We have queried several existing replication cohorts and found no support of these associations. We conclude that the fetal genetic contribution to PTB is unlikely due to single common genetic variant, but could be explained by interactions of multiple common variants, or of rare variants affected by environmental influences, all not detectable using a GWAS alone.

    View details for PubMedID 29317701

  • Scaling up child development centres in Bangladesh CHILD CARE HEALTH AND DEVELOPMENT Khan, N. Z., Sultana, R., Ahmed, F., Shilpi, A. B., Sultana, N., Darmstadt, G. L. 2018; 44 (1): 19–30

    View details for DOI 10.1111/cch.12530

    View details for Web of Science ID 000417933500004

  • Scaling up early childhood development programmes in low and middle-income countries. Child: care, health and development Darmstadt, G. L., Khan, N. Z., Lombardi, J. n., Richter, L. M. 2018; 44 (1): 1–3

    View details for PubMedID 29235168

  • Scaling up child development centres in Bangladesh. Child: care, health and development Khan, N. Z., Sultana, R. n., Ahmed, F. n., Shilpi, A. B., Sultana, N. n., Darmstadt, G. L. 2018; 44 (1): 19–30


    Child Development Centres (CDCs) have been established within government medical college tertiary hospitals across Bangladesh. Services entail a parent-professional partnership in a child and family friendly environment with a focus on assessment, diagnosis, and management of a range of neurodevelopmental disorders in children and adolescents 0-16 years of age. Services are provided by a multidisciplinary team of professionals (child health physician, child psychologist, and developmental therapist) who emphasize quality of services over the numbers of children seen.In 2008, Dhaka Shishu (Children's) Hospital was given the mandate by the government to conceptualize, train, and monitor CDCs nationwide. Here, we describe the rationale and processes for the establishment of the national network of CDCs and discuss lessons learned on scaling up early childhood development services in a low resource setting.Fifteen CDCs were established in major government hospitals across Bangladesh and have recorded 208,866 patient visits. The majority (79%) of children were from the lowest and middle-income families, and about one third (30%) were < 2 years of age at first presentation. Two thirds of children seen in follow-up demonstrated improvements in functional skills since their first visit, 77% in their adaptive behaviour (i.e., activities of daily living) and 70% in cognitive functions.CDCs are expanding coverage for child neurodevelopment services across Bangladesh through a tiered system of home-based screening, community- and clinic-based functional assessment, and CDC-based diagnosis, support, and referral. Vulnerable populations-the lowest income groups and younger children-comprised the majority of patients, among whom there is high unmet need for psychological services that is being met for the first time. Innovative human resource development, including a 3-month training for the multidisciplinary teams, enabled wide coverage for assessment and diagnosis of a range of neurodevelopmental problems. Demand for services is growing, especially among non-government and private hospitals.

    View details for PubMedID 29235172

  • Scaling up early childhood development programmes in low and middle-income countries CHILD CARE HEALTH AND DEVELOPMENT Darmstadt, G. L., Khan, N. Z., Lombardi, J., Richter, L. M. 2018; 44 (1): 1–3

    View details for DOI 10.1111/cch.12441

    View details for Web of Science ID 000417933500001

  • Childhood Illness and the Gender Gap in Adolescent Education in Low- and Middle-Income Countries PEDIATRICS Alsan, M., Xing, A., Wise, P., Darmstadt, G. L., Bendavid, E. 2017; 140 (1)


    Achieving gender equality in education is an important development goal. We tested the hypothesis that the gender gap in adolescent education is accentuated by illnesses among young children in the household.Using Demographic and Health Surveys on 41 821 households in 38 low- and middle-income countries, we used linear regression to estimate the difference in the probability adolescent girls and boys were in school, and how this gap responded to illness episodes among children <5 years old. To test the hypothesis that investments in child health are related to the gender gap in education, we assessed the relationship between the gender gap and national immunization coverage.In our sample of 120 708 adolescent boys and girls residing in 38 countries, girls were 5.08% less likely to attend school than boys in the absence of a recent illness among young children within the same household (95% confidence interval [CI], 5.50%-4.65%). This gap increased to 7.77% (95% CI, 8.24%-7.30%) and 8.53% (95% CI, 9.32%-7.74%) if the household reported 1 and 2 or more illness episodes, respectively. The gender gap in schooling in response to illness was larger in households with a working mother. Increases in child vaccination rates were associated with a closing of the gender gap in schooling (correlation coefficient = 0.34, P = .02).Illnesses among children strongly predict a widening of the gender gap in education. Investments in early childhood health may have important effects on schooling attainment for adolescent girls.

    View details for PubMedID 28759395

    View details for PubMedCentralID PMC5495535

  • Group B Streptococcus among pregnant women and newborns in Mirzapur, Bangladesh: Colonization, vertical transmission and serotype distribution. Journal of clinical microbiology Saha, S. K., Ahmed, Z. B., Modak, J. K., Naziat, H., Saha, S., Uddin, M. A., Islam, M., Baqui, A. H., Darmstadt, G. L., Schrag, S. J. 2017


    Group B Streptococcus (GBS) infection is a leading cause of death in newborns in developed countries. Data on burden of GBS in Asian countries is lacking. This study aimed to understand i) rate of maternal recto-vaginal GBS carriage, ii) vertical transmission of GBS as determined by culturing ear, umbilicus and nasal swabs, and iii) distribution of GBS serotypes. This prospective observational study was conducted from September 2012 to November 2013 at Kumudini Hospital, a secondary level hospital, at Mirzapur, Bangladesh. The study enrolled pregnant women who visited the out-patient clinic for antenatal care (ANC) and/or delivered a child at the in-patient department of Kumudini Hospital, and babies born to these mothers. Among 1151 enrolled pregnant women, 172 (15%; 95% CI: 13%-17%) carried GBS and 26 (38%; 95% CI: 27%-51%) babies born to the mothers (n=68) with carriage had GBS on their body surface, indicating vertical transmission. Typing of the isolates (n=172) identified all 10 GBS serotypes, most commonly Ia (40%; 69/172), V (23%; 40/172), II (14%; 24/172), and III (12%; 20/172). This study shows that Bangladesh has all the ingredients for invasive GBS diseases, including colonization of mothers by invasive serotypes and vertical transmission to babies.

    View details for DOI 10.1128/JCM.00380-17

    View details for PubMedID 28515218

  • Detection of macrolide resistance genes in culture-negative specimens from Bangladeshi children with invasive pneumococcal diseases. Journal of global antimicrobial resistance Hasanuzzaman, M., Malaker, R., Islam, M., Baqui, A. H., Darmstadt, G. L., Whitney, C. G., Saha, S. K. 2017; 8: 131-134


    In recent years, an increasing prevalence of macrolide resistance among pneumococci in Bangladesh has been observed. However, the scenario remains incomplete, as few isolates (<1%) are available from pneumonia cases and most pneumococcal meningitis cases (>80%) are culture-negative. This study optimised a triplex PCR method to detect macrolide resistance genes (MRGs) (mefA and ermB) and cpsA from culture-negative pneumococcal cases to predict the prevalence and level of macrolide resistance.The presence of MRGs among pneumococcal strains (n=153) with a wide range of erythromycin MICs (<0.5 to ≥256mg/L) was determined by PCR. Triplex PCR was validated by simultaneous detection of MRG(s) and cpsA in culture-negative clinical specimens and corresponding isolates. The known impact of the presence of specific MRG(s) on MICs of strains was used to predict the MICs of non-culturable strains based on the presence/absence of MRG(s) in the specimens.None of the erythromycin-susceptible isolates possessed any of the MRGs, and all non-susceptible strains had ≥1 MRG. MICs were 2-16mg/L and ≥256mg/L for 93% of strains with mefA and ermB, respectively, whereas 100% of isolates with both genes had MICs≥256mg/L. PCR for body fluids showed 100% concordance with corresponding isolates when tested for MRG(s) in parallel.Erythromycin MICs can be predicted for non-culturable strains with 93-100% precision based on detection of ermB and/or mefA. This method will be useful for establishing comprehensive surveillance for macrolide resistance among pneumococci, specifically in the population with prior antibiotic use.

    View details for DOI 10.1016/j.jgar.2016.11.009

    View details for PubMedID 28132873

  • Investing in the foundation of sustainable development: pathways to scale up for early childhood development LANCET Richter, L. M., Daelmans, B., Lombardi, J., Heymann, J., Boo, F. L., Behrman, J. R., Lu, C., Lucas, J. E., Perez-Escamilla, R., Dua, T., Bhutta, Z. A., Stenberg, K., Gertler, P., Darmstadt, G. L. 2017; 389 (10064): 103-118
  • Taking on the gender challenge in organisations: what does it take? GLOBAL PUBLIC HEALTH Henry, S. K., Sandler, J., Passerini, L., Darmstadt, G. L. 2017; 12 (7): 846-857
  • Prioritizing research for integrated implementation of early childhood development and maternal, newborn, child and adolescent health and nutrition platforms. Journal of global health Sharma, R. n., Gaffey, M. F., Alderman, H. n., Bassani, D. G., Bogard, K. n., Darmstadt, G. L., Das, J. K., de Graft-Johnson, J. E., Hamadani, J. D., Horton, S. n., Huicho, L. n., Hussein, J. n., Lye, S. n., Pérez-Escamilla, R. n., Proulx, K. n., Marfo, K. n., Mathews-Hanna, V. n., Mclean, M. S., Rahman, A. n., Silver, K. L., Singla, D. R., Webb, P. n., Bhutta, Z. A. 2017; 7 (1): 011002


    Existing health and nutrition services present potential platforms for scaling up delivery of early childhood development (ECD) interventions within sensitive windows across the life course, especially in the first 1000 days from conception to age 2 years. However, there is insufficient knowledge on how to optimize implementation for such strategies in an integrated manner. In light of this knowledge gap, we aimed to systematically identify a set of integrated implementation research priorities for health, nutrition and early child development within the 2015 to 2030 timeframe of the Sustainable Development Goals (SDGs).We applied the Child Health and Nutrition Research Initiative method, and consulted a diverse group of global health experts to develop and score 57 research questions against five criteria: answerability, effectiveness, deliverability, impact, and effect on equity. These questions were ranked using a research priority score, and the average expert agreement score was calculated for each question.The research priority scores ranged from 61.01 to 93.52, with a median of 82.87. The average expert agreement scores ranged from 0.50 to 0.90, with a median of 0.75. The top-ranked research question were: i) "How can interventions and packages to reduce neonatal mortality be expanded to include ECD and stimulation interventions?"; ii) "How does the integration of ECD and MNCAH&N interventions affect human resource requirements and capacity development in resource-poor settings?"; and iii) "How can integrated interventions be tailored to vulnerable refugee and migrant populations to protect against poor ECD and MNCAH&N outcomes?". Most highly-ranked research priorities varied across the life course and highlighted key aspects of scaling up coverage of integrated interventions in resource-limited settings, including: workforce and capacity development, cost-effectiveness and strategies to reduce financial barriers, and quality assessment of programs.Investing in ECD is critical to achieving several of the SDGs, including SDG 2 on ending all forms of malnutrition, SDG 3 on ensuring health and well-being for all, and SDG 4 on ensuring inclusive and equitable quality education and promotion of life-long learning opportunities for all. The generated research agenda is expected to drive action and investment on priority approaches to integrating ECD interventions within existing health and nutrition services.

    View details for PubMedID 28685048

  • Gender disparities in child development in the east Asia-Pacific region: a cross-sectional, population-based, multicountry observational study. The Lancet. Child & adolescent health Weber, A. n., Darmstadt, G. L., Rao, N. n. 2017; 1 (3): 213–24


    Gender differences in child development have been extensively studied in high-income countries, but few data are available from low-income and middle-income countries. Our objective was to assess gender disparities in child development that might arise from differential investment in child health, nutrition, and education in six countries across the east Asia-Pacific region.In this cross-sectional, population-based study we quantified the magnitude of gender differences in child development using the East Asia-Pacific Early Child Development Scales (EAP-ECDS) in six countries (Cambodia, China, Mongolia, Papua New Guinea, Timor-Leste, and Vanuatu). We used stratified random sampling (according to age, residence [urban vs rural], and sex) in all countries to recruit eligible children aged 3-5 years from non-ethnic minority populations with no identified or suspected special educational needs for whom EAP-ECDS scores for five or more of seven domains and urban-rural residence information were available. Gender differences in development associated with four national indicators of gender equality (sex ratio at birth, Gender Development Index, Gender Inequality Index, and Gender Parity Index for primary school enrolment) were also examined. We used generalised estimating equation regression to study moderation of differences by family socioeconomic status and wealth, and structural equation models with maximum likelihood to test mediation through health, nutrition, and education.Between June 1, 2013, and Dec 13, 2013, 7582 eligible children were included from Cambodia (n=1189), China (n=1618), Mongolia (n=1230), Papua New Guinea (n=1639), Timor-Leste (n=1176), and Vanuatu (n=730). Girls had significantly higher development scores than boys in Cambodia (difference in composite score: β=1·87 points, 95% CI 0·29 to 3·45; p=0·747), China (2·66 points, 1·20 to 4·13; p=0·0004), Vanuatu (3·10 points, 1·65 to 4·55; p<0·0001), and Mongolia (3·94 points, 2·67 to 5·21; p<0·0001), but not Papua New Guinea (-0·43 points, -1·19 to 0·33; p=0·272) or Timor-Leste (0·09 points, -0·96 to 1·14; p=0·861). Differences in favour of girls were the largest for language skills in Mongolia (5·30 points, 95% CI 4·45 to 6·15); differences in language skills were smallest in the two poorest countries, Timor-Leste (-0·07 points, -1·03 to 0·88) and Papua New Guinea (0·05 points, -1·02 to 1·12). Greater differences in composite scores for girls compared with boys-in favour of girls-were associated with higher national Gender Development Index values (R2=0·790). In Mongolia, smaller gender differences in development were associated with increased household wealth (6·07 points [95% CI 3·22 to 8·92] in the lowest wealth quartile vs 2·27 points [1·38 to 3·15] in the highest wealth quartile), whereas in Timor-Leste, girls only outperformed boys when living in households with higher socioeconomic status (2·87 points [0·27 to 5·47] in the highest wealth quartile and 3·74 points [2·17 to 5·31] in the highest quartile of parental socioeconomic status). Mediating pathways explained up to 37% (in Vanuatu) of the association between gender and development, controlling for family socioeconomic status.Girls aged 3-5 years generally outperformed boys on tests of development, and increasing levels of gender equality across six countries in the east Asia-Pacific region were associated with improved performance of young girls relative to boys. Greater opportunities for economic development are anticipated to result from improvements in gender equality and in the development of girls. Further study is warranted to understand family-level processes and societal norms that lead to gender differences in child development in the early years.UNICEF, the Asia-Pacific Regional Network for Early Childhood, and the Open Society Foundations.

    View details for PubMedID 30169170

  • Gender disparities in child development in the east Asia-Pacific region: a cross-sectional, population-based, multicountry observational study The Lancet Child & Adolescent Health Weber, A., Darmstadt, G. L., Rao, N. 2017; 1 (3)
  • Global services and support for children with developmental delays and disabilities: Bridging research and policy gaps. PLoS medicine Collins, P. Y., Pringle, B. n., Alexander, C. n., Darmstadt, G. L., Heymann, J. n., Huebner, G. n., Kutlesic, V. n., Polk, C. n., Sherr, L. n., Shih, A. n., Sretenov, D. n., Zindel, M. n. 2017; 14 (9): e1002393


    Pamela Collins and colleagues explain the research and policy approaches needed globally to ensure children with developmental delays and disabilities are fully included in health and education services.

    View details for PubMedID 28922419

    View details for PubMedCentralID PMC5603146

  • Risky Business: Meeting the Structural Needs of Transdisciplinary Science. The Journal of pediatrics Wise, P. H., Shaw, G. M., Druzin, M. L., Darmstadt, G. L., Quaintance, C. n., Mäkinen, E. n., Relman, D. A., Quake, S. R., Butte, A. J., Angst, M. S., Muglia, L. J., Macones, G. n., Driscoll, D. n., Ober, C. n., Simpson, J. L., Katz, M. n., Howse, J. n., Stevenson, D. K. 2017; 191: 255–58

    View details for PubMedID 29173314

  • An immune clock of human pregnancy. Science immunology Aghaeepour, N. n., Ganio, E. A., Mcilwain, D. n., Tsai, A. S., Tingle, M. n., Van Gassen, S. n., Gaudilliere, D. K., Baca, Q. n., McNeil, L. n., Okada, R. n., Ghaemi, M. S., Furman, D. n., Wong, R. J., Winn, V. D., Druzin, M. L., El-Sayed, Y. Y., Quaintance, C. n., Gibbs, R. n., Darmstadt, G. L., Shaw, G. M., Stevenson, D. K., Tibshirani, R. n., Nolan, G. P., Lewis, D. B., Angst, M. S., Gaudilliere, B. n. 2017; 2 (15)


    The maintenance of pregnancy relies on finely tuned immune adaptations. We demonstrate that these adaptations are precisely timed, reflecting an immune clock of pregnancy in women delivering at term. Using mass cytometry, the abundance and functional responses of all major immune cell subsets were quantified in serial blood samples collected throughout pregnancy. Cell signaling-based Elastic Net, a regularized regression method adapted from the elastic net algorithm, was developed to infer and prospectively validate a predictive model of interrelated immune events that accurately captures the chronology of pregnancy. Model components highlighted existing knowledge and revealed previously unreported biology, including a critical role for the interleukin-2-dependent STAT5ab signaling pathway in modulating T cell function during pregnancy. These findings unravel the precise timing of immunological events occurring during a term pregnancy and provide the analytical framework to identify immunological deviations implicated in pregnancy-related pathologies.

    View details for PubMedID 28864494

  • Prevalence, Serotype Distribution and Mortality Risk Associated With Group B Streptococcus Colonization of Newborns in Rural Bangladesh PEDIATRIC INFECTIOUS DISEASE JOURNAL Islam, M. S., Saha, S. K., Islam, M., Modak, J. K., Shah, R., Talukder, R. R., El Arifeen, S., Baqui, A. H., Darmstadt, G. L., Mullany, L. C. 2016; 35 (12): 1309-1312


    Group B Streptococcus (GBS) is a predominant cause of early-onset neonatal sepsis globally; however, the impact of this organism on the health of newborns in South Asia is debated, due in part to a paucity of community-based assessments. We estimated the prevalence and serotypes of GBS colonization of the umbilical cord stump and the association of colonization with mortality in a population-based cohort of newborns in rural Sylhet District, Bangladesh.Umbilical cord swabs were collected from 646 newborns up to 3 times within the first week after birth (ages <24 hours, ~3 days, ~6 days) and processed to identify GBS serotypes.GBS was isolated from 6.3% (41/646) of newborns. Sixty-one percent of the GBS colonization occurred in neonates within 24 hours of delivery. Serotypes VII (37.1%, n = 13/36) and Ia (33.3%, n = 12/36) were the most predominant colonizing GBS isolates. Other detected serotypes were Ib (11.1%, n = 4/36), II (11.1%, n = 4/36), V (5.6%, n = 2/36) and VI (2.8%, n = 1/36). Mortality risk among newborns with GBS colonization was 6.6 (95% confidence interval: 2.1-20.4) times higher than for those without GBS.The overall prevalence of GBS colonization was lower than in settings, where GBS is a predominant etiology of neonatal illness. In addition, the GBS serotype distribution differed from that reported in the developed part of the world. However, further studies are needed to understand the true burden of GBS-related illness. Mortality risk was substantially increased in the presence of GBS on the umbilical stump, providing support for chlorhexidine antisepsis to the cord to prevent colonization of invasive pathogens.

    View details for DOI 10.1097/INF.0000000000001306

    View details for Web of Science ID 000388217900012

    View details for PubMedID 27455441

  • Does addressing gender inequalities and empowering women and girls improve health and development programme outcomes? Health policy and planning Taukobong, H. F., Kincaid, M. M., Levy, J. K., Bloom, S. S., Platt, J. L., Henry, S. K., Darmstadt, G. L. 2016; 31 (10): 1492-1514


    This article presents evidence supporting the hypothesis that promoting gender equality and women's and girls' empowerment (GEWE) leads to better health and development outcomes. We reviewed the literature across six sectors-family planning (FP); maternal, newborn and child health (MNCH); nutrition; agriculture; water, sanitation and hygiene; and financial services for the poor-and found 76 studies from low and middle-income countries that met our inclusion criteria. Across these studies, we identified common GEWE variables that emerged repeatedly as significant predictors of sector outcomes. We grouped these variables into 10 thematic categories, which we termed 'gender-related levers'. These levers were then classified by the strength of evidence into Wedges, Foundations and Facilitators. Wedges are gender-related levers that had strong associations with improved outcomes across multiple sectors. They include: 'control over income/assets/resources', 'decision-making power' and 'education'. Elements of these levers overlap, but combined, they encapsulate agency. Increasing female agency promotes equality and broadly improves health and development for women, their families and their communities. The second classification, Foundations, displayed strong, positive associations across FP, MNCH and nutrition. Foundations have a more proximal relationship with sector outcomes and include: 'equitable interpersonal relationships', 'mobility' and 'personal safety'. Finally, the third group of levers, Facilitators, was associated with improved outcomes in two to three sectors and include: 'access to information', 'community groups', 'paid labour' and 'rights'. These levers make it easier for women and girls to achieve their goals and are more traditional elements of development programmes. Overall, gender-related levers were associated with improvements in a variety of health and development outcomes. Furthermore, these associations were cross-sectoral, suggesting that to fully realize the benefits of promoting GEWE, the development community must collaborate in co-ordinated and integrated ways across multiple sectors. More research is needed to identify the mechanisms by which gendered interventions work and under what circumstances.

    View details for PubMedID 27371549

  • Mapping the Fetomaternal Peripheral Immune System at Term Pregnancy. Journal of immunology Fragiadakis, G. K., Baca, Q. J., Gherardini, P. F., Ganio, E. A., Gaudilliere, D. K., Tingle, M., Lancero, H. L., McNeil, L. S., Spitzer, M. H., Wong, R. J., Shaw, G. M., Darmstadt, G. L., Sylvester, K. G., Winn, V. D., Carvalho, B., Lewis, D. B., Stevenson, D. K., Nolan, G. P., Aghaeepour, N., Angst, M. S., Gaudilliere, B. L. 2016


    Preterm labor and infections are the leading causes of neonatal deaths worldwide. During pregnancy, immunological cross talk between the mother and her fetus is critical for the maintenance of pregnancy and the delivery of an immunocompetent neonate. A precise understanding of healthy fetomaternal immunity is the important first step to identifying dysregulated immune mechanisms driving adverse maternal or neonatal outcomes. This study combined single-cell mass cytometry of paired peripheral and umbilical cord blood samples from mothers and their neonates with a graphical approach developed for the visualization of high-dimensional data to provide a high-resolution reference map of the cellular composition and functional organization of the healthy fetal and maternal immune systems at birth. The approach enabled mapping of known phenotypical and functional characteristics of fetal immunity (including the functional hyperresponsiveness of CD4(+) and CD8(+) T cells and the global blunting of innate immune responses). It also allowed discovery of new properties that distinguish the fetal and maternal immune systems. For example, examination of paired samples revealed differences in endogenous signaling tone that are unique to a mother and her offspring, including increased ERK1/2, MAPK-activated protein kinase 2, rpS6, and CREB phosphorylation in fetal Tbet(+)CD4(+) T cells, CD8(+) T cells, B cells, and CD56(lo)CD16(+) NK cells and decreased ERK1/2, MAPK-activated protein kinase 2, and STAT1 phosphorylation in fetal intermediate and nonclassical monocytes. This highly interactive functional map of healthy fetomaternal immunity builds the core reference for a growing data repository that will allow inferring deviations from normal associated with adverse maternal and neonatal outcomes.

    View details for PubMedID 27793998

  • Early childhood development: the foundation of sustainable development. Lancet Daelmans, B., Darmstadt, G. L., Lombardi, J., Black, M. M., Britto, P. R., Lye, S., Dua, T., Bhutta, Z. A., Richter, L. M. 2016

    View details for DOI 10.1016/S0140-6736(16)31659-2

    View details for PubMedID 27717607

  • Investing in the foundation of sustainable development: pathways to scale up for early childhood development. Lancet Richter, L. M., Daelmans, B., Lombardi, J., Heymann, J., Boo, F. L., Behrman, J. R., Lu, C., Lucas, J. E., Perez-Escamilla, R., Dua, T., Bhutta, Z. A., Stenberg, K., Gertler, P., Darmstadt, G. L. 2016


    Building on long-term benefits of early intervention (Paper 2 of this Series) and increasing commitment to early childhood development (Paper 1 of this Series), scaled up support for the youngest children is essential to improving health, human capital, and wellbeing across the life course. In this third paper, new analyses show that the burden of poor development is higher than estimated, taking into account additional risk factors. National programmes are needed. Greater political prioritisation is core to scale-up, as are policies that afford families time and financial resources to provide nurturing care for young children. Effective and feasible programmes to support early child development are now available. All sectors, particularly education, and social and child protection, must play a role to meet the holistic needs of young children. However, health provides a critical starting point for scaling up, given its reach to pregnant women, families, and young children. Starting at conception, interventions to promote nurturing care can feasibly build on existing health and nutrition services at limited additional cost. Failure to scale up has severe personal and social consequences. Children at elevated risk for compromised development due to stunting and poverty are likely to forgo about a quarter of average adult income per year, and the cost of inaction to gross domestic product can be double what some countries currently spend on health. Services and interventions to support early childhood development are essential to realising the vision of the Sustainable Development Goals.

    View details for DOI 10.1016/S0140-6736(16)31698-1

    View details for PubMedID 27717610

  • Strengthening the Reporting of Observational Studies in Epidemiology for Newborn Infection (STROBE-NI): an extension of the STROBE statement for neonatal infection research LANCET INFECTIOUS DISEASES Fitchett, E. J., Seale, A. C., Vergnano, S., Sharland, M., Heath, P. T., Saha, S. K., Agarwal, R., Ayede, A. I., Bhutta, Z. A., Black, R., Bojang, K., Campbell, H., Cousens, S., Darmstadt, G. L., Madhi, S. A., Sobanjo-ter Meulen, A., Modi, N., Patterson, J., Qazi, S., Schrag, S. J., Stoll, B. J., Wall, S. N., Wammanda, R. D., Lawn, J. E. 2016; 16 (10): E202-E213


    Neonatal infections are estimated to account for a quarter of the 2·8 million annual neonatal deaths, as well as approximately 3% of all disability-adjusted life-years. Despite this burden, few data are available on incidence, aetiology, and outcomes, particularly regarding impairment. We aimed to develop guidelines for improved scientific reporting of observational neonatal infection studies, to increase comparability and to strengthen research in this area. This checklist, Strengthening the Reporting of Observational Studies in Epidemiology for Newborn Infection (STROBE- NI), is an extension of the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement. STROBE-NI was developed following systematic reviews of published literature (1996-2015), compilation of more than 130 potential reporting recommendations, and circulation of a survey to relevant professionals worldwide, eliciting responses from 147 professionals from 37 countries. An international consensus meeting of 18 participants (with expertise in infectious diseases, neonatology, microbiology, epidemiology, and statistics) identified priority recommendations for reporting, additional to the STROBE statement. Implementation of these STROBE-NI recommendations, and linked checklist, aims to improve scientific reporting of neonatal infection studies, increasing data utility and allowing meta-analyses and pathogen-specific burden estimates to inform global policy and new interventions, including maternal vaccines.

    View details for DOI 10.1016/S1473-3099(16)30082-2

    View details for Web of Science ID 000383469000001

    View details for PubMedID 27633910

  • Global research priorities to accelerate early child development in the sustainable development era. The Lancet. Global health Dua, T., Tomlinson, M., Tablante, E., Britto, P., Yousfzai, A., Daelmans, B., Darmstadt, G. L. 2016

    View details for DOI 10.1016/S2214-109X(16)30218-2

    View details for PubMedID 27717631

  • Validation of a rapid neurodevelopmental assessment tool for 10- to 16-year-old young adolescents in Bangladesh. Child: care, health and development Muslima, H., Khan, N. Z., Shilpi, A. B., Begum, D., Parveen, M., McConachie, H., Darmstadt, G. L. 2016; 42 (5): 658-665


    To validate a Rapid Neurodevelopmental Assessment (RNDA) tool for use by child health professionals to determine neurodevelopmental impairments (NDIs) in young adolescents aged 10-16 years in Bangladesh.In a convenience sample of community children (n = 47), inter-rater reliability was determined between four testers, and concurrent validity was determined by simultaneous administration of an intelligence quotient (IQ) test (Wechsler Intelligence Scale for Children, Revised) by a child psychologist.Inter-rater reliability was excellent between the testers on the 47 children administered the RNDA (kappa = 1.00). Significantly lower IQ scores were obtained in those identified with 'any (>1) NDI' (n = 34) compared with those with no NDI (n = 13) on Verbal IQ (P-value < 0.0001), Performance IQ (P-value < 0.0001) and Full-scale IQ (P-value < 0.0001) scores on the Wechsler Intelligence Scale for Children, Revised.The RNDA shows promise as a tool for use by child health professionals for identifying NDIs in young adolescents aged 10-16 years. A larger study sample is needed to determine its usefulness for identification of some impairments not found in the study population, i.e. gross motor, fine motor, hearing and seizures.

    View details for DOI 10.1111/cch.12362

    View details for PubMedID 27357744

  • PCR-Based Serotyping of Streptococcus pneumoniae from Culture-Negative Specimens: Novel Primers for Detection of Serotypes within Serogroup 18. Journal of clinical microbiology Tanmoy, A. M., Saha, S., Darmstadt, G. L., Whitney, C. G., Saha, S. K. 2016; 54 (8): 2178-2181


    Six multiplex-compatible PCR primers were designed to distinguish Streptococcus pneumoniae serotypes within serogroup 18 from culturable/nonculturable pneumococcal specimens, with no cross-reactivity with other serotypes and respiratory organisms. These primers will aid in the generation of better data on vaccine/nonvaccine serotypes in invasive and carriage pneumococcal surveillance and contribute to future vaccine formulation and impact studies.

    View details for DOI 10.1128/JCM.00419-16

    View details for PubMedID 27252464

    View details for PubMedCentralID PMC4963509

  • Prevention of Congenital Disorders and Care of Affected Children: A Consensus Statement. JAMA pediatrics Darmstadt, G. L., Howson, C. P., Walraven, G., Armstrong, R. W., Blencowe, H. K., Christianson, A. L., Kent, A., Malherbe, H., Murray, J. C., Padilla, C. D., Walani, S. R. 2016; 170 (8): 790-793


    As the Sustainable Development Goals are adopted by United Nations member states, children with congenital disorders remain left behind in policies, programs, research, and funding. Although this finding was recognized by the creation and endorsement of the 63rd World Health Assembly Resolution in 2010 calling on United Nations member states to strengthen prevention of congenital disorders and the improvement of care of those affected, there has been little to no action since then. The Sustainable Development Goals call for the global health and development community to focus first and foremost on the most vulnerable and those left behind in the Millennium Development Goal era. To maximize the opportunity for every woman and couple to have a healthy child and to reduce the mortality and severe disability associated with potentially avoidable congenital disorders and their consequences for the children affected, their families and communities, and national health care systems, we propose priority measures that should be taken urgently to address this issue.

    View details for DOI 10.1001/jamapediatrics.2016.0388

    View details for PubMedID 27366873

  • Epidemiology of Invasive Pneumococcal Disease in Bangladeshi Children Before Introduction of Pneumococcal Conjugate Vaccine PEDIATRIC INFECTIOUS DISEASE JOURNAL Saha, S. K., Hossain, B., Islam, M., Hasanuzzaman, M., Saha, S., Hasan, M., Darmstadt, G. L., Chowdury, M., El Arifeen, S., Baqui, A. H., Breiman, R. F., Santosham, M., Luby, S. P., Whitney, C. G. 2016; 35 (6): 655-661


    Because Bangladesh intended to introduce pneumococcal conjugate vaccine (PCV)-10 in 2015, we examined the baseline burden of invasive pneumococcal disease (IPD) to measure impact of PCV.During 2007-2013, we performed blood and cerebrospinal fluid cultures in children <5 years old with suspected IPD identified through active surveillance at 4 hospitals. Isolates were serotyped by quellung and tested for antibiotic susceptibility by disc diffusion and E-test. Serotyping of culture-negative cases, detected by Binax or polymerase chain reaction, was done by sequential multiplex polymerase chain reaction. Trends in IPD case numbers were analyzed by serotype and clinical syndrome.The study identified 752 IPD cases; 78% occurred in children <12 months old. Serotype information was available for 78% (442/568), including 197 of 323 culture-negative cases available for serotyping. We identified 50 serotypes; the most common serotypes were 2 (16%), 1 (10 %), 6B (7%), 14 (7%) and 5 (7%). PCV-10 and PCV-13 serotypes accounted for 46% (range 29%-57% by year) and 50% (range 37%-64% by year) of cases, respectively. Potential serotype coverage for meningitis and nonmeningitis cases was 45% and 49% for PCV-10, and 48% and 57% for PCV-13, respectively. Eighty-two percent of strains were susceptible to all antibiotics except cotrimoxazole.The distribution of serotypes causing IPD in Bangladeshi children is diverse, limiting the proportion of IPD cases PCV can prevent. However, PCV introduction is expected to have major benefits as the country has a high burden of IPD-related mortality, morbidity and disability.

    View details for DOI 10.1097/INF.0000000000001037

    View details for Web of Science ID 000379343700016

    View details for PubMedID 26658530

  • The Grand Divergence in Global Child Health: Confronting Data Requirements in Areas of Conflict and Chronic Political Instability. JAMA pediatrics Wise, P. H., Darmstadt, G. L. 2016; 170 (3): 195-197

    View details for DOI 10.1001/jamapediatrics.2015.4275

    View details for PubMedID 26809944

  • Effect of community-based newborn care on cause-specific neonatal mortality in Sylhet district, Bangladesh: findings of a cluster-randomized controlled trial JOURNAL OF PERINATOLOGY Baqui, A. H., Williams, E., El-Arifeen, S., APPLEGATE, J. A., Mannan, I., Begum, N., Rahman, S. M., Ahmed, S., BLACK, R. E., Darmstadt, G. L. 2016; 36 (1): 71-76

    View details for DOI 10.1038/jp.2015.139

    View details for PubMedID 26540248

  • A shortened verbal autopsy instrument for use in routine mortality surveillance systems BMC MEDICINE Serina, P., Riley, I., Stewart, A., Flaxman, A. D., Lozano, R., Mooney, M. D., Luning, R., Hernandez, B., Black, R., Ahuja, R., Alam, N., Alam, S. S., Ali, S. M., Atkinson, C., Baqui, A. H., Chowdhury, H. R., Dandona, L., Dandona, R., Dantzer, E., Darmstadt, G. L., Das, V., Dhingra, U., Dutta, A., Fawzi, W., Freeman, M., Gamage, S., Gomez, S., Hensman, D., James, S. L., Joshi, R., Kalter, H. D., Kumar, A., Kumar, V., Lucero, M., Mehta, S., Neal, B., Ohno, S. L., Phillips, D., Pierce, K., Prasad, R., Praveen, D., Premji, Z., Ramirez-Villalobos, D., Rampatige, R., Remolador, H., Romero, M., Said, M., Sanvictores, D., Sazawal, S., Streatfield, P. K., Tallo, V., Vadhatpour, A., Wijesekara, N., Murray, C. J., Lopez, A. D. 2015; 13


    Verbal autopsy (VA) is recognized as the only feasible alternative to comprehensive medical certification of deaths in settings with no or unreliable vital registration systems. However, a barrier to its use by national registration systems has been the amount of time and cost needed for data collection. Therefore, a short VA instrument (VAI) is needed. In this paper we describe a shortened version of the VAI developed for the Population Health Metrics Research Consortium (PHMRC) Gold Standard Verbal Autopsy Validation Study using a systematic approach.We used data from the PHMRC validation study. Using the Tariff 2.0 method, we first established a rank order of individual questions in the PHMRC VAI according to their importance in predicting causes of death. Second, we reduced the size of the instrument by dropping questions in reverse order of their importance. We assessed the predictive performance of the instrument as questions were removed at the individual level by calculating chance-corrected concordance and at the population level with cause-specific mortality fraction (CSMF) accuracy. Finally, the optimum size of the shortened instrument was determined using a first derivative analysis of the decline in performance as the size of the VA instrument decreased for adults, children, and neonates.The full PHMRC VAI had 183, 127, and 149 questions for adult, child, and neonatal deaths, respectively. The shortened instrument developed had 109, 69, and 67 questions, respectively, representing a decrease in the total number of questions of 40-55%. The shortened instrument, with text, showed non-significant declines in CSMF accuracy from the full instrument with text of 0.4%, 0.0%, and 0.6% for the adult, child, and neonatal modules, respectively.We developed a shortened VAI using a systematic approach, and assessed its performance when administered using hand-held electronic tablets and analyzed using Tariff 2.0. The length of a VA questionnaire was shortened by almost 50% without a significant drop in performance. The shortened VAI developed reduces the burden of time and resources required for data collection and analysis of cause of death data in civil registration systems.

    View details for DOI 10.1186/s12916-015-0528-8

    View details for PubMedID 26670275

  • Improving performance of the Tariff Method for assigning causes of death to verbal autopsies BMC MEDICINE Serina, P., Riley, I., Stewart, A., James, S. L., Flaxman, A. D., Lozano, R., Hernandez, B., Mooney, M. D., Luning, R., Black, R., Ahuja, R., Alam, N., Alam, S. S., Ali, S. M., Atkinson, C., Baqui, A. H., Chowdhury, H. R., Dandona, L., Dandona, R., Dantzer, E., Darmstadt, G. L., Das, V., Dhingra, U., Dutta, A., Fawzi, W., Freeman, M., Gomez, S., Gouda, H. N., Joshi, R., Kalter, H. D., Kumar, A., Kumar, V., Lucero, M., Maraga, S., Mehta, S., Neal, B., Ohno, S. L., Phillips, D., Pierce, K., Prasad, R., Praveen, D., Premji, Z., Ramirez-Villalobos, D., Rarau, P., Remolador, H., Romero, M., Said, M., Sanvictores, D., Sazawal, S., Streatfield, P. K., Tallo, V., Vadhatpour, A., Vano, M., Murray, C. J., Lopez, A. D. 2015; 13


    Reliable data on the distribution of causes of death (COD) in a population are fundamental to good public health practice. In the absence of comprehensive medical certification of deaths, the only feasible way to collect essential mortality data is verbal autopsy (VA). The Tariff Method was developed by the Population Health Metrics Research Consortium (PHMRC) to ascertain COD from VA information. Given its potential for improving information about COD, there is interest in refining the method. We describe the further development of the Tariff Method.This study uses data from the PHMRC and the National Health and Medical Research Council (NHMRC) of Australia studies. Gold standard clinical diagnostic criteria for hospital deaths were specified for a target cause list. VAs were collected from families using the PHMRC verbal autopsy instrument including health care experience (HCE). The original Tariff Method (Tariff 1.0) was trained using the validated PHMRC database for which VAs had been collected for deaths with hospital records fulfilling the gold standard criteria (validated VAs). In this study, the performance of Tariff 1.0 was tested using VAs from household surveys (community VAs) collected for the PHMRC and NHMRC studies. We then corrected the model to account for the previous observed biases of the model, and Tariff 2.0 was developed. The performance of Tariff 2.0 was measured at individual and population levels using the validated PHMRC database.For median chance-corrected concordance (CCC) and mean cause-specific mortality fraction (CSMF) accuracy, and for each of three modules with and without HCE, Tariff 2.0 performs significantly better than the Tariff 1.0, especially in children and neonates. Improvement in CSMF accuracy with HCE was 2.5%, 7.4%, and 14.9% for adults, children, and neonates, respectively, and for median CCC with HCE it was 6.0%, 13.5%, and 21.2%, respectively. Similar levels of improvement are seen in analyses without HCE.Tariff 2.0 addresses the main shortcomings of the application of the Tariff Method to analyze data from VAs in community settings. It provides an estimation of COD from VAs with better performance at the individual and population level than the previous version of this method, and it is publicly available for use.

    View details for DOI 10.1186/s12916-015-0527-9

    View details for PubMedID 26644140

  • Kangaroo mother care: a multi-country analysis of health system bottlenecks and potential solutions BMC PREGNANCY AND CHILDBIRTH Vesel, L., Bergh, A., Kerber, K. J., Valsangkar, B., Mazia, G., Moxon, S. G., Blencowe, H., Darmstadt, G. L., Johnson, J. d., Dickson, K. E., Ruiz Pelaez, J. G., von Xylander, S. R., Lawn, J. E. 2015; 15


    Preterm birth is now the leading cause of under-five child deaths worldwide with one million direct deaths plus approximately another million where preterm is a risk factor for neonatal deaths due to other causes. There is strong evidence that kangaroo mother care (KMC) reduces mortality among babies with birth weight <2000 g (mostly preterm). KMC involves continuous skin-to-skin contact, breastfeeding support, and promotion of early hospital discharge with follow-up. The World Health Organization has endorsed KMC for stabilised newborns in health facilities in both high-income and low-resource settings. The objectives of this paper are to: (1) use a 12-country analysis to explore health system bottlenecks affecting the scale-up of KMC; (2) propose solutions to the most significant bottlenecks; and (3) outline priority actions for scale-up.The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale-up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for KMC.Marked differences were found in the perceived severity of health system bottlenecks between Asian and African countries, with the former reporting more significant or very major bottlenecks for KMC with respect to all the health system building blocks. Community ownership and health financing bottlenecks were significant or very major bottlenecks for KMC in both low and high mortality contexts, particularly in South Asia. Significant bottlenecks were also reported for leadership and governance and health workforce building blocks.There are at least a dozen countries worldwide with national KMC programmes, and we identify three pathways to scale: (1) champion-led; (2) project-initiated; and (3) health systems designed. The combination of all three pathways may lead to more rapid scale-up. KMC has the potential to save lives, and change the face of facility-based newborn care, whilst empowering women to care for their preterm newborns.

    View details for DOI 10.1186/1471-2393-15-S2-S5

    View details for Web of Science ID 000381897700005

    View details for PubMedID 26391115

    View details for PubMedCentralID PMC4577801

  • Treatment of neonatal infections: a multi-country analysis of health system bottlenecks and potential solutions BMC PREGNANCY AND CHILDBIRTH Simen-Kapeu, A., Seale, A. C., Wall, S., Nyange, C., Qazi, S. A., Moxon, S. G., Young, M., Liu, G., Darmstadt, G. L., Dickson, K. E., Lawn, J. E. 2015; 15


    Around one-third of the world's 2.8 million neonatal deaths are caused by infections. Most of these deaths are preventable, but occur due to delays in care-seeking, and access to effective antibiotic treatment with supportive care. Understanding variation in health system bottlenecks to scale-up of case management of neonatal infections and identifying solutions is essential to reduce mortality, and also morbidity.A standardised bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the development of the Every Newborn Action Plan. Country workshops involved technical experts to complete a survey tool, to grade health system "bottlenecks" hindering scale up of maternal-newborn intervention packages. Quantitative and qualitative methods were used to analyse the data, combined with literature review, to present priority bottlenecks and synthesise actions to improve case management of newborn infections.For neonatal infections, the health system building blocks most frequently graded as major or significant bottlenecks, irrespective of mortality context and geographical region, were health workforce (11 out of 12 countries), and community ownership and partnership (11 out of 12 countries). Lack of data to inform decision making, and limited funding to increase access to quality neonatal care were also major challenges.Rapid recognition of possible serious bacterial infection and access to care is essential. Inpatient hospital care remains the first line of treatment for neonatal infections. In situations where referral is not possible, the use of simplified antibiotic regimens for outpatient management for non-critically ill young infants has recently been reported in large clinical trials; WHO is developing a guideline to treat this group of young infants. Improving quality of care through more investment in the health workforce at all levels of care is critical, in addition to ensuring development and dissemination of national guidelines. Improved information systems are needed to track coverage and adequately manage drug supply logistics for improved health outcomes. It is important to increase community ownership and partnership, for example through involvement of community groups.

    View details for DOI 10.1186/1471-2393-15-S2-S6

    View details for Web of Science ID 000381897700006

    View details for PubMedID 26391217

  • Taking on the gender challenge in organisations: what does it take? Global public health Henry, S. K., Sandler, J., Passerini, L., Darmstadt, G. L. 2015: 1-12


    Clear patterns emerged and are summarised on conditions for success in integrating a gender equality perspective across organisational programmes and culture. In short, organisations should consider five key 'ingredients' when designing their approach to integrating a gender equality perspective: (1) have a clear vision of success with measurable indicators; (2) have high-level, consistent, visible support; (3) take an intentional approach deeply rooted in the organisational culture and competencies; (4) ensure accountability at all levels and (5) invest both financial and technical resources. A vibrant community exists in virtually every region of the world of highly experienced gender equality experts that can support organisations on this path. Late adopters of integrating a gender equality perspective can benefit from decades of practice and a robust evidence base which has shifted focus among development organisations from asking 'why' addressing gender inequalities is important to learning 'how' to most effectively do this in programmes, policies, research and organisational culture while building a strong results framework.

    View details for PubMedID 26857439

  • Strategic governance: Addressing neonatal mortality in situations of political instability and weak governance SEMINARS IN PERINATOLOGY Wise, P. H., Darmstadt, G. L. 2015; 39 (5): 387-392


    Neonatal mortality is increasingly concentrated globally in situations of conflict and political instability. In 1991, countries with high levels of political instability accounted for approximately 10% of all neonatal deaths worldwide; in 2013, this figure had grown to 31%. This has generated a "grand divergence" between those countries showing progress in neonatal mortality reduction compared to those lagging behind. We present new analyses demonstrating associations of neonatal mortality with political instability (r = 0.55) and poor governance (r = 0.70). However, heterogeneity in these relationships suggests that progress is possible in addressing neonatal mortality even in the midst of political instability and poor governance. In order to address neonatal mortality more effectively in such situations, we must better understand how specific elements of "strategic governance"-the minimal conditions of political stability and governance required for health service implementation-can be leveraged for successful introduction of specific health services. Thus, a more strategic approach to policy and program implementation in situations of conflict and political instability could lead to major accelerations in neonatal mortality reduction globally. However, this will require new cross-disciplinary collaborations among public health professionals, political scientists, and country actors.

    View details for DOI 10.1053/j.semperi.2015.06.008

    View details for Web of Science ID 000359877300008

    View details for PubMedID 26166561

  • Implementation of the Every Newborn Action Plan: Progress and lessons learned SEMINARS IN PERINATOLOGY Kinney, M. V., Cocoman, O., Dickson, K. E., Daelmans, B., Zaka, N., Rhoda, N. R., Moxon, S. G., Kak, L., Lawn, J. E., Khadka, N., Darmstadt, G. L. 2015; 39 (5): 326-337


    Progress in reducing newborn mortality has lagged behind progress in reducing maternal and child deaths. The Every Newborn Action Plan (ENAP) was launched in 2014, with the aim of achieving equitable and high-quality coverage of care for all women and newborns through links with other global and national plans and measurement and accountability frameworks. This article aims to assess country progress and the mechanisms in place to support country implementation of the ENAP. A country tracking tool was developed and piloted in October-December 2014 to collect data on the ENAP-related national milestones and implementation barriers in 18 high-burden countries. Simultaneously, a mapping exercise involving 47 semi-structured interviews with partner organizations was carried out to frame the categories of technical support available in countries to support care at and around the time of birth by health system building blocks. Existing literature and reports were assessed to further supplement analysis of country progress. A total of 15 out of 18 high-burden countries have taken concrete actions to advance newborn health; four have developed specific action plans with an additional six in process and a further three strengthening newborn components within existing plans. Eight high-burden countries have a newborn mortality target, but only three have a stillbirth target. The ENAP implementation in countries is well-supported by UN agencies, particularly UNICEF and WHO, as well as multilateral and bilateral agencies, especially in health workforce training. New financial commitments from development partners and the private sector are substantial but tracking of national funding remains a challenge. For interventions with strong evidence, low levels of coverage persists and health information systems require investment and support to improve quality and quantity of data to guide and track progress. Some of the highest burden countries have established newborn health action plans and are scaling up evidence based interventions. Further progress will only be made with attention to context-specific implementation challenges, especially in areas that have been neglected to date such as quality improvement, sustained investment in training and monitoring health worker skills, support to budgeting and health financing, and strengthening of health information systems.

    View details for DOI 10.1053/j.semperi.2015.06.004

    View details for Web of Science ID 000359877300002

    View details for PubMedID 26249104

  • Enculturating science: Community-centric design of behavior change interactions for accelerating health impact SEMINARS IN PERINATOLOGY Kumar, V., Kumar, A., Ghosh, A. K., Samphel, R., Yadav, R., Yeung, D., Darmstadt, G. L. 2015; 39 (5): 393-415


    Despite significant advancements in the scientific evidence base of interventions to improve newborn survival, we have not yet been able to "bend the curve" to markedly accelerate global rates of reduction in newborn mortality. The ever-widening gap between discovery of scientific best practices and their mass adoption by families (the evidence-practice gap) is not just a matter of improving the coverage of health worker-community interactions. The design of the interactions themselves must be guided by sound behavioral science approaches such that they lead to mass adoption and impact at a large scale. The main barrier to the application of scientific approaches to behavior change is our inability to "unbox" the "black box" of family health behaviors in community settings. The authors argue that these are not black boxes, but in fact thoughtfully designed community systems that have been designed and upheld, and have evolved over many years keeping in mind a certain worldview and a common social purpose. An empathetic understanding of these community systems allows us to deconstruct the causal pathways of existing behaviors, and re-engineer them to achieve desired outcomes. One of the key reasons for the failure of interactions to translate into behavior change is our failure to recognize that the content, context, and process of interactions need to be designed keeping in mind an organized community system with a very different worldview and beliefs. In order to improve the adoption of scientific best practices by communities, we need to adapt them to their culture by leveraging existing beliefs, practices, people, context, and skills. The authors present a systems approach for community-centric design of interactions, highlighting key principles for achieving intrinsically motivated, sustained change in social norms and family health behaviors, elucidated with progressive theories from systems thinking, management sciences, cross-cultural psychology, learning and social cognition, and the behavioral sciences. These are illustrated through a case study of designing effective interactions in Shivgarh, India, that led to rapid and substantial changes in newborn health behaviors and reduction in NMR by half over a span of 16 months.

    View details for DOI 10.1053/j.semperi.2015.06.010

    View details for Web of Science ID 000359877300009

    View details for PubMedID 26215599

  • Scaling-up impact in perinatology through systems science: Bridging the collaboration and translational divides in cross-disciplinary research and public policy SEMINARS IN PERINATOLOGY Munar, W., Hovmand, P. S., Fleming, C., Darmstadt, G. L. 2015; 39 (5): 416-423


    Despite progress over the past decade in reducing the global burden of newborn deaths, gaps in the knowledge base persist, and means of translating empirical findings into effective policies and programs that deliver life-saving interventions remain poorly understood. Articles in this issue highlight the relevance of transdisciplinary research in perinatology and calls for increased efforts to translate research into public policy and to integrate interventions into existing primary care delivery systems. Given the complexity and multi-causality of many of the remaining challenges in newborn health, and the effects that social and economic factors have over many newborn conditions, it has further been proposed that integrated, multi-sector public policies are also required. In this article, we discuss the application of systems science methods to advance transdisciplinary research and public policy-making in perinatology. Such approaches to research and public policy have been used to address various global challenges but have rarely been implemented in developing country settings. We propose that they hold great promise to improve not only our understanding of complex perinatology problems but can also help translate research-based insights into effective, multi-pronged solutions that deliver positive, intended effects. Examples of successful transdisciplinary science exist, but successes and failures are context specific, and there are no universal blueprints or formulae to reproduce what works in a specific context into different social system settings. Group model building is a tool, based in the field of System Dynamics, that we have used to facilitate transdisciplinary research and, to a lesser extent, policy formulation in a systematic and replicable way. In this article, we describe how group model building can be used and argue for scaling its use to further the translation of empirical evidence and insights into policy and action that increase maternal and neonatal survival and well-being.

    View details for DOI 10.1053/j.semperi.2015.06.003

    View details for Web of Science ID 000359877300010

    View details for PubMedID 26184341

  • Enhancing the child survival agenda to promote, protect, and support early child development SEMINARS IN PERINATOLOGY Jensen, S. K., Bouhouch, R. R., Walson, J. L., Daelmans, B., Bahl, R., Darmstadt, G. L., Dua, T. 2015; 39 (5): 373-386


    High rates of child mortality and lost developmental potential in children under 5 years of age remain important challenges and drivers of inequity in the developing world. Substantive progress has been made toward Millennium Development Goal (MDG) 4 to improve child survival, but as we move into the post-2015 sustainable development agenda, much more work is needed to ensure that all children can realize their full and holistic physical, cognitive, psychological, and socio-emotional development potential. This article presents child survival and development as a continuous and multifaceted process and suggests that a life-course perspective of child development should be at the core of future policy making, programing, and research. We suggest that increased attention to child development, beyond child survival, is key to operationalize the sustainable development goals (SDGs), address inequities, build on the demographic dividend, and maximize gains in human potential. An important step toward implementation will be to increase integration of existing interventions for child survival and child development. Integrated interventions have numerous potential benefits, including optimization of resource use, potential additive impacts across multiple domains of health and development, and opportunity to realize a more holistic approach to client-centered care. However, a notable challenge to integration is the continued division between the health sector and other sectors that support child development. Despite these barriers, empirical evidence is available to suggest that successful multi-sectoral coordination is feasible and leads to improved short- and long-term outcomes in human, social, and economic development.

    View details for DOI 10.1053/j.semperi.2015.06.002

    View details for Web of Science ID 000359877300007

    View details for PubMedID 26234921

  • Impact of family planning programs in reducing high-risk births due to younger and older maternal age, short birth intervals, and high parity SEMINARS IN PERINATOLOGY Brown, W., Ahmed, S., Roche, N., Sonneveldt, E., Darmstadt, G. L. 2015; 39 (5): 338-344


    Several studies show that maternal and neonatal/infant mortality risks increase with younger and older maternal age (<18 and >34 years), high parity (birth order >3), and short birth intervals (<24 months). Family planning programs are widely viewed as having contributed to substantial maternal and neonatal mortality decline through contraceptive use-both by reducing unwanted births and by reducing the burden of these high-risk births. However, beyond averting births, the empirical evidence for the role of family planning in reducing high-risk births at population level is limited. We examined data from 205 Demographic and Health Surveys (DHS), conducted between 1985 and 2013, to describe the trends in high-risk births and their association with the pace of progress in modern contraceptive prevalence rate (yearly increase in rate of MCPR) in 57 developing countries. Using Blinder-Oaxaca decomposition technique, we then examine the contributions of family planning program, economic development (GDP per capita), and educational improvement (secondary school completion rate) on the progress of MCPR in order to link the net contribution of family planning program to the reduction of high-risk births mediated through contraceptive use. Countries that had the fastest progress in improving MCPR experienced the greatest declines in high-risk births due to short birth intervals (<24 months), high parity births (birth order >3), and older maternal age (>35 years). Births among younger women <18 years, however, did not decline significantly during this period. The decomposition analysis suggests that 63% of the increase in MCPR was due to family planning program efforts, 21% due to economic development, and 17% due to social advancement through women's education. Improvement in MCPR, predominately due to family planning programs, is a major driver of the decline in the burden of high-risk births due to high parity, shorter birth intervals, and older maternal age in developing countries. The lack of progress in the decline of births in younger women <18 years of age underscores the need for more attention to ensure that quality contraceptive methods are available to adolescent women in order to delay first births. This study substantiates the significance of family planning programming as a major health intervention for preventing high-risk births and associated maternal and child mortality, but it highlights the need for concerted efforts to strengthen service provision for adolescents.

    View details for DOI 10.1053/j.semperi.2015.06.006

    View details for Web of Science ID 000359877300003

    View details for PubMedID 26169538

  • Population-based Incidence and Etiology of Community-acquired Neonatal Viral Infections in Bangladesh: A Community-based and Hospital-based Surveillance Study. Pediatric infectious disease journal Farzin, A., Saha, S. K., Baqui, A. H., Choi, Y., Ahmed, N. U., Simoes, E. A., El Arifeen, S., Al-Emran, H. M., Bari, S., Rahman, S. M., Mannan, I., Crook, D., Seraji, H. R., Begum, N., Black, R. E., Santosham, M., Darmstadt, G. L. 2015; 34 (7): 706-711


    The etiology of >90% of cases of suspected neonatal infection remains unknown. We conducted community-based surveillance in conjunction with hospital-based surveillance in a rural region in Bangladesh from June 2006 to September 2007 to assess the incidence and etiology of community-acquired viral infections among neonates.Community health workers (CHWs) assessed neonates at home on days 0, 2, 5 and 8 after birth and referred cases of suspected illness to the hospital (CHW surveillance). Among neonates with clinically suspected upper respiratory tract infection (URTI), pneumonia, sepsis and/or meningitis, virus identification studies were conducted on nasal wash, cerebrospinal fluid and/or blood specimens. In the hospital-based surveillance, similar screening was conducted among all neonates (referred by CHWs and self-referred) who were admitted to the hospital.CHW surveillance found an incidence rate of 15.6 neonatal viral infections per 1000 live births with 30% of infections identified on the day of birth. Among neonates with suspected sepsis, a viral etiology was identified in 36% of cases, with enterovirus accounting for two-thirds of those infections. Respiratory syncytial virus was the most common etiologic agent among those with viral pneumonia (91%) and URTI (68%). There was a low incidence (1.2%) of influenza in this rural population.Viral infections are commonly associated with acute newborn illness, even in the early neonatal period. The estimated incidence was 5-fold greater than reported previously for bacterial infections. Low-cost preventive measures for neonatal viral infections are urgently needed.

    View details for DOI 10.1097/INF.0000000000000726

    View details for PubMedID 25961894

  • Effective interventions and strategies for improving early child development. BMJ (Clinical research ed.) Daelmans, B., Black, M. M., Lombardi, J., Lucas, J., Richter, L., Silver, K., Britto, P., Yoshikawa, H., Perez-Escamilla, R., MacMillan, H., Dua, T., Bouhouch, R. R., Bhutta, Z., Darmstadt, G. L., Rao, N. 2015; 351: h4029-?

    View details for DOI 10.1136/bmj.h4029

    View details for PubMedID 26371213

  • Ensuring healthy pregnancies, births, and babies. Seminars in perinatology Darmstadt, G. L. 2015; 39 (5): 321–25

    View details for PubMedID 26184342

  • Sex differences in morbidity and care-seeking during the neonatal period in rural southern Nepal. Journal of health, population, and nutrition Rosenstock, S., Katz, J., Mullany, L. C., Khatry, S. K., LeClerq, S. C., Darmstadt, G. L., Tielsch, J. M. 2015; 33 (1): 11-?


    South Asian studies, including those from Nepal, have documented increased risk of neonatal mortality among girls, despite their early biologic survival advantage. We examined sex differences in neonatal morbidity and care-seeking behavior to determine whether such differences could help explain previously observed excess late neonatal mortality among girls in Nepal.A secondary analysis of data from a trial of chlorhexidine use among neonates in rural Nepal was conducted. The objective was to examine sex differences in neonatal morbidity and care-seeking behavior for ill newborns. Girls were used as the reference group.Referral for care was higher during the early neonatal period (ENP: 0-7 days old) (50.7%) than the late neonatal period (LNP: 8-28 days old) (31.3%), but was comparable by sex. There were some significant differences in reasons for referral by sex. Boys were significantly more often referred for convulsions/stiffness, having yellow body/eyes, severe skin infection, and having at least two of the following: difficulty breathing, difficulty feeding, fever, or vomiting during the ENP. Girls were more often referred for hypothermia. During the LNP, boys were significantly more often referred for having yellow body/eyes, persistent watery stool, and severe skin infection. There were no referral types in the LNP for which girls were more often referred. Less than half of those referred at any point were taken for care (47.0%) and referred boys were more often taken than girls (Neonatal Period OR: 1.77, 95% CI: 1.64 - 1.91). Family composition differentially impacted the relationship between care-seeking and sex. The greatest differences were in families with only prior living girls (Pahadi - ENP OR: 1.78, 95% CI: 1.29 - 2.45 and LNP OR: 1.51, 95% CI: 1.03 - 2.21; Madeshi - ENP OR: 2.86, 95% CI: 2.28 - 3.59 and LNP OR: 2.45, 95% CI: 1.84 - 3.26).Care-seeking was inadequate for both sexes, but ill boys were consistently more often taken for care than girls, despite comparable referral. Behavioral interventions to improve care-seeking, especially in the early neonatal period, are needed to improve neonatal survival. Addressing gender bias in care-seeking, explicitly and within interventions, is essential to reducing neonatal mortality differentials between boys and girls.

    View details for DOI 10.1186/s41043-015-0014-0

    View details for PubMedID 26825276

  • Validation of Rapid Neurodevelopmental Assessment for 2-to 5-Year-Old Children in Bangladesh PEDIATRICS Khan, N. Z., Muslima, H., Shilpi, A. B., Begum, D., Parveen, M., Akter, N., Ferdous, S., Nahar, K., McConachie, H., Darmstadt, G. L. 2013; 131 (2): E486-E494


    Validate a tool to determine neurodevelopmental impairments (NDIs) in >2- to 5-year-old children in a country with limited child development expertise.Rapid Neurodevelopmental Assessment (RNDA) is a tool designed to detect functional status and NDIs across multiple neurodevelopmental domains. Validity was determined in 77 children enrolled by door-to-door sampling in Dhaka and who were administered the RNDA by 1 of 6 testers (4 developmental therapists, 2 special education teachers) and simultaneously administered a test of adaptive behavior (AB; Independent Behavior Assessment Scale) and intelligence quotient (IQ) tests (Bayley Scales of Infant Development II, Stanford Binet Intelligence Scale, Wechsler Preschool and Primary Scales of Intelligence) by psychologists.Interrater reliability ranged from good to excellent. There were significant differences in AB in mean percentile scores on the Independent Behavior Assessment Scale for motor (P = .0001), socialization (P = .001), communication (P = .001), and full-scale (P = .001) scores in children with ≥1 NDI ("any NDI") versus no NDI. Significant differences in those with versus those without "any NDI" were found on IQ scores. Sensitivity and specificity for "significant difficulties" (defined as AB z-scores < -2 SDs and/or IQ <70) and "mild difficulties included" (AB z-scores < -1SD and/or IQ <85) were 90% and 60% and 80% and 76%, respectively.The RNDA validity results are promising for use by child care professionals in field and clinical settings, but the tool needs further replication and refinement for assessment of specific impairments of vision, hearing, and seizures.

    View details for DOI 10.1542/peds.2011-2421

    View details for Web of Science ID 000314355100018

    View details for PubMedID 23359579

  • Evaluation of neonatal verbal autopsy using physician review versus algorithm-based cause-of-death assignment in rural Nepal PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Freeman, J. V., Christian, P., Khatry, S. K., Adhikari, R. K., LeClerq, S. C., Katz, J., Darmstadt, G. L. 2005; 19 (4): 323-331


    Verbal autopsy (VA) is used to ascertain cause-specific neonatal mortality using parental/familial recall. We sought to compare agreement between causes of death obtained from the VA by physician review vs. computer-based algorithms. Data were drawn from a cluster-randomised trial involving 4130 live-born infants and 167 neonatal deaths in the rural Sarlahi District of Nepal. We examined the agreement between causes ascertained by physician review and algorithm assignment by the kappa (kappa) statistic. We also compared responses to identical questions posed posthumously during neonatal VA interviews with those obtained during maternal interviews and clinical examinations regarding condition of newborns soon after birth. Physician reviewers assigned prematurity or acute lower respiratory infection (ALRI) as causes of 48% of neonatal deaths; 41% were assigned as uncertain. The algorithm approach assigned sepsis (52%), ALRI (31%), birth asphyxia (29%), and prematurity (24%) as the most common causes of neonatal death. Physician review and algorithm assignment of causes of death showed high kappa for prematurity (0.73), diarrhoea (0.81) and ALRI (0.68), but was low for congenital malformation (0.44), birth asphyxia (0.17) and sepsis (0.00). Sensitivity and specificity of VA interview questions varied by symptom, with positive predictive values ranging from 50% to 100%, when compared with maternal interviews and examinations of neonates soon after birth. Analysis of the VA data by physician review and computer-based algorithms yielded disparate results for some causes but not for others. We recommend an analysis technique that combines both methods, and further validation studies to improve performance of the VA for assigning causes of neonatal death.

    View details for Web of Science ID 000229782200009

    View details for PubMedID 15958155

  • Perianal lymphangioma circumscriptum mistaken for genital warts PEDIATRICS Darmstadt, G. L. 1996; 98 (3): 461-463

    View details for Web of Science ID A1996VF50600023

    View details for PubMedID 8784378

  • Clinical picture ARCHIVES OF FAMILY MEDICINE Darmstadt, G. L., Tunnessen, W. W. 1996; 5 (8): 437-438

    View details for Web of Science ID A1996VH34100001

    View details for PubMedID 8797543

  • IMPETIGO - AN OVERVIEW PEDIATRIC DERMATOLOGY Darmstadt, G. L., Lane, A. T. 1994; 11 (4): 293-303


    This article reviews in detail the pathogenesis, clinical characteristics and management of impetigo in children. Impetigo is the most common bacterial skin infection of children. Most cases of nonbullous impetigo and all cases of bullous impetigo are caused by Staphylococcus aureus. The remainder of cases of nonbullous impetigo are due to group A beta hemolytic streptococci (GABHS). GABHS colonize the skin directly by binding to sites on fibronectin that are exposed by trauma. In contrast, S. aureus colonizes the nasal epithelium first; from this reservoir, colonization of the skin occurs. Patients with recurrent impetigo should be evaluated for carriage of S. aureus. Superficial, localized impetigo may be treated successfully in more than 90% of cases with topical application of mupirocin ointment. Impetigo that is widespread or involves deeper tissues should be treated with a beta-lactamase-resistant oral antibiotic. The choice of antibiotics is affected by the local prevalence of resistance to erythromycin among strains of S. aureus, antibiotic cost and availability, and issues of compliance.

    View details for Web of Science ID A1994PY11400001

    View details for PubMedID 7899177

  • PROTEUS SYNDROME PEDIATRIC DERMATOLOGY Darmstadt, G. L., Lane, A. T. 1994; 11 (3): 222-226


    A 10-month-old girl had macrodactyly, facial and extremity hemihypertrophy, plantar cerebriform hyperplasia, a subcutaneous mass on the back, macrocephaly, and lumbar kyphosis. These findings were diagnostic of Proteus syndrome. The clinical features, etiology, management, and points of differential diagnosis are discussed.

    View details for Web of Science ID A1994PE28000005

    View details for PubMedID 7971556


    View details for Web of Science ID A1994ND42800012

    View details for PubMedID 8143012