Claudia Cappa

Health of the world's adolescents: a synthesis of internationally comparable data

Adolescence and young adulthood offer opportunities for health gains both through prevention and early clinical intervention. Yet development of health information systems to support this work has been weak and so far lagged behind those for early childhood and adulthood. With falls in the number of deaths in earlier childhood in many countries and a shifting emphasis to non-communicable disease risks, injuries, and mental health, there are good reasons to assess the present sources of health information for young people. We derive indicators from the conceptual framework for the Series on adolescent health and assess the available data to describe them. We selected indicators for their public health importance and their coverage of major health outcomes in young people, health risk behaviours and states, risk and protective factors, social role transitions relevant to health, and health service inputs. We then specify definitions that maximise international comparability. Even with this optimisation of data usage, only seven of the 25 indicators, covered at least 50% of the worlds adolescents. The worst adolescent health profiles are in sub-Saharan Africa, with persisting high mortality from maternal and infectious causes. Risks for non-communicable diseases are spreading rapidly, with the highest rates of tobacco use and overweight, and lowest rates of physical activity, predominantly in adolescents living in low-income and middle-income countries. Even for present global health agendas, such as HIV infection and maternal mortality, data sources are incomplete for adolescents. We propose a series of steps that include better coordination and use of data collected across countries, greater harmonisation of school-based surveys, further development of strategies for socially marginalised youth, targeted research into the validity and use of these health indicators, advocating for adolescent-health information within new global health initiatives, and a recommendation that every country produce a regular report on the health of its adolescents.

Progress for children: a report card on adolescents.

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Child disability screening, nutrition, and early learning in 18 countries with low and middle incomes: data from the third round of UNICEF's Multiple Indicator Cluster Survey (2005-06).

BACKGROUND Child disability is an emerging global health priority. To address the need for internationally comparable information about the frequency and situation of children with disabilities, UNICEF has recommended that countries include the Ten Questions screen for disability in the Multiple Indicator Cluster Survey (MICS) programme. We examined child disability screening and its association with nutrition and early learning in countries with low and middle incomes. METHODS Cross-sectional data for the percentage of children screening positive for or at risk of disability were obtained for 191 199 children aged 2-9 years in 18 countries participating in the third round of MICS in 2005-06. Screening results were descriptively analysed according to sociodemographic, nutritional, early-learning, and schooling variables. We constructed a weighted analysis to account for the sampling design in every country and tested for differences within countries using chi(2) analyses. FINDINGS A median 23% (range 3-48) of children aged 2-9 years screened positive for disability in the 18 participating countries. For children aged 2-4 years, screening positive for disability was significantly more likely in children who were not breastfed versus those who were (median 36% [9-56] vs 26% [4-51]) in eight of 18 countries, in children who had not received vitamin A supplementation versus those who had (36% [7-53] vs 29% [4-50]) in five of ten countries assessed, in children who met criteria for stunting (26% [6-54]) or being underweight (36% [3-61]) versus those who did not (25% [3-42] and 26% [4-43], respectively) in five of 15 countries assessed for stunting and in seven of 15 countries assessed for being underweight, and in those who participated in few early-learning activities versus others (31% [7-54] vs 24% [4-51]) in eight of 18 countries. Children aged 6-9 years who did not attend school screened positive for disability more often than did children attending school (29% [2-83] vs 22% [3-47]) in eight of 18 countries. INTERPRETATION Our results draw attention to the need for improved global capacity to assess and provide services for children at risk of disability. Further research is needed in countries with low and middle incomes to understand and address the role of nutritional deficiencies and restricted access to learning opportunities as both potential antecedents of childhood disability and consequences of discrimination. FUNDING UNICEF; Department of Population Health Sciences, University of Wisconsin-Madison, USA.

Systems and strategies for identifying and enumerating children outside of family care

Methodologies to identify and enumerate children outside of family care vary as do the vulnerability categories of the children themselves. Children outside of family care is a broad term encompassing children absent of permanent family care, e.g., institutionalized children, children on/of the street, child-headed households, separated or unaccompanied children, trafficked children, children working in exploitive labor situations, etc. This paper reviews the various methodologies applied to identify and enumerate these often hidden and/or mobile populations. Methodologies that identify and enumerate children outside of family strive to meet two objectives: (1) to estimate the number and characteristics of a specific vulnerability category and (2) to determine eligibility to receive services. The paper reviews eight methodologies; six are categorized as survey sample methods (time-location sampling, capture recapture sampling, respondent driven sampling, the neighborhood method, household surveys, and establishment surveys) while two were labeled as data management systems (child labor management system, and databases of institutions). Each review includes a concise description of the methodology, its strengths and limitations, the most appropriate population it is suited to identify and/or enumerate, and any necessary conditions. Conclusions from these reviews advocate for tailoring a methodology (or a combination of methodologies) to the specific circumstances under which it is meant to identify or enumerate children outside of family care. In addition, further research and validation studies are needed to identify the conditions under which the strategies described here can be used and to develop appropriate protocols for utilization.

Estimating the number of children in formal alternative care: Challenges and results

Given the relatively large body of literature documenting the adverse impacts of institutionalization on childrens developmental outcomes and well-being, it is essential that countries work towards reducing the number of children in alternative care (particularly institutional care), and, when possible, reunite children with their families. In order to do so, reliable estimates of the numbers of children living in such settings are essential. However, many countries still lack functional administrative systems for enumerating children living outside of family care. The purpose of this paper is to provide a snapshot of the availability and coverage of data on children living in residential and foster care from some 142 countries covering more than 80 per cent of the worlds children. Utilizing these country-level figures, it is estimated that approximately 2.7 million children between the ages of 0 and 17 years could be living in institutional care worldwide. Where possible, the article also presents regional estimates of the number of children living in residential and foster care. This work represents an important step to systematically identify and compile sources of data on children in alternative care and provides updated global and regional estimates on the magnitude of the issue. Its findings contribute to raising awareness of the urgent need to strengthen the capacity of countries to improve national systems for counting, monitoring and reporting on these vulnerable children.

Predicting Maternal Health Care Use by Age at Marriage in Multiple Countries

PURPOSE In light of the global pervasiveness of child marriage and given that improving maternal health care use is an effective strategy in reducing maternal and child morbidity and mortality, the available empirical evidence on the association of child marriage with maternal health care utilization seems woefully inadequate. Furthermore, existing studies have not considered the interaction of type of place of residence and parity with child marriage, which can give added insight to program managers. METHODS Demographic Health Survey data for seven countries are used to estimate logistic regression models including interactions of age at marriage with area of residence and birth order. Adjusted predicted probabilities at representative values and marginal effects are computed for each outcome. RESULTS The results show a negative association between child marriage and maternal health care use in most study countries, and this association is more negative in rural areas and with higher orders of parity. However, the association between age at marriage and maternal health care use is not straightforward but depends on parity and area of residence and varies across countries. The marginal effects in use of delivery care services between women married at age 14 years or younger and those married at age 18 years or older are more than 10% and highly significant in Bangladesh, Burkina Faso, and Nepal. CONCLUSIONS The studys findings call for the formulation of country-and age at marriage-specific recommendations to improve maternal and child health outcomes.

Who perpetrates violence against children? A systematic analysis of age-specific and sex-specific data

Objective The epidemiology of violence against children is likely to differ substantially by sex and age of the victim and the perpetrator. Thus far, investment in effective prevention strategies has been hindered by lack of clarity in the burden of childhood violence across these dimensions. We produced the first age-specific and sex-specific prevalence estimates by perpetrator type for physical, sexual and emotional violence against children globally. Design We used random effects meta-regression to estimate prevalence. Estimates were adjusted for relevant quality covariates, variation in definitions of violence and weighted by region-specific, age-specific and sex-specific population data to ensure estimates reflect country population structures. Data sources Secondary data from 600 population or school-based representative datasets and 43 publications obtained via systematic literature review, representing 13 830 estimates from 171 countries. Eligibility criteria for selecting studies Estimates for recent violence against children aged 0–19 were included. Results The most common perpetrators of physical and emotional violence for both boys and girls across a range of ages are household members, with prevalence often surpassing 50%, followed by student peers. Children reported experiencing more emotional than physical violence from both household members and students. The most common perpetrators of sexual violence against girls aged 15–19 years are intimate partners; however, few data on other perpetrators of sexual violence against children are systematically collected internationally. Few age-specific and sex-specific data are available on violence perpetration by schoolteachers; however, existing data indicate high prevalence of physical violence from teachers towards students. Data from other authority figures, strangers, siblings and other adults are limited, as are data on neglect of children. Conclusions Without further investment in data generation on violence exposure from multiple perpetrators for boys and girls of all ages, progress towards Sustainable Development Goals 4, 5 and 16 may be slow. Despite data gaps, evidence shows violence from household members, peers in school and for girls, from intimate partners, should be prioritised for prevention. Trial registration number PROSPERO 2015: CRD42015024315.

Differential effects of young maternal age on child growth

Background The association of early maternal birthing age with smaller children has been widely observed. However, it is unclear if this is due to confounding by factors such as socioeconomic status, or the age at which child growth restriction first occurs. Objective To examine the effect of early maternal birthing age on the first-born childs height-for-age in a sample of developing countries in Africa, Asia, and Latin America. Design Cross-sectional data from Demographic Health Surveys from 18 countries were used, to select the first-born child of mothers aged 15–24 years and a range of potential confounding factors, including maternal height. Child length/height-for-age z-scores (HAZs) was estimated in age bands of 0–11, 12–23, 24–35, 36–47, and 48–59 months; HAZ was first compared between maternal age groups of 15–17, 18–19, and 20–24 years. Results 1) There were significant bivariate associations between low child HAZ and young maternal age (71 of 180 possible cases; at p<0.10), but the majority of these did not persist when controlling for confounders (41 cases, 23% of the 180). 2) For children <12 months, when controlling for confounders, three out of seven Asian countries showed a significant association between lower infant HAZ and low maternal age, as did six out of nine African countries (15–17 or 15–19 years vs. the older group). 3) The association (adjusted) continued after 24 months in 12 of the 18 countries, in Africa, Asia, and Latin America. 4) The stunting differences for children between maternal age groups were around 9 percentage points (ppts) in Asia, 14 ppts in Africa, and 10 ppts in Latin America. These data do not show whether this is due to, for example, socioeconomic factors that were not included, an emerging effect of intrauterine growth restriction, or the child feeding or caring behaviors of young mothers. The latter is considered to be the most likely. Conclusions The effect of low maternal age on child height restriction from 0 to 11 months occurred in half the countries studied after adjusting for confounders. Poorer growth continuing after 24 months in children of younger mothers was observed in all regions, but needs further research to determine the causes. The effects were about double (in stunting prevalence terms) in Africa, where there was an increase in 10 ppts in stunting for children of young mothers.Background The association of early maternal birthing age with smaller children has been widely observed. However, it is unclear if this is due to confounding by factors such as socioeconomic status, or the age at which child growth restriction first occurs. Objective To examine the effect of early maternal birthing age on the first-born childs height-for-age in a sample of developing countries in Africa, Asia, and Latin America. Design Cross-sectional data from Demographic Health Surveys from 18 countries were used, to select the first-born child of mothers aged 15-24 years and a range of potential confounding factors, including maternal height. Child length/height-for-age z-scores (HAZs) was estimated in age bands of 0-11, 12-23, 24-35, 36-47, and 48-59 months; HAZ was first compared between maternal age groups of 15-17, 18-19, and 20-24 years. Results 1) There were significant bivariate associations between low child HAZ and young maternal age (71 of 180 possible cases; at p<0.10), but the majority of these did not persist when controlling for confounders (41 cases, 23% of the 180). 2) For children <12 months, when controlling for confounders, three out of seven Asian countries showed a significant association between lower infant HAZ and low maternal age, as did six out of nine African countries (15-17 or 15-19 years vs. the older group). 3) The association (adjusted) continued after 24 months in 12 of the 18 countries, in Africa, Asia, and Latin America. 4) The stunting differences for children between maternal age groups were around 9 percentage points (ppts) in Asia, 14 ppts in Africa, and 10 ppts in Latin America. These data do not show whether this is due to, for example, socioeconomic factors that were not included, an emerging effect of intrauterine growth restriction, or the child feeding or caring behaviors of young mothers. The latter is considered to be the most likely. Conclusions The effect of low maternal age on child height restriction from 0 to 11 months occurred in half the countries studied after adjusting for confounders. Poorer growth continuing after 24 months in children of younger mothers was observed in all regions, but needs further research to determine the causes. The effects were about double (in stunting prevalence terms) in Africa, where there was an increase in 10 ppts in stunting for children of young mothers.

Disparities by sex in early childhood and adolescence

Gender discrimination is widely assumed to start before birth, persist during childhood, and progressively worsen in adolescence. A UNICEF report suggests that, although this assumption is largely true, disparities between boys and girls during early childhood are less stark than previously thought. The report Boys and girls in the life cycle presents the latest available sex-disaggregated statistics on indicators used to monitor children’s rights and wellbeing in the developing world, and identifi es areas in which diff erences between boys and girls are small, as well as those in which disparities persist. In the past decade, availability of data for children and families has increased substantially, off ering opportunities to explore the extent to which gender aff ects wellbeing. UNICEF’s report uses data from household surveys, mainly the UNICEF-supported Multiple Indicator Cluster Surveys (MICS) and the USAID-supported Demographic and Health Surveys (DHS), for boys and girls in diff erent domains, including survival, nutrition, education, and exposure to violence and exploitation. Biological and social factors aff ect boys and girls diff erently, and aff ect their chances of survival and wellbeing. For example, boys are known to have higher mortality rates during infancy than girls. Societal beliefs about gender roles and choices based on such beliefs also have a role in disparities between the sexes. Research suggests that parents demonstrate diff erent attitudes towards boys and girls, and hold diff erent expectations about their future. These attitudes contribute to diff erent experiences as boys and girls grow older, and form a basis for diff erent forms of discrimination. In human populations, it is normal for more boys to be born than girls. This disparity usually gradually decreases after birth, as a result of higher mortality in males. However, in a few countries the number of boys born is much higher than the number of girls. In some of these countries girls also tend to have higher mortality. In early childhood (<5 years), gender disparities in surviving children are small with regard to the indicators examined. For example, no signifi cant diff erence in exclusive breastfeeding rates in the fi rst 6 months of life was recorded between boys and girls in the developing world. Similarly, children of both sexes younger than 5 years are equally likely to be undernourished (stunted, wasted, or underweight). In India (which has the largest number of stunted children), for example, rates of stunting are the same for boys and girls younger than 5 years. Greinacher and colleagues promptly undertook a well thought out prospective cohort trial in patients with haemolytic uraemic syndrome during the recent severe EHEC O104:H4 outbreak. Immunoadsorption was reported to be a promising therapeutic option for patients with neurological sequelae, and the outcomes suggest a novel pathophysiology involving IgG in diarrhoea-associated haemolytic uraemic syndrome.

Measuring child functioning:the Unicef/ Washington Group Module

The Convention on the Rights of the Child, adopted in 1989 included the first explicit provision relating to the rights of children with disabilities. It included a prohibition against discrimination on the grounds of disability (art. 2), and obligations to provide services for children with disabilities, in order to enable them to achieve the fullest possible social integration (art.23)…