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Rice I, Opondo C, Nyesigomwe L, Ekude D, Magezi J, Kalanzi A, Kerac M, Hayes J, Robello M, Halfman S, DeLacey E. Children with disabilities lack access to nutrition, health and WASH services: A secondary data analysis. Matern Child Nutr 2024:e13642. [PMID: 38563355 DOI: 10.1111/mcn.13642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 04/04/2024]
Abstract
Malnutrition and disability are major global public health problems. Poor diets, inadequate access to nutrition/health services (NaHS), and poor water, sanitation and hygiene (WASH) all increase the risk of malnutrition and infection. This leads to poor health outcomes, including disability. To better understand the relationship between these factors, we explored access to NaHS and household WASH and dietary adequacy among households with and without children with disabilities in Uganda. We used cross-sectional secondary data from 2021. Adjusted logistic regression was used to explore associations between disabilities, access to NaHS, WASH and dietary adequacy. Of the 6924 households, 4019 (57.9%) reported having access to necessary NaHS, with deworming and vaccination reported as both the most important and most difficult to access services. Access to services was lower for households with children with disabilities compared to those without, after adjusting for likely confounding factors (Odds ratio = 0.70; 95% CI 0.55-0.89, p = 0.003). There is evidence of an interaction between disability and WASH adequacy, with improved WASH adequacy associated with improved access to services, including for children with disabilities (interaction odds ratio = 1.12, 95% CI: 1.02-1.22, p = 0.012). The proportion of malnourished children was higher among households with children with disabilities than households without it (6.3% vs. 2.4% p < 0.001). There are concerning gaps in access to NaHS services in Uganda, with households with children with disabilities reporting worse access, particularly for those with low WASH adequacy. Improved and inclusive access to NaHS and WASH needs to be urgently prioritized, especially for children with disabilities.
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Affiliation(s)
- Isabel Rice
- Department of Population Health, London School of Hygiene & Tropical Medicine, Faculty of Epidemiology and Population Health, University of London, London, UK
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, Faculty of Epidemiology and Population Health, University of London, London, UK
| | | | - Daniel Ekude
- Holt International-Uganda Office, Kampala, Uganda
| | | | | | - Marko Kerac
- Department of Population Health, London School of Hygiene & Tropical Medicine, Faculty of Epidemiology and Population Health, University of London, London, UK
- London School of Hygiene & Tropical Medicine, Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH), University of London, London, UK
| | | | | | | | - Emily DeLacey
- Department of Population Health, London School of Hygiene & Tropical Medicine, Faculty of Epidemiology and Population Health, University of London, London, UK
- London School of Hygiene & Tropical Medicine, Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH), University of London, London, UK
- Holt International, Eugene, Oregon, USA
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Hayes J, Quiring M, Kerac M, Smythe T, Tann CJ, Groce N, Gultie Z, Nyesigomwe L, DeLacey E. Mid-upper arm circumference (MUAC) measurement usage among children with disabilities: A systematic review. Nutr Health 2023:2601060231181607. [PMID: 37338528 DOI: 10.1177/02601060231181607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Background: Anthropometric measurements, including mid-upper arm circumference (MUAC), are used for monitoring and evaluating children's nutritional status. Evidence is limited on optimal nutritional assessment for children with disabilities, who are at high risk for malnutrition. Aim: This study describes MUAC use among children with disabilities. Methods: Four databases (Embase, Global Health, Medline, and CINHAL) were searched from January 1990 through September 2021 using a predefined search strategy. Of the 305 publications screened, 32 papers were included. Data included children 6 months to 18 years old with disabilities. Data including general study characteristics, methods for MUAC measurement, terminology, and measurement references were extracted into Excel. Due to heterogeneity of the data, a narrative synthesis was used. Results: Studies from 24 countries indicate that MUAC is being used as part of nutritional assessment, but MUAC measurement methods, references, and cutoffs were inconsistent. Sixteen (50%) reported MUAC as a mean ± standard deviation (SD), 11 (34%) reported ranges or percentiles, 6 (19%) reported z-scores, and 4 (13%) used other methods. Fourteen (45%) studies included both MUAC and weight-for-height but nonstandard reporting limited comparability of the indicators for identifying those at risk of malnutrition. Conclusion: Although its speed, simplicity, and ease of use afford MUAC great potential for assessing children with disabilities, more research is needed to understand its appropriateness, and how it performs at identifying nutritionally high-risk children in comparison to other measures. Without validated inclusive measures to identify malnutrition and monitor growth and health, millions of children could have severe consequences for their development.
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Affiliation(s)
- Julia Hayes
- Nutrition and Health Services, Holt International, Eugene, Oregon, USA
| | - Michael Quiring
- Nutrition and Health Services, Holt International, Eugene, Oregon, USA
| | - Marko Kerac
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, University of London, London, UK
- Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH), London School of Hygiene & Tropical Medicine, University of London, London, UK
| | - Tracey Smythe
- International Centre for Evidence in Disability, Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, University of London, London, UK
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Cape Town, South Africa
| | - Cally J Tann
- Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH), London School of Hygiene & Tropical Medicine, University of London, London, UK
- Infectious Disease Epidemiology & International Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, University of London, London, UK
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
- Neonatal Medicine, University College London Hospitals NHS Trust, London, UK
| | - Nora Groce
- UCL International Disability Research Centre, Department of Epidemiology and Health Care, University College London, London UK
| | | | | | - Emily DeLacey
- Nutrition and Health Services, Holt International, Eugene, Oregon, USA
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, University of London, London, UK
- Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH), London School of Hygiene & Tropical Medicine, University of London, London, UK
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DeLacey E, Allen E, Tann C, Groce N, Hilberg E, Quiring M, Kaplan T, Smythe T, Kaui E, Catt R, Miller R, Gombo M, Dam H, Kerac M. Feeding practices of children within institution‐based care: A retrospective analysis of surveillance data. Maternal & Child Nutrition 2022; 18:e13352. [PMID: 35318809 PMCID: PMC9218330 DOI: 10.1111/mcn.13352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/25/2022] [Accepted: 02/24/2022] [Indexed: 11/27/2022]
Abstract
There is limited information on the feeding practices of 9.42 million children living within institution‐based care (IBC) worldwide. Poor feeding practices can predispose or exacerbate malnutrition, illness and disability. Here we describe the feeding practices of children living within IBC based on a retrospective analysis of records from 3335 children, 0–18 years old, participating in Holt International's Child Nutrition Program (CNP), from 36 sites in six countries. Data analysed included demographic information on age, sex, feeding practices, disabilities and feeding difficulties. Descriptive statistics were produced. A generalised linear model explored associations between feeding difficulties and disability and 2 × 2 tables examined feeding difficulties over time. An additional set of feeding observations with qualitative and quantitative data was analysed. At baseline, the median age of children was 16 months (0.66–68 months) with 1650/3335 (49.5%) females. There were 757/3335 (22.7%) children with disabilities; 550/984 (55.9%) were low birth weight; 311/784 (39.7%) were premature; 447/3113 (14.4%) had low body mass index and 378/3335 (11.3%) had feeding difficulties. The adjusted risk of having a feeding difficulty was 5.08 ([95% confidence interval: 2.65–9.7], p ≤ 0.001) times greater in children with disabilities than those without. Many children saw their feeding difficulties resolve after 1‐year in CNP, 54/163 (33.1%) for children with disabilities and 57/106 (53.8%) for those without disabilities. Suboptimal hygiene, dietary and feeding practices were reported. In conclusion, feeding difficulties were common in IBC, especially among children with disabilities. Supporting safe interactive mealtimes for children living within IBC should be prioritised, to ensure overall health and development. Feeding difficulties are common among children living in institution‐based care (IBC), particularly but not exclusively among those children with disabilities. Suboptimal feeding practices were common in IBC and encompassed inadequate hygiene, limited support for self‐feeding, reading children's feeding cues (especially around pacing and satiety), addressing feeding difficulties, such as difficulty chewing or swallowing. These should be prioritised in training and supervision for caregivers. Addressing the needs of this vulnerable group should include support for safe feeding techniques. These should be prioritised to help ease the transition into eventual family‐based care if we are to move towards deinstitutionalizing children and strengthening families.
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Affiliation(s)
- Emily DeLacey
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine University of London London UK
- Nutrition and Health Services Holt International Eugene Oregon USA
- Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH), Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine University of London London UK
| | - Elizabeth Allen
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine University of London London UK
| | - Cally Tann
- Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH), Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine University of London London UK
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine University of London London UK
- MRC/UVRI & LSHTM Uganda Research Unit, London School of Hygiene & Tropical Medicine University of London Entebbe Uganda
- Department of Neonatal Medicine University College London Hospitals NHS Trust London UK
| | - Nora Groce
- UCL International Disability Research Centre, Department of Epidemiology and Public Health University College London London UK
| | - Evan Hilberg
- Nutrition and Health Services Holt International Eugene Oregon USA
| | - Michael Quiring
- Nutrition and Health Services Holt International Eugene Oregon USA
| | - Tracy Kaplan
- Nutrition and Health Services Holt International Eugene Oregon USA
| | - Tracey Smythe
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine University of London London UK
- International Centre for Evidence in Disability, Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine University of London London UK
| | - Erin Kaui
- Nutrition and Health Services Holt International Eugene Oregon USA
| | - Rachael Catt
- Nutrition and Health Services Holt International Eugene Oregon USA
| | - Raeanne Miller
- Nutrition and Health Services Holt International Eugene Oregon USA
| | - Maijargal Gombo
- Nutrition and Health Services Holt International Eugene Oregon USA
| | - Hang Dam
- Nutrition and Health Services Holt International Eugene Oregon USA
| | - Marko Kerac
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine University of London London UK
- Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH), Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine University of London London UK
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DeLacey E, Hilberg E, Allen E, Quiring M, Tann CJ, Groce NE, Vilus J, Bergman E, Demasu-Ay M, Dam HT, Kerac M. Nutritional status of children living within institution-based care: a retrospective analysis with funnel plots and control charts for programme monitoring. BMJ Open 2021. [PMCID: PMC8719208 DOI: 10.1136/bmjopen-2021-050371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objectives The aim of this study is to fill a key information gap on the nutrition-related epidemiology of orphaned and vulnerable children living within institution-based care (IBC) across six countries. Design A retrospective analysis with Shewhart control charts and funnel plots to explore intersite and over time variations in nutritional status. Setting We conducted a retrospective analysis of records from Holt International’s Child Nutrition Programme from 35 sites in six countries; Mongolia, India, Ethiopia, Vietnam, China and the Philippines. Participants Deidentified health records from Holt International’s online nutrition screening database included records from 2926 children, 0–18 years old. Data were collected from 2013 to 2020 and included demographic and health information. Results At initial screening, 717 (28.7%) children were anaemic, 788 (34.1%) underweight, 1048 (37.3%) stunted, 212 (12.6%) wasted, 135 (12%) overweight or obese and 339 (31%) had small head circumference. Many had underlying conditions: low birth weight, 514 (57.5%); prematurity, 294 (42.2%) and disabilities, 739 (25.3%). Children with disabilities had higher prevalence of malnutrition compared with counterparts without disabilities at baseline and 1-year screenings. There was marked intersite variation. Funnel plots highlight sites with malnutrition prevalence outside expected limits for this specific population taking into consideration natural variation at baseline and at 1 year. Control charts show changes in site mean z-scores over time in relation to site control limits. Conclusions Malnutrition is prevalent among children living within IBC, notably different forms of undernutrition (stunting, underweight, wasting). Underlying risk factors are also common: prematurity, low birth weight and disability. Nutrition interventions should take into account the needs of this vulnerable population, especially for infants and those with disabilities. Using control charts to present data could be especially useful to programme managers as sites outside control limits could represent: problems to be investigated; good practices to be shared.
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Affiliation(s)
- Emily DeLacey
- Department of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Nutrition & Health Department, Holt International, Eugene, Oregon, USA
- Centre for Maternal Adolescent Reproductive and Child Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Evan Hilberg
- Nutrition & Health Department, Holt International, Eugene, Oregon, USA
| | - Elizabeth Allen
- Department of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Michael Quiring
- Nutrition & Health Department, Holt International, Eugene, Oregon, USA
| | - Cally J Tann
- Centre for Maternal Adolescent Reproductive and Child Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Neonatal Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Nora Ellen Groce
- International Disability Research Centre, University College London, London, UK
| | - James Vilus
- Holt Haiti Country Office, Holt International, Port-au-Prince, Haiti
| | - Ethan Bergman
- Department of Health Sciences, Central Washington University, Ellensburg, Washington, USA
| | - Merzel Demasu-Ay
- Nutrition Department, Kaisahang Buhay Foundation, Inc, Quezon City, Philippines
| | - Hang T Dam
- Nutrition & Health Department, Holt International, Eugene, Oregon, USA
| | - Marko Kerac
- Department of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Centre for Maternal Adolescent Reproductive and Child Health, London School of Hygiene and Tropical Medicine, London, UK
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Ivey R, Kerac M, Quiring M, Dam HT, Doig S, DeLacey E. The Nutritional Status of Individuals Adopted Internationally as Children: A Systematic Review. Nutrients 2021; 13:245. [PMID: 33467102 PMCID: PMC7829835 DOI: 10.3390/nu13010245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 12/12/2022] Open
Abstract
Since 1955, international adoption has been a way of finding homes for children who have been orphaned or abandoned. We aimed to describe the nutritional status of individuals adopted internationally and their long-term nutritional and health outcomes. We searched four databases for articles published from January 1995 to June 2020, which included information on anthropometric or micronutrient status of children adopted internationally (CAI). Mean Z-scores on arrival to adoptive country ranged from -2.04 to -0.31 for weight for age; -0.94 to 0.39 for weight for height; -0.7 to 0 for body mass index; -1.89 to -0.03 for height for age; -1.43 to 0.80 for head circumference for age. Older children, those adopted from institutionalized care or with underlying disability, were more likely to be malnourished. Though long-term data was scarce, mean Z-scores post-adoption ranged from -0.59 to 0.53 for weight for age; -0.31 to 1.04 for weight for height; 0.39 to 1.04 for body mass index; -1.09 to 0.58 for height for age; -0.06 to 1.23 for head circumference for age. We conclude that though CAI are at high risk of malnutrition at baseline, marked catch-up growth is possible, including for those older than two years of age on arrival. This has implications not only for CAI but for the wider population of malnourished children worldwide. Research on how to optimize catch-up growth is a priority.
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Affiliation(s)
- Richard Ivey
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, University of London, London WC1E 7HU, UK; (M.K.); (E.D.)
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine, University of London, London WC1E 7HU, UK
| | - Marko Kerac
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, University of London, London WC1E 7HU, UK; (M.K.); (E.D.)
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine, University of London, London WC1E 7HU, UK
| | - Michael Quiring
- Holt International, Eugene, OR 97401, USA; (M.Q.); (H.T.D.); (S.D.)
| | - Hang T. Dam
- Holt International, Eugene, OR 97401, USA; (M.Q.); (H.T.D.); (S.D.)
| | - Susie Doig
- Holt International, Eugene, OR 97401, USA; (M.Q.); (H.T.D.); (S.D.)
| | - Emily DeLacey
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, University of London, London WC1E 7HU, UK; (M.K.); (E.D.)
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine, University of London, London WC1E 7HU, UK
- Holt International, Eugene, OR 97401, USA; (M.Q.); (H.T.D.); (S.D.)
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DeLacey E, Tann C, Groce N, Kett M, Quiring M, Bergman E, Garcia C, Kerac M. The nutritional status of children living within institutionalized care: a systematic review. PeerJ 2020; 8:e8484. [PMID: 32071812 PMCID: PMC7007983 DOI: 10.7717/peerj.8484] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 12/29/2019] [Indexed: 12/19/2022] Open
Abstract
Background There are an estimated 2.7 million children living within institutionalized care worldwide. This review aimed to evaluate currently available data on the nutrition status of children living within institutionalized care. Methods We searched four databases (Pubmed/Medline, CINHAL Plus, Embase and Global Health Database) for relevant articles published from January 1990 to January 2019. Studies that included information on anthropometry or micronutrient status of children living within institutionalized care were eligible for inclusion. The review is registered on PROSPERO: CRD42019117103. Results From 3,602 titles screened, we reviewed 98 full texts, of which 25 papers were eligible. Two (8%) studies reported data from multiple countries, nine (36%) were from Asia, four (16%) from Africa, three (12%) from Eastern Europe, four (16%) from the European Union and one (4%) from each of the remaining regions (Middle East, South America and the Caribbean). Twenty-two (88%) were cross sectional. Ten (40%) of the studies focused on children >5 years, seven (28%) on children <5 years, seven (28%) covered a wide age range and one did not include ages. Low birth weight prevalence ranged from 25–39%. Only five (20%) included information on children with disabilities and reported prevalence from 8–75%. Prevalence of undernutrition varied between ages, sites and countries: stunting ranged from 9–72%; wasting from 0–27%; underweight from 7–79%; low BMI from 5–27%. Overweight/obesity ranged from 10–32% and small head circumference from 17–41%. The prevalence of HIV was from 2–23% and anemia from 3–90%. Skin conditions or infections ranged from 10–31% and parasites from 6–76%. Half the studies with dietary information found inadequate intake or diet diversity. Younger children were typically more malnourished than older children, with a few exceptions. Children living within institutions were more malnourished than community peers, although children living in communities were also often below growth standards. High risk of bias was found. Conclusions This study highlights the limited amount of evidence-based data available on the nutritional status of children in institutions. Of the studies reviewed, children living within institutionalized care were commonly malnourished, with undernutrition affecting young children particularly. Micronutrient deficiencies and obesity were also prevalent. Data quality was often poor: as well as suboptimal reporting of anthropometry, few looked for or described disabilities, despite disability being common in this population and having a large potential impact on nutrition status. Taken together, these findings suggest a need for greater focus on improving nutrition for younger children in institutions, especially those with disabilities. More information is needed about the nutritional status of the millions of children living within institutionalized care to fully address their right and need for healthy development.
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Affiliation(s)
- Emily DeLacey
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, University of London, London, United Kingdom.,Holt International, Eugene, OR, United States of America.,Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH), London School of Hygiene & Tropical Medicine, University of London, London, United Kingdom
| | - Cally Tann
- Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH), London School of Hygiene & Tropical Medicine, University of London, London, United Kingdom.,Department of Infectious Disease Epidemiology, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, University of London, London, United Kingdom.,MRC/UVRI & LSHTM Uganda Research Unit, London School of Hygiene & Tropical Medicine, University of London, Entebbe, Uganda.,Neonatal Medicine, University College London Hospitals NHS Trust, London, United Kingdom
| | - Nora Groce
- UCL International Disability Research Centre, Department of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Maria Kett
- UCL International Disability Research Centre, Department of Epidemiology and Health Care, University College London, London, United Kingdom
| | | | - Ethan Bergman
- Department of Health Sciences, College of Education and Professional Studies, Central Washington University, Ellensburg, WA, United States of America
| | - Caryl Garcia
- Holt International, Eugene, OR, United States of America
| | - Marko Kerac
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, University of London, London, United Kingdom.,Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH), London School of Hygiene & Tropical Medicine, University of London, London, United Kingdom
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