We investigate the extent to which asylum policies that aim to deter individuals from migrating irregularly in fact do so. We specifically consider effects of Germany’s 2023 asylum policy adjustments, which include accelerated asylum decision processes, the prospect of asylum processing outside of Europe, the introduction of a payment card to replace cash benefits, and an extended waiting period for native-level benefits. To estimate the effects of these policy measures on irregular migration intent, we implement a conjoint experiment with 989 men aged 18–40 in four cities in Senegal, a country where irregular migration to Europe is highly salient. Offshoring the asylum process substantially lowers irregular migration intentions, and extending the waiting time for native-level benefits only has a small effect on intent. Neither reducing asylum processing times nor replacing cash benefits with a payment card alters intentions. Our study does not resolve political and normative questions concerning these policies.

Stock estimates of missing women suggest that excess female deaths are concentrated in South and East Asia and among young children. In contrast, flow estimates suggest that gender bias in mortality is much larger than previously estimated using stock measures, is as severe among adults as it is among children in India and China, and is larger in Sub-Saharan Africa than in India and China. We show that the different stock and flow measure results rely on the choice of the reference standard for mortality and an incomplete correction for different disease environments in the flow measure. Alternative reference standards reconcile the results of the two measures.

We study the impact of the COVID-19 pandemic on domestic violence against women in Germany in 2020. The analysis draws on three data sources: (1) longitudinal administrative data on the volume of help requests to helplines, shelters and counselling services, (2) cross-sectional survey data collected during the first wave of the pandemic, and (3) a qualitative online survey with counsellors and domestic violence experts. The number of violence-related requests at helplines increased significantly by 34% with the first physical distancing measures, whereas ambulatory care services such as shelters experienced a 14% increase in help requests only after physical distancing restrictions were lifted. Our results indicate that individuals substituted help services away from ambulatory care towards helplines. We do not observe exacerbated violence in states with greater mobility reductions, lower day care capacity for childcare or higher COVID-19 infection numbers. Yet, our cross-sectional household-level data suggests that home quarantine and financial distress may have been triggers of violence. Our findings highlight the importance of providing easily accessible online counselling offers for survivors of violence and governmental financial relief packages.

We report experimental results from Ghana, where treated subjects received information on regional income differentials. We do not see an effect on migration intentions directly post-treatment, but rather eighteen months later, and we reflect on the delayed effects. JEL Codes: J31, O15.

Evidence on cardiovascular disease (CVD) risk factor prevalence among adults living below the World Bank's international line for extreme poverty (those with income <$1.90 per day) globally is sparse. Here we pooled individual-level data from 105 nationally representative household surveys across 78 countries, representing 85% of people living in extreme poverty globally, and sorted individuals by country-specific measures of household income or wealth to identify those in extreme poverty. CVD risk factors (hypertension, diabetes, smoking, obesity and dyslipidaemia) were present among 17.5% (95% confidence interval (CI) 16.7-18.3%), 4.0% (95% CI 3.6-4.5%), 10.6% (95% CI 9.0-12.3%), 3.1% (95% CI 2.8-3.3%) and 1.4% (95% CI 0.9-1.9%) of adults in extreme poverty, respectively. Most were not treated for CVD-related conditions (for example, among those with hypertension earning <$1.90 per day, 15.2% (95% CI 13.3-17.1%) reported taking blood pressure-lowering medication). The main limitation of the study is likely measurement error of poverty level and CVD risk factors that could have led to an overestimation of CVD risk factor prevalence among adults in extreme poverty. Nonetheless, our results could inform equity discussions for resource allocation and design of effective interventions.

Information frictions about benefits of migration can lead to inefficient migration choices. We study effects of randomly assigned information treatments concerning regional income differentials in Ghana and Uganda to explore participants’ belief updating and changes in internal migration intentions, destination preferences, and actual migration. Treated participants prefer higher income destinations, while effects on intent plausibly follow subjects’ initial under- or overestimation of potential gains, with asymmetric updating propensities. Effects persist for 18 months, and discussions with others about migrating increase, but actual migration does not. Knowledge about income affects intentions and destination choices, but barriers to actual relocation are complex.

Evidence from small-scale randomised controlled trials suggests that interventions relying on community involvement through a participatory learning and action (PLA) approach can improve health outcomes in resource-poor settings. However, it is only poorly understood whether PLA-based interventions are effective after scale-up in a real-world setting. In a cluster-randomised controlled trial in Bihar, India, we assessed whether the PLA approach improved health, nutrition, water, sanitation, and hygiene (HNWASH) outcomes in adults and children when implemented state-wide by a government-supported agency. In the intervention, trained female facilitators ran 20 structured participatory meetings about key HNWASH topics in state-supported women's groups. Unlike the strong results of small-scale trials, in the scaled-up government implemented intervention we do not observe systematic improvements in HNWASH knowledge, attitudes, practices or health outcomes. We discuss aspects of programme implementation that could explain these null effects. Our findings call for caution when promising public health interventions are transformed into large policy programmes.

Early-childhood interventions are important for poverty reduction but difficult to target. We study two interventions in rural India for children below age 2 that are simple and easy to scale: a durable device for iron fortification at home and caregiver training in dialogic reading. Outcomes were measured blinded. When delivered together, the interventions improved receptive language skills of children who were not anemic at baseline, suggesting that health endowment complements parental investments in the production of human capital. The dialogic reading intervention further shows positive spillovers on untreated children. Overall, shorter-lived interventions are potentially effective in healthier populations.

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'Stock estimates' of missing women suggest that the problem is concentrated in South and East Asia and among young children. In contrast, 'flow estimates' suggest that gender bias in mortality is much larger, is as severe among adults as it is among children in India and China, and is larger in Sub-Saharan Africa than in India and China. We show that the different stock and flow measure results rely on the choice of the reference standard for mortality and an incomplete correction for different disease environments in the flow measure. Alternative reference standards reconcile the results of the two measures.

We propose a novel son preference measure that relates the preference to a specific child. We find child-specific son preference to be more common among later born children and in families with fewer sons. Using the novel measure and an interaction instrumental variables approach, we estimate a penalty in early mental functions for unwanted girls of 0.7 standard deviations. This penalty appears to be partially driven by discrimination against girls and partially by pampering of boys. Children's health and parental inputs do not mediate the effect from son preference to mental development. Our findings highlight the relevance of parents' attitudes for a nurturing home environment and healthy brain development.

Incomplete and absent doses in routine childhood vaccinations are of major concern. Health systems in low- and middle-income countries (LMIC), in particular, often struggle to enable full vaccination of children, which affects their immunity against communicable diseases. Data on child vaccination cards from a cross-sectional primary survey with 1,967 households were used to assess the vaccination status. The association of timely postnatal care (PNC) and the place of delivery with any-dose (at least one dose of each vaccine) and full vaccination of children between 10-20 months in Bihar, India, was investigated. Bivariate and multivariable logistic regression models were used. The vaccines included targeted tuberculosis, hepatitis B, polio, diphtheria/pertussis/tetanus (DPT) and measles. Moreover predictors for perinatal health care uptake were analysed by multivariable logistic regression. Of the 1,011 children with card verification, 47.9% were fully vaccinated. Timely PNC was positively associated with full vaccination (adjusted odds ratio (aOR) 1.48, 95% confidence interval (CI) 1.06-2.08) and with the administration of at least one dose (any-dose) of polio vaccine (aOR 3.37 95% CI 1.79-6.36), hepatitis B/pentavalent vaccine (aOR 2.11 95% CI 1.24-3.59), and DPT/pentavalent vaccine (aOR 2.29 95% CI 1.35-3.88). Additionally, delivery in a public health care facility was positively associated with at least one dose of hepatitis B/pentavalent vaccine administration (aOR 4.86 95% CI 2.97-7.95). Predictors for timely PNC were institutional delivery (public and private) (aOR 2.7 95% CI 1.96-3.72, aOR 2.38 95% CI 1.56-3.64), at least one ANC visit (aOR 1.59 95% CI 1.18-2.15), wealth quintile (Middle aOR 1.57 95% CI 1.02-2.41, Richer aOR 1.51 95% CI 1.01-2.25, Richest aOR 2.06 95% CI 1.28-3.31) and household size (aOR 0.95 95% CI 0.92-0.99). The findings indicate a correlation between childhood vaccination and timely postnatal care. Further, delivery in a public facility correlates with the administration of at least one dose of hepatitis B vaccine and thus impedes zero-dose vaccination. Increasing uptake of timely PNC, encouraging institutional delivery, and improving vaccination services before discharge of health facilities may lead to improved vaccination rates among children.

OBJECTIVES:To determine the prevalence and frequency of using any tobacco product and each of a detailed set of tobacco products, how tobacco use and frequency of use vary across countries, world regions, and World Bank country income groups, and the socioeconomic and demographic gradients of tobacco use and frequency of use within countries. DESIGN:Secondary analysis of nationally representative, cross-sectional, household survey data from 82 low and middle income countries collected between 1 January 2015 and 31 December 2020. SETTING:Population based survey data. PARTICIPANTS:1 231 068 individuals aged 15 years and older. MAIN OUTCOME MEASURES:Self-reported current smoking, current daily smoking, current smokeless tobacco use, current daily smokeless tobacco use, pack years, and current use and use frequencies of each tobacco product. Products were any type of cigarette, manufactured cigarette, hand rolled cigarette, water pipe, cigar, oral snuff, nasal snuff, chewing tobacco, and betel nut (with and without tobacco). RESULTS:The smoking prevalence in the study sample was 16.5% (95% confidence interval 16.1% to 16.9%) and ranged from 1.1% (0.9% to 1.3%) in Ghana to 50.6% (45.2% to 56.1%) in Kiribati. The user prevalence of smokeless tobacco was 7.7% (7.5% to 8.0%) and prevalence was highest in Papua New Guinea (daily user prevalence of 65.4% (63.3% to 67.5%)). Although variation was wide between countries and by tobacco product, for many low and middle income countries, the highest prevalence and cigarette smoking frequency was reported in men, those with lower education, less household wealth, living in rural areas, and higher age. CONCLUSIONS:Both smoked and smokeless tobacco use and frequency of use vary widely across tobacco products in low and middle income countries. This study can inform the design and targeting of efforts to reduce tobacco use in low and middle income countries and serve as a benchmark for monitoring progress towards national and international goals.

BACKGROUND:Effective equity-focused health policy for hypertension in low- and middle-income countries (LMICs) requires an understanding of the condition's current socioeconomic gradients and how these are likely to change in the future as countries develop economically. OBJECTIVES:This cross-sectional study aimed to determine how hypertension prevalence in LMICs varies by individuals' education and household wealth, and how these socioeconomic gradients in hypertension prevalence are associated with a country's gross domestic product (GDP) per capita. METHODS:We pooled nationally representative household survey data from 76 LMICs. We disaggregated hypertension prevalence by education and household wealth quintile, and used regression analyses to adjust for age and sex. RESULTS:We included 1,211,386 participants in the analysis. Pooling across all countries, hypertension prevalence tended to be similar between education groups and household wealth quintiles. The only world region with a clear positive association of hypertension with education or household wealth quintile was Southeast Asia. Countries with a lower GDP per capita had, on average, a more positive association of hypertension with education and household wealth quintile than countries with a higher GDP per capita, especially in rural areas and among men. CONCLUSIONS:Differences in hypertension prevalence between socioeconomic groups were generally small, with even the least educated and least wealthy groups having a substantial hypertension prevalence. Our cross-sectional interaction analyses of GDP per capita with the socioeconomic gradients of hypertension suggest that hypertension may increasingly affect adults in the lowest socioeconomic groups as LMICs develop economically.

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality globally.1 In recent decades, a rising prevalence of major CVD risk factors including diabetes, hypertension and hyperlipidemia has been observed in many low- and middle-income countries (LMICs) where CVD was not previously considered a major health priority. As economic development drives urbanization and changes in lifestyles in many LMICs, this trend is expected to continue.2–4 Although ∼80% of CVD deaths now occur in LMICs,5 there are few data sources that allow empirical estimation of key CVD indicators and relationships relevant to epidemiology, health behaviour, and health services. In this profile, we provide an overview of a novel data resource for the study of CVD risk factors in LMICs, entitled the Global Health and Population Project on Access to Care for Cardiometabolic Diseases (HPACC). HPACC was initiated in 2016 by researchers at the University of Göttingen, Harvard University and Heidelberg University, in collaboration with in-country partners, with the objective to gather and harmonize household survey data on CVD and its risk factors. The HPACC dataset comprises nationally representative, population-based, individual-level surveys conducted in 2005 or later that are collated and then harmonized. The harmonization process is guided by the World Health Organization STEPwise approach to Surveillance (STEPS) survey instrument. This process is complex and includes aligning variable definitions across surveys such as income and asset data, checking data quality and ensuring consistency especially for biomarker measures, documenting variable skip patterns and confirming sample weights. To date, our efforts have resulted in a dataset covering 76 LMICs (Figure 1) and including data from 1 269 542 participants. These 76 countries represent 4.4 billion adults, which is 79% of the LMIC and 65% of the global adult population. The dataset is dynamic and new surveys are added as they become available. Furthermore, in many countries, eligible surveys are conducted periodically, at least once every 5–10 years. For the most part, these repeat surveys consist of a subsequent cross-section of the population but do not follow the same participants longitudinally. The current version of the HPACC dataset includes the most recent data in a cross-sectional harmonization but there is an ongoing effort to expand the dataset to include repeated cross-sections where available. Availability of repeat surveys by country is provided in detail in Table 1. The dataset is not publicly available, but access can be granted upon request.

Supplemental Digital Content is available in the text. Background: Current hypertension guidelines vary substantially in their definition of who should be offered blood pressure–lowering medications. Understanding the effect of guideline choice on the proportion of adults who require treatment is crucial for planning and scaling up hypertension care in low- and middle-income countries. Methods: We extracted cross-sectional data on age, sex, blood pressure, hypertension treatment and diagnosis status, smoking, and body mass index for adults 30 to 70 years of age from nationally representative surveys in 50 low- and middle-income countries (N = 1 037 215). We aimed to determine the effect of hypertension guideline choice on the proportion of adults in need of blood pressure–lowering medications. We considered 4 hypertension guidelines: the 2017 American College of Cardiology/American Heart Association guideline, the commonly used 140/90 mm Hg threshold, the 2016 World Health Organization HEARTS guideline, and the 2019 UK National Institute for Health and Care Excellence guideline. Results: The proportion of adults in need of blood pressure–lowering medications was highest under the American College of Cardiology/American Heart Association, followed by the 140/90 mm Hg, National Institute for Health and Care Excellence, and World Health Organization guidelines (American College of Cardiology/American Heart Association: women, 27.7% [95% CI, 27.2–28.2], men, 35.0% [95% CI, 34.4–35.7]; 140/90 mm Hg: women, 26.1% [95% CI, 25.5–26.6], men, 31.2% [95% CI, 30.6–31.9]; National Institute for Health and Care Excellence: women, 11.8% [95% CI, 11.4–12.1], men, 15.7% [95% CI, 15.3–16.2]; World Health Organization: women, 9.2% [95% CI, 8.9–9.5], men, 11.0% [95% CI, 10.6–11.4]). Individuals who were unaware that they have hypertension were the primary contributor to differences in the proportion needing treatment under different guideline criteria. Differences in the proportion needing blood pressure–lowering medications were largest in the oldest (65–69 years) age group (American College of Cardiology/American Heart Association: women, 60.2% [95% CI, 58.8–61.6], men, 70.1% [95% CI, 68.8–71.3]; World Health Organization: women, 20.1% [95% CI, 18.8–21.3], men, 24.1.0% [95% CI, 22.3–25.9]). For both women and men and across all guidelines, countries in the European and Eastern Mediterranean regions had the highest proportion of adults in need of blood pressure–lowering medicines, whereas the South and Central Americas had the lowest. Conclusions: There was substantial variation in the proportion of adults in need of blood pressure–lowering medications depending on which hypertension guideline was used. Given the great implications of this choice for health system capacity, policy makers will need to carefully consider which guideline they should adopt when scaling up hypertension care in their country.

BACKGROUND:The prevalence of overweight, obesity, and diabetes is rising rapidly in low-income and middle-income countries (LMICs), but there are scant empirical data on the association between body-mass index (BMI) and diabetes in these settings. METHODS:In this cross-sectional study, we pooled individual-level data from nationally representative surveys across 57 LMICs. We identified all countries in which a WHO Stepwise Approach to Surveillance (STEPS) survey had been done during a year in which the country fell into an eligible World Bank income group category. For LMICs that did not have a STEPS survey, did not have valid contact information, or declined our request for data, we did a systematic search for survey datasets. Eligible surveys were done during or after 2008; had individual-level data; were done in a low-income, lower-middle-income, or upper-middle-income country; were nationally representative; had a response rate of 50% or higher; contained a diabetes biomarker (either a blood glucose measurement or glycated haemoglobin [HbA1c]); and contained data on height and weight. Diabetes was defined biologically as a fasting plasma glucose concentration of 7·0 mmol/L (126·0 mg/dL) or higher; a random plasma glucose concentration of 11·1 mmol/L (200·0 mg/dL) or higher; or a HbA1c of 6·5% (48·0 mmol/mol) or higher, or by self-reported use of diabetes medication. We included individuals aged 25 years or older with complete data on diabetes status, BMI (defined as normal [18·5-22·9 kg/m2], upper-normal [23·0-24·9 kg/m2], overweight [25·0-29·9 kg/m2], or obese [≥30·0 kg/m2]), sex, and age. Countries were categorised into six geographical regions: Latin America and the Caribbean, Europe and central Asia, east, south, and southeast Asia, sub-Saharan Africa, Middle East and north Africa, and Oceania. We estimated the association between BMI and diabetes risk by multivariable Poisson regression and receiver operating curve analyses, stratified by sex and geographical region. FINDINGS:Our pooled dataset from 58 nationally representative surveys in 57 LMICs included 685 616 individuals. The overall prevalence of overweight was 27·2% (95% CI 26·6-27·8), of obesity was 21·0% (19·6-22·5), and of diabetes was 9·3% (8·4-10·2). In the pooled analysis, a higher risk of diabetes was observed at a BMI of 23 kg/m2 or higher, with a 43% greater risk of diabetes for men and a 41% greater risk for women compared with a BMI of 18·5-22·9 kg/m2. Diabetes risk also increased steeply in individuals aged 35-44 years and in men aged 25-34 years in sub-Saharan Africa. In the stratified analyses, there was considerable regional variability in this association. Optimal BMI thresholds for diabetes screening ranged from 23·8 kg/m2 among men in east, south, and southeast Asia to 28·3 kg/m2 among women in the Middle East and north Africa and in Latin America and the Caribbean. INTERPRETATION:The association between BMI and diabetes risk in LMICs is subject to substantial regional variability. Diabetes risk is greater at lower BMI thresholds and at younger ages than reflected in currently used BMI cutoffs for assessing diabetes risk. These findings offer an important insight to inform context-specific diabetes screening guidelines. FUNDING:Harvard T H Chan School of Public Health McLennan Fund: Dean's Challenge Grant Program.