An Analysis of Determinants of Under-5 Mortality across Countries: Defining Priorities to Achieve Targets in Sustainable Developmental Goals

The current state of pediatric gastroenterology in under-resourced nations

Background

Pediatric gastroenterology (GI) care in low- and middle-income countries (LMICs) faces substantial challenges due to limited healthcare infrastructure, inadequate resources, and a shortage of specialized healthcare professionals. These challenges lead to delayed diagnoses and treatment, exacerbating the morbidity and mortality associated with pediatric GI diseases, which include both infectious conditions like diarrhea and chronic conditions such as inflammatory bowel disease (IBD) and liver diseases.

Aim

The aim of this review is to examine the current state of pediatric GI care in LMICs, identify the key challenges these regions face, and propose strategies to improve healthcare outcomes for children affected by GI disorders.

Methods

This review synthesizes existing literature from a range of LMICs, analyzing factors such as the economic burden of healthcare, barriers to access, the availability of diagnostic and therapeutic services, and the state of pediatric hepatology and endoscopy. Studies included in the review were sourced from countries in sub-Saharan Africa, South Asia, and other LMIC regions, focusing on pediatric GI disorders and healthcare delivery.

Results

Economic burden: Families in LMICs face significant economic barriers in accessing pediatric GI care, with treatment costs often exceeding household income, especially in private healthcare settings. Healthcare access: Limited access to healthcare facilities, especially in rural areas, coupled with the shortage of trained pediatric gastroenterologists and necessary medical equipment, leads to delayed diagnoses and inadequate care for conditions like Helicobacter pylori infections and chronic liver diseases. Sanitation and infectious diseases: Poor sanitation and lack of access to clean water contribute to the high prevalence of diarrheal diseases, which can be reduced through better hygiene practices and improved infrastructure. Training gaps: The shortage of trained healthcare workers, particularly pediatric specialists, hinders effective care delivery, with healthcare workers often overburdened due to workforce migration and low salaries. Hepatology and endoscopy: Pediatric hepatology, especially in the context of viral hepatitis, and the availability of pediatric GI endoscopy are severely limited in LMICs, further complicating the management of liver diseases and GI conditions in children.

Conclusion

Improving pediatric GI care in LMICs requires addressing systemic challenges such as inadequate healthcare infrastructure, limited financial resources, and a shortage of trained professionals. Prevention strategies like vaccination, sanitation improvements, and public health education campaigns are crucial for reducing the prevalence of pediatric GI diseases. In addition, enhancing access to specialized training, healthcare services, and diagnostic tools will improve outcomes for children in resource-limited settings. Continued international collaboration and investment in local healthcare systems are essential for creating sustainable solutions and bridging the gap in pediatric GI care.

Factors associated with infant mortality in Nigeria: A scoping review

BACKGROUND

Infant mortality persists as a global public health concern, particularly in lower-middle-income countries (LIMCs) such as Nigeria. The risk of an infant dying before one year of age is estimated to be six times higher in Africa than in Europe. Nigeria recorded an infant mortality rate of 72.2 deaths per 1,000 live births in 2020, in contrast to the global estimate of 27.4 per 1,000 live births. Several studies have been undertaken to determine the factors influencing infant mortality.

OBJECTIVE

This scoping review sought to identify and summarise the breadth of evidence available on factors associated with infant mortality in Nigeria.

METHODS

This review followed the five-stage principles of Arksey and O'Malley's framework. Four electronic databases were searched with no limit to publication date or study type: Ovid MEDLINE, PubMed, CINAHL Complete, and Web of Science. Selected studies were imported into Endnote software and then exported to Rayyan software where duplicates were removed. Included articles were thematically analysed and synthesised using the socioecological model.

RESULTS

A total of 8,139 references were compiled and screened. Forty-eight articles were included in the final review. At the individual level, maternal- and child-related factors were revealed to influence infant mortality; socioeconomic and sociocultural factors at the interpersonal level; provision and utilisation of health services, health workforce, hospital resources and access to health services at the organisational level; housing/neighbourhood and environmental factors at the community level; and lastly, governmental factors were found to affect infant mortality at the public policy level.

CONCLUSION

Factors related to the individual, interpersonal, organisational, community and public policy levels were associated with infant mortality in Nigeria.

The use of traditional medicine practitioner services for childhood illnesses among childbearing women: a multilevel analysis of demographic and health surveys in 32 sub-Saharan African countries

BACKGROUND

Insights into the use of traditional medicine practitioners (TMP)-for common childhood diseases such as diarrhea and respiratory infections are important to understand the role of Traditional Medicine (TM) in reducing the increasing childhood morbidity and mortality in sub-Saharan Africa (SSA). However, a comprehensive picture of TMP utilisation and its associated factors for childhood illness in SSA is lacking. This study aimed to estimate the prevalence of the use of traditional medicine practitioner services to treat childhood illnesses among women with children under five years old and to identify individual and community-level factors associated with TMP use in SSA.

METHODS

The analysis used Demographic and Health Surveys (DHS) dataset collected between 2010 and 2021 among 353,463 under-fives children from 32 SSA countries. Our outcome variable was the use of TMP for childhood illness, defined as having diarrhoea or fever/cough or both. Using STATA v14, we employed the random effect meta-analysis to estimate the pooled prevalence of TMP use for childhood illness and a two-level multivariable multilevel modelling to determine the individual and community-level factors associated with consultation of a TMP.

RESULTS

Approximately [2.80% (95%CI: 1.88-3.90)] women who sought healthcare for childhood illnesses utilised the service of a TMP with the highest occurring in Cote d'Ivoire [16.3% (95%CI: 13.87-19.06)] and Guinea (13.80% (95%CI: 10.74-17.57)] but the lowest in Sierra Leone [0.10%(95%CI:0.01-1.61)]. Specifically, approximately [1.95% (95%CI: 1.33-2.68)] and [1.09% (95%CI:0.67-1.60)] of women sought the service of a TMP for childhood diarrhea and fever/cough, respectively. Women with no formal education [AOR = 1.62;95%CI:1.23-2.12], no media access [AOR = 1.19;95%CI:1.02-1.39), who lived in a male-headed household [AOR = 1.64;95%CI:1.27-2.11], without health insurance [AOR = 2.37;95%CI: 1.53-3.66], who considered it a problem getting permission to visit a health facility [AOR = 1.23;95%CI:1.03-1.47] and who perceived the size of their children at birth to be above average[AOR = 1.20;95%CI:1.03-1.41] had higher odds of using TMP for childhood illnesses.

CONCLUSIONS

Although the prevalence of TMP for childhood illnesses appeared low, our findings highlight that TMPs continue to play a critical role in managing childhood illnesses in SSA. It is essential that policymakers and service providers should incorporate the potential role of TMPs in the design, review and implementation of child health policies in SSA. Also, the interventions for curtailing childhood illnesses should be focused on the characteristics of women who use TMPs for childhood diseases identified in our study.

What is the impact of national public expenditure and its allocation on neonatal and child mortality? A machine learning analysis

BACKGROUND

Understanding the impact of national public expenditure and its allocation on child mortality may help governments move towards target 3.2 proposed in the 2030 Agenda. The objective of this study was to estimate the impacts of governmental expenditures, total, on health, and on other sectors, on neonatal mortality and mortality of children aged between 28 days and five years.

METHODS

This study has an ecological design with a population of 147 countries, with data between 2012 and 2019. Two steps were used: first, the Generalized Propensity Score of public spending was calculated; afterward, the Generalized Propensity Score was used to estimate the expenditures' association with mortality rates. The primary outcomes were neonatal mortality rates (NeoRt) and mortality rates in children between 28 days and 5 years (NeoU5Rt).

RESULTS

The 1% variation in Int$ Purchasing Power Parity (Int$ PPP) per capita in total public expenditures, expenditure in health, and in other sectors were associated with a variation of -0.635 (95% CI -1.176, -0.095), -2.17 (95% CI -3.051, -1.289) -0.632 (95% CI -1.169, -0.095) in NeoRt, respectively The same variation in public expenditures in sectors other than health, was associates with a variation of -1.772 (95% CI -6.219, -1.459) on NeoU5Rt. The results regarding the impact of total and health public spending on NeoU5Rt were not consistent.

CONCLUSION

Public investments impact mortality in children under 5 years of age. Likely, the allocation of expenditures between the health sector and the other social sectors will have different impacts on mortality between the NeoRt and the NeoU5Rt.

Planetary health and health education in Brazil: Facing inequalities

Brazil has the world's fifth-largest population and seventh-largest economy. However, it also has many inequalities, especially in health education, which impacts health sector services. Thus, this article aims to describe the situation of planetary health and health education in Brazil, identifying how current policies support the cause of planetary health. This study had a qualitative approach characterised as exploratory research based on an integrative review and documentary research. The results show that, in recent decades, there have been positive improvements to achieve collective and planetary health, which advocates empathy and pro-environmental and humanitarian attitudes. However, the pursuit of planetary health in Brazil is being influenced by various challenges, ranging from the need for a sound policy framework to provisions of education and training on planetary health. Based on the need to address these deficiencies, the paper suggests some measures which should be considered as part of efforts to realise the potential of planetary health in the fifth largest country in the world.

Acute Gastroenteritis in Children of the World: What Needs to Be Done?

The incidence of gastroenteritis has greatly reduced due to improved hygiene conditions in developing countries and the use of rotavirus vaccine. Still thousands of children, however, die from gastroenteritis, most of them in poor countries. Yet gastroenteritis management is simple, inexpensive, and effective and is largely the same all over the world. Universal guidelines for gastroenteritis guide the management and include simple interventions put forward early in the course of the disease. Treatment includes rehydration, continuing oral feeding, and anti-infective drugs in selected clinical conditions related to the symptoms or to host-related risk, and possible additional drug treatment to reduce the duration and severity of symptoms. There may be minor geographical differences in the treatment applied due to health care organizations that do not substantially change the standard universal recommendations. Prevention is recommended with sanitation interventions and rotavirus universal immunization. Implementation of those interventions through educational initiatives and local programs in target areas are needed. A series of recommendations for interventions, education, and research priorities are included here with the aim of reducing the burden of gastroenteritis, to be pursued by scientists, physicians, policy makers, and stakeholders involved. They include the need of recommendations for the management of gastroenteritis in malnourished children, in those with chronic conditions, in neonates, and in emergency settings. A reference system to score dehydration, the definition of optimal composition of rehydration solution and the indications for anti-infective therapy are also included. Rotavirus immunization should be actively promoted, and evidence-based guidelines should be universally implemented. Research priorities are also indicated.

Priority setting towards achieving under-five mortality target in Africa in context of sustainable development goals: an ordinary least squares (OLS) analysis

Background

Africa reduced its under-5 mortality rate (U5MR) by more than 50% during the MDGs era. However, it still has by far the highest average U5MR in the world – 81 deaths compared to a global average of 43 deaths per 1000 births, with eight of the ten countries in the world with the highest child mortality rates. The primary objective of our study was to examine the socioeconomic, healthcare, and environmental determinants that most account for U5MR disparities between African countries.

Methods

We used a series of ordinary least squares (OLS) regression models to assess the effects of 14 distinct socioeconomic, environmental and healthcare variables that account for the high U5MR differentials that persist between African countries. We conducted our analysis on 43 countries for which data were available. Using a dummy variable, we also emphasized factors that may be accounting for the disparity between the eight worst-performing countries and the remainder of the continent.

Results

Among all the determinants analyzed in our study, the results reveal that the factors that most account for the inequities observed are, in order, expenditure on healthcare (p < 0.01), total fertility rate (p < 0.01), income per capita (p < 0.05), and access to clean water (p < 0.1).

Conclusions

Our results show that the gap between the best and worst performing countries in Africa can be significantly narrowed if government and donor interventions will target downstream factors such as improving education for mothers and sensitising them about birth control since fertility rate differences play a critical role. Improving accessibility to clean water sources to reduce outbreaks of diarrhea diseases is also observed as a critical factor.

The impact of the health care workforce on under-five mortality in rural China

BACKGROUND

Previous studies have focused on the relationship between increases in the health care workforce and child health outcomes, but little is known about how this relationship differs in contexts where economic growth differs by initial level and pace. This study evaluates the association between increased health professionals and the under-five mortality rate (U5MR) in rural Chinese counties from 2008 to 2014 and examines whether this relationship differs among counties with different patterns of economic growth over this period.

METHODS

We estimated fixed effects models with rural counties as the unit of analysis to evaluate the association between health professional density and U5MR. Covariates included county-level gross domestic product (GDP) per capita, female illiteracy rate, value of medical equipment per bed, and province-level health expenditures (measured as a proportion of provincial GDP). To explore modification effects, we assessed interactions between health professionals and county types defined by county poverty status and county-level trajectories of growth in GDP per capita. U5MR data have been adjusted for county-level underreporting, and all other data were obtained from administrative and official sources.

RESULTS

The U5MR dropped by 36.19% during the study period. One additional health professional per 1000 population was associated with a 2.6% reduction in U5MR, after controlling for other covariates. County poverty status and GDP trajectories moderated this relationship: the U5MR reductions attributed to a one-unit increase in health professionals were 6.8% among poor counties, but only 1.1% among non-poor ones. These reductions were, respectively, 6.7%, 0.7%, and 4.3% in counties with initially low GDP that slowly increased, medium-level GDP that rose at a moderate pace, and high GDP that rose rapidly.

CONCLUSIONS

This study demonstrates that increased health professionals were associated with reductions in U5MR. The largest association was seen in poor counties and those with low and slowly increasing GDP per capita, which justifies further expansion of the health care workforce in these areas. This study could be instructive for other developing countries to achieve Sustainable Development Goal 3 by helping them identify where additional health professionals would make the greatest contribution.

Microneedle patch delivery of influenza vaccine during pregnancy enhances maternal immune responses promoting survival and long-lasting passive immunity to offspring

Influenza virus causes life-threatening infections in pregnant women and their newborns. Immunization during pregnancy is the most effective means of preventing maternal and infant mortality/morbidity; however, influenza vaccination rates of pregnant women remain under 50%. Furthermore, the availability of vaccines in low-resource populations is limited. Skin immunization with microneedle patches (MN) is a novel and safe vaccination platform featuring thermostable vaccine formulations. Cold-chain independence and the potential for self-administration can expand influenza vaccination coverage in developing countries. In this study of pregnant BALB/c mice immunized with subunit H1N1 influenza vaccine, we demonstrate the advantage of skin vaccination over intramuscular delivery of a two-fold higher vaccine dose. MN vaccine induced superior humoral immune responses and conferred protective immunity against a lethal challenge dose of homologous influenza virus. Importantly, MN vaccination of mice at mid-gestation resulted in enhanced and long-lasting passive immunity of the offspring, measured by neutralizing antibody titers and survival rates after virus challenge. We conclude that skin vaccination using MN is a superior immunization approach with the potential to overcome immune tolerance observed in pregnancy, and lower vaccination costs through antigen dose-sparing, which is especially relevant in underserved countries.