The effects of education and family planning programs on fertility in Indonesia

Numerous studies indicate that female education is a major determinant of fertility and that the estimated effects are large relative to other variables, including family planning program variables. There are, however, two serious deficiencies in the research relating educational attainment to fertility that could give rise to invalid inferences. First, many public programs, including health and family planning programs, may influence a woman’s decisions about education, and these indirect programmatic effects might be large. Second, nearly all existing studies of the impacts of education on fertility assume that a woman's educational attainment is exogenous. Education could be serving as a proxy for such unobservable determinants as ability, motivation, and parental background, as these factors most likely are important determinants of a woman's educational attainment. We use the 1993 Indonesian Family Life Survey to compare the estimated impacts of education on fertility from a simple model that assumes the exogeneity of education and an unobserved factor model that allows for endogeneity of schooling. The model imposing questionable exogeneity assumptions appears to overpredict the fertility‐reducing effects of female education, better schools, and higher government health expenditures and to underpredict the importance of family planning programs for reducing fertility and for inducing young women to remain in school

Determinants of infant feeding: a household production approach.

The presentation of the infant-feeding decision as a joint selection of breast milk, breast milk, substitutes, and supplemental foods is an entirely new approach. It represents one of the first efforts to model the structure of household production decisions. The approach provides a plausible statistical 'reenactment' of how one small but important household decision is made: how to feed a baby. Statistically, the work suggests that the omission of correlations among feeding methods may lead to incorrect inferences. The results show that the independent variables appear not to affect breast-feeding behaviour strongly per se but to affect the feeding of breast milk substitutes and the timing of supplementation with solid food, which in turn work in a somewhat diluted fashion on breast-feeding

The demand for primary health care services in the Bicol Region of the Philippines.

Analyzes the demand for primary health care using community and household data from one of the poorest regions of the Philippines. Finds, among other things that the distance is not nearly as important to health service demand as it has often been assumed to be; and that visit prices, drug and transport costs, and waiting times do not greatly affect demand patterns for essential or more optional services

Longitudinal Examination of Which Married Young Women Use Contraception to Delay a First Pregnancy in Bihar and Uttar Pradesh, India

Early marriage and childbearing put young women and their babies at risk of poor health and well-being. This study uses two rounds of longitudinal data from young women ages 15–19 in 2015–2016 and followed in 2018–2019 to determine factors associated with contraceptive use before a first pregnancy among young, married women in Bihar and Uttar Pradesh, India. Discrete time hazard models were used to analyze time to first use starting from the month of marriage. Overall, use of contraception prior to a first pregnancy was low in this sample (between 12 to 20% used before a first pregnancy). Young women who reported that someone discussed the importance of delaying a first birth at the time of marriage were significantly more likely to have used a method of family planning (FP) before a first pregnancy than those who did not receive this information. Further, women who discussed FP with their husband before a first pregnancy were more likely to use contraception. Finally, among recently married young women, those who experienced pressure to have a child were less likely to use before a first pregnancy. As young women recognize the advantages of delaying a first birth and adopt FP to meet their needs, social norms around early childbearing will slowly adjust and early use to delay a first pregnancy will become more normative

The caloric and sugar content of beverages purchased at different store-types changed after the sugary drinks taxation in Mexico

Background: Following the 2014 sugary drinks tax implementation in Mexico, promising reduction in the volume of purchases of taxed beverages were observed overall and at different store-types. However, the tax's effects on purchasing patterns of calories and sugar remain unclear. Methods: Using longitudinal data from Mexican households (n = 7038), we examined changes in volume, calories and total sugar of packaged beverages purchased from 2012 to 2016 overall and by store-type. We used fixed effects models to estimate means for volume, calories, and sugar of households. To address the potential selectivity from households shopping at different stores, we calculated inverse probability weights to model the purchases changes over time by store-type. Results: For taxed beverages, the volume of purchases declined by-49 ml and-30 ml in the first year and second year post tax (2014 and 2015, respectively), while purchases leveled off in the third year of the tax (2016). Calories and sugar from taxed beverage purchases decreased over time, with the majority of the declines occurring in the first two years post-tax implementation. The volume of untaxed beverage purchases increased, whereas changes in calories and total sugar of untaxed beverages were minimal. Store level purchases of taxed beverages significantly decreased in the first two years post taxation (2014 and to 2015) only in supermarkets and traditional stores. The steepest declines in purchases of taxed beverages in 2014 were observed at supermarkets (-40 ml or-45%). The volume of purchases of untaxed beverages increased over time in almost all store-types, while calories and sugar minimally decreased over time. Conclusion: Although the Mexican tax on SSBs has lowered the purchases of sugary drinks 3 years after the tax implementation, the tax should be strengthened and store-specific interventions should be implemented to further reduce SSBs purchases in the Mexican population

Accounting for Selectivity Bias and Correlation Across the Sequence from Elevated Blood Pressure to Hypertension Diagnosis and Treatment

BACKGROUND It is unknown whether efforts to reduce hypertension burden in countries with very high prevalence, would be more effective if directed at hypertension diagnosis vs. treatment. Most analyses do not address bias and correlation across the sequence from elevated blood pressure (BP) to hypertension diagnosis and treatment, leading to potentially misleading findings. METHODS Using data spanning 18 years of the China Health and Nutrition Survey (n = 18,926; ages 18-75 years), we used an innovative 3-step, integrated system of equations to predict the sequence from: (i) elevated BP (systolic/diastolic BP ≥ 140/90 mm Hg) to (ii) diagnosed hypertension conditional on elevated BP, and to (iii) treatment (medication use) conditional on diagnosis, accounting for measured and unmeasured individual- and community-level confounders at each of the 3 steps. We compared results to separate traditional logistic regression models without control for unmeasured confounding. RESULTS Using our 3-step model, elevated BP increased from 12.6% and 8.5% (1991) to 36.8% and 29% (2009) in men and women, respectively, but diagnosis remained under 50%. We found widening disparities in hypertension diagnosis (higher hypertension at lower vs. higher education (difference of 2% in 1991 that widened to 5% in 2009)) and narrowing disparities in education (difference of 6% in 1991 to 4% in 2009) and insurance status (difference of 7% in 1991 to 2% in 2009) for treatment. CONCLUSIONS Our 3-step model improved model fit over traditionally used models. Our findings highlight serious barriers to hypertension diagnosis in Chinese adults, particularly among men and individuals of low attained education

Understanding bias in relationships between the food environment and diet quality: The Coronary Artery Risk Development in Young Adults (CARDIA) study

Background The relationship between food environment exposures and diet behaviours is unclear, possibly because the majority of studies ignore potential residual confounding. Methods We used 20 years (1985-1986, 1992-1993 2005-2006) of data from the Coronary Artery Risk Development in Young Adults (CARDIA) study across four US cities (Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; Oakland, California) and instrumental variables (IV) regression to obtain causal estimates of longitudinal associations between the percentage of neighbourhood food outlets (per total food outlets within 1 km network distance of respondent residence) and an a priori diet quality score, with higher scores indicating higher diet quality. To assess the presence and magnitude of bias related to residual confounding, we compared results from causal models (IV regression) to non-causal models, including ordinary least squares regression, which does not account for residual confounding at all and fixed-effects regression, which only controls for time-invariant unmeasured characteristics. Results The mean diet quality score across follow-up was 63.4 (SD=12.7). A 10% increase in fast food restaurants (relative to full-service restaurants) was associated with a lower diet quality score over time using IV regression (β=-1.01, 95% CI -1.99 to -0.04); estimates were attenuated using non-causal models. The percentage of neighbourhood convenience and grocery stores (relative to supermarkets) was not associated with diet quality in any model, but estimates from non-causal models were similarly attenuated compared with causal models. Conclusion Ignoring residual confounding may generate biased estimated effects of neighbourhood food outlets on diet outcomes and may have contributed to weak findings in the food environment literature

Does unmeasured confounding influence associations between the retail food environment and body mass index over time? The Coronary Artery Risk Development in Young Adults (CARDIA) study

Background: Findings in the observational retail food environment and obesity literature are inconsistent, potentially due to a lack of adjustment for residual confounding. Methods: Using data from the CARDIA study (n ¼ 12 174 person-observations; 6 examinations; 1985-2011) across four US cities (Birmingham, AL; Chicago, IL; Minneapolis, MN; Oakland, CA), we used instrumental-variables (IV) regression to obtain causal estimates of the longitudinal associations between the percentage of neighbourhood food stores or restaurants (per total food outlets within 1 km network distance of respondent residence) with body mass index (BMI), adjusting for individual-level socio-demographics, health behaviours, city, year, total food outlets and market-level prices. To determine the presence and extent of bias, we compared the magnitude and direction of results with ordinary least squares (OLS) and random effects (RE) regression, which do not control for residual confounding, and with fixed effects (FE) regression, which does not control for time-varying residual confounding. Results: Relative to neighbourhood supermarkets (which tend to be larger and have healthier options than grocery stores), a higher percentage of grocery stores [mean-¼ 53.4%; standard deviation (SD) ¼ 31.8%] was positively associated with BMI [b ¼ 0.05; 95% confidence interval (CI) ¼ 0.01, 0.10] using IV regression. However, associations were negligible or null using OLS (b ¼ 0.001; 95% CI ¼ 0.01, 0.01), RE (b ¼ 0.003; 95% CI ¼ 0.01, 0.0001) and FE (b ¼ 0.003; 95% CI ¼ 0.01, 0.0002) regression. Neighbourhood convenience stores and fast-food restaurants were not associated with BMI in any model. Conclusions: Longitudinal associations between neighbourhood food outlets and BMI were greater in magnitude using a causal model, suggesting that weak findings in the literature may be due to residual confounding