Child growth in urban deprived settings: does household poverty status matter? At which stage of child development?

Utilizing a multi-stage transition model for analysing child stunting in two urban slum settlements of Nairobi: A longitudinal analysis, 2011-2014

INTRODUCTION

Stunting is common among children in many low and middle income countries, particularly in rural and urban slum settings. Few studies have described child stunting transitions and the associated factors in urban slum settlements. We describe transitions between stunting states and associated factors among children living in Nairobi slum settlements.

METHODS

This study used data collected between 2010 and 2014 from the Nairobi Urban and Demographic Surveillance System (NUHDSS) and a vaccination study nested within the surveillance system. A subset of 692 children aged 0 to 3 years, with complete anthropometric data, and household socio-demographic data was used for the analysis. Height-for-age Z-scores (HAZ) was used to define stunting: normal (HAZ ≥ 1), marginally stunted (-2 ≤ HAZ < -1), moderately stunted (-3 ≤ HAZ < -2), and severely stunted (HAZ < -3). Transitions from one stunting level to another and in the reverse direction were computed. The associations between explanatory factors and the transitions between four child stunting states were modeled using a continuous-time multi-state model.

RESULTS

We observed that 48%, 39%, 41%, and 52% of children remained in the normal, marginally stunted, moderately stunted, and severely stunted states, respectively. About 29% transitioned from normal to marginally stunted state, 15% to the moderately stunted state, and 8% to the severely stunted state. Also, 8%, 12%, and 29% back transitioned from severely stunted, moderately stunted, and marginally stunted states, to the normal state, respectively. The shared common factors associated with all transitions to a more severe state include: male gender, ethnicity (only for mild and severe transition states), child's age, and household food insecurity. In Korogocho, children whose parents were married and those whose mothers had attained primary or post-primary education were associated with a transition from a mild state into a moderately stunted state. Children who were breastfed exclusively were less likely to transition from moderate to severe stunting state.

CONCLUSION

These findings reveal a high burden of stunting and transitions in urban slums. Context-specific interventions targeting the groups of children identified by the socio-demographic factors are needed. Improving food security and exclusive breastfeeding could potentially reduce stunting in the slums.

The role of dairy consumption in the relationship between wealth and early life physical growth in India: evidence from multiple national surveys

INTRODUCTION

Prevalence of undernutrition continues to be high in India and low household wealth is consistently associated with undernutrition. This association could be modified through improved dietary intake, including dairy consumption in young children. The beneficial effect of dairy on child growth has not been explored at a national level in India. The present analyses aimed to evaluate the direct and indirect (modifying association of household level per adult female equivalent milk and milk product consumption) associations between household wealth index on height for age (HAZ) and weight for age (WAZ) in 6-59 months old Indian children using data from of nationally representative surveys.

METHODS

Two triangulated datasets of two rounds of National Family Health Survey, (NFHS-3 and 4) and food expenditure (National Sample Survey, NSS61 and 68) surveys, were produced by statistical matching of households using Non-Iterative Bayesian Approach to Statistical Matching technique. A Directed Acyclic Graph was constructed to map the pathways in the relationship of household wealth with HAZ and WAZ based on literature. The direct association of wealth index and its indirect association through per adult female equivalent dairy consumption on HAZ and WAZ were estimated using separate path models for each round of the surveys.

RESULTS

Wealth index was directly associated with HAZ and WAZ in both the rounds, but the association decreased from NFHS-3 (βHAZ: 0.145; 95% CI: 0.129, 0.16) to NFHS-4 (βHAZ: 0.102; 95%CI: 0.093, 0.11). Adult female equivalent milk intake (increase of 10gm/day) was associated with higher HAZ (β_NFHS-3=0.001;95% CI: 0, 0.002; β_NFHS-4=0.002;95% CI: 0.002, 0.003) but had no association with WAZ. The indirect association of wealth with HAZ through dairy consumption was 2-fold higher in NFHS-4 compared to NFHS-3.

CONCLUSIONS

The analysis of triangulated survey data shows that household level per- adult female equivalent dairy consumption positively modified the association between wealth index and HAZ, suggesting that regular inclusion of milk and milk products in the diets of children from households across all wealth quintiles could improve linear growth in this population.

Small area vulnerability, household food insecurity and child malnutrition in Medellin, Colombia: results from a repeated cross-sectional study

Background

Malnutrition and food insecurity might be driven not only by individual factors but also by contextual conditions, such as area-level deprivation or vulnerability. This study aimed to analyze the association between area-level vulnerability and i) household food insecurity and ii) malnutrition in children in Medellin, Colombia, during the years 2017 and 2018.

Methods

We obtained data from two different sources: the Living Standards Measurement Survey (LSMS) and the nutrition surveillance system of Medellin. The main outcomes were food insecurity in households with children and anthropometric indicators for children under five. The main predictor was area-level vulnerability. Mixed effects Poisson regression with robust standard errors models were conducted to test the association of quintiles of deprivation with each outcome.

Findings

Households with children living in areas with the highest deprivation had 1.9 times the prevalence of food insecurity as compared to those living in areas with the lowest deprivation (PR 1.91, 95% CI 1.42-2.57). Similar results were observed for underweight/risk of underweight (PR 1.26, 95% CI 1.11-1.42), stunting/risk of stunting (PR 1.36, 95% CI 1.22-1.53) and stunting (PR 1.93 95% CI 1.55-2.39) among children under five. We found no consistent associations with wasting/risk of wasting or excess weight/risk of overweight across quintiles of deprivation.

Interpretation

This study sheds light on the role of area-level vulnerability on malnutrition in children in Medellin, Colombia, showing a pattern of increasing prevalence of food insecurity, underweight and stunting by quintile of deprivation.

Funding

Swiss School of Public Health (SSPH+) and Centre for Global Health Inequalities Research (CHAIN).

The Effects of Financial Stress and Household Socio-Economic Deprivation on the Malnutrition Statuses of Children under Five during the COVID-19 Lockdown in a Marginalized Region of South Punjab, Pakistan

The lockdown after the COVID-19 pandemic not only caused public health crises and income stress but also put millions at risk of food insecurity and malnutrition across the globe, especially in low and middle-income countries [LMICs]. This study evaluated the effects of financial stress and household socio-economic deprivation on the nutritional status of 1551 children under the age of five during COVID-19 in Pakistan. A self-administered questionnaire was used between November 2020 and April 2021 to collect information on age, height, children's weight, and socio-economic status from 1152 rural households from underdeveloped regions in Punjab, Pakistan. With the help of the proportionate simple random sampling method, this study employed a model (binary logistic regression) to calculate the likelihood of malnourishment. The findings showed that the stunting, underweight, and wasting prevalence rates during COVID-19 were 58.86%, 41.89%, and 8.11%, respectively, in the Bahawalpur region. According to the binary logistic regression analysis, among the household deprivation status (HDS) categories, the risks of childhood malnutrition were lesser in HDS-2 (OR = 0.05, 95% CI: 0. 005-0.879) and HDS-3 (OR = 0.04, 95% CI: 0.008-0.193). Similar to this, within the financial stress index (FSI) categories, the children in homes with medium financial stress had reduced odds of malnutrition (OR = 0.10, 95% CI: 0.018-0.567), and the children in households with low financial stress had reduced risks of malnutrition (OR = 0.006, 95% CI: 0.005-0.061). The proposed research found that stunting and underweight increased by 17.26% and 12.29% during the COVID-19 lockdown in the Bahawalpur region. Additionally, financial stress and socio-economic deprivation strongly affected children's nutritional statuses during the COVID-19 lockdown in the Bahawalpur region of Southern Punjab.

Antecedents of Subjective Health among Korean Senior Citizens Using Archival Data

This study aimed to investigate the determinants of subjective health among South Korean senior citizens. Secondary data for the year 2018 was used from the Senior Citizen Research Panel data collected by the Korea Employment Information Service. A total of 3822 valid observations were analyzed. The dependent variable was subjective health, and the independent variables were religion participation, social gathering participation, economic activity, food expenditure, leisure expenditure, travel frequency, and art watching frequency. Descriptive analysis, correlation matrix, and independent t-test were carried out for data analysis. Multiple linear regression analysis was employed using assets, age, and gender as control variables to test the research hypotheses. The results indicate that all the proposed attributes have a significant positive impact on the subjective health of Korean senior citizens, with implications for policy making.

Basic determinants of child linear growth outcomes in sub-Saharan Africa: a cross-sectional survey analysis of positive deviants in poor households

Childhood malnutrition is a significant public health problem confronting countries across the globe. Although there is evidence of a downward trend in undernutrition globally, sub-Saharan Africa did not experience significant improvement in the past decades. This study investigated the basic determinants of linear growth among children living in poor households. We analysed a nationally representative sample of children aged 0–59 months (N = 24,264). The study countries were Ghana, Kenya, the Democratic Republic of Congo (DRC), Nigeria, and Mozambique. The child’s height-for-age Z-scores (HAZ), categorised into HAZ > − 2 standard deviations (SD) (not stunted) and HAZ < − 2 SD (stunted) was the outcome variable of interest. We used logistic regression as our analytical strategy. In DRC, Ghana, Kenya and Nigeria, maternal years of schooling was associated with positive linear growth among children living in poor households. In Ghana and DRC, four antenatal visits had a positive effect on better linear growth, while in Nigeria, healthy maternal body mass index (kg/m²) had a positive effect on child's linear growth. The putative socio-demographic determinants investigated in our study can promote the linear growth of children living in poor households. Interventions aimed at fostering linear growth among children living in poverty should focus on enhancing these factors.

Prevalence of child malnutrition and household socioeconomic deprivation: A case study of marginalized district in Punjab, Pakistan

Better socioeconomic status and well-being in households decrease malnutrition and health risks in children. The objective of the present study is to assess the current nutritional status of pre-school children and to correlate the prevalence of malnutrition with Household Deprivation Status (HDS) in one of the deprived districts of the Punjab province in Pakistan. Using primary data collected from 384 households through a proportional purposive random sampling technique, this study calculates the z-scores of weight-for-age (WAZ), weight-for-height (WHZ), and height-for-age (HAZ). The study has used a cut-off point which is -2 standard deviations below the median of the WHO/NCHS reference population for each anthropometric indicator. The results indicate that the underweight, stunting, and wasting prevalence rates are 46.1%, 34.83%, and 15.49% respectively in district Rahimyar Khan. Also, the expected tendency of malnutrition is worst for HDS-1 and HDS-2 which are the most deprived segments of the population. As the household shifts from HDS-1 to HDS-2 and further to HDS-3, the rates of stunting (HAZ) and underweight (WAZ) decreases but wasting (WHZ) does not. The study concludes that the high prevalence of malnutrition in the district is correlated with overall socio-economic deprivation.

Food security, poverty and household resilience to COVID-19 in Burkina Faso: Evidence from urban small traders' households

Analyses of the effects of the COVID-19 pandemic on food security of urban households and their resilience are increasingly receiving scholarly interest. In Burkina Faso, urban households whose primary activity is trade were the most immediately impacted by COVID-19 due to the closure of markets. The objective of this research was to analyze the effect of income loss due to COVID-19 on food security and poverty among urban small traders' households by considering their resilience capacity. A survey was performed on 503 households of small traders operating in 5 markets in Ouagadougou. Objective and subjective indicators of food security were calculated, as well as several indices of resilience capacity. A simple logit model and ordered logit model were used for the socioeconomic analysis. Three main results emerge. First, COVID-19 has increased the likelihood of households being food insecure due to their lower food consumption scores. Second, estimates show that COVID-19 has reduced households' incomes by increasing their likelihood of entering poverty. Finally, at all levels of analysis, households with adaptive capacity were able to adjust to the shock, but social security was not a mitigating factor. Implications in terms of economic policies are discussed.

Spatial location, temperature and rainfall diversity affect the double burden of malnutrition among women in Kenya

Studies have looked into how environmental and climate covariates affect under-and over-nutrition, but little is known about the spatial distribution of different forms of malnutrition in Kenya and whether there are locations that suffer from double-burden of malnutrition. This research quantifies spatial variations and estimates how climatic and environmental factors affect under-and over-nutrition among women in Kenya. This enables us to determine if the patterns in which these factors affect the malnutrition indicators are similar and whether there are overlaps in the spatial distributions. The study used data from the Demographic and Health Survey, which included cross-sectional data on malnutrition indicators as well as some climate and environmental variables. A multicategorical response variable that classified the women into one of four nutritional classes was generated from the body mass index (BMI) of the women, and a Bayesian geoadditive regression model with an estimate based on the Markov chain Monte Carlo simulation technique was adopted. Findings show that women in Turkana, Samburu, Isiolo, Baringo, Garissa, and West Pokot counties are more likely to be underweight than women in other counties while being overweight is prevalent in Kirinyag'a and Kitui counties. Obesity is prevalent in Kirinyag'a, Lamu, Kiambu, Murang'a, and Taita Taveta counties. The study further shows that as mean temperature and precipitation increase, the likelihood of being underweight reduces. The chances of being underweight are lower among literate women [OR: 0.614; 95% CrI: 0.513,0.739], married women [OR: 0.702; 95% CrI: 0.608,0.819] and those from rich households [OR: 0.617; 95% CrI: 0.489,0.772], which is not the case for overweight and obesity. The generated spatial maps identify hot spots of the double burden of malnutrition that can assist the government and donor agencies in channeling resources efficiently.

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Low- and middle-income countries have been experiencing double burden of malnutrition.

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The generated spatial maps identify hot spots of the double burden of malnutrition.

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Carefully thought-out policy plans are required to curb the challenges of the double burden of malnutrition.

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Burden of undernutrition has decreased but the cost of being overweight or obese is increasing among women.

Psychosocial challenges and individual strategies for coping with mental stress among pregnant and postpartum adolescents in Nairobi informal settlements: a qualitative investigation

BACKGROUND

This study was part of a project funded under the Grand Challenges Explorations initiative to engage adolescent girls living in the main slums of Nairobi. This involved an innovative co-creation initiative through jointly designing and testing the feasibility of a toolkit of information, skill, and confidence-building, and coping mechanisms that can effectively shield them and their peers against the risks of mental stress during pregnancy and early motherhood.

METHODS

Qualitative interviews and discussions from visual methodologies including Photovoice, digital storytelling, and public service announcements were conducted with 30 pregnant and adolescent mothers aged 14-19 years in four informal settlements either pregnant or having a child less than 2 years. The aims included; to generate an inventory of mental stressors during pregnancy and early motherhood; understand how mental stress affects the ability to seek care for themselves and their child, and understand individual coping strategies.

RESULTS

The psychosocial challenges identified in order of importance included: chased from home by the parents; economic hardship; neglect and abandonment by the person responsible for the pregnancy; stigmatization by family, friends, and the community; feelings of shattered dreams; and daily stress related to living in poor and unhygienic conditions. During the pregnancy and early motherhood, the participants experienced feelings of embarrassment, shame, hopelessness, and to the extreme, suicidal thoughts clouded their minds. Main coping strategies included social isolation for some, socializing with other pregnant and adolescent mothers, and negative behaviors like the uptake of illicit drugs and alcohol and risky sexual relationships.

CONCLUSION

The unpreparedness for early motherhood infused with inadequate psychosocial support led to increased mental stress and risk of depression. The interconnection between the triggers to mental stress showed the need to focus on a multifaceted approach to address the wellbeing of pregnant and adolescent mothers.

Verbal/social autopsy analysis of causes and determinants of under-5 mortality in Tanzania from 2010 to 2016

Background

Tanzania has decreased its child mortality rate by more than 70 percent in the last three decades and is striving to develop a nationally-representative sample registration system with verbal autopsy to help focus health policies and programs toward further reduction. As an interim measure, a verbal and social autopsy study was conducted to provide vital information on the causes and social determinants of neonatal and child deaths.

Methods

Causes of neonatal and 1-59 month-old deaths identified by the 2015-16 Tanzania Demographic and Health Survey were assessed using the expert algorithm verbal autopsy method. The social autopsy examined prevalence of key household, community and health system indicators of preventive and curative care provided along the continuum of care and Pathway to Survival models. Careseeking for neonates and 1-59 month-olds was compared, and tests of associations of age and cause of death to careseeking indicators and place of death were conducted.

Results

The most common causes of death of 228 neonates and 351 1-59 month-olds, respectively, were severe infection, intrapartum related events and preterm delivery, and pneumonia, diarrhea and malaria. Coverage of early initiation of breastfeeding (24%), hygienic cord care (29%), and full immunization of 12-59 month-olds (33%) was problematic. Most (88.8%) neonates died in the first week, including 44.3% in their birth facility before leaving. Formal care was sought for just 41.9% of newborns whose illness started at home and was delayed by 5.3 days for 1-59 month-olds who sought informal care. Care was less likely to be sought for the youngest neonates and infants and severely ill children. Although 70.3% of 233 under-5 year-olds were moderately or severely ill on discharge from their first provider, only 29.0%-31.2% were referred.

Conclusions

The study highlights needed actions to complete Tanzania’s child survival agenda. Low levels of some preventive interventions need to be addressed. The high rate of facility births and neonatal deaths requires strengthening of institutionally-based interventions targeting maternal labor and delivery complications and neonatal causes of death. Scale-up of Integrated Community Case Management should be considered to strengthen careseeking for the youngest newborns, infants and severely ill children and referral practices at first level facilities.

Economics of healthcare access in low-income and middle-income countries: a protocol for a scoping review of the economic impacts of seeking healthcare on slum-dwellers compared with other city residents

INTRODUCTION

People living in slums face several challenges to access healthcare. Scarce and low-quality public health facilities are common problems in these communities. Costs and prevalence of catastrophic health expenditures (CHE) have also been reported as high in studies conducted in slums in developing countries and those suffering from chronic conditions and the poorest households seem to be more vulnerable to financial hardship. The COVID-19 pandemic may be aggravating the economic impact on the extremely vulnerable population living in slums due to the long-term consequences of the disease. The objective of this review is to report the economic impact of seeking healthcare on slum-dwellers in terms of costs and CHE. We will compare the economic impact on slum-dwellers with other city residents.

METHODS AND ANALYSIS

This scoping review adopts the framework suggested by Arksey and O'Malley. The review is part of the accountability and responsiveness of slum-dwellers (ARISE) research consortium, which aims to enhance accountability to improve the health and well-being of marginalised populations living in slums in India, Bangladesh, Sierra Leone and Kenya. Costs of accessing healthcare will be updated to 2020 prices using the inflation rates reported by the International Monetary Fund. Costs will be presented in International Dollars by using purchase power parity. The prevalence of CHE will also be reported.

ETHICS AND DISSEMINATION

Ethical approval is not required for scoping reviews. We will disseminate our results alongside the events organised by the ARISE consortium and international conferences. The final manuscript will be submitted to an open-access international journal. Registration number at the Research Registry: reviewregistry947.

Do inequalities exist in the disadvantaged populations? Levels and trends of full and on-time vaccination coverage in two Nairobi urban informal settlements

There has been an improvement in childhood vaccination coverage over the last two decades worldwide. However, inequities exist among different populations. Vaccination programs should focus not only on increasing coverage but as also in timeliness to ensure maximum protection. This study examined the levels, inequities, and trends of full and on-time vaccination coverage in two urban informal settlements in Nairobi. The study used longitudinal data from the Nairobi Urban Health and Demographic Surveillance System from 2003 to 2017 to estimate full and on-time vaccination coverage and assess inequalities by background characteristics. The frailty shared Cox model was used to assess time to full- and on-time- immunization coverage. Out of 32,018 children aged 12 to 59 months, less than half (46.7%) produced a vaccination card during the interview. Full and timely immunization coverage was higher in Viwandani site, among Kikuyu and Kamba ethnic groups, and children from the richest quintile. Timely vaccination was below 50% throughout the survey periods. After accounting for the intragroup correlations, for a given level of frailty, the hazard for being fully immunized was 10% more likely among the wealthiest compared to the poorest children. The hazard for being fully immunized was 16%, 16% to 19% less likely for Luhya, Luo, and others as compared to the Kikuyu ethnicity respectively. In conclusion, the study has shown that coverage has been increasing over the years but inequalities exist in immunization coverage among the most disadvantaged populations. More focused intervention approaches that target the disadvantaged groups are needed.

Inequality in child undernutrition among urban population in India: a decomposition analysis

Background

With increasing urbanization in India, child growth among urban poor has emerged as a paramount public health concern amidst the continuously growing slum population and deteriorating quality of life. This study analyses child undernutrition among urban poor and non-poor and decomposes the contribution of various factors influencing socio-economic inequality. This paper uses data from two recent rounds of National Family Health Survey (NFHS-3&4) conducted during 2005–06 and 2015–16.

Methods

The concentration index (CI) and the concentration curve (CC) measure socio-economic inequality in child growth in terms of stunting, wasting, and underweight. Wagstaff decomposition further analyses key contributors in CI by segregating significant covariates into five groups-mother’s factor, health-seeking factors, environmental factors, child factors, and socio-economic factors.

Results

The prevalence of child undernutrition was more pronounced among children from poor socio-economic strata. The concentration index decreased for stunting (− 0.186 to − 0.156), underweight (− 0.213 to − 0.162) and wasting (− 0.116 to − 0.045) from 2005 to 06 to 2015–16 respectively. The steepness in growth was more among urban poor than among urban non-poor in every age interval. Maternal education contributed about 19%, 29%, and 33% to the inequality in stunting, underweight and wasting, respectively during 2005–06. During 2005–06 as well as 2015–16, maternal factors (specifically mother’s education) were the highest contributory factors in explaining rich-poor inequality in stunting as well as underweight. More than 85% of the economic inequality in stunting, underweight, and wasting among urban children were explained by maternal factors, environmental factors, and health-seeking factors.

Conclusion

All the nutrition-specific and nutrition-sensitive interventions in urban areas should be prioritized, focusing on urban poor, who are often clustered in low-income slums. Rich-poor inequality in child growth calls out for integration and convergence of nutrition interventions with policy interventions aimed at poverty reduction. There is also a need to expand the scope of the Integrated Child Development Services (ICDS) program to provide mass education regarding nutrition and health by making provisions of home visits of workers primarily focusing on pregnant and lactating mothers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09864-2.

Improving nutritional status among urban poor children in sub-Saharan Africa: An evidence-informed Delphi-based consultation

In sub‐Saharan Africa (SSA), rapid urbanisation coupled with the high prevalence of infant and young child (IYC) undernutrition in low‐income settings means that interventions to support IYC nutrition are a priority. Little is known about how urbanisation influences IYC feeding (IYCF) practices, and evidence‐based interventions to improve IYC health/nutrition in the urban poor are lacking. Therefore, this research aimed to (a) systematically review evidence on interventions for improving the nutritional status of IYC aged 6–23 months living in urban poor areas (PROSPERO CRD42018091265) and (b) engage stakeholders to identify the highest ranking evidence gaps for improving IYCF programmes/policies. First, a rapid systematic review was conducted. This focused on the literature published regarding nutrition‐specific and nutrition‐sensitive complementary feeding interventions in urban poor areas, specifically low‐income informal settlements, in low‐ and middle‐income countries (LMICs). Six intervention studies met the review inclusion criteria. Intervention adherence was generally high, and indicators of maternal knowledge and IYC nutritional intake typically increased because of the interventions, but the impact on anthropometric status was small. Second, stakeholders working across SSA were engaged via a Delphi‐based approach to identify priority areas for future intervention. Stakeholders reported that a situational analysis was required to better understand IYCF in urban poor areas, particularly the causes of IYC undernutrition, and highlighted the need to involve local communities in defining how future work should proceed. Together, these findings indicate a need for more evidence regarding IYCF and the factors that drive it in urban poor areas across LMIC settings, but particularly in SSA.

Material deprivation, parenting practices, and children's psychological health and wellbeing in China

This paper examined the extent and risk factors of child subjective wellbeing and psychological health empirically using China Family Panel Studies data set. Child subjective wellbeing was measured in this paper using six indicators including the frequency in feelings of depression, nervousness, restlessness, hopelessness, helplessness, and meaninglessness. Risk factors of child subjective wellbeing have also been examined in particular to the domains of household multidimensional material deprivation, parenting practices, and children's personal health conditions. The results of this paper implied that providing adequate nutrition and ensuring children's access to basic water and sanitation facilities were important strategies for promoting children's psychological health and wellbeing. Also important factor for child wellbeing is parenting styles and practices, that is, how parents interact with children in daily lives and how they behave as parents.

Complete and on-time routine childhood immunisation: determinants and association with severe morbidity in urban informal settlements, Nairobi, Kenya

Background: Completion of the full series of childhood vaccines on-time is crucial to ensuring greater protection against vaccine-preventable diseases.Aim: To examine determinants of complete and on-time vaccination and evaluate the relationship between vaccination patterns and severe morbidity outcomes.Subjects and methods: Vaccination information from infants in Nairobi Urban Health and Demographic Surveillance System was used to evaluate full and on-time vaccination coverage of routine immunisation. Logistic regression was used to identify determinants of full and on-time vaccination coverage. Cox regression model was used to evaluate the relationship between vaccination status and subsequent severe morbidity. A shared frailty cox model was fitted to account for the heterogeneity in hospitalisation episodes.Results: Maternal age, post-natal care, parity, ethnicity, and residence place were identified as determinants of vaccination completion. Institutional deliveries and residence place were identified as the determinants of on-time vaccination. A significant 58% (confidence interval [CI]: 15-79%) (p = .017) lower mortality was observed among fully immunised children compared with not fully immunised. Lower mortality was observed among on-time immunised children, 64% (CI: 20-84%) compared to those with delays.Conclusions: Improving vaccination timeliness and completion schedule is critical for protection against vaccine preventable diseases and may potentially provide protection beyond these targets.

Family Income and Children's Emotional Wellbeing: the Mediational Role of Parents' Life Satisfaction and Emotional Wellbeing in China

Utilizing the Chinese Family Panel Studies (CFPS) dataset and the structural equation model, this paper examines the direct and indirect influences of family income on children’s emotional wellbeing as a function of parents’ life satisfaction and parents’ emotional wellbeing. Firstly, the empirical analysis of this paper shows that family income exerts a positive influence on children’s emotional wellbeing outcomes, including depressed, hopeless, helpless, and meaningless feelings. Secondly, the findings show that family income is significantly associated with parents’ emotional wellbeing, through which children’s wellbeing is affected. The intergenerational emotional transmission mechanism is validated. The ability to control personal emotions is an important skill, related not only to personal health but also to children’s health and wellbeing. Furthermore, parents’ life satisfaction serves as the mediator between family income and parents’ emotional wellbeing. If parents are more satisfied with their own lives, they are less likely to experience emotional problems. Policy implications are discussed in the end.

Socio-economic Determinants of Increasing Household Food Insecurity during and after a Drought in the District of iLembe, South Africa

In 2015 and 2016, South Africa experienced a severe drought resulting in water restrictions and food price inflation. A year later, while the proportion of food secure households remained constant, the proportion of those experiencing severe food insecurity increased. This paper investigates the socio-economic determinants of increasing food insecurity during and after the drought. Two cross-sectional household surveys were carried out in the district of iLembe in November 2016 and 2017. Household food insecurity was measured using the Coping Strategies Index. The results indicated changes in socio-economic determinants of food insecurity over time, with the poorest households experiencing the worst levels of food insecurity. After the drought, having a child under-five years was positively associated with food insecurity, while being located in a rural area was negatively associated. Policies that limit household vulnerability to price inflation, and interventions that protect poorer households from the effects of drought should be considered.

Coping through a drought: the association between child nutritional status and household food insecurity in the district of iLembe, South Africa

OBJECTIVE

To assess and compare the association between household food insecurity and child nutritional status over two time-points taking into consideration the effects of a severe drought.

DESIGN

The study used two cross-sectional household surveys during and after a severe drought, consistent with a natural experiment design.

SETTING

The study took place in the district of iLembe, KwaZulu-Natal, South Africa.

PARTICIPANTS

Households with children aged <5 years were invited to participate in the survey. Anthropometric measures were taken for the respective children in each of the participating households.

RESULTS

The results indicated that all forms of poor nutritional status increased over the two time-points, with the most significant increases being for stunting (P < 0·016) and obesity (P < 0·001). There was evidence of an association between increasing food insecurity and stunting (P < 0·003) at the end of the drought, but not wasting, underweight or overweight. The results indicated a strong link between chronic food insecurity and chronic undernutrition. The results also showed stronger evidence of an association between food insecurity and stunting for urban households (P < 0·001) compared to their rural counterparts (P < 0·019).

CONCLUSIONS

The negative effects of drought appear to contribute to increased rates of child stunting through higher levels of household food insecurity. Future research should assess this relationship through longitudinal studies. Interventions aimed at improving food security may assist in reducing child malnutrition, but policymakers should consider urban-rural differences as well as climatic and environmental events.

Agricultural wealth better predicts mental wellbeing than market wealth among highly vulnerable households in Haiti: Evidence for the benefits of a multidimensional approach to poverty

OBJECTIVES

Lack of wealth (poverty) impacts almost every aspect of human biology. Accordingly, many studies include its assessment. In almost all cases, approaches to assessing poverty are based on lack of success within cash economies (eg, lack of income, employment). However, this operationalization deflects attention from alternative forms of poverty that may have the most substantial influence on human wellbeing. We test how a multidimensional measure of poverty that considers agricultural assets expands the explanatory power of the construct of household poverty by associating it with one key aspect of wellbeing: symptoms of mental health.

METHODS

We used the case of three highly vulnerable but distinctive communities in Haiti-urban, town with a rural hinterland, and rural. Based on survey responses from adults in 4055 geographically sampled households, linear regression models were used to predict depression and anxiety symptom levels controlling for a wide range of covariates related to detailed measures of material poverty, including cash-economy and agricultural assets, income, financial stress, and food insecurity.

RESULTS

Household assets related to the cash economy were significantly associated with lower (ie, better) depression scores (-0.7, [95% CI: -1.2 to, -0.1]) but unrelated to anxiety scores (-0.3 [95% CI: -0.8 to 0.3]). Agricultural wealth was significantly-and more strongly-associated with both reductions in depression symptoms (-1.4 [95% CI: -2.2 to -0.7]) and anxiety symptoms (-1.8 [95% CI: -2.6 to -1.0]). These associations were consistent across the three sites, except in the fully urban site in Port-au-Prince where level of depression symptoms was not significantly associated with household agricultural wealth.

CONCLUSIONS

Standard measures of poverty based on success in the cash economy can mask important associations between poverty and wellbeing, in this case related to household-level subsistence capacity and crucial food-producing household assets.

Challenges and responses to infant and young child feeding in rural Rwanda: a qualitative study

BACKGROUND

Despite different interventions to improve child nutrition conditions, chronic malnutrition is still a public health concern in Rwanda, with a high stunting prevalence of 38% among under 5-year-olds children. In Rwanda, only 18% of children aged 6-23 months are fed in accordance with the recommendations for infant and young child feeding practices. The aim of this study was to explore challenges to infant and young child feeding practices and the responses applied to overcome these challenges in Muhanga District, Southern province of Rwanda.

METHODS

Sixteen (16) focus group discussions were held with mothers, fathers, grandmothers, and community health workers from 4 rural sectors of Muhanga District. The discussions were recorded, transcribed verbatim, and thematically analyzed using qualitative data analysis software, Atlas.ti.

RESULTS

Two main themes emerged from the data. Firstly, there was a discourse on optimal infant and young child feeding (IYCF) practices that reflects the knowledge and efforts to align with early initiation of breastfeeding, exclusive breastfeeding for the first 6 months, as well as initiation of complementary foods at 6 months recommendations. Secondly, challenging situations against optimal practices and coping responses applied were presented in a discourse on struggling with everyday reality. The challenging situations that emerged as impeding appropriate IYCF practices included perceived lack of breast milk, infant cues, women's heavy workload, partner relations and living in poverty. Family and social support from community health workers and health facility staff, financial support through casual labor, and mothers saving and lending groups, as well as kitchen gardens, were used to cope with challenges.

CONCLUSION

Factors influencing IYCF practices are multifaceted. Hence, intervention strategies to improve child nutrition should acknowledge the socially embedded nature of IYCF and address economic and social environmental constraints and opportunities, in addition and above knowledge only.

Family influences on child nutritional outcomes in Nairobi's informal settlements

BACKGROUND

Improving child nutritional status is an important step towards achieving the Sustainable Development Goals 2 and 3 in developing countries. Most child nutrition interventions in these countries remain variably effective because the strategies often target the child's mother/caregiver and give limited attention to other household members. Quantitative studies have identified individual level factors, such as mother and child attributes, influencing child nutritional outcomes.

METHODS

We used a qualitative approach to explore the influence of household members on child feeding, in particular, the roles of grandmothers and fathers, in two Nairobi informal settlements. Using in-depth interviews, we collected data from mothers of under-five children, grandmothers, and fathers from the same households.

RESULTS

Our findings illustrate that poverty is a root cause of poor nutrition. We found that mothers are not the sole decision makers within the household regarding the feeding of their children, as grandmothers appear to play key roles. Even in urban informal settlements, three-generation households exist and must be taken into account. Fathers, however, are described as providers of food and are rarely involved in decision making around child feeding. Lastly, we illustrate that promotion of exclusive breastfeeding for 6 months, as recommended by the World Health Organization, is hard to achieve in this community.

CONCLUSIONS

These findings call for a more holistic and inclusive approach for tackling suboptimal feeding in these communities by addressing poverty, targeting both mothers and grandmothers in child nutrition strategies, and promoting environments that support improved feeding practices such as home-based support for breastfeeding and other baby-friendly initiatives.

Factors associated with recovery from stunting among under-five children in two Nairobi informal settlements

Childhood stunting is a public health concern in many low-and-middle income countries, as it is associated with both short-term and long-term negative effects on child cognitive development, physical health, and schooling outcomes. There is paucity of studies on recovery from stunting among under five children in these countries. Most studies focused on the recovery much later in adolescence. We used longitudinal data from two Nairobi urban settlements to determine the incidence of recovery from stunting and understand the factors associated with post-stunting linear growth among under-five children. A total of 1,816 children were recruited between birth and 23 months and were followed-up until they reached five years. We first looked at the time to recover from stunting using event history analysis and Cox regression. Second, we used height-for-age z-score slope modelling to estimate the change in linear growth among children who were stunted. Finally, we fitted a linear regression model of the variation in HAZ on a second degree fractional polynomials in child’s age to identify the factors associated with post-stunting linear growth. The principal findings are: i) the incidence of recovery from stunting was 45% among stunted under-five children in the two settlements; ii) timely child immunization, age at stunting, mother’s parity and household socioeconomic status are important factors associated with time to recover from stunting within the first five years of life; and iii) child illness status and age at first stunting, mother’s parity and age have a strong influence on child post-stunting linear growth. Access to child health services and increased awareness among health professionals and child caregivers, would be critical in improving child growth outcomes in the study settings. Additionally, specific maternal and reproductive health interventions targeting young mothers in the slums may be needed to reduce adolescent and young mother’s vulnerability and improve their child health outcomes.

Analysing child linear growth trajectories among under-5 children in two Nairobi informal settlements

OBJECTIVE

We sought to identify factors associated with linear growth among under-5 children in two urban informal settlements in Nairobi.

DESIGN

We used longitudinal data for the period 2007-2012 from under-5 children recruited in the two sites between birth and 23 months and followed up until they reached 5 years of age. We fitted a generalized linear model on height-for-age Z-scores using the generalized estimating equations method to model linear growth trajectories among under-5 children. Known for its flexibility, the model provides strong parameter estimates and accounts for correlated observations on the same child.

SETTING

Two urban informal settlements in Nairobi, Kenya.ParticipantsUnder-5 children (n 1917) and their mothers (n 1679).

RESULTS

The findings show that child weight at birth, exclusive breast-feeding and immunization status were key determinants of linear growth among under-5 children. Additionally, maternal characteristics (mother's age, marital status) and household-level factors (socio-economic status, size of household) were significantly associated with child linear growth. There were biological differences in linear growth, as female children were more likely to grow faster than males. Finally, the model captured significant household-level effects to investigate further.

CONCLUSIONS

Findings from the study point to the need to improve the targeting of child health programmes directed at the urban poor population in Nairobi. Specific modifiable determinants of child linear growth, particularly child weight at birth, exclusive breast-feeding, immunization status and mother's background characteristics, should be considered when designing interventions aiming at addressing child health inequities in these settings.

Childbearing desires and behaviour: a prospective assessment in Nairobi slums

BACKGROUND

Advancing an understanding of childbearing desires is an important precursor to achievement of the policy goal of reducing unintended pregnancies. It has been long debated that concepts of fertility desires and planning may be particularly problematic in sub-Saharan Africa. However, examination of the utility of fertility preference measures and their link to reproductive behaviour is still rare in the region. The aim of this study is to assess the predictive validity of future childbearing desires on subsequent reproduction among women living in the highly unpredictable circumstances of Nairobi slums.

METHODS

We used data from a longitudinal study (2007-2010) nested in the Nairobi Urban Health Demographic Surveillance System that is located in two slums in Nairobi, Kenya. We analysed baseline fertility desires among 4577 postpartum women. Cox proportional hazard model was employed to examine the effect of fertility desires on subsequent reproduction.

RESULTS

One-third of the women wanted no more children and 37% wanted to wait for at least five years at baseline. While two-thirds of the women who wanted to have a child soon became pregnant within three years, less than one-third of those wanting no more children became pregnant. The multivariable analysis shows that the probability of becoming pregnant among women who expressed desires to stop or delay childbearing at least for five years was 50% less than among women who wanted to have a child in two to four years. In addition to prospective fertility desires, level of woman's education, residence and ethnicity exerted important influences on implementation of baseline preferences.

CONCLUSIONS

Our study finds a strong link between baseline fertility desires and subsequent reproduction. A large difference in pregnancy risk was observed between those who wanted no more children and those who wanted another child. The link between a woman's stated desire to stop childbearing and subsequent childbearing is just as strong in the Nairobi slums as elsewhere. In addition, the findings revealed a pronounced gradient in pregnancy risk according to preferred spacing length, which support other evidence on the important contribution of long-term spacing or postponement to fertility decline in sub-Saharan Africa.

How socioeconomic status moderates the stunting-age relationship in low-income and middle-income countries

Introduction

Reducing stunting is an important part of the global health agenda. Despite likely changes in risk factors as children age, determinants of stunting are typically analysed without taking into account age-related heterogeneity. We aim to fill this gap by providing an in-depth analysis of the role of socioeconomic status (SES) as a moderator for the stunting-age pattern.

Methods

Epidemiological and socioeconomic data from 72 Demographic and Health Surveys (DHS) were used to calculate stunting-age patterns by SES quartiles, derived from an index of household assets. We further investigated how differences in age-specific stunting rates between children from rich and poor households are explained by determinants that could be modified by nutrition-specific versus nutrition-sensitive interventions.

Results

While stunting prevalence in the pooled sample of 72 DHS is low in children up to the age of 5 months (maximum prevalence of 17.8% (95% CI 16.4;19.3)), stunting rates in older children tend to exceed those of younger ones in the age bracket of 6–20 months. This pattern is more pronounced in the poorest than in the richest quartile, with large differences in stunting prevalence at 20 months (stunting rates: 40.7% (95% CI 39.5 to 41.8) in the full sample, 50.3% (95% CI 48.2 to 52.4) in the poorest quartile and 29.2% (95% CI 26.8 to 31.5) in the richest quartile). When adjusting for determinants related to nutrition-specific interventions only, SES-related differences decrease by up to 30.1%. Much stronger effects (up to 59.2%) occur when determinants related to nutrition-sensitive interventions are additionally included.

Conclusion

While differences between children from rich and poor households are small during the first 5 months of life, SES is an important moderator for age-specific stunting rates in older children. Determinants related to nutrition-specific interventions are not sufficient to explain these SES-related differences, which could imply that a multifactorial approach is needed to reduce age-specific stunting rates in the poorest children.

Malnutrition, morbidity and infection in the informal settlements of Nairobi, Kenya: an epidemiological study

Background

Malnutrition constitutes one of the major public health challenges throughout the developing world. Urban poverty and malnutrition have been on the rise, with an increased rate of morbidity. We herein explore the relationship between infections and nutritional status and the related association with hygienic conditions as risk of infection in children residing in the slums of Nairobi.

Methods

Case-control study based on a secondary analysis of quantitative data collected from a cluster randomized trial carried out in two slums of Nairobi. The following information about resident children were selected: babies’ anthropometric measurements, related life conditions, data on infant-feeding practices, food security, hygiene, immunization coverage and morbidity were collected and updated with structured questionnaires until 12 months of life. Prevalence of malnutrition was calculated, then both bivariate and multivariate analysis were used to explore the relationship between malnutrition and its determinants.

Results

The study involved a total of 1119 babies registered at birth (51.28% male and 48.03% female infants). Overall the prevalence of malnutrition was high, with 26.3% of the children being stunted, 6.3% wasted and 13.16% underweight. Prevalence of wasting was higher in the first months of life, while in older children more case of stunting and underweight were captured. Wasted infants were significantly associated with common childhood illnesses: with cough and rapid breathing as well as with diarrhea (p-value< 0.05). Stunting was associated with hygienic conditions (p-value< 0.05 in households that did not perform any water treatment and for children that had a toilet within the house compound), immunization program and low-birth-weight. Moreover, regression analysis showed that significant determinants of stunting were sex and feeding practices. Underweight was significantly associated with socio-demographic factors.

Conclusions

In the specific environment where the study was conducted acute malnutrition is correlated with acute infections, while chronic malnutrition is more influenced by WASH conditions. Therefore, our findings suggest that one cannot separate infection and its risk factors as determinants of the whole malnutrition burden.

Associação entre a Pobreza Familiar e o Desenvolvimento Neuropsicomotor de Crianças na Educação Infantil

Este estudo teve o objetivo de analisar o desenvolvimento neuropsicomotor de crianças de uma Unidade de Educação Infantil do município de Belém e a sua associação com o Índice de Pobreza Familiar. Trata-se de um estudo transversal, com caráter descritivo-exploratório. Participaram desse estudo 19 crianças, de ambos os sexos e seus responsáveis. Utilizou-se o Teste de Triagem do Desenvolvimento de Denver II, O Critério Brasil e o Índice de Pobreza Familiar. Para analisar os dados foi utilizado estatística descritiva e inferencial, pelo teste Exato de Fisher, com nível de significância de 5% (p-valor <0,05). Das 19 crianças avaliadas, o percentual de suspeita de atraso no desenvolvimento chegou a 57,9%, sendo que a área com maior incidência foi a linguagem (47,4%). Em relação ao Critério Brasil, a maioria das crianças com suspeita de atraso pertenciam a famílias enquadradas na categoria C. Quanto ao Índice de Pobreza da Família, as crianças com maiores suspeitas de atraso eram de família com maior índice de pobreza – Grupo 2 (G2) 81,8%. Assim, destaca-se a contribuição deste estudo em compreender a multinacionalidade da pobreza e sua relação com o desenvolvimento neuropsicomotor.

Body mass index and wealth index: positively correlated indicators of health and wealth inequalities in Nairobi slums

Introduction

Wealth index is a known predictor of body mass index (BMI). Many studies have reported a positive association between BMI and socioeconomic status (SES). However, an in-depth investigation of the relationship between BMI and wealth index is lacking for urban slum settings.

Objective

To examine the association between BMI and wealth index in an urban slum setting in Nairobi, Kenya.

Methods

A total of 2003 adults between 40 and 60 years of age were included. BMI was derived from direct weight and height measurements. Wealth Index was computed using the standard principal component analysis of household amenities ownership. The relationship between BMI and wealth index was assessed using both linear and logistic regression models.

Results

We found that BMI linearly increased across the five quintiles of wealth index in both men and women, after adjusting for potential confounding factors. The prevalence of obesity increased from 10% in the first wealth quintile to 26.2% in the fifth wealth quintile. The average BMI for women entered the overweight category at the second quintile wealth status, or the third quintile for the total population.

Conclusion

There exists a strong positive relationship between BMI and wealth index in slum settings. Health promotion interventions aimed at reducing obesity may consider using wealth index in priority setting.

Association between household food security and infant feeding practices in urban informal settlements in Nairobi, Kenya

Studies in urban informal settlements show widespread inappropriate infant and young child feeding (IYCF) practices and high rates of food insecurity. This study assessed the association between household food security and IYCF practices in two urban informal settlements in Nairobi, Kenya. The study adopted a longitudinal design that involved a census sample of 1110 children less than 12 months of age and their mothers aged between 12 and 49 years. A questionnaire was used to collect information on: IYCF practices and household food security. Logistic regression was used to determine the association between food insecurity and IYFC practices. The findings showed high household food insecurity; only 19.5% of the households were food secure based on Household Insecurity Access Score. Infant feeding practices were inappropriate: 76% attained minimum meal frequency; 41% of the children attained a minimum dietary diversity; and 27% attained minimum acceptable diet. With the exception of the minimum meal frequency, infants living in food secure households were significantly more likely to achieve appropriate infant feeding practices than those in food insecure households: minimum meal frequency (adjusted odds ratio (AOR)=1.26, P=0.530); minimum dietary diversity (AOR=1.84, P=0.046) and minimum acceptable diet (AOR=2.35, P=0.008). The study adds to the existing body of knowledge by demonstrating an association between household food security and infant feeding practices in low-income settings. The findings imply that interventions aimed at improving infant feeding practices and ultimately nutritional status need to also focus on improving household food security.

Effectiveness of home-based nutritional counselling and support on exclusive breastfeeding in urban poor settings in Nairobi: a cluster randomized controlled trial

BACKGROUND

Exclusive breastfeeding (EBF) improves infant health and survival. We tested the effectiveness of a home-based intervention using Community Health Workers (CHWs) on EBF for six months in urban poor settings in Kenya.

METHODS

We conducted a cluster-randomized controlled trial in Korogocho and Viwandani slums in Nairobi. We recruited pregnant women and followed them until the infant's first birthday. Fourteen community clusters were randomized to intervention or control arm. The intervention arm received home-based nutritional counselling during scheduled visits by CHWs trained to provide specific maternal infant and young child nutrition (MIYCN) messages and standard care. The control arm was visited by CHWs who were not trained in MIYCN and they provided standard care (which included aspects of ante-natal and post-natal care, family planning, water, sanitation and hygiene, delivery with skilled attendance, immunization and community nutrition). CHWs in both groups distributed similar information materials on MIYCN. Differences in EBF by intervention status were tested using chi square and logistic regression, employing intention-to-treat analysis.

RESULTS

A total of 1110 mother-child pairs were involved, about half in each arm. At baseline, demographic and socioeconomic factors were similar between the two arms. The rates of EBF for 6 months increased from 2% pre-intervention to 55.2% (95% CI 50.4-59.9) in the intervention group and 54.6% (95% CI 50.0-59.1) in the control group. The adjusted odds of EBF (after adjusting for baseline characteristics) were slightly higher in the intervention arm compared to the control arm but not significantly different: for 0-2 months (OR 1.27, 95% CI 0.55 to 2.96; p = 0.550); 0-4 months (OR 1.15; 95% CI 0.54 to 2.42; p = 0.696), and 0-6 months (OR 1.11, 95% CI 0.61 to 2.02; p = 0.718).

CONCLUSIONS

EBF for six months significantly increased in both arms indicating potential effectiveness of using CHWs to provide home-based counselling to mothers. The lack of any difference in EBF rates in the two groups suggests potential contamination of the control arm by information reserved for the intervention arm. Nevertheless, this study indicates a great potential for use of CHWs when they are incentivized and monitored as an effective model of promotion of EBF, particularly in urban poor settings. Given the equivalence of the results in both arms, the study suggests that the basic nutritional training given to CHWs in the basic primary health care training, and/or provision of information materials may be adequate in improving EBF rates in communities. However, further investigations on this may be needed. One contribution of these findings to implementation science is the difficulty in finding an appropriate counterfactual for community-based educational interventions.

TRIAL REGISTRATION

ISRCTN ISRCTN83692672 . Registered 11 November 2012. Retrospectively registered.

Spatial analysis of food insecurity and obesity by area-level deprivation in children in early years settings in England

Background

we assessed manager perceptions of food security and obesity in young children attending nurseries across England, assessing spatial differences by area-level deprivation.

Methods

we conducted an adjusted multinomial logistic regression and an adjusted geographically weighted logistic regression examining the odds of a manager perceiving obesity, food insecurity, or both as a problem among children in care measured via a mailed survey.

Results

851 (54.3%) managers returned the survey. A nursery being in the highest tertile of area-level deprivation was associated with a 1.89 (95% CI 1.00, 3.57) greater odds of perceiving obesity as a problem, a 3.06 (95% CI 1.94, 4.84) greater odds of perceiving food insecurity as a problem, and a 8.39 (95% CI 4.36, 16.15) greater odds of perceiving both as a problem, compared with the lowest tertile.

Conclusions

we observed differences in manager perception by area-level deprivation, but the relationship was especially pronounced for food insecurity.

Age-Specific Correlates of Child Growth

Growth faltering describes a widespread phenomenon that height- and weight-for-age of children in developing countries collapse rapidly in the first two years of life. We study age-specific correlates of child nutrition using Demographic and Health Surveys from 56 developing countries to shed light on the potential drivers of growth faltering. Applying nonparametric techniques and exploiting within-mother variation, we find that maternal and household factors predict best the observed shifts and bends in child nutrition age curves. The documented interaction between age and maternal characteristics further underlines the need not only to provide nutritional support during the first years of life but also to improve maternal conditions.

Linear growth trajectories in Zimbabwean infants

BACKGROUND

Undernutrition in early life underlies 45% of child deaths globally. Stunting malnutrition (suboptimal linear growth) also has long-term negative effects on childhood development. Linear growth deficits accrue in the first 1000 d of life. Understanding the patterns and timing of linear growth faltering or recovery during this period is critical to inform interventions to improve infant nutritional status.

OBJECTIVE

We aimed to identify the pattern and determinants of linear growth trajectories from birth through 24 mo of age in a cohort of Zimbabwean infants.

DESIGN

We performed a secondary analysis of longitudinal data from a subset of 3338 HIV-unexposed infants in the Zimbabwe Vitamin A for Mothers and Babies trial. We used k-means clustering for longitudinal data to identify linear growth trajectories and multinomial logistic regression to identify covariates that were associated with each trajectory group.

RESULTS

For the entire population, the mean length-for-age z score declined from -0.6 to -1.4 between birth and 24 mo of age. Within the population, 4 growth patterns were identified that were each characterized by worsening linear growth restriction but varied in the timing and severity of growth declines. In our multivariable model, 1-U increments in maternal height and education and infant birth weight and length were associated with greater relative odds of membership in the least-growth restricted groups (A and B) and reduced odds of membership in the more-growth restricted groups (C and D). Male infant sex was associated with reduced odds of membership in groups A and B but with increased odds of membership in groups C and D.

CONCLUSION

In this population, all children were experiencing growth restriction but differences in magnitude were influenced by maternal height and education and infant sex, birth weight, and birth length, which suggest that key determinants of linear growth may already be established by the time of birth. This trial was registered at clinicaltrials.gov as NCT00198718.

Malnutrition Affects the Urban-Poor Disproportionately: A Study of Nigerian Urban Children of Different Socio-Economic Statuses

Income inequality within the same place of residence may impact the nutritional status of children. This study therefore investigated the impact of income inequality on the nutritional status of children living in the same place of residence, using anthropometric tools. Children in four schools (Schools 1–4) within the vicinity of a housing estate in Umuahia, Nigeria, that charge fees making them ‘very affordable’, ‘affordable’, ‘expensive’ and ‘very expensive’, respectively, were recruited for the study. Thinness, overweight and obesity were defined using the Cole et al. reference standards. Thinness was present in 10.4% (13.0% of boys, 7.6% of girls); 20.4% (15.6% of boys, 27.3% of girls; and 0.7% (1.4% of boys, 0.0% of girls) of children in Schools 1–3, respectively; but absent in school 4. Only 3.7% (1.4% of boys, 6.1% of girls) and 5.6% (6.3% of boys, 4.5% of girls) of children in Schools 1 and 2, respectively, were overweight/obese. Conversely, 25.8% (18.9% of boys, 32.5% of girls) and 41.6% (38.8% of boys, 45.3% of girls) of children in Schools 3 and 4, respectively, were overweight/obese. The urban-poor (School 2) are clearly affected by malnutrition disproportionately.

How does poverty affect children's nutritional status in Nairobi slums? A qualitative study of the root causes of undernutrition

Objective

Children in slums are at high risk of undernutrition, which has long-term negative consequences on their physical growth and cognitive development. Severe undernutrition can lead to the child’s death. The present paper aimed to understand the causes of undernutrition in children as perceived by various groups of community members in Nairobi slums, Kenya.

Design

Analysis of ten focus group discussions and ten individual interviews with key informants. The main topic discussed was the root causes of child undernutrition in the slums. The focus group discussions and key informant interviews were recorded and transcribed verbatim. The transcripts were coded in NVivo by extracting concepts and using a constant comparison of data across the different categories of respondents to draw out themes to enable a thematic analysis.

Setting

Two slum communities in Nairobi, Kenya.

Subjects

Women of childbearing age, community health workers, elders, leaders and other knowledgeable people in the two slum communities (n 90).

Results

Participants demonstrated an understanding of undernutrition in children.

Conclusions

Findings inform target criteria at community and household level that can be used to identify children at risk of undernutrition. To tackle the immediate and underlying causes of undernutrition, interventions recommended should aim to: (i) improve maternal health and nutrition; (ii) promote optimal infant and young children feeding practices; (iii) support mothers in their working role; (iv) increase access to family planning; (v) improve water, sanitation and hygiene (WASH); (vi) address alcohol problems at all levels; and (vii) address street food issues with infant feeding counselling.

Association between family poverty and the neuropsychomotor development of children in the administrative districts of Belém

Abstract Introduction: Childhood development represents a sequence of changes in behavior and underlying processes, influenced by biological and environmental factors. Screening and monitoring of neurodevelopment show effective procedures for early identification of different disorders of childhood development. Objective: To analyze the neurodevelopment, using the Denver Developmental Screening Test II, of children enrolled in preschools of Administrative Districts in Belém and to map the districts and the percentage of development evaluated as normal and suspected delay. Methods: This was a cross-sectional and exploratory descriptive study. A questionnaire was administered to parents to collect the personal, contextual and family data and an instrument to measure the level of family poverty. Results: Of the 319 children assessed, 77.7% showed a suspected delay in neuropsychomotor developmental and 59.2% in language. The family poverty level variable showed a statistically significant association with the overall level of development (p = .011) and of language (p = .003). Conclusion: It is hoped that this study will contribute to generate an impact in improving the ecological conditions of children and their families, reducing the risks to which they are exposed.

MG, Henry A, Deosaran JD, Muliyil J, Kang G. Measuring Poverty in Southern India: A Comparison of Socio-Economic Scales Evaluated against Childhood Stunting

INTRODUCTION

Socioeconomic status (SES) scales measure poverty, wealth and economic inequality in a population to guide appropriate economic and public health policies. Measurement of poverty and comparison of material deprivation across nations is a challenge. This study compared four SES scales which have been used locally and internationally and evaluated them against childhood stunting, used as an indicator of chronic deprivation, in urban southern India.

METHODS

A door-to-door survey collected information on socio-demographic indicators such as education, occupation, assets, income and living conditions in a semi-urban slum area in Vellore, Tamil Nadu in southern India. A total of 7925 households were categorized by four SES scales-Kuppuswamy scale, Below Poverty Line scale (BPL), the modified Kuppuswamy scale, and the multidimensional poverty index (MDPI) and the level of agreement compared between scales. Logistic regression was used to test the association of SES scales with stunting.

FINDINGS

The Kuppuswamy, BPL, MDPI and modified Kuppuswamy scales classified 7.1%, 1%, 5.5%, and 55.3% of families as low SES respectively, indicating conservative estimation of low SES by the BPL and MDPI scales in comparison with the modified Kuppuswamy scale, which had the highest sensitivity (89%). Children from low SES classified by all scales had higher odds of stunting, but the level of agreement between scales was very poor ranging from 1%-15%.

CONCLUSION

There is great non-uniformity between existing SES scales and cautious interpretation of SES scales is needed in the context of social, cultural, and economic realities.

Potential effectiveness of Community Health Strategy to promote exclusive breastfeeding in urban poor settings in Nairobi, Kenya: a quasi-experimental study

Early nutrition is critical for later health and sustainable development. We determined potential effectiveness of the Kenyan Community Health Strategy in promoting exclusive breastfeeding (EBF) in urban poor settings in Nairobi, Kenya. We used a quasi-experimental study design, based on three studies [Pre-intervention (2007-2011; n=5824), Intervention (2012-2015; n=1110) and Comparison (2012-2014; n=487)], which followed mother-child pairs longitudinally to establish EBF rates from 0 to 6 months. The Maternal, Infant and Young Child Nutrition (MIYCN) study was a cluster randomized trial; the control arm (MIYCN-Control) received standard care involving community health workers (CHWs) visits for counselling on antenatal and postnatal care. The intervention arm (MIYCN-Intervention) received standard care and regular MIYCN counselling by trained CHWs. Both groups received MIYCN information materials. We tested differences in EBF rates from 0 to 6 months among four study groups (Pre-intervention, MIYCN-Intervention, MIYCN-Control and Comparison) using a χ(2) test and logistic regression. At 6 months, the prevalence of EBF was 2% in the Pre-intervention group compared with 55% in the MIYCN-Intervention group, 55% in the MIYCN-Control group and 3% in the Comparison group (P<0.05). After adjusting for baseline characteristics, the odds ratio for EBF from birth to 6 months was 66.9 (95% CI 45.4-96.4), 84.3 (95% CI 40.7-174.6) and 3.9 (95% CI 1.8-8.4) for the MIYCN-Intervention, MIYCN-Control and Comparison group, respectively, compared with the Pre-intervention group. There is potential effectiveness of the Kenya national Community Health Strategy in promoting EBF in urban poor settings where health care access is limited.

Determinants of undernutrition among children aged 6 to 59 months in rural Zambézia Province, Mozambique: Results of two population-based serial cross-sectional surveys

BACKGROUND

While many countries are transitioning from epidemics of undernutrition to overnutrition, Mozambique's very high 44% prevalence of stunting in children under age 5 years is cause for serious concern.

METHODS

We conducted two population-based cross-sectional surveys of ~4000 female heads of households each in Zambézia Province, Mozambique from August-September 2010 (Baseline) and April-May 2014 (Endline) as part of the USAID funded Strengthening Communities through Integrated Programs (SCIP) grant. Anthropometric measurements were collected on 560 children aged 6-59 months at Baseline and 912 children at Endline and classified as: "stunted," a height-for-age z-score less than -2; "wasted," weight-for-height z-score less than -2; and "underweight," weight-for-age z-score less than -2. Descriptive statistics and logistic regression using Stata 13.1 were used to examine factors associated with undernutrition.

RESULTS

Of children under age five years, 43% were undernourished in 2010 and 55% in 2014. The most common form of undernutrition was stunting (39% in 2010, 51% in 2014), followed by underweight (13% in both 2010 and 2014), and wasting (7% in 2010, 5% in 2014). Child's age was found to have a non-linear association with stunting. Vitamin A supplementation was associated with a 31% (p=0.04) decreased odds of stunting. Children who were exclusively breastfed for at least six months had an 80% (p=0.02) lower odds of wasting in 2014 and 57% (p=0.05) decreased odds of being underweight in 2014. Introducing other foods after age six months was associated with a five-fold increased odds of wasting in 2014 (p=0.02); household food insecurity was associated with wasting (OR=2.08; p=0.03) and underweight in 2010 (OR=2.31; p=0.05). Children whose mother washed her hands with a cleaning agent had a 40% (p=0.05) decreased odds of being underweight. Surprisingly, per point increase in household dietary diversity score, children had 12% greater odds of being stunted in 2010 (p=0.01) but 9% decreased odds of being underweight in 2014 (p=0.02).

CONCLUSIONS

A combination of household and individual level factors was associated with undernutrition. As such, employment of multidimensional interventions should be considered to decrease undernutrition in children under five years old.

Household food (in)security and nutritional status of urban poor children aged 6 to 23 months in Kenya

BACKGROUND

Millions of people in low and low middle income countries suffer from extreme hunger and malnutrition. Research on the effect of food insecurity on child nutrition is concentrated in high income settings and has produced mixed results. Moreover, the existing evidence on food security and nutrition in children in low and middle income countries is either cross-sectional and/or is based primarily on rural populations. In this paper, we examine the effect of household food security status and its interaction with household wealth status on stunting among children aged between 6 and 23 months in resource-poor urban setting in Kenya.

METHODS

We use longitudinal data collected between 2006 and 2012 from two informal settlements in Nairobi, Kenya. Mothers and their new-borns were recruited into the study at birth and followed prospectively. The analytical sample comprised 6858 children from 6552 households. Household food security was measured as a latent variable derived from a set of questions capturing the main domains of access, availability and affordability. A composite measure of wealth was calculated using asset ownership and amenities. Nutritional status was measured using Height-for-Age (HFA) z-scores. Children whose HFA z-scores were below -2 standard deviation were categorized as stunted. We used Cox regression to analyse the data.

RESULTS

The prevalence of stunting was 49 %. The risk of stunting increased by 12 % among children from food insecure households. When the joint effect of food security and wealth status was assessed, the risk of stunting increased significantly by 19 and 22 % among children from moderately food insecure and severely food insecure households and ranked in the middle poor wealth status. Among the poorest and least poor households, food security was not statistically associated with stunting.

CONCLUSION

Our results shed light on the joint effect of food security and wealth status on stunting. Study findings underscore the need for social protection policies to reduce the high rates of child malnutrition in the urban informal settlements.

Evidence of a Double Burden of Malnutrition in Urban Poor Settings in Nairobi, Kenya

Background

Many low- and middle-income countries are undergoing a nutrition transition associated with rapid social and economic transitions. We explore the coexistence of over and under- nutrition at the neighborhood and household level, in an urban poor setting in Nairobi, Kenya.

Methods

Data were collected in 2010 on a cohort of children aged under five years born between 2006 and 2010. Anthropometric measurements of the children and their mothers were taken. Additionally, dietary intake, physical activity, and anthropometric measurements were collected from a stratified random sample of adults aged 18 years and older through a separate cross-sectional study conducted between 2008 and 2009 in the same setting. Proportions of stunting, underweight, wasting and overweight/obesity were dettermined in children, while proportions of underweight and overweight/obesity were determined in adults.

Results

Of the 3335 children included in the analyses with a total of 6750 visits, 46% (51% boys, 40% girls) were stunted, 11% (13% boys, 9% girls) were underweight, 2.5% (3% boys, 2% girls) were wasted, while 9% of boys and girls were overweight/obese respectively. Among their mothers, 7.5% were underweight while 32% were overweight/obese. A large proportion (43% and 37%%) of overweight and obese mothers respectively had stunted children. Among the 5190 adults included in the analyses, 9% (6% female, 11% male) were underweight, and 22% (35% female, 13% male) were overweight/obese.

Conclusion

The findings confirm an existing double burden of malnutrition in this setting, characterized by a high prevalence of undernutrition particularly stunting early in life, with high levels of overweight/obesity in adulthood, particularly among women. In the context of a rapid increase in urban population, particularly in urban poor settings, this calls for urgent action. Multisectoral action may work best given the complex nature of prevailing circumstances in urban poor settings. Further research is needed to understand the pathways to this coexistence, and to test feasibility and effectiveness of context-specific interventions to curb associated health risks.

Patterns of fertility preferences and contraceptive behaviour over time: change and continuities among the urban poor in Nairobi, Kenya

The main objective of this paper is to investigate the association between fertility preferences and contraceptive use among 15-49-year-old women living in Korogocho and Viwandani, informal settlements in Nairobi, Kenya. We draw on longitudinal data collected under the Maternal and Child Health project conducted between 2006 and 2010 in the two settlements. There is substantial regularity and stability but also unusual instability in reported fertility preferences over time among women living in these settings. Younger women, aged 15-24 years, are likely to change their preferences over time, passing from limiting to wanting additional children. But women aged 35-49 are likely to change their preferences from desiring more children to limiting their childbearing. The desire to limit childbearing is strongly associated with the use of modern and long-acting contraceptive methods. Findings have major implications for the success of family planning programmes in informal settlements where access to and knowledge about contraception may be limited.

Short-term and long-term associations between household wealth and physical growth: a cross-comparative analysis of children from four low- and middle-income countries

BACKGROUND

Stunting, a form of anthropometric failure, disproportionately affects children in developing countries with a higher burden on children living in poverty. How early life deprivation affects physical growth over various life stages is less well-known.

OBJECTIVE

We investigate the short- and long-run associations between household wealth in early life with physical growth in childhood in four low- and middle-income countries to understand the persistent implications of early life conditions of poverty and resource constraints on physical growth.

DESIGN

Longitudinal study of eight cohorts of children in four countries - Ethiopia, India, Peru, and Vietnam (n=10,016) - ages 6 months to 15 years, using data from the Young Lives project, 2002-2009. Physical growth outcomes are standardized height-for-age z-scores (HAZ) and stunting. The key exposure is household wealth measured at baseline using a wealth index, an asset-based indicator. Covariates include child's age and sex, caregiver's educational status, household size, and place of residence.

RESULTS

Baseline wealth index is significantly associated with higher physical growth rates as suggested by higher HAZ and lower odds of stunting. We found these associations in all four countries, for younger and older cohorts and for children who experienced changes in living standards. For the older cohort, despite the timing of the first survey at age 7-8 years, which is beyond the critical period of 1,000 days, there are lasting influences of early poverty, even for those who experienced changes in wealth.

CONCLUSIONS

Household wealth in early life matters for physical growth with conditions of poverty and deprivation influencing growth faltering even beyond the 1,000 days window. The influences of early childhood poverty, so prevalent among children in low- and middle-income countries, must be addressed by policies and programs targeting early life but also focusing on older children experiencing growth faltering.

Factors associated with growth and blood pressure patterns in children with sickle cell anemia: Silent Cerebral Infarct Multi-Center Clinical Trial cohort

Individuals with sickle cell anemia (SCA) exhibit delayed growth trajectories and lower blood pressure (BP) measurements than individuals without SCA. We evaluated factors associated with height, weight, and BP and established reference growth curves and BP tables using data from the Silent Cerebral Infarct Multi-Center Clinical (SIT) Trial (NCT00072761). Quantile regression models were used to determine the percentiles of growth and BP measurements. Multivariable quantile regression was used to test associations of baseline variables with height, weight, and BP measurements. Height and weight measurements were collected from a total of 949 participants with median age of 10.5 years [Interquartile range (IQR) 8.2-12.9] and median follow-up time of 3.2 years (IQR 1.8-4.7, range 0-12.9). Serial BP measurements were collected from a total of 944 and 943 participants, respectively, with median age of 10.6 years (IQR = 8.3-12.9 years), and median follow-up time of 3.3 years (IQR = 1.7-4.8). Multivariable quantile regression analysis revealed that higher hemoglobin measurements at baseline were associated with greater height (P < 0.001), weight (P = 0.000), systolic BP (P < 0.001), and diastolic BP (P = 0.003) measurements. We now provide new reference values for height, weight, and BP measurements that are now readily available for medical management.

Factors affecting actualisation of the WHO breastfeeding recommendations in urban poor settings in Kenya

Poor breastfeeding practices are widely documented in Kenya, where only a third of children are exclusively breastfed for 6 months and only 2% in urban poor settings. This study aimed to better understand the factors that contribute to poor breastfeeding practices in two urban slums in Nairobi, Kenya. In‐depth interviews (IDIs), focus group discussions (FGDs) and key informant interviews (KIIs) were conducted with women of childbearing age, community health workers, village elders and community leaders and other knowledgeable people in the community. A total of 19 IDIs, 10 FGDs and 11 KIIs were conducted, and were recorded and transcribed verbatim. Data were coded in NVIVO and analysed thematically. We found that there was general awareness regarding optimal breastfeeding practices, but the knowledge was not translated into practice, leading to suboptimal breastfeeding practices. A number of social and structural barriers to optimal breastfeeding were identified: (1) poverty, livelihood and living arrangements; (2) early and single motherhood; (3) poor social and professional support; (4) poor knowledge, myths and misconceptions; (5) HIV; and (6) unintended pregnancies. The most salient of the factors emerged as livelihoods, whereby women have to resume work shortly after delivery and work for long hours, leaving them unable to breastfeed optimally. Women in urban poor settings face an extremely complex situation with regard to breastfeeding due to multiple challenges and risk behaviours often dictated to them by their circumstances. Macro‐level policies and interventions that consider the ecological setting are needed.