Conflict in Somalia: impact on child undernutrition

Predicting the short and long term effects of food price inflation, armed conflicts, and climate variability on global acute malnutrition in Somalia

BACKGROUND

Malnutrition poses a substantial challenge in Somalia, impacting approximately 1.8 million children. This critical issue is exacerbated by a multifaceted interplay of factors. Consequently, this study seeks to examine the long-term and short-term effects of armed conflicts, food price inflation, and climate variability on global acute malnutrition in Somalia.

METHODS

The study utilized secondary data spanning from January 2015 to December 2022, sourced from relevant databases. Two distinct analytical approaches were employed to comprehensively investigate the dynamics of global acute malnutrition in Somalia. Firstly, dynamic autoregressive distributed lag (ARDL) simulations were applied, allowing for a nuanced understanding of the short and long-term effects of armed conflicts, food price inflation, and climate variability on malnutrition. Additionally, the study employed kernel-based regularized least squares, a sophisticated statistical technique, to further enhance the robustness of the findings. The analysis was conducted using STATA version 17.

RESULTS

In the short run, armed conflicts and food price inflation exhibit positive associations with global acute malnutrition, particularly in conflict-prone areas and during inflationary periods. Moreover, climatic variables, specifically temperature and rainfall, demonstrate positive associations. It is important to note that temperature lacks a statistically significant relationship with global acute malnutrition in the short run. In the long run, armed conflicts and food price inflation maintain persistent impacts on global acute malnutrition, as confirmed by the dynamic ARDL simulations model. Furthermore, both temperature and rainfall continue to show positive associations with global acute malnutrition, but it is worth noting that temperature still exhibits a non-significant relationship. The results from kernel-based regularized least squares were consistent, further enhancing the robustness of the findings.

CONCLUSIONS

Increased armed conflicts, food price inflation, temperature, and rainfall were associated with increased global acute malnutrition. Strategies such as stabilizing conflict-prone regions, diplomatic interventions, and peace-building initiatives are crucial, along with measures to control food price inflation. Implementing climate adaptation strategies is vital to counter temperature changes and fluctuating rainfall patterns, emphasizing the need for resilience-building. Policymakers and humanitarian organizations can leverage these insights to design targeted interventions, focusing on conflict resolution, food security, and climate resilience to enhance Somalia's overall nutritional well-being.

Excess Child Mortality Associated With Colombia's Armed Conflict, 1998-2019

Importance

Armed conflicts are directly and indirectly associated with morbidity and mortality due to destruction of health infrastructure and diversion of resources, forced displacement, environmental damage, and erosion of social and economic security. Colombia's conflict began in the 1940s and has been uniquely long-lasting and geographically dynamic.

Objective

To estimate the proportion of infant and child mortality associated with armed conflict exposure from 1998 to 2019 in Colombia.

Design, Setting, and Participants

This ecological cohort study includes data from all 1122 municipalities in Colombia from 1998 to 2019. Statistical analysis was conducted from February 2022 to June 2023.

Exposure

Armed conflict exposure was measured dichotomously by the occurrence of conflict-related events in each municipality-year, enumerated and reported by the Colombian National Center for Historic Memory.

Main Outcomes and Measures

Deaths among children younger than 5 years and deaths among infants younger than 1 year, offset by the number of births in that municipality-year, enumerated by Colombia's national vital statistics.

Results

The analytical sample included 24 157 municipality-years and 223 101 conflict events covering the period from 1998 to 2019. Overall, the presence of armed conflict in a municipality was associated with a 52% increased risk of death for children younger than 5 years of age (relative risk, 1.52 [95% CI, 1.34-1.72]), with similar results for 1- and 5-year lagged analyses. Armed conflict was associated with a 61% increased risk in infant (aged <1 year) death (relative risk, 1.61 [95% CI, 1.43-1.82]). On the absolute scale, this translates to a risk difference of 3.7 excess child deaths per 1000 births (95% CI, 2.7-4.7 per 1000 births) and 3.0 excess infant deaths per 1000 births (95% CI, 2.3-3.6 per 1000 births) per year, beyond what would be expected in the absence of armed conflict. Across the 22-year study period, the population attributable risk was 31.7% (95% CI, 23.5%-39.1%) for child deaths and 35.3% (95% CI, 27.8%-42.0%) for infant deaths.

Conclusions and Relevance

This ecological cohort study of Colombia's spatiotemporally dynamic armed conflict suggests that municipal exposure to armed conflict was associated with excess child and infant deaths. With a record number of children living near active conflict zones in 2020, policy makers and health professionals should understand the magnitude of and manner in which armed conflicts directly and indirectly undermine child health.

The effect of conflict on child and adolescent health in Amhara region, Ethiopia: Cross-Sectional Study

BACKGROUND

Currently, conflict become common phenomenon in the world affecting the lives of millions of children. Due the continued conflict in Ethiopia millions of children are suffering from extreme levels of violence, lack of basic humanitarian needs, and lack of health services.

OBJECTIVE

This study was designed to assess the effect of conflict on child and adolescent health in Amhara region, September 2022.

METHODS

A community-based cross-sectional study was employed among children agedd < 18 years in conflict affected areas of Amhara region. The sample size was determined using a single population proportion formula. Data was collected through face-to-face interviews of children or child legal guardians. Data was cleaned, verified, and entered into EpiData version 3.1 and analysis was done using SPSS version 24 statistical software.

RESULT

Seven hundred and ninety-eight children agedd less than 18 years were involved with a response rate of 94.33 percent. More than one thirds (276, 34.59%) of children were displaced due to the conflict. Three hundred and thirty one (41.48%) children get diseased with the majority didn't receive treatment. More than two thirds (557, 69.80%) of children had experienced violence of different types. One hundred and thirty four (41.23%) children had acute malnutrition with two third (66.42%) of them had severe acute malnutrition.

CONCLUSION

Conflict had deadly impacts on the lives of children and adolescents. It causes massive displacement, lack of basic humanitarian needs, extreme level of violence, hunger and malnutrition, and lack of health services. The government and other national and international humanitarian aids should give special attention to children living in war zone of Amhara region. In addition, rehabilitation services and resilience training should be designed and provided to children affected by the conflict.

Prevalence and multi-level factors associated with acute malnutrition among children aged 6-59 months from war affected communities of Tigray, Northern Ethiopia, 2021: a cross-sectional study

BACKGROUND

Armed conflicts greatly affect the health, nutrition, and food security of conflict affected settings particularly children. However, no empirical data exist regarding context specific factors contributing towards acute malnutrition in the war-torn Tigray, Ethiopia. Thus, this study aimed to identify individual and community level factors associated with acute malnutrition among children aged 6-59 months from armed conflict affected settings of Tigray, Ethiopia.

METHODS

A community based cross-sectional study was conducted among 3,614 children aged 6-59 months in Tigray, from July 15 to Aug 15, 2021. Study participants were selected using a two-stage random sampling method. A structured questionnaire was used to collect data by interviewing mothers/caregivers. Mid upper arm circumference (MUAC) measurements were taken from upper left arm of the children using MUAC tapes. Multivariable multilevel logistic regression analysis was used to determine factors associated with acute malnutrition. Adjusted Odds ratio (AOR) with 95% CI were estimated to describe the strength of associations at p < 0.05.

RESULTS

More than half (52.5%) of the sampled children were males in sex. Immediately after the first nine months into the conflict, the prevalence of severe, moderate, and global acute malnutrition was very high (5.1%, 21.8%, and 26.9%, respectively) in Tigray. The lowest and highest burden of child acute malnutrition was reported from Mekelle zone (13.3%) and Southeastern zone (36.7%), respectively. Individual-level factors such as older child age (AOR = 0.13, 95% CI: 0.10, 0.18), female child sex (AOR = 1.24, 95% CI 1.05, 1.480.95), Vitamin-A supplementation (AOR = 1.3, 95% CI: 1.05, 1.65), and history of diarrhea (AOR = 1.22, 95%CI: 1.02, 1.53) and community-level factors like unimproved drinking water source (AOR = 1.31, 95%CI: 1.08, 1.58), unimproved toilet facility (AOR = 1.24, 95% CI: 1.01, 1.52), and severe food insecurity (AOR = 1.55, 95% CI: 1.16. 2.07) were significantly associated with childhood acute malnutrition.

CONCLUSIONS

The burden of acute malnutrition is a severe public health problem in Tigray. To prevent the untimely suffering and death of children, regular nutrition screening, speedy, and appropriate referral of all malnourished children to nutritional services and large-scale humanitarian assistance including access to food; nutrition supplies; water, sanitation and hygiene supplies; and health care in a timely manner are required. In the prevailing armed conflict, these have been very difficult to achieve. Thus, immediate international intervention is needed.

Population health trends and disease profile in Somalia 1990-2019, and projection to 2030: will the country achieve sustainable development goals 2 and 3?

OBJECTIVES

This study aims to evaluate whether Somalia will reach Sustainable Development Goals 2 and 3 by 2030 and what the country requires to advance closer to these objectives.

SETTING

Somalia.

PARTICIPANTS

We carried out analyses of secondary data obtained from the following open-access databases: Global Burden of Disease 2019 study; United Nations (UN) Department of Economic and Social Affairs Population Division; World Bank World Development Indicators; United Nations Children's Fund (UNICEF); UNICEF/World Health Organisation (WHO)/World Bank Joint Child Malnutrition Estimates; and UN Interagency Group for Child Mortality Estimation (UN IGME), disaggregated by sex.

PRIMARY OUTCOME MEASURES

stillbirth, neonatal, infant, under-five, maternal and child mortality; under-five malnutrition; life expectancy; health-adjusted life expectancy; age-standardised all-cause mortality; age-standardised cause-specific mortality for the leading causes of death; disability-adjusted life years.

SECONDARY OUTCOME MEASURES

vitamin A coverage; stunting, overweight in children under 5; top risk factors contributing to cause-specific mortality.

RESULTS

life expectancy in Somalia will increase to 65.42 years (95% UI 62.30-68.54) for females and 58.54 years (95% UI 54.89-62.19) for males in 2030. Stunting will continue to decline to 25.2% (90% UI 13.9-39.5%), and the under-five mortality rate will drop to 85.9 per 1000 live births (90% UI 22.0-228.1 per 1000 live births) for females and 96.4 per 1000 live births (90% UI 24.8-255.3 per 1000 live births) for males in 2030. This study's analyses predict that the maternal mortality ratio in Somalia will decline to 696.42 deaths per 100,000 live births in 2030.

CONCLUSIONS

there has been progress towards SDG targets in Somalia since 1990. To achieve these, Somalia requires greater health improvements than observed between 1990 and 2019.

Conflict and Climate Factors and the Risk of Child Acute Malnutrition Among Children Aged 24-59 Months: A Comparative Analysis of Kenya, Nigeria, and Uganda

Acute malnutrition affects a sizeable number of young children around the world, with serious repercussions for mortality and morbidity. Among the top priorities in addressing this problem are to anticipate which children tend to be susceptible and where and when crises of high prevalence rates would be likely to arise. In this article, we highlight the potential role of conflict and climate conditions as risk factors for acute malnutrition, while also assessing other vulnerabilities at the individual- and household-levels. Existing research reflects these features selectively, whereas we incorporate all the features into the same study. The empirical analysis relies on integration of health, conflict, and environmental data at multiple scales of observation to focuses on how local conflict and climate factors relate to an individual child's health. The centerpiece of the analysis is data from the Demographic and Health Surveys conducted in several different cross-sectional waves covering 2003-2016 in Kenya, Nigeria, and Uganda. The results obtained from multi-level statistical models indicate that in Kenya and Nigeria, conflict is associated with lower weight-for-height scores among children, even after accounting for individual-level and climate factors. In Nigeria and Kenya, conflict lagged 1-3 months and occurring within the growing season tends to reduce WHZ scores. In Uganda, however, weight-for-height scores are primarily associated with individual-level and household-level conditions and demonstrate little association with conflict or climate factors. The findings are valuable to guide humanitarian policymakers and practitioners in effective and efficient targeting of attention, interventions, and resources that lessen burdens of acute malnutrition in countries prone to conflict and climate shocks.

Conflict and Child Malnutrition: a Systematic Review of the Emerging Quantitative Literature

PURPOSE OF REVIEW

Reduction of child malnutrition in conflict settings is on top of the international agenda on sustainable development. This association between child malnutrition and conflict has been hypothesised in the academic literature but not rigorously examined empirically till recently. This paper reviews the emerging quantitative literature, including conflict as an explanatory variable to understand the aspects of child malnutrition studied and how violent events are associated with child nutritional status. Limitations are also highlighted.

RECENT FINDINGS

Child malnutrition is investigated into its three main dimensions of stunting, wasting and undernourishment computed as z-score. Conflict is mostly studied in terms of duration, number of events, typology and intensity. The emerging literature generally establishes a significant and negative association between conflict and child malnutrition. However, limitations persist and are mainly due to the type of available data.

The prevalence of stunting among children and adolescents living in the Middle East and North Africa region (MENA): A systematic review and meta-analysis

Background

Given the strategic importance of the MENA, the state of war and inequity in the region and its effect on malnutrition which leads to mortality and reduced economic development in this region, the current study purposed to examine the prevalence of stunting as an indicator of chronic malnutrition in the MENA region, with consideration given HDI, rural/urban area, and war-involved countries.

Methods

The electronic databases of PubMed, SCOPUS, Web of science, and Embase were systematically searched, and English-language articles published between January 1, 2009 and December 31, 2019 were included in this study. The POLIS (population, outcome, location, indicator, study design) criteria were used to perform the systematic review, and studies involving children 2 to 18 years of age were selected.

Results

Fifty-eight (n = 2 202 869) were included based on the study's inclusion criteria. The prevalence of stunting in children in the total MENA region was 22.0% (95% confidence interval (CI) = 20.4-23.6; I² = 99.92%, P < 0.0001). The studies included in the meta-analysis were analyzed by subgroups. The pooled prevalence of stunting in children aged 2-5 years old and children aged 6 and older was 25.7% and 16.5%, respectively. The pooled prevalence of stunting was 34.1% in rural and 12.4% in urban areas. The pooled prevalence of stunting according to HDI was 30.1%, 28.5%, 13.1%, in low, medium, and high HDI countries, respectively. Furthermore, the pooled prevalence of stunting according to war status was 28.5% in war-involved countries vs 20.6% in others.

Conclusions

High prevalence of malnutrition was seen based on stunting indicator in the meta-analysis study in the MENA region, and this issue became more pronounced when the data was divided into subgroups based on age, residential area, and HDI. Inequality regarding social, economic, and political factors leads to significant malnutrition in the mentioned region.

Child nutritional status as screening tool for identifying undernourished mothers: an observational study of mother–child dyads in Mogadishu, Somalia, from November 2019 to March 2020

Background

Active screening of only pregnant and lactating mothers (PLMs) excludes other mothers of reproductive age susceptible to undernutrition. Our analysis evaluated if mothers presenting with wasted children were more likely to be undernourished themselves.

Methods

The observational study enrolled mother and child dyads presenting to an outpatient facility in Mogadishu, Somalia, between November 2019 and March 2020. Trained nurses recorded lower extremity oedema for children aged 6–59 months, parity and gestational status for women aged 19–50 years and age, access to care, height/length, mid-upper arm circumference (MUAC) and weight for both. Weight-for-height z-score (WHZ) for children and body mass index (BMI) for mothers were calculated using standard procedures. Wasting was defined as WHZ <−2, MUAC <12.5 cm and/or presence of oedema for children. Undernutrition was defined as MUAC <23 cm for PLMs and BMI <18.5 kg/m² for neither pregnant nor lactating mothers (non-PLMs). Four multivariable linear regression models were fit to evaluate maternal anthropometric indicators (BMI or MUAC) given child anthropometric indicators (MUAC or WHZ), adjusting for maternal age, parity and gestational status.

Results

A total of 93.6% (2142/2288) of enrolled dyads met inclusion criteria. Wasting was observed among 57.5% of children; 20.2% of pregnant mothers, 20.0% of lactating mothers and 7.95% of non-PLMs were undernourished. Models suggest significant, positive associations between child and maternal anthropometrics; a one-unit increase in WHZ and a 1 cm increase in child MUAC were associated with 0.22 kg/m² (95% CI 0.22 to 0.24) and 0.19 kg/m² (95% CI 0.16 to 0.21) increases in maternal BMI, respectively, and 0.20 cm (95% CI 0.18 to 0.22) and 0.24 cm (95% CI 0.23 to 0.25) increases in maternal MUAC, respectively. Adjusted R² values were low (range 0.06–0.10).

Conclusions

Undernutrition among non-PLMs illustrates the importance of expanding screening. However, while significant, the strength of association between mother and child anthropometrics does not support child nutritional status as a screening tool for identifying at-risk mothers.

One planet one health: What about the kids?

Humans in their increasing numbers and wealth are changing ecosystems through accelerated consumption of food, natural resources and energy which continue to cause significant damage to the planet. Using 'stunting in children' as a case study, we show how the traditional siloed (specialist) approaches have failed to reduce stunting world-wide. Despite significant effort, traditional approaches fail to appreciate the interconnectedness of the multiple factors that underpin stunting. We will not improve the lives of the millions of children living in poverty by doing the same things we have always done, rather we need to adopt approaches that recognise the interconnectedness of all the component parts and apply One Health methods designed to solve these intractable problems.

Implications of armed conflict for maternal and child health: A regression analysis of data from 181 countries for 2000-2019

BACKGROUND

Armed conflicts have major indirect health impacts in addition to the direct harms from violence. They create enduring political instability, destabilise health systems, and foster negative socioeconomic and environmental conditions-all of which constrain efforts to reduce maternal and child mortality. The detrimental impacts of conflict on global maternal and child health are not robustly quantified. This study assesses the association between conflict and maternal and child health globally.

METHODS AND FINDINGS

Data for 181 countries (2000-2019) from the Uppsala Conflict Data Program and World Bank were analysed using panel regression models. Primary outcomes were maternal, under-5, infant, and neonatal mortality rates. Secondary outcomes were delivery by a skilled birth attendant and diphtheria, pertussis, and tetanus (DPT) and measles vaccination coverage. Models were adjusted for 10 confounders, country and year fixed effects, and conflict lagged by 1 year. Further lagged associations up to 10 years post-conflict were tested. The number of excess deaths due to conflict was estimated. Out of 3,718 country-year observations, 522 (14.0%) had minor conflicts and 148 (4.0%) had wars. In adjusted models, conflicts classified as wars were associated with an increase in maternal mortality of 36.9 maternal deaths per 100,000 live births (95% CI 1.9-72.0; 0.3 million excess deaths [95% CI 0.2 million-0.4 million] over the study period), an increase in infant mortality of 2.8 per 1,000 live births (95% CI 0.1-5.5; 2.0 million excess deaths [95% CI 1.6 million-2.5 million]), a decrease in DPT vaccination coverage of 4.9% (95% CI 1.5%-8.3%), and a decrease in measles vaccination coverage of 7.3% (95% CI 2.7%-11.8%). The long-term impacts of war were demonstrated by associated increases in maternal mortality observed for up to 7 years, in under-5 mortality for 3-5 years, in infant mortality for up to 8 years, in DPT vaccination coverage for up to 3 years, and in measles vaccination coverage for up to 2 years. No evidence of association between armed conflict and neonatal mortality or delivery by a skilled birth attendant was found. Study limitations include the ecological study design, which may mask sub-national variation in conflict intensity, and the quality of the underlying data.

CONCLUSIONS

Our analysis indicates that armed conflict is associated with substantial and persistent excess maternal and child deaths globally, and with reductions in key measures that indicate reduced availability of organised healthcare. These findings highlight the importance of protecting women and children from the indirect harms of conflict, including those relating to health system deterioration and worsening socioeconomic conditions.

Lockdowns, lives and livelihoods: the impact of COVID-19 and public health responses to conflict affected populations - a remote qualitative study in Baidoa and Mogadishu, Somalia

BACKGROUND

Authorities in Somalia responded with drastic measures after the first confirmed COVID-19 case in mid-March 2020, closing borders, schools, limiting travel and prohibiting most group functions. However, the impact of the pandemic in Somalia thereafter remained unclear. This study employs a novel remote qualitative research method in a conflict-affected setting to look at how some of the most at-risk internally displaced and host populations were impacted by COVID-19, what determined their responses, and how this affected their health and socio-economic vulnerability.

METHODS

We conducted a remote qualitative study, using Katikati, a 1-to-1 conversation management and analysis platform using short message service (SMS) developed by Lark Systems with Africa's Voices Foundation (AVF), for semi-structured interviews over three months with participants in Mogadishu and Baidoa. We recruited a gender balanced cohort across age groups, and used an analytical framework on the social determinants of health for a narrative analysis on major themes discussed, triangulating data with existing peer-reviewed and grey literature.

RESULTS

The remote research approach demonstrated efficacy in sustaining trusted and meaningful conversations for gathering qualitative data from hard-to-reach conflict-affected communities. The major themes discussed by the 35 participants included health, livelihoods and education. Two participants contracted the disease, while others reported family or community members affected by COVID-19. Almost all participants faced a loss of income and/or education, primarily as a result of the strict public health measures. Some of those who were heavily affected economically but did not directly experienced disease, denied the pandemic. Religion played an important role in participants' beliefs in protection against and salvation from the disease. As lockdowns were lifted in August 2020, many believed the pandemic to be over.

CONCLUSIONS

While the official COVID-19 burden has remained relatively low in Somalia, the impact to people's daily lives, income and livelihoods due to public health responses, has been significant. Participants describe those 'secondary' outcomes as the main impact of the pandemic, serving as a stark reminder of the need to broaden the public health response beyond disease prevention to include social and economic interventions to decrease people's vulnerability to future shocks.

Estimating indirect mortality impacts of armed conflict in civilian populations: panel regression analyses of 193 countries, 1990-2017

BACKGROUND

Armed conflict can indirectly affect population health through detrimental impacts on political and social institutions and destruction of infrastructure. This study aimed to quantify indirect mortality impacts of armed conflict in civilian populations globally and explore differential effects by armed conflict characteristics and population groups.

METHODS

We included 193 countries between 1990 and 2017 and constructed fixed effects panel regression models using data from the Uppsala Conflict Data Program and Global Burden of Disease study. Mortality rates were corrected to exclude battle-related deaths. We assessed separately four different armed conflict variables (capturing binary, continuous, categorical, and quintile exposures) and ran models by cause-specific mortality stratified by age groups and sex. Post-estimation analyses calculated the number of civilian deaths.

RESULTS

We identified 1118 unique armed conflicts. Armed conflict was associated with increases in civilian mortality-driven by conflicts categorised as wars. Wars were associated with an increase in age-standardised all-cause mortality of 81.5 per 100,000 population (β 81.5, 95% CI 14.3-148.8) in adjusted models contributing 29.4 million civilian deaths (95% CI 22.1-36.6) globally over the study period. Mortality rates from communicable, maternal, neonatal, and nutritional diseases (β 51.3, 95% CI 2.6-99.9); non-communicable diseases (β 22.7, 95% CI 0.2-45.2); and injuries (β 7.6, 95% CI 3.4-11.7) associated with war increased, contributing 21.0 million (95% CI 16.3-25.6), 6.0 million (95% CI 4.1-8.0), and 2.4 million deaths (95% CI 1.7-3.1) respectively. War-associated increases in all-cause and cause-specific mortality were found across all age groups and both genders, but children aged 0-5 years had the largest relative increases in mortality.

CONCLUSIONS

Armed conflict, particularly war, is associated with a substantial indirect mortality impact among civilians globally with children most severely burdened.

Determinants of anthropometric characteristics of under-five children in internally displaced persons´ camps in Abuja municipal area council, Abuja, Nigeria

INTRODUCTION

displacement predisposes to deprivation and hunger and consequently malnutrition. In Nigeria, information on anthropometric characteristics and associated factors among displaced under-five children is important to strengthen strategies to ameliorate malnutrition and promote child health. This study was conducted to identify the determinants on anthropometric indices among under-five children in internally displaced persons' camps in Abuja, Nigeria.

METHODS

this cross-sectional study involved 317 mother-child (0-59 months) pairs selected using two-stage simple random sampling technique. Information on socio-demographic, care practices (infant feeding, immunization, deworming) and anthropometric characteristics of index children was obtained using semi-structured, interviewer-administered questionnaire. Weight and length/height were assessed using standard procedure and analysed using World Health Organization (WHO) Anthro software. Data were analysed using descriptive statistics and logistic regression at p<0.05.

RESULTS

median age was 24 months, 50.8% were male and 42.3% were delivered at health facility. Only 45.4% were exclusively breastfed, 28.8% were fed complementary foods too early, 45.4% were dewormed in the preceding six months and 43.9% had complete/up-to-date immunisation. Prevalence of underweight, stunting and wasting was 42%, 41% and 29.3%, respectively. Poor anthropometric indices were higher among male than female children, except wasting. Having good anthropometric index was 2.5 times higher among children <12 months than children ≥37 months (CI: 1.08-5.8), 2.4 times higher among 1st birth order than 5th orders (CI: 0.19-0.93), 1.7 times higher among female than male children (CI: 1.08-2.82).

CONCLUSION

malnutrition is a major health problem among under-five children in internally displaced camps and major determinants include age, birth order, gender and deworming status.

The impact of civil conflict on infant and child malnutrition, Nigeria, 2013

The new millennium brought renewed attention to improving the health of women and children. In this same period, direct deaths from conflicts have declined worldwide, but civilian deaths associated with conflicts have increased. Nigeria is among the most conflict-prone countries in Sub-Saharan Africa, especially recently with the Boko Haram insurgency in the north. This paper uses two data sources, the 2013 Demographic and Health Survey for Nigeria and the Social Conflict Analysis Database, linked by geocode, to study the effect of these conflicts on infant and young child acute malnutrition (or wasting). We show a strong association in 2013 between living close to a conflict zone and acute malnutrition in Nigerian children, with larger effects for rural children than urban children. This is related to the severity of the conflict, measured both in terms of the number of conflict deaths and the length of time the child was exposed to conflict. Undoubtedly, civil conflict is limiting the future prospects of Nigerian children and the country's economic growth. In Nigeria, conflicts in the north are expected to continue with sporadic attacks and continued damaged infrastructure. Thus, Nigerian children, innocent victims of the conflict, will continue to suffer the consequences documented in this study.

Multisector nutrition gains amidst evidence scarcity: scoping review of policies, data and interventions to reduce child stunting in Afghanistan

Background

Child health indicators have substantially improved across the last decade, yet Afghanistan has among the highest child stunting and malnutrition rates in Asia. Multisectoral approaches were recently introduced but evidence for this approach to improve support for and implementation of child nutrition programmes is limited compared to other countries.

Methods

We reviewed policy and programme data to identify best practices and gaps surrounding child malnutrition in Afghanistan. We conducted a scoping review using broad search categories and approaches, including database and website searches, reference hand-searches, purposive policy and programme document request, and key informant interviews. Inclusion and exclusion criteria were developed iteratively, with abstracts and documents assessed against the final criteria. We abstracted documents systematically and summarised and synthesised content to generate the main findings.

Results

We included 18 policies and strategies, 45 data sources and reports, and 20 intervention evaluations. Movement towards multisectoral efforts to address malnutrition at the policy level has started; however, integrated nutrition-specific and nutrition-sensitive interventions are not yet uniformly delivered at the community level. Many data sources capturing nutrition, food security and WASH (water, sanitation and hygiene) indicators are available but indicator definitions are not standardised and there are few longitudinal nutrition surveys. Political will to improve household nutrition status has shown increased government and donor investments in nutrition-sensitive and nutrition-specific programmes through combined small- and large-scale interventions between 2004 and 2013; however, evidence for interventions that effectively decrease stunting prevalence is limited.

Conclusions

This review shows a breadth of nutrition programme, policy and data in Afghanistan. Multisector approaches faced challenges of reaching sufficient coverage as they often included a package of food security, livelihoods and health interventions but were each implemented independently. Further implementation evidence is needed to aid policy and programmes on effective integration of nutrition, food security and WASH in Afghanistan.

Armed conflict as a determinant of children malnourishment: a cross-sectional study in The Sudan

Background

Children’s nutritional status influences their physical, socioemotional and cognitive development throughout the life course. We aimed to determine the role of armed conflict on the prevalence of childhood malnourishment in The Sudan, and understand the underlying mechanisms using a framework based on the social determinants of health.

Methods

We analysed cross-sectional data from the 2014-Sudan Multiple Indicator Cluster Survey (n = 14,081) to compare the prevalence of malnourishment in states undergoing armed conflict and states free of conflict. Four-level multilevel multivariate modelling was conducted to identify the contribution of the social determinants of malnourishment in explaining the role of armed conflict in child health, with conflict status as the central predictor and progressive adjustments for child-, household- and cluster- and state-level predictors.

Results

Armed conflict is strongly associated with greater risk of severe and moderate underweight among children under-5. Adjusting for key social determinants of health reduced the strength of the association between armed conflict and risk of underweight, but there is statistical evidence of association between armed conflict and risk of severe underweight (OR: 1.60, 95%CI: 1.03–2.49 for the low intensity group).

Conclusion

Conflict-exposed children are particularly vulnerable to malnourishment, and this association is mostly explained by key socio-demographic factors. With the prolonged political instability in The Sudan, sustainable nutritional interventions are necessary to ease hard conditions in conflict-exposed states, and also among disadvantaged families in conflict-free regions.

Review of policies, data, and interventions to improve maternal nutrition in Afghanistan

Malnutrition contributes to direct and indirect causes of maternal mortality, which is particularly high in Afghanistan. Women's nutritional status before, during, and after pregnancy affects their own well‐being and mortality risk and their children's health outcomes. Though maternal nutrition interventions have documented positive impact on select child health outcomes, there are limited data regarding the effects of maternal nutrition interventions on maternal health outcomes globally. This scoping review maps policies, data, and interventions aiming to address poor maternal nutrition outcomes in Afghanistan. We used broad search categories and approaches including database and website searches, hand searches of reference lists from relevant articles, policy and programme document requests, and key informant interviews. Inclusion and exclusion criteria were developed by type of source document, such as studies with measures related to maternal nutrition, relevant policies and strategies, and programmatic research or evaluation by a third party with explicit interventions targeting maternal nutrition. We abstracted documents systematically, summarized content, and synthesized data. We included 20 policies and strategies, 29 data reports, and nine intervention evaluations. The availability of maternal nutrition intervention data and the inclusion of nutrition indicators, such as minimum dietary diversity, have increased substantially since 2013, yet few nutrition evaluations and population surveys include maternal outcomes as primary or even secondary outcomes. There is little evidence on the effectiveness of interventions that target maternal nutrition in Afghanistan. Policies and strategies more recently have shifted towards multisectoral efforts and specifically target nutrition needs of adolescent girls and women of reproductive age. This scoping review presents evidence from more than 10 years of efforts to improve the maternal nutrition status of Afghan women. We recommend a combination of investments in measuring maternal nutrition indicators and improving maternal nutrition knowledge and behaviours.

Using gridded population and quadtree sampling units to support survey sample design in low-income settings

BACKGROUND

Household surveys are the main source of demographic, health and socio-economic data in low- and middle-income countries (LMICs). To conduct such a survey, census population information mapped into enumeration areas (EAs) typically serves a sampling frame from which to generate a random sample. However, the use of census information to generate this sample frame can be problematic as in many LMIC contexts, such data are often outdated or incomplete, potentially introducing coverage issues into the sample frame. Increasingly, where census data are outdated or unavailable, modelled population datasets in the gridded form are being used to create household survey sampling frames.

METHODS

Previously this process was done by either sampling from a set of the uniform grid cells (UGC) which are then manually subdivided to achieve the desired population size, or by sampling very small grid cells then aggregating cells into larger units to achieve a minimum population per survey cluster. The former approach is time and resource-intensive as well as results in substantial heterogeneity in the output sampling units, while the latter can complicate the calculation of unbiased sampling weights. Using the context of Somalia, which has not had a full census since 1987, we implemented a quadtree algorithm for the first time to create a population sampling frame. The approach uses gridded population estimates and it is based on the idea of a quadtree decomposition in which an area successively subdivided into four equal size quadrants, until the content of each quadrant is homogenous.

RESULTS

The quadtree approach used here produced much more homogeneous sampling units than the UGC (1 × 1 km and 3 × 3 km) approach. At the national and pre-war regional scale, the standard deviation and coefficient of variation, as indications of homogeneity, were calculated for the output sampling units using quadtree and UGC 1 × 1 km and 3 × 3 km approaches to create the sampling frame and the results showed outstanding performance for quadtree approach.

CONCLUSION

Our approach reduces the manual burden of manually subdividing UGC into highly populated areas, while allowing for correct calculation of sampling weights. The algorithm produces a relatively homogenous population counts within the sampling units, reducing the variation in the weights and improving the precision of the resulting estimates. Furthermore, a protocol of creating approximately equal-sized blocks and using tablets for randomized selection of a household in each block mitigated potential selection bias by enumerators. The approach shows labour, time and cost-saving and points to the potential use in wider contexts.

Malnutrition and morbidity trends in Somalia between 2007 and 2016: results from 291 cross-sectional surveys

BACKGROUND

More than two decades of conflict and natural disasters in Somalia have resulted in one of the longest running humanitarian crises in the world. Nutrition data have been collected over the years despite challenges to inform programmatic action. This paper explores malnutrition and morbidity trends in Somalia during the last decade, disaggregated by geographical zone and livelihood system.

METHODS

We used data from 291 cross-sectional surveys conducted in children aged 6-59 months between 2007 and 2016 in Somalia. Wasting, morbidity and stunting prevalences over time were analysed by geographic area, livelihood system and season. Logistic regressions were used to test trends.

RESULTS

The wasting trends show a striking peak in 2011, more marked in southern and central Somalia and coinciding with the famine declaration. The trend declines slightly thereafter although not consistently across all zones and livelihoods, and it raises again in 2016 especially among internally displaced persons (IDPs). Stunting declined for all groups and in all zones but with more consistent patterns in northern Somalia.Morbidity also showed a declining trend, although with multiple peaks depicting disease outbreaks.Pastoralist showed the lowest stunting estimates overall, while agrarian populations showed the lowest prevalence of wasting and morbidity. IDPs were the most affected by all outcomes. Seasonality affected the three outcomes differently by livelihood system. Stunting rates increased after the 2011 famine for all age groups within children under 5 years.

CONCLUSIONS

Despite the continuous complex situation in Somalia, there has been a sustained decline in stunting and morbidity in the last decade. Wasting trends have remained at very high levels especially in north-east and the south zones of Somalia. The findings support the importance of performing trend analyses disaggregated by zone and livelihood groups within countries to better identify priorities for programme intervention.

Short-term nutrition and growth indicators in 6-month- to 6-year-old children are improved following implementation of a multidisciplinary community-based programme in a chronic conflict setting

Objective:

We investigated short- and long-term indicators of malnutrition and diet before and after the community-based ‘Breaking the Cycle of Poverty’ multidisciplinary intervention.

Design:

A historically and geographically controlled study using data collected in 2013 and 2016. We compared the prevalence of short-term indicators (anaemia, breast-feeding duration and minimum dietary diversity) and long-term indicators (stunting and wasting) in exposed communities at two time points. We then compared these factors in geographic areas exposed or not exposed to intervention. We conducted logistic regression analyses on the 2016 sample to measure associations between living in intervention communities and child growth indicators.

Setting:

Berd region, a chronic conflict zone near the north-eastern border of Armenia and Azerbaijan.

Participants:

Children aged 6 months to 6 years.

Results:

Analyses included data from 2013 comprising 382 children, and data from 2016 comprising 348 children living in communities where the programme was implemented, and 635 children from unexposed communities. Anaemia prevalence in exposed communities was significantly lower in 2016 v. 2013 (10·9 v. 19·1 %, P < 0·01). Minimum dietary diversity (79·0 v. 68·1 %, P < 0·001) and breast-feeding duration (13·0 v. 11·5 months, P < 0·002) were significantly improved in exposed communities. Prevalences of stunting (11·5 v. 10·2 %, P = 0·57) and wasting (4·8 v. 2·0 %, P = 0·07) were not significantly different. Odds of anaemia were significantly lower (OR = 0·24, 95 % CI 0·16, 0·36) in intervention communities.

Conclusions:

Exposure to a community-based multidisciplinary intervention reduced the rate of anaemia and improved dietary indicators.

Association of Exposure to Civil Conflict With Maternal Resilience and Maternal and Child Health and Health System Performance in Afghanistan

IMPORTANCE

Current studies examining the effects of Afghanistan's conflict transition on the performance of health systems, health service delivery, and health outcomes are outdated and small in scale and do not span all essential reproductive, maternal, newborn, and child health interventions.

OBJECTIVE

To evaluate associations of conflict severity with improvement of health system performance, use of health services, and child nutrition outcomes in Afghanistan during the 2003 to 2018 reconstruction period.

DESIGN, SETTING, AND PARTICIPANTS

This population-based survey study included a sequential cross-sectional analysis of individual-level panel data across 2 periods (2003-2010 and 2010-2018) and a difference-in-differences design. Surveys included the 2003 to 2004 and 2010 to 2011 Multiple Indicator Cluster Surveys and the 2018 Afghanistan Health Survey. Afghanistan's 2013 National Nutrition Survey was used to assess nutritional outcomes, and the annual Balanced Scorecard data sets were used to evaluate health system performance. Participants included girls and women aged 12 to 49 years and children younger than 5 years who completed nationally representative household surveys. All analyses were conducted from January 1 through April 30, 2019.

EXPOSURES

Provinces were categorized as experiencing minimal-, moderate-, and severe-intensity conflict using battle-related death data from the Uppsala Conflict Data Program.

MAIN OUTCOMES AND MEASURES

Health intervention coverage was examined using 10 standard indicators: contraceptive method (any or modern); antenatal care by a skilled health care professional; facility delivery; skilled birth attendance (SBA); bacille Calmette-Guérin vaccination (BCG); diphtheria, pertussis, and tetanus vaccination (DPT3) or DPT3 plus hepatitis B and poliomyelitis (penta); measles vaccination; care-seeking for acute respiratory infection; oral rehydration therapy for diarrhea; and the Composite Coverage Index. The health system performance was analyzed using the following standard Balanced Scorecard composite domains: client and community, human resources, physical capacity, quality of service provision, management systems, and overall mission. Child stunting, wasting, underweight, and co-occurrence of stunting and wasting were estimated using World Health Organization growth reference cutoffs.

RESULTS

Responses from 64 815 women (mean [SD] age, 31.0 [8.5] years) were analyzed. Provinces with minimal-intensity conflict had greater gains in contraceptive use (mean annual percentage point change [MAPC], 1.3% vs 0.5%; P < .001), SBA (MAPC, 2.7% vs 1.5%; P = .005), BCG vaccination (MAPC, 3.3% vs -0.5%; P = .002), measles vaccination (MAPC, 1.9% vs -1.0%; P = .01), and DPT3/penta vaccination (MAPC, 1.0% vs -2.0%; P < .001) compared with provinces with moderate- to severe-intensity conflict after controlling for confounders. Provinces with severe-intensity conflict fared significantly worse than those with minimal-intensity conflict in functioning infrastructure (MAPC, -1.6% [95% CI, -2.4% to -0.8%]) and the client background and physical assessment index (MAPC, -1.0% [95% CI, -0.8% to 2.7%]) after adjusting for confounders. Child wasting was significantly worse in districts with greater conflict severity (full adjusted β for association between logarithm of battle-related deaths and wasting, 0.33 [95% CI, 0.01-0.66]; P = .04).

CONCLUSIONS AND RELEVANCE

Associations between conflict and maternal and child health in Afghanistan differed by health care intervention and delivery domain, with several key indicators lagging behind in areas with higher-intensity conflict. These findings may be helpful for planning and prioritizing efforts to reach the United Nations' Sustainable Development Goals in Afghanistan.

Mapping child growth failure in Africa between 2000 and 2015

Insufficient growth during childhood is associated with poor health outcomes and an increased risk of death. Between 2000 and 2015, nearly all African countries demonstrated improvements for children under 5 years old for stunting, wasting, and underweight, the core components of child growth failure. Here we show that striking subnational heterogeneity in levels and trends of child growth remains. If current rates of progress are sustained, many areas of Africa will meet the World Health Organization Global Targets 2025 to improve maternal, infant and young child nutrition, but high levels of growth failure will persist across the Sahel. At these rates, much, if not all of the continent will fail to meet the Sustainable Development Goal target—to end malnutrition by 2030. Geospatial estimates of child growth failure provide a baseline for measuring progress as well as a precision public health platform to target interventions to those populations with the greatest need, in order to reduce health disparities and accelerate progress.

Geospatial estimates of child growth failure in Africa provide a baseline for measuring progress and a precision public health platform to target interventions to those populations with the greatest need.

Severe childhood malnutrition

The main forms of childhood malnutrition occur predominantly in children <5 years of age living in low-income and middle-income countries and include stunting, wasting and kwashiorkor, of which severe wasting and kwashiorkor are commonly referred to as severe acute malnutrition. Here, we use the term 'severe malnutrition' to describe these conditions to better reflect the contributions of chronic poverty, poor living conditions with pervasive deficits in sanitation and hygiene, a high prevalence of infectious diseases and environmental insults, food insecurity, poor maternal and fetal nutritional status and suboptimal nutritional intake in infancy and early childhood. Children with severe malnutrition have an increased risk of serious illness and death, primarily from acute infectious diseases. International growth standards are used for the diagnosis of severe malnutrition and provide therapeutic end points. The early detection of severe wasting and kwashiorkor and outpatient therapy for these conditions using ready-to-use therapeutic foods form the cornerstone of modern therapy, and only a small percentage of children require inpatient care. However, the normalization of physiological and metabolic functions in children with malnutrition is challenging, and children remain at high risk of relapse and death. Further research is urgently needed to improve our understanding of the pathophysiology of severe malnutrition, especially the mechanisms causing kwashiorkor, and to develop new interventions for prevention and treatment.