Determinants of perceived morbidity and use of health services by children less than 15 years old in rural Bangladesh

Excess risk of subsequent infection in hospitalized children from a community cohort study in Cambodia and Madagascar

BACKGROUND

Children in low- and middle-income countries are particularly vulnerable in the months following an initial health event (IHE), with increased risk of mortality caused mostly by infectious diseases. Due to exposure to a wide range of environmental stressors, hospitalization in itself might increase child vulnerability at discharge. The goal of this study was to disentangle the role of hospitalization on the risk of subsequent infection.

METHODS

Data from a prospective, longitudinal, international, multicenter mother-and-child cohort were analysed. The main outcome assessed was the risk of subsequent infection within 3 months of initial care at hospital or primary healthcare facilities. First, risk factors for being hospitalized for the IHE (Step 1) and for having a subsequent infection (Step 2) were identified. Then, inpatients were matched with outpatients using propensity scores, considering the risk factors identified in Step 1. Finally, adjusted on the risk factors identified in Step 2, Cox regression models were performed on the matched data set to estimate the effect of hospitalization at the IHE on the risk of subsequent infection.

RESULTS

Among the 1312 children presenting an IHE, 210 (16%) had a subsequent infection, mainly lower-respiratory infections. Although hospitalization did not increase the risk of subsequent diarrhoea or unspecified sepsis, inpatients were 1.7 (95% Confidence Intervals [1.0-2.8]) times more likely to develop a subsequent lower-respiratory infection than comparable outpatients.

CONCLUSION

For the first time, our findings suggest that hospitalization might increase the risk of subsequent lower-respiratory infection adjusted on severity and symptoms at IHE. This highlights the need for robust longitudinal follow-up of at-risk children and the importance of investigating underlying mechanisms driving vulnerability to infection.

Sex and Gender Differences in Acute Pediatric Diarrhea: A Secondary Analysis of the DHAKA Study

Pediatric diarrheal disease is a significant source of morbidity and mortality in the developing world. While several studies have demonstrated an increased incidence of diarrheal illness in boys compared with girls in low- and middle-income countries (LMIC), the reasons for this difference are unclear. This secondary analysis of the dehydration: assessing kids accurately (DHAKA) derivation and validation studies included children aged <5 years old with acute diarrhea in Dhaka, Bangladesh. The dehydration status was established by percentage weight change with rehydration. Multivariable regression was used to compare percent dehydration, while controlling for differences in age and nutritional status. In this cohort, a total of 1396 children were analyzed; 785 were male (56.2%) and 611 were female (43.8%). Girls presenting with diarrhea were older than boys (median age 17 months vs. 15 months, p = 0.02) and had significantly more malnutrition than boys, even when controlled for age (mean 134.2 mm vs. 136.4 mm, p < 0.01). The mean percent dehydration did not differ between boys and girls after controlling for age and nutrition status (p = 0.25). Although girls did have higher rates of malnutrition than boys, measures of diarrhea severity were similar between the two groups, arguing against a cultural bias in care-seeking behavior that favors boys.

Parents' healthcare-seeking behavior for their children among the climate-related displaced population of rural Bangladesh

In Bangladesh climate change has contributed to a massive displacement of people. This study examines the effects of climate-related displacement, socioeconomic status, availability of healthcare providers and disease-related attributes on the healthcare-seeking behaviors of parents for their children. Using cross-sectional survey data from the parents of 1003 children aged under 15 who were ill in the four weeks prior to the interview, collected from 600 randomly-selected households in climate displacement-susceptible areas and 600 households in non-climate-displacement-susceptible areas in Bangladesh, we use multivariate logistic regression to identify the factors associated with parental healthcare-seeking behaviors. The results show that 15.5% of the children who had been ill receive either no care or curative care at home. Of those receiving care outside the home, only 22.1% are treated by trained providers. Climate-related displaced parents are significantly less likely to seek care or to use provider-prescribed care to manage children's illnesses. Areas lacking local healthcare providers, poorer households, females, child age and mild illness are also associated with a child being significantly less likely to be treated outside the home. The children of climate-related displaced parents are around half as likely as those of non-displaced parents to be treated by a trained provider. The local availability of medical doctors, cost of reaching a healthcare center, household income, type and severity of illness, child's age, and joint parental decision-making about care providers are also important predictors of the selection of trained healthcare providers for children. Thus, climate-related displacement affects the healthcare-seeking behaviors of parents for their children. Policy aimed at improving child health should address the socioeconomic disadvantage and access to healthcare of the displaced, the training of local untrained providers about Primary Health Care service provision, and the numbers of medical doctors in the displacement-prone areas.

Pneumonia Mortality in Children Aged <5 Years in 56 Countries: A Retrospective Analysis of Trends from 1960 to 2012

Background

Pneumonia is now the second leading cause of death for children aged <5 years worldwide. However, analyses of the long-term evolution of under-5 mortality from pneumonia are still scarce in the literature. We aimed to explore long-term trends of under-5 mortality from pneumonia in 56 countries from 1960 to 2012.

Methods

Data on under-5 mortality from pneumonia were extracted from the World Health Organization mortality database. Long-term trends were assessed for 56 countries and for 4 national income transition groups. We also used joinpoint regression analysis to detect distinct period segments of long-term trends and estimate the annual percent of changes of each period segment.

Results

The average mortality rate from pneumonia for children aged 0-4 years in 56 countries declined from 163.0 per 100000 children (95% confidence interval [CI], 119.4 to 212.8) in 1960 to 9.9 per 100000 children (95% CI, 6.4 to 13.4) in 2012, with an average annual percent of change of -5.6% (95% CI, -7.2% to -3.9%). The temporal trends of childhood mortality were different between national income transition groups.

Conclusions

Our findings suggest a striking overall downward trend in under-5 mortality from pneumonia between 1960 and 2012. However, the rate and absolute terms of decline differ by national income transition group. These variable patterns between national income transition groups may inform further intervention setting and priority setting.

Synthesizing qualitative and quantitative evidence on non-financial access barriers: implications for assessment at the district level

Introduction

A key element of the global drive to universal health coverage is ensuring access to needed health services for everyone, and to pursue this goal in an equitable way. This requires concerted efforts to reduce disparities in access through understanding and acting on barriers facing communities with the lowest utilisation levels. Financial barriers dominate the empirical literature on health service access. Unless the full range of access barriers are investigated, efforts to promote equitable access to health care are unlikely to succeed. This paper therefore focuses on exploring the nature and extent of non-financial access barriers.

Methods

We draw upon two structured literature reviews on barriers to access and utilization of maternal, newborn and child health services in Ghana, Bangladesh, Vietnam and Rwanda. One review analyses access barriers identified in published literature using qualitative research methods; the other in published literature using quantitative analysis of household survey data. We then synthesised the key qualitative and quantitative findings through a conjoint iterative analysis.

Results

Five dominant themes on non-financial access barriers were identified: ethnicity; religion; physical accessibility; decision-making, gender and autonomy; and knowledge, information and education. The analysis highlighted that non-financial factors pose considerable barriers to access, many of which relate to the acceptability dimension of access and are challenging to address. Another key finding is that quantitative research methods, while yielding important findings, are inadequate for understanding non-financial access barriers in sufficient detail to develop effective responses. Qualitative research is critical in filling this gap. The analysis also indicates that the nature of non-financial access barriers vary considerably, not only between countries but also between different communities within individual countries.

Conclusions

To adequately understand access barriers as a basis for developing effective strategies to address them, mixed-methods approaches are required. From an equity perspective, communities with the lowest utilisation levels should be prioritised and the access barriers specific to that community identified. It is, therefore, critical to develop approaches that can be used at the district level to diagnose and act upon access barriers if we are to pursue an equitable path to universal health coverage.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-015-0181-z) contains supplementary material, which is available to authorized users.

The pattern of pediatric respiratory illnesses admitted in ebonyi state university teaching hospital South-East Nigeria

Background:

Reports from the developed nations reveal respiratory tract infections as the leading cause of childhood hospital admissions. Children may be admitted for a variety of respiratory illnesses. Data on the spectrum of pediatric respiratory illnesses admitted in the hospital is scarce.

Aim:

To determine the pattern of pediatrics respiratory illness admissions, seasonal frequency, underlying risk factors and outcome.

Subjects and Methods:

A retrospective assessment of respiratory cases admitted in the pediatric ward from 2005 to 2010 was conducted using case notes. Parameters considered included month of presentation, age, sex, immunization and nutritional status, tools of diagnosis and patient outcome. Results were analyzed using the Statistical Package for the Social Sciences with the level of significance P ≤ 0.05.

Results:

Of the 239 cases admitted, there were more males than females (1.4:1). The commonest case was Bronchopneumonia, 71.6% (171/239 out of which 161 were uncomplicated, 5 had effusions and 6 were associated with measles). Other cases were Pulmonary Tuberculosis, 10.9% (26/239), Lobar pneumonia 8.8% (21/239), Bronchiolitis, 5% (12/239), Aspiration pneumonitis 2.1% (5/239) and Bronchial asthma, 0.8% (2/239). Mortality was 7.5% (18/239) mostly from Bronchopneumonia amongst the 1–5 years old. Mortality was significantly associated with malnutrition (P < 0.001) and poor immunization status (P < 0.01).

Conclusion:

Bronchopneumonia was found to be the commonest illness with significant mortality and peak occurrence in the rainy season. More emphasis must be laid on anticipatory guidance and prevention by encouraging the immunization, good nutrition and increased attention on children even after 1 year of age.

Global and regional burden of hospital admissions for severe acute lower respiratory infections in young children in 2010: a systematic analysis

BACKGROUND

The annual number of hospital admissions and in-hospital deaths due to severe acute lower respiratory infections (ALRI) in young children worldwide is unknown. We aimed to estimate the incidence of admissions and deaths for such infections in children younger than 5 years in 2010.

METHODS

We estimated the incidence of admissions for severe and very severe ALRI in children younger than 5 years, stratified by age and region, with data from a systematic review of studies published between Jan 1, 1990, and March 31, 2012, and from 28 unpublished population-based studies. We applied these incidence estimates to population estimates for 2010, to calculate the global and regional burden in children admitted with severe ALRI in that year. We estimated in-hospital mortality due to severe and very severe ALRI by combining incidence estimates with case fatality ratios from hospital-based studies.

FINDINGS

We identified 89 eligible studies and estimated that in 2010, 11·9 million (95% CI 10·3-13·9 million) episodes of severe and 3·0 million (2·1-4·2 million) episodes of very severe ALRI resulted in hospital admissions in young children worldwide. Incidence was higher in boys than in girls, the sex disparity being greatest in South Asian studies. On the basis of data from 37 hospital studies reporting case fatality ratios for severe ALRI, we estimated that roughly 265,000 (95% CI 160,000-450,000) in-hospital deaths took place in young children, with 99% of these deaths in developing countries. Therefore, the data suggest that although 62% of children with severe ALRI are treated in hospitals, 81% of deaths happen outside hospitals.

INTERPRETATION

Severe ALRI is a substantial burden on health services worldwide and a major cause of hospital referral and admission in young children. Improved hospital access and reduced inequities, such as those related to sex and rural status, could substantially decrease mortality related to such infection. Community-based management of severe disease could be an important complementary strategy to reduce pneumonia mortality and health inequities.

FUNDING

WHO.

A concept development of the village health worker

PROBLEM

Village health workers (VHWs) promote health and provide basic health care in areas of the world where basic health knowledge and health professionals are scarce. The 1960s-1980s saw a dramatic increase in the training of VHWs in resource-limited environments. Politics changed, disillusionment set in, and enthusiasm waned. Recently, increased pressures on health resources have led to the resurgence of VHWs. Until the shortage of health professionals is alleviated, the need for VHWs to extend the reach of scientifically verified health care into remote and conflict areas will remain acute. This need provides a compelling reason to pursue research concerning VHWs. Village health workers are usually trained by professional nurses and refer patients to them, so nursing is positioned to lead this important research.

METHODS

The author developed the concept of the VHW using Meleis's Integrated Approach. Meleis's approach was chosen because it is appropriate for undeveloped concepts, emphasizes exploration and discovery, and can begin with clinical practice, taking advantage of the author's experience with VHWs.

RESULTS

The resultant concept definition, with antecedents and consequences, provides a foundation other nurse researchers can build upon. Existing research concerning VHWs was reviewed and gaps suitable for future nursing research were identified.

Diagnosis of chronic conditions with modifiable lifestyle risk factors in selected urban and rural areas of Bangladesh and sociodemographic variability therein

Background

Bangladesh suffers from a lack of healthcare providers. The growing chronic disease epidemic's demand for healthcare resources will further strain Bangladesh's limited healthcare workforce. Little is known about how Bangladeshis with chronic disease seek care. This study describes chronic disease patients' care seeking behavior by analyzing which providers diagnose these diseases.

Methods

During 2 month periods in 2009, a cross-sectional survey collected descriptive data on chronic disease diagnoses among 3 surveillance populations within the International Center for Diarrheal Disease Research, Bangladesh (ICDDR, B) network. The maximum number of respondents (over age 25) who reported having ever been diagnosed with a chronic disease determined the sample size. Using SAS software (version 8.0) multivariate regression analyses were preformed on related sociodemographic factors.

Results

Of the 32,665 survey respondents, 8,591 self reported having a chronic disease. Chronically ill respondents were 63.4% rural residents. Hypertension was the most prevalent disease in rural (12.4%) and urban (16.1%) areas. In rural areas chronic disease diagnoses were made by MBBS doctors (59.7%) and Informal Allopathic Providers (IAPs) (34.9%). In urban areas chronic disease diagnoses were made by MBBS doctors (88.0%) and IAP (7.9%). Our analysis identified several groups that depended heavily on IAP for coverage, particularly rural, poor and women.

Conclusion

IAPs play important roles in chronic disease care, particularly in rural areas. Input and cooperation from IAPs are needed to minimize rural health disparities. More research on IAP knowledge and practices regarding chronic disease is needed to properly utilize this potential healthcare resource.