Bridget Fenn

Co-coverage of preventive interventions and implications for child-survival strategies: evidence from national surveys

BACKGROUND In most low-income countries, several child-survival interventions are being implemented. We assessed how these interventions are clustered at the level of the individual child. METHODS We analysed data from Bangladesh, Benin, Brazil, Cambodia, Eritrea, Haiti, Malawi, Nepal, and Nicaragua. A co-coverage score was obtained by adding the number of interventions received by each child (including BCG, diphtheria-pertussis-tetanus, and measles vaccines), tetanus toxoid for the mother, vitamin A supplementation, antenatal care, skilled delivery, and safe water. Socioeconomic status was assessed through principal components analysis of household assets, and concentration indices were calculated. FINDINGS The percentage of children who did not receive a single intervention ranged from 0.3% (14/5495) in Nicaragua to 18.8% (1154/6144) in Cambodia. The proportions receiving all available interventions varied from 0.8% (48/6144) in Cambodia to 13.3% (733/5495) in Nicaragua. There were substantial inequities within all countries. In the poorest wealth quintile, 31% of Cambodian children received no interventions and 17% only one intervention; in Haiti, these figures were 15% and 17%, respectively. Inequities were inversely related to coverage levels. Countries with higher coverage rates tended to show bottom inequity patterns, with the poorest lagging behind all other groups, whereas low-coverage countries showed top inequities with the rich substantially above the rest. INTERPRETATION The inequitable clustering of interventions at the level of the child raises the possibility that the introduction of new technologies might primarily benefit children who are already covered by existing interventions. Packaging several interventions through a single delivery strategy, while making economic sense, could contribute to increased inequities unless population coverage is very high. Co-coverage analyses of child-health surveys provide a way to assess these issues.

Perceptions of heatwave risks to health: interview-based study of older people in London and Norwich, UK

BACKGROUND Most projections of climate change suggest an increased frequency of heatwaves in England over coming decades; older people are at particular risk. This could result in substantial mortality and morbidity. OBJECTIVE To determine elderly peoples knowledge and perceptions of heat-related risks to health, and of protective behaviours. METHODS Semi-structured interviews: 73 men and women, 72-94 years, living in their own homes in London and Norwich, UK. RESULTS Few respondents considered themselves either old or at risk from the effects of heat, even though many had some form of relevant chronic illness; they did recognize that some medical conditions might increase risks in others. Most reported that they had taken appropriate steps to reduce the effects of heat. Some respondents considered it appropriate for the government to take responsibility for protecting vulnerable people, but many thought state intervention was unnecessary, intrusive and unlikely to be effective. Respondents were more positive about the value of appropriately disseminated advice and solutions by communities themselves. CONCLUSION The Heatwave Plan should consider giving greater emphasis to a population-based information strategy, using innovative information dissemination methods to increase awareness of vulnerability to heat among the elderly and to ensure clarity about behaviour modification measures.

Association of mortality with high temperatures in a temperate climate: England and Wales

Background It is well known that high ambient temperatures are associated with increased mortality, even in temperate climates, but some important details are unclear. In particular, how heat–mortality associations (for example, slopes and thresholds) vary by climate has previously been considered only qualitatively. Methods An ecological time-series regression analysis of daily counts of all-cause mortality and ambient temperature in summers between 1993 and 2006 in the 10 government regions was carried out, focusing on all-cause mortality and 2-day mean temperature (lags 0 and 1). Results All regions showed evidence of increased risk on the hottest days, but the specifics, in particular the threshold temperature at which adverse effects started, varied. Thresholds were at about the same centile temperatures (the 93rd, year-round) in all regions—hotter climates had higher threshold temperatures. Mean supra-threshold slope was 2.1%/°C (95% CI 1.6 to 2.6), but regions with higher summer temperatures showed greater slopes, a pattern well characterised by a linear model with mean summer temperature. These climate-based linear-threshold models capture most, but not all, the association; there was evidence for some non-linearity above thresholds, with slope increasing at highest temperatures. Conclusion Effects of high daily summer temperatures on mortality in English regions are quite well approximated by threshold-linear models that can be predicted from the regions climate (93rd centile and mean summer temperature). It remains to be seen whether similar relationships fit other countries and climates or change over time, such as with climate change.

Associations between maternal experiences of intimate partner violence and child nutrition and mortality: findings from Demographic and Health Surveys in Egypt, Honduras, Kenya, Malawi and Rwanda

Background If effective interventions are to be used to address child mortality and malnutrition, then it is important that we understand the different pathways operating within the framework of child health. More attention needs to be given to understanding the contribution of social influences such as intimate partner violence (IPV). Aim To investigate the relationship between maternal exposure to IPV and child mortality and malnutrition using data from five developing countries. Methods Population data from Egypt, Honduras, Kenya, Malawi and Rwanda were analysed. Logistic regression analysis was used to generate odds ratios of the associations between several categories of maternal exposure to IPV since the age of 15 and three child outcomes: under-2-year-old (U2) mortality and moderate and severe stunting (<–2 Z-score height-for-age and <–3 Z-score height-for-age) in 6–59-month-old children. Analyses were adjusted for potential confounders, and the role of mediating factors was explored. Results The prevalence of physical and/or sexual IPV since the age of 15 years ranged from 15.5% (Honduras) to 46.2% (Kenya). For child stunting, prevalence ranged from 25.4% (Egypt) to 58.0% (Malawi) and for U2 mortality from 3.6% (Honduras) to 15.2% (Rwanda). In Kenya, maternal exposure to IPV was associated with higher U2 mortality (adjusted odds ratio (OR)=1.42, 95% CI 1.18 to 1.71) and child stunting (adjusted OR=1.36, 95% CI 1.16 to 1.61). In Malawi and Honduras, marginal associations were observed between IPV and severe stunting and U2 mortality, respectively, with strength of associations varying by type of violence. Conclusion The relationship between IPV and U2 mortality and stunting in Kenya, Honduras and Malawi suggests that, in these countries, IPV plays a role in child malnutrition and mortality. This contributes to a growing body of evidence that broader public health benefits may be incurred if efforts to address IPV are incorporated into a wider range of maternal and child health programmes; however, the authors highlight the need for more research that can establish temporality, use data collected on the basis of the studys objectives, and further explore the causal framework of this relationship using more advanced statistical analysis.

Do childhood growth indicators in developing countries cluster? Implications for intervention strategies.

OBJECTIVE The effectiveness of geographic targeting in nutrition programmes depends largely on the degree to which malnutrition clusters within particular areas. This study investigates the extent to which the childhood nutrition indicators, stunting (height-for-age Z-score <-2) and wasting (weight-for-height Z-score <-2), are spatially clustered; this information is used to determine the implications of spatial clustering for the effectiveness of geographic targeting. DESIGN Analysis of data from Demographic and Health Survey (DHS) results. Clustering is assessed by calculating intra-cluster correlation coefficients (ICCs). Estimating the proportion of malnourished children covered by a programme successfully targeting 10% of clusters with the highest malnutrition prevalences allows an assessment of the effectiveness of geographic targeting. SETTING Fifty-eight DHS III (1992-1997) and DHS IV (1998-2001) reports from 46 developing countries. SUBJECTS Pre-school children of mothers interviewed by DHS. MAIN RESULTS The extent of clustering of nutritional status was surprisingly low (median ICC for national samples: stunting=0.054, wasting=0.032) and most countries were characterised by having an ICC <0.1--i.e. low clustering--for childhood undernutrition (91% of countries for wasting and 78% for stunting). Our assessment of the effectiveness of geographic targeting showed that coverage was better for wasting than for stunting; for wasting, 23% of countries would achieve less than 20% coverage, compared with 76% of countries achieving less than 20% coverage for stunting. Coverage is dependent on the overall prevalence of malnutrition and the ICC. CONCLUSIONS Childhood nutritional status is determined at the household, or even individual, level; nutrition programmes that are geographically targeted may result in high levels of under-coverage and leakage, thereby compromising their cost-effectiveness; the lack of clustering questions the appropriateness of current nutrition interventions.

Low‐dose RUTF protocol and improved service delivery lead to good programme outcomes in the treatment of uncomplicated SAM: a programme report from Myanmar

Abstract The treatment of uncomplicated severe acute malnutrition (SAM) requires substantial amounts of ready‐to‐use therapeutic food (RUTF). In 2009, Action Contre la Faim anticipated a shortfall of RUTF for their nutrition programme in Myanmar. A low‐dose RUTF protocol to treat children with uncomplicated SAM was adopted. In this protocol, RUTF was dosed according to beneficiarys body weight, until the child reached a Weight‐for‐Height z‐score of ≥−3 and mid‐upper arm circumference ≥110 mm. From this point, the child received a fixed quantity of RUTF per day, independent of body weight until discharge. Specific measures were implemented as part of this low‐dose RUTF protocol in order to improve service quality and beneficiary support. We analysed individual records of 3083 children treated from July 2009 to January 2010. Up to 90.2% of children recovered, 2.0% defaulted and 0.9% were classified as non‐responders. No deaths were recorded. Among children who recovered, median [IQR] length of stay and weight gain were 42 days [28; 56] and 4.0 g kg–1 day–1 [3.0; 5.7], respectively. Multivariable logistic regression showed that children older than 48 months had higher odds of non‐response to treatment than younger children (adjusted odds ratio: 3.51, 95% CI: 1.67–7.42). Our results indicate that a low‐dose RUTF protocol, combined with specific measures to ensure good service quality and beneficiary support, was successful in treating uncomplicated SAM in this setting. This programmatic experience should be validated by randomised studies aiming to test, quantify and attribute the effect of the protocol adaptation and programme improvements presented here.