Fernanda Claudio

Diarrhoea and Suboptimal Feeding Practices in Nigeria: Evidence from the National Household Surveys.

BACKGROUND Globally, Nigeria has the largest burden of infectious diseases (including diarrhoea). Optimal feeding practices have been well-documented to protect against diarrhoea in other contexts; but this benefit has not been broadly studied in Nigeria. The study aimed to examine the association between diarrhoea and childhood feeding practices to provide country-specific evidence. METHOD Data from the Nigeria Demographic and Health Survey for the period spanning 1999-2013 were used. Prevalence of diarrhoea by infant and young child feeding indicators was estimated, and the association between diarrhoea and childhood feeding indicators was examined using multilevel regression analyses. RESULTS Prevalence of diarrhoea was higher among children whose mothers did not initiate breast feeding within the first hour of birth, infants who were not exclusively breastfed, and infants who were prematurely introduced to complementary foods. Early initiation of breast feeding was significantly associated with lower risk of diarrhoea (RR 0.68, 95% confidence interval (CI) 0.63, 0.74). Exclusively breastfed infants were less likely to develop diarrhoea compared to non-exclusively breastfed infants (RR 0.61, 95% CI 0.44, 0.86). Predominant breast feeding was significantly associated with a lower risk of diarrhoea (RR 0.66, 95% CI 0.54, 0.80). Bottle feeding and introduction of complementary foods were associated with a higher risk of diarrhoea. CONCLUSION Early initiation of breast feeding as well as exclusive and predominant breast feeding protect against diarrhoea in Nigeria, while bottle feeding and introduction of complementary foods were risk factors for diarrhoea. Community- and facility-based initiatives are needed to improve feeding practices, and to reduce diarrhoea prevalence in Nigeria.

Trends in complementary feeding indicators in Nigeria, 2003-2013.

Objective The study aimed to examine secular trends and determinants of changes in complementary feeding indicators in Nigeria. Design, setting and participants Data on 79 953 children aged 6–23 months were obtained from the Nigeria Demographic and Health Surveys (NDHS) for the period spanning 2003–2013. The surveys used a stratified two-stage cluster sample of eligible mothers aged 15–49 years from the six geopolitical zones of Nigeria. Trends in complementary feeding indicators and socioeconomic, health service and individual characteristics including factors associated with complementary feeding indicators were examined using multilevel logistic regression analyses. Results Minimum dietary diversity for children aged 6–23 months worsened from 26% in 2003 to 16% in 2013. Minimum meal frequency improved from 43% in 2003 to 56% in 2013 and minimum acceptable diet worsened from 11% to 9%. Among educated mothers, there was a decreasing prevalence of the introduction of solid, semisolid and soft foods in infants aged 6–8 months (67% in 2003 to 57% in 2013); minimum dietary diversity (33% in 2003 to 24% in 2013) and minimum acceptable diet (13% in 2003 to 8% in 2013). Mothers with a higher education level and mothers who reported more health service contacts were more likely to meet the minimum dietary diversity. Similarly, the odds for minimum acceptable diet were higher among mothers from higher socioeconomic status groups and mothers who reported frequent health services use. Conclusions Complementary feeding practices in Nigeria declined over the study period and are below the expected levels required to ensure adequate growth and development of Nigerian children. National policies and programmes that ensure sustainability of projects post-MDGs and higher health service coverage for mothers, including community-based education initiatives, are proposed to improve complementary feeding practices among Nigerian mothers.

Conflict in least-developed countries: challenging the Millennium Development Goals

Five years before the 2015 deadline for achieving the United Nations’ Millennium Development Goals (MDGs), the picture on progress is mixed. Persisting challenges include dysfunctional health systems, gaps in reliable morbidity and mortality data, uneven progress between goals and growing inequity between subpopulations.1–3 Jan Vandemoortele, one of the architects of the MDGs, emphasizes that the MDGs are globally aggregated and “not meant as a uniform yardstick for measuring performance across countries”.4 Progress across regions and in individual countries varies with social and political structures, geography and local history. The impact of conflict cannot be underestimated: countries suffering conflict are also performing poorly in meeting their MDGs. One-third of countries with low human development are in conflict, with the impact spilling across borders into neighbouring regions.5 Sub-Saharan Africa, the site of 40% of the world’s major conflicts, suffered the highest direct death toll in the decade before 2000. The indirect health implications compound the situation with deaths from consequent disease and malnutrition. In 2008, there were an estimated 41.2 million internally displaced people and refugees globally.3 In these situations, more than any other, the context of MDG progress is critical: conflict disrupts health systems and other government institutions, compromises capacity and renders governance and the legitimacy of authorities uncertain. While securing peace is the main goal, building local ownership of the MDG process and mapping out locally effective programmes are important priorities within that process.4 Afghanistan provides an intriguing and, in certain ways, encouraging example: in 2000, the declaration of the MDGs was irrelevant to the (then) Taliban government and its patchwork of warlord allies. At 0.345, its development index – a composite of life expectancy, education and economic performance – ranked it 174th of 178 countries. Neonatal and infant mortality rates were high. Its maternal mortality ratio, with estimates ranging from 1600 to 2200 per 100 000 live births (6500 reported in Badakshan province), compared poorly with its neighbours.6 Development assistance was minimal. Women were prohibited access to education. The health system was fractured and dysfunctional. Then, in 2001, the “war on terrorism” brought Afghanistan to the centre of international attention. In the immediate aftermath of the defeat of the Taliban, the health systems vacuum was rapidly filled by international development assistance. Health services, provided by international civil and military agencies, developed without effective integration, sustained by project support in major population centres and lacking a coordinating policy framework or effective governance structures. There were early attempts to secure a strategic approach for development. In 2002, the National development framework7 focused on the acute rehabilitation needs of the country. The 2004 document Securing Afghanistan’s future: accomplishments and the strategic path forward,8 while adopting a longer-term perspective, and arguing for more sustainable development of sectors including health, lacked Afghan engagement and a sense of local ownership. In March 2004, the government appointed a high-level commission to adapt the MDG framework to the Afghan context. The commission was systematic in estimating the extent of attrition during the 1990s, and the constraints imposed by insurgency and lack of quality data. Acknowledging the disadvantages that Afghanistan faced, coming late to the MDG process, they courageously – and unilaterally – extended their MDG deadline by five years to 2020, and added a ninth goal: national security. These “Afghanized MDGs” have been integrated into national planning processes, set as the monitoring framework for the Afghanistan National Development Strategy and reiterated in the “Afghan Compact”, a partnership of donors, multilateral organizations and the government. Despite limited local resources and technical expertise, an unevenly distributed workforce and the challenges of managing multiple international agencies (including the military), the national government maintains its intention to coordinate interventions in health. Progress against the MDGs has been uneven, but broadly positive: immunization rates against diphtheria, pertussis and tetanus have increased from 54% of infants in 2003 to 85% in 2008; mortality rates for children aged less than 5 years have reduced from 257 per 1000 live births in 2001 to 191 in 2006; infant mortality rates have reduced from 165 per 1000 live births to 129 in the same period. For complex social, geographical and political reasons, maternal mortality remains a challenge, though skilled birth attendance has risen from 14% in 2003 to 19% in 2007, and the massive increase in access to health services from virtually no coverage to 82% in 2006 provides a base from which to build further positive progress. The case-study offers salutary lessons for progress towards MDGs. First, conflict must be addressed if progress is to occur: the context within which the MDGs are monitored is critical. In volatile settings, interim targets, with progressive review and extension, will be more effective in informing programme management than distant goals.4 The assertion of ownership reflected in extending the deadline to 2020, and the addition of what it sees as an obvious and overlooked goal of security, has reframed the MDGs so that they serve local development, rather than sit in judgement on it.

Determinants of trends in breast-feeding indicators in Nigeria 1999-2013.

OBJECTIVE The present study aimed to examine the trends and differentials in key breast-feeding indicators in Nigeria for the period 1999-2013. DESIGN Longitudinal study of trends (1999-2013) in optimal feeding practices using a series of population-based Nigerian Demographic and Health Surveys. Trends in socio-economic, health service and individual characteristics associated with key breast-feeding indicators were examined using multilevel regression analyses. SETTING Nigeria. SUBJECTS Children (n 88 152) aged under 24 months (n 8199 in 1999; n 7620 in 2003; n 33 385 in 2008; n 38 948 in 2013). RESULTS Among educated mothers, there was an increase in prevalence of exclusive breast-feeding (26% in 1999 to 30% in 2013) and predominant breast-feeding (27% in 1999 to 39% in 2013) compared with mothers with no schooling. A similar increasing trend was evident for mothers from wealthier households and mothers who had a higher frequency of health service access compared with mothers from poorer households and women who reported no health service access, respectively. Mothers with no schooling predominantly breast-fed, but the odds for bottle-feeding were higher among educated mothers and women from wealthier households. The odds for early initiation of breast-feeding were lower for mothers who reported no health service contacts and mothers of lower socio-economic status. CONCLUSIONS Significant increasing trends in key breast-feeding indicators were evident among mothers with higher socio-economic status and mothers who had more health service access in Nigeria. Broader national and sub-national policies that underpin nursing mothers in work environments and a comprehensive community-based approach are proposed to improve feeding practices in Nigeria.

Have policy responses in Nigeria resulted in improvements in infant and young child feeding practices in Nigeria

BackgroundNigeria initiated a range of programs and policies (from 1992 to 2005) to improve infant and young child feeding (IYCF) practices. However, the prevalence of children fed in accordance with IYCF recommendations in Nigeria remains low. This paper presents time trends in IYCF practices in Nigeria for the period (1999–2013), and considers trends in the context of key national policy responses and initiatives.MethodsPrevalence and percentage change (including 95% confidence intervals) of IYCF indicators were investigated over the period 1999–2013 based on a total of 88,152 maternal responses from the Nigeria Demographic and Health Surveys, (n = 8,199 in 1999; n = 7,620 in 2003; n = 33,385 in 2008 and n = 38,948 in 2013).ResultsEarly or timely initiation of breastfeeding decreased significantly by 4.3% (95% Confidence Interval [CI]: −8.1, −0.5; p = 0.0280 for the period (1999–2013); while exclusive breastfeeding remained unchanged 1.6% (95% CI: −2.7, 5.9; p = 0.478). From 2003 to 2013, minimum meal frequency increased significantly by 13.8% (95% CI: 9.9, 17.8; p < 0.001), but minimum dietary diversity and minimum acceptable decreased significantly by 9.7% (95% CI: −9.2, −6.3; p < 0.001) and 3.5% (95% CI: −5.7, −1.3; p = 0.002), respectively. Predominant breastfeeding increased significantly by 13.1% (p < 0.001), and children ever breastfed declined by 16.4% (p < 0.001) over time.ConclusionDespite considerable improvements in national legislation, health system responses and community level development, IYCF practices in Nigeria are still below expected levels. Strengthening community and facility based participation, and broader stand-alone/integrated IYCF policy implementations are needed to improve the current feeding practices of Nigerian mothers.

Remedying Africa's self-propelled corruption: the missing link

ABSTRACT This paper analyses mechanisms and circumstances that facilitate and mitigate against corruption in African countries. We focus on governance indicators that strongly correlate with corruption and suggest that this phenomenon in Africa results from poor democratic practice enabled by asymmetrical concentration of power in governments and the rise of alliances between elites and corporate interests within neo-liberal economic systems. Countries with low corruption have processes in which citizens engage robustly in public governance and public accountability, suggesting that solutions to corruption can originate from within existing governance practices in Africa. We explore African countries that manage to mitigate corruption by reviewing processes of citizen participation in governance occurring through innovations in contemporary mechanisms of decision-making and reintegration of traditional practices in public governance institutions and processes. We argue that corruption in Africa is not a ‘cultural’ phenomenon, but rather that long-standing cultural practices provide innovations in governance that reduce corruption. This paper concludes that wider citizen engagement in public governance strengthens ‘voice and accountability’, balances power asymmetries in decision-making processes of governments, and promotes ‘socially conscious’ leaderships committed to greater transparency and accountability in government.

The CSG arena: a critical review of unconventional gas developments and best-practice health impact assessment in Queensland, Australia

Abstract This paper compares a government-commissioned health study of coal seam gas (CSG) developments in Queensland with international best-practice health impact assessment (HIA) methodologies. A literature review was conducted of (HIA) methods and health studies of CSG development areas in Queensland. Forty-eight interviews were conducted in the Darling Downs CSG region in Queensland. One Queensland Health report was identified but failed to meet HIA international best practice because 7 of 9 key steps were omitted. Interview participants reported poor consultation by government and industry within affected communities. Lack of and poor quality health data was found to exacerbate community tensions. We recommend application of HIAs, epidemiological studies, consultation with communities and consideration of social risks of poor quality health studies.