Getting it right for children: a review of UNICEF joint health and nutrition strategy for 2006-15

The unfinished agenda in child survival

10 years ago, The Lancet published a Series about child survival. In this Review, we examine progress in the past decade in child survival, with a focus on epidemiology, interventions and intervention coverage, strategies of health programmes, equity, evidence, accountability, and global leadership. Knowledge of child health epidemiology has greatly increased, and although more and better interventions are available, they still do not reach large numbers of mothers and children. Child survival should remain at the heart of global goals in the post-2015 era. Many countries are now making good progress and need the time and support required to finish the task. The global health community should show its steadfast commitment to child survival by amassing knowledge and experience as a basis for ever more effective programmes. Leadership and accountability for child survival should be strengthened and shared among the UN system; governments in high-income, middle-income, and low-income countries; and non-governmental organisations.

Epidemiology and etiology of childhood pneumonia in 2010: estimates of incidence, severe morbidity, mortality, underlying risk factors and causative pathogens for 192 countries

Background

The recent series of reviews conducted within the Global Action Plan for Pneumonia and Diarrhoea (GAPPD) addressed epidemiology of the two deadly diseases at the global and regional level; it also estimated the effectiveness of interventions, barriers to achieving high coverage and the main implications for health policy. The aim of this paper is to provide the estimates of childhood pneumonia at the country level. This should allow national policy–makers and stakeholders to implement proposed policies in the World Health Organization (WHO) and UNICEF member countries.

Methods

We conducted a series of systematic reviews to update previous estimates of the global, regional and national burden of childhood pneumonia incidence, severe morbidity, mortality, risk factors and specific contributions of the most common pathogens: Streptococcus pneumoniae (SP), Haemophilus influenzae type B (Hib), respiratory syncytial virus (RSV) and influenza virus (flu). We distributed the global and regional–level estimates of the number of cases, severe cases and deaths from childhood pneumonia in 2010–2011 by specific countries using an epidemiological model. The model was based on the prevalence of the five main risk factors for childhood pneumonia within countries (malnutrition, low birth weight, non–exclusive breastfeeding in the first four months, solid fuel use and crowding) and risk effect sizes estimated using meta–analysis.

Findings

The incidence of community–acquired childhood pneumonia in low– and middle–income countries (LMIC) in the year 2010, using World Health Organization's definition, was about 0.22 (interquartile range (IQR) 0.11–0.51) episodes per child–year (e/cy), with 11.5% (IQR 8.0–33.0%) of cases progressing to severe episodes. This is a reduction of nearly 25% over the past decade, which is consistent with observed reductions in the prevalence of risk factors for pneumonia throughout LMIC. At the level of pneumonia incidence, RSV is the most common pathogen, present in about 29% of all episodes, followed by influenza (17%). The contribution of different pathogens varies by pneumonia severity strata, with viral etiologies becoming relatively less important and most deaths in 2010 caused by the main bacterial agents – SP (33%) and Hib (16%), accounting for vaccine use against these two pathogens.

Conclusions

In comparison to 2000, the primary epidemiological evidence contributing to the models of childhood pneumonia burden has improved only slightly; all estimates have wide uncertainty bounds. Still, there is evidence of a decreasing trend for all measures of the burden over the period 2000–2010. The estimates of pneumonia incidence, severe morbidity, mortality and etiology, although each derived from different and independent data, are internally consistent – lending credibility to the new set of estimates. Pneumonia continues to be the leading cause of both morbidity and mortality for young children beyond the neonatal period and requires ongoing strategies and progress to reduce the burden further.

Utilization of health care services for childhood morbidity and associated factors in India: a national cross-sectional household survey

Background

Information about utilization of health services and associated factors are useful for improving service delivery to achieve universal health coverage.

Methods

Data on a sample of ever-married women from India Demographic and Health survey 2005–06 was used. Mothers of children aged 0–59 months were asked about child’s illnesses and type of health facilities where treatment was given during 15 days prior to the survey date. Type of health facilities were grouped as informal provider, public provider and private provider. Factors associated with utilization of health services for diarrhea and fever/cough was assessed according to Andersen’s health behavior model. Multinomial logistic regression analyses were done considering sampling weights for complex sampling design.

Results

A total of 48,679 of ever-married women reported that 9.1% 14.8% and 17.67% of their children had diarrhea, fever and cough respectively. Nearly one-third of the children with diarrhea and fever/cough did not receive any treatment. Two-thirds of children who received treatment were from private health care providers (HCPs). Among predisposing factors, children aged 1–2 years and those born at health facility (public/private) were more likely to be taken to any type of HCP during illness. Among enabling factors, as compared to poorer household, wealthier households were 2.5 times more likely to choose private HCPs for any illness. Children in rural areas were likely to be taken to any type of HCP for diarrhea but rural children were less likely to utilize private HCP for fever/cough. ‘Need’ factors i.e. children having severe symptoms were 2–3 times more likely to be taken to any type of HCP.

Conclusion

Private HCPs were preferred for treatment of childhood illnesses. Involvement of private HCPs may be considered while planning child health programs. Health insurance scheme for childhood illnesses may to protect economically weaker sections from out-of-pocket health expenditure during child illness.

Diarrhoeal diseases and the global health agenda: measuring and changing priority

We investigate priority setting and the global health agenda by analysing the control of diarrhoeal diseases (CDD). CDD was one of the 'twin engines' of the 1980s' child survival movement, but now has a low priority on the global health agenda, even though diarrhoeal diseases still claim around 1.5 million children annually. In this article, we develop a framework and four indicators of priority to measure CDD's overall prominence on the global health agenda over the last three decades: trends in treatment coverage, changes in perceived priority, changes in financial support and institutional involvement and bibliographic trends. We find that CDD's priority is now one-sixth to one-third of its level in 1985. We then use political analysis to suggest strategies for reframing CDD as an issue and promoting its priority on the global health agenda.

Community-based interventions to optimize early childhood development in low resource settings

OBJECTIVE

Interventions targeting the early childhood period (0 to 3 years) help to improve neuro-cognitive functioning throughout life. Some of the more low cost, low resource-intensive community practices for this age-group are play, reading, music and tactile stimulation. This research was conducted to summarize the evidence regarding the effectiveness of such strategies on child development, with particular focus on techniques that may be transferable to developing countries and to children at risk of developing secondary impairments.

STUDY DESIGN

PubMed, PsycInfo, Embase, ERIC, CINAHL and Cochrane were searched for studies involving the above strategies for early intervention. Reference lists of these studies were scanned and other studies were incorporated based on snow-balling.

RESULT

Overall, 76 articles corresponding to 53 studies, 24 of which were randomized controlled trials, were identified. Sixteen of those studies were from low- and middle-income countries. Play and reading were the two commonest interventions and showed positive impact on intellectual development of the child. Music was evaluated primarily in intensive care settings. Kangaroo Mother Care, and to a lesser extent massage, also showed beneficial effects. Improvement in parent-child interaction was common to all the interventions.

CONCLUSION

Play and reading were effective interventions for early childhood interventions in low- and middle-income countries. More research is needed to judge the effectiveness of music. Kangaroo Mother Care is effective for low birth weight babies in resource poor settings, but further research is needed in community settings. Massage is useful, but needs more rigorous research prior to being advocated for community-level interventions.

Validation of the MedDietScore via the determination of plasma fatty acids

BACKGROUND

The purpose of the present work was to validate the MedDietScore by means of plasma fatty acid levels.

METHODS

The study sample consisted of 189 men (44+/-13 years old) and 185 women (40+/-15 years old), randomly selected from the ATTICA study database. All participants completed a food frequency questionnaire (the EPIC-Greek FFQ), and a modified version of the MedDietScore (using weights) was then calculated to evaluate the level of adherence to the Mediterranean diet. Plasma and dietary fatty acids were measured.

RESULTS

Correlation analysis revealed a strong positive relationship between the MedDietScore, monounsaturated fatty acids (P <0.001), monounsaturated fatty acids to saturated fatty acids (P <0.001), docosahexaenoic acid (22:6 n-3) (P <0.05) and n-3 fatty acids (P <0.001), and inverse correlations between the diet score and polyunsaturated fatty acids (comprised of the sum of n-3 and n-6 fatty acids) (P <0.001), saturated fatty acids (P <0.01), and total n-6 fatty acids (P <0.001). The effect size of the relationships between the weighted-MedDietScore and fatty acids was better than the relationships with the initial version of the diet score.

CONCLUSIONS

Our findings suggest that the modified MedDietScore is a valid measure of various plasma fatty acids, and may prove a useful tool in assessing diet quality of adults.

Child survival gains in Tanzania: analysis of data from demographic and health surveys

BACKGROUND

A recent national survey in Tanzania reported that mortality in children younger than 5 years dropped by 24% over the 5 years between 2000 and 2004. We aimed to investigate yearly changes to identify what might have contributed to this reduction and to investigate the prospects for meeting the Millennium Development Goal for child survival (MDG 4).

METHODS

We analysed data from the four demographic and health surveys done in Tanzania since 1990 to generate estimates of mortality in children younger than 5 years for every 1-year period before each survey back to 1990. We estimated trends in mortality between 1990 and 2004 by fitting Lowess regression, and forecasted trends in mortality in 2005 to 2015. We aimed to investigate contextual factors, whether part of Tanzania's health system or not, that could have affected child mortality.

FINDINGS

Disaggregated estimates of mortality showed a sharp acceleration in the reduction in mortality in children younger than 5 years in Tanzania between 2000 and 2004. In 1990, the point estimate of mortality was 141.5 (95% CI 141.5-141.5) deaths per 1000 livebirths. This was reduced by 40%, to reach a point estimate of 83.2 (95% CI 70.1-96.3) deaths per 1000 livebirths in 2004. The change in absolute risk was 58.4 (95% CI 32.7-83.8; p<0.0001). Between 1999 and 2004 we noted important improvements in Tanzania's health system, including doubled public expenditure on health; decentralisation and sector-wide basket funding; and increased coverage of key child-survival interventions, such as integrated management of childhood illness, insecticide-treated nets, vitamin A supplementation, immunisation, and exclusive breastfeeding. Other determinants of child survival that are not related to the health system did not change between 1999 and 2004, except for a slow increase in the HIV/AIDS burden.

INTERPRETATION

Tanzania could attain MDG 4 if this trend of improved child survival were to be sustained. Investment in health systems and scaling up interventions can produce rapid gains in child survival.

Effective international action against undernutrition: why has it proven so difficult and what can be done to accelerate progress?

Many transnational organisations work to support efforts to eliminate maternal and child undernutrition in high-burden countries. Financial, intellectual, and personal linkages bind these organisations loosely together as components of an international nutrition system. In this paper, we argue that such a system should deliver in four functional areas: stewardship, mobilisation of financial resources, direct provision of nutrition services at times of natural disaster or conflict, and human and institutional resource strengthening. We review quantitative and qualitative data from various sources to assess the performance of the system in each of these areas, and find substantial shortcomings. Fragmentation, lack of an evidence base for prioritised action, institutional inertia, and failure to join up with promising developments in parallel sectors are recurrent themes. Many of these weaknesses can be attributed to systemic problems affecting most organisations working in the field; these are analysed using a problem tree approach. We also make recommendations to overcome some of the most important problems, and we propose five priority actions for the development of a new international architecture.

Childhood disability in low- and middle-income countries: overview of screening, prevention, services, legislation, and epidemiology

BACKGROUND

Childhood disability affects millions of children around the world, most of whom are in low- and middle-income countries. Despite the large burden on child development, family life, and economics, research in the area of childhood disability is woefully inadequate, especially from low- and middle-income countries.

OBJECTIVE

The objective of this review was to generate information about current knowledge on childhood disability in low- and middle-income countries and identify gaps to guide future research.

METHODS

Electronic databases (PubMed, Embase, PsycInfo) were searched by using specific search terms related to childhood disability in developing countries. The Cochrane Library was also searched to identify any similar reviews. Whole texts of articles that met study criteria were scrutinized for information regarding research method, screening tools, epidemiology, disability-related services, legislation, and prevention and promotion activities. Quantitative and qualitative information was collated, and frequency distributions of research parameters were generated.

RESULTS

Eighty articles were included in the review (41 from low-income countries). Almost 60% of the studies were cross-sectional; case-control, cohort, and randomized, controlled trials accounted for only 15% of the studies. Of the 80 studies, 66 focused on epidemiologic research. Hearing (26%) and intellectual (26%) disabilities were the commonly studied conditions. The Ten Questionnaire was the most commonly used screening tool. Information on specific interventions, service utilization, and legislation was lacking, and study quality generally was inadequate. Data on outcomes of morbidities, including delivery complications and neonatal and early childhood illness, is particularly lacking.

CONCLUSIONS

With this review we identified potential gaps in knowledge, especially in the areas of intervention, service utilization, and legislation. Even epidemiologic research was of inadequate quality, and research was lacking on conditions other than hearing and intellectual disabilities. Future researchers should not only address these gaps in current knowledge but also take steps to translate their research into public health policy changes that would affect the lives of children with disabilities in low- and middle-income countries.