Determinants of short birth intervals among married women: A cross-sectional study in Karachi, Pakistan

Introduction: Birth spacing is a critical pathway to improving reproductive health. WHO recommends a minimum of 33-month interval between two consecutive births to reduce maternal, perinatal, infant morbidity and mortality. Our study evaluated factors associated with short birth intervals (SBIs) of less than 33 months between two consecutive births, in Karachi, Pakistan.Methods: We used data from a cross-sectional study among married women of reproductive age (MWRA) who had at least one live birth in the 6 years preceding the survey (N=2394). Information regarding their sociodemographic characteristics, reproductive history, fertility preferences, family planning history and a 6-year reproductive calendar were collected. To identify factors associated with SBIs, we fitted simple and multiple Cox proportional hazards models and computed HRs with their 95% CIs.Results: The median birth interval was 25 months (IQR: 14-39 months), with 22.9% (833) of births occurring within 33 months of the index birth. Women\u27s increasing age (25-30 years (aHR 0.63 (0.53 to 0.75), 30+ years (aHR 0.29, 95% CI 0.22 to 0.39) compared with 20-24 years; secondary education (aHR 0.75, 95% CI 0.63 to 0.88), intermediate education (aHR 0.62, 95% CI 0.48 to 0.80), higher education (aHR 0.69, 95% CI 0.51 to 0.92) compared with no education, and a male child of the index birth (aHR 0.81, 95% CI 0.70 to 0.94) reduced the likelihood of SBIs. Women\u27s younger age \u3c20 years (aHR 1.24, 95% CI 1.05 to 1.24) compared with 20-24 years, and those who did not use contraception within 9 months of the index birth had a higher likelihood for SBIs for succeeding birth compared with those who used contraception (aHR 2.23, 95% CI 1.93 to 2.58).Conclusion: Study shows that birth intervals in the study population are lower than the national average. To optimise birth intervals, programmes should target child spacing strategies and counsel MWRA on the benefits of optimal birth spacing, family planning services and contraceptive utilisation

Evaluating implementation of management of possible serious bacterial infection (PSBI) when referral is not feasible in primary health care facilities in Sindh province, Pakistan

Background: The World Health Organization (WHO) launched a guideline in 2015 for managing Possible Serious Bacterial Infection (PSBI) when referral is not feasible in young infants aged 0-59 days. This guideline was implemented across 303 Basic Health Unit (BHU) Plus primary health care (PHC) facilities in peri-urban and rural settings of Sindh, Pakistan. We evaluated the implementation of PSBI guideline, and the quality of care provided to sick young infants at these facilities.Methods: Thirty (10%) out of 303 BHU Plus facilities were randomly selected for evaluation. A survey team visited each facility for one day, assessed the health system support, observed the management of sick young infants by health care providers (HCP), validated their management, interviewed HCPs and caretakers of sick infants. HCPs who were unable to see a young infant on the day of survey were evaluated using pre-prepared case scenarios.Results: Thirty (100%) BHU Plus facilities had oral amoxicillin, injectable gentamicin, thermometers, baby weighing scales and respiratory timers available; 29 (97%) had disposable syringes and needles; 28 (93%) had integrated management of childhood illness (IMCI)/PSBI chart booklets and job aids and 18 (60%) had a functional ambulance. Each facility had at least one HCP trained in PSBI, and 21 (70%) facilities had been visited by a supervisor in the preceding six months. Of 42 HCPs, 19 (45.3%) were trained within the preceding 12 months. During the survey, 26 sick young infants were identified in 18 facilities. HCPs asked about history of breastfeeding in 23 (89%) infants, history of vomiting in 17 (65%), and history of convulsions in 14 (54%); weighed 25 (97%) infants; measured respiratory rate in all (100%) and temperature in 24 (92%); assessed 20 (77%) for movement and 14 (54%) for chest indrawing. HCPs identified two infants with fast breathing pneumonia and managed them correctly per IMCI/PSBI protocol. HCPs identified six (23%) infants with clinical severe infection (CSI), two of them were referred to a higher-level facility, only one accepted the referral advice. Only one CSI patient was managed correctly per IMCI/PSBI protocol at the outpatient level. HCPs described the PSBI danger signs to eight (31%) caretakers. Caretakers of five infants with CSI and two with pneumonia were not counselled for PSBI danger signs. Five of the six CSI cases categorized by HCPs were validated as CSI on re-examination, whereas one had pneumonia. Similarly, one of the two pneumonia patients categorized by HCPs had CSI and one identified as local bacterial infection was classified as CSI upon re-examination.Conclusion: Health system support was adequate but clinical management and counselling by HCPs was sub-optimal particularly with CSI cases who are at higher risk of adverse outcomes. Scaling up PSBI management is potentially feasible in PHC facilities in Pakistan, provided that HCPs are trained well and mentored, receive refresher training to appropriately manage sick young infants, and have adequate supplies and counselling skills

Risk factors for acute respiratory infections in children between 0 and 23 months of age in a peri-urban district in Pakistan: A matched case–control study

Background: Acute respiratory infection (ARI) accounts for nearly 15% of all childhood mortality in South Asia, with children from rural areas at higher risk due to inaccessibility to healthcare facilities. We therefore aimed to identify risk factors associated with ARI in children under 2 years of age in rural Pakistan. Methods: A retrospective 1:2 matched case-control study was conducted between October and December 2018 in Taluka Kotri, Jamshoro District of Pakistan. Cases were identified as children between 0 and 23 months of age with a history of fever, cough, sore throat, fast breathing, difficulty breathing, or chest indrawing in the 2 weeks prior to the survey. Controls were participants without symptoms of ARI, matched based on age in months. Data analysis was conducted using STATA version 15. Univariate and multivariable conditional logistic regression analyses were used to identify factors associated with ARI, and p \u3c 0.05 was considered statistically significant. Results: We identified 1,071 cases of ARI who were matched with 2,142 controls. Multivariable analysis revealed that female gender [odds ratio (OR) 0.78, 95% confidence interval (CI): 0.67-0.91], exclusive breastfeeding (OR 0.81, 95% CI: 0.69-0.97), and comorbidity with diarrhea (OR: 1.64, 95% CI: 1.40-1.91) were significantly associated with ARI. Conclusion: Pakistan continues to progress toward reducing childhood mortality, particularly ARI-related deaths, for which it bears a great burden. This study identifies risk factors such as the male gender, breastfeeding, and comorbidities with diarrhea, which could open grounds for further programmatic implications in targeting a multifaceted approach to reducing incidences of ARI in rural areas of the country

Understanding perceptions and practices for designing an appropriate community-based kangaroo mother care implementation package: Qualitative exploratory study

Background: Low birth weight (LBW) is a common outcome of preterm birth, which increases the risk of an infant\u27s morbidity and mortality. Approximately 20 million infants are born with LBW globally per year. Since a significant number of births in Pakistan take place at home, it is important to focus on the use of kangaroo mother care (KMC), the practice of skin-to-skin contact, in communities to prevent neonatal mortality and morbidity.Objective: We employed a formative research approach to understand the context of communities and facilities with regard to neonatal care and KMC practice. The broader aims were to inform the design and delivery of culturally appropriate platforms to introduce KMC in communities, and develop effective recruitment and retention strategies of KMC in rural areas of the Dadu district in the Sindh province of Pakistan.Methods: We conducted focus group discussions, in-depth interviews, and key informant interviews with families of LBW babies, community members, health care providers, and hospital administrators to identify barriers, enablers, and a knowledge base for KMC interventions.Results: Newborn care practices in communities were found to be suboptimal. The community was generally unaware of the KMC intervention for the care of LBW babies. However, facility health care providers, the community, and family members were willing to provide KMC to improve outcomes. We found significant support from the community members and health care providers for KMC practices. Mothers were also ready to provide intermittent KMC. The administrative staff at the hospitals accepted the introduction of KMC practices for LBW babies.Conclusions: KMC as a method of treating LBW babies is widely accepted in the community. This formative research provides strategically valuable information that will be helpful for developing effective implementation strategies by identifying common community practices for LBW babies, along with identifying the barriers and enablers to KMC practice

Association of multimorbidity of non-communicable diseases with mortality: A 10-year prospective study of 0.5 million chinese adults

Objectives: Non-communicable diseases (NCDs) account for seven out of 10 deaths worldwide, whereas the pattern of multimorbidity of NCDs and its long-term impact on all-cause mortality remains largely unknown, especially among the Chinese population. This study aimed to investigate the associations between the number and patterns of multimorbidity with long-term risks of mortality and to estimate the influence of age on the relationship between multimorbidity and mortality.Study design: This was a prospective population-based cohort study.Methods: Data were obtained from the China Kadoorie Biobank study, which enrolled adults aged 30-79 years from 10 regions of China. The outcome was all-cause mortality, which was measured at a 10-year follow-up (9.93 ± 1.82 years). A principal component analysis (PCA) was used to identify patterns of individuals with multimorbidity based on 16 self-reported or baseline-detected chronic conditions. Cox proportional hazards models were used to examine the associations of both the number and patterns of multimorbidity of NCDs with all-cause mortality. Stratified analyses were carried out to explore whether the associations of multimorbidity with all-cause mortality were modified by age, number, and the patterns of multimorbidity.Results: We included 512,712 individuals in our analysis, of which 176,619 (34.5%) had only one long-term condition (LTC), and 81,360 (15.9%) had multimorbidity. The crude mortality rate was highest in those aged between 70 and 79 years who also had ≥4 LTCs (44.38 per 1000 person-years). In participants with at least four LTCs at baseline, fully adjusted HRs were 4.58 (95% CI 2.65-7.93) for people belongs to 1960s-1970s, compared to 2.73 (95% CI 2.50-2.97) for 1920s-1930s. Six multimorbidity patterns were identified, including cardiometabolic syndrome, respiratory diseases, digestive/renal/urologic diseases, articular/rheumatic diseases, and neuropsychiatric diseases. For the multimorbidity patterns of cardiometabolic syndrome, fully adjusted HRs for all-cause mortality were 1.60 (95% CI 1.55-1.65) in participants with one LTC and 8.19 (95% CI 6.45-10.40) in those with four LTCs compared with the reference group (no LTCs).Conclusions: The observed higher risk of mortality in younger people with multimorbidity, as middle aged (30-49 years), calls for advocating primary prevention in the younger population and secondary prevention for the elderly to strengthen early detection and timely treatment. Health systems need to shift from single-disease models to more effective multimorbidity management

Bridge Employment and Longevity: Evidence from a 10-year follow-up cohort study in 0.16 million Chinese

Objectives: Bridge employment has been encouraged by many countries worldwide as the societies age rapidly. However, the health impact on bridge employment is not consistent in previous studies. This study aims to explore the association between bridge employment and the long-term health outcome among the Chinese population.Method: In this prospective cohort study, we used a subset of the China Kadoorie Biobank study, in which 163,619 participants who reached the statutory age of retirement at baseline (2004-2008) were included in this study. Mortality statistics were obtained from death registries in the Death Surveillance Points system annually. We used a Cox proportional hazard model to analyze the association between bridge employment and all-cause mortality.Results: Overall, we found that compared to retired/non-employed men and women, hazards of all-cause mortality were lower in older people with bridge employment (Men: 0.82, 95% CI: 0.77-0.88; Women: 0.79, 95% CI: 0.74-0.94) in healthy populations. The protective effect of bridge employment was stronger among older adults living in rural areas and among those from a relatively low socioeconomic status.Conclusion: The lower risk of all-cause mortality associated with bridge employment was consistently observed among older men and women. Our findings may provide important insights from the health dimension on the retirement policy-making in China as a hyper-ageing society

Prevalence and associated socioeconomic factors of multimorbidity in 10 regions of China: An analysis of 0.5 million adults

Background: The epidemiology of multiple chronic conditions in China is poorly understood. We investigated the prevalence of multimorbidity among the middle-aged and elderly population in China and analyzed its demographic and socioeconomic correlates. Methods: Data were obtained from the baseline of the China Kadoorie Biobank Study, which recruited over 0.5 million participants between 2004 and 2008. We calculated the prevalence by the characteristics of multimorbidity. The demographic and socioeconomic correlates were analyzed using a multivariable logistic regression model. Results: 15.9% of the participants were multimorbid. Although the prevalence of multimorbidity increased with age, the absolute number of people with multimorbidity was much higher among middle-aged adults (30-60 years, n = 42 041) than the elderly group (\u3e60 years, n = 38 834). The odd of multimorbidity was higher in males (aOR =1.09, 95% CI: 1.07-1.11) and among those who were unemployed (aOR = 1.58, 95% CI: 1.55-1.62). Those who received the highest level of education were most likely to be multimorbid compared with those with no education (aOR = 1.14, 95% CI: 1.09-1.19). Such an association was similar when treating multimorbidity as multinomial variable. Conclusions: Multimorbidity is a public health concern, with higher prevalence among the elderly, males and those who belong to a lower socioeconomic stratum. Actions are needed to curb multimorbidity epidemic in China

Understanding the context of healthcare utilisation for children under-five with diarrhoea in the DRC: Based on andersen behavioural model

Background: Diarrhoea is one of the leading causes of death among children under 5 years old in the Democratic Republic of the Congo (DRC). Despite positive effects on prognosis, there is limited literature about the healthcare-seeking behaviours of children with diarrhoea, especially in the DRC. This study used the Andersen Behavioural Model, a theoretical framework, which was commonly adopted to study healthcare utilisation, to investigate and predict factors associated with the use of healthcare to treat diarrhoea in the DRC. Methods: Data collected from 2626 under-five children with diarrhoea in the last 2 weeks from the Multiple Indicators Cluster Survey conducted by the National Institute of Statistics in 2017-2018, in collaboration with the United Nations Children\u27s Fund were used in this study. Both direct and indirect relationships among four latent variables: predisposing traits, enabling resources access, health needs, and health services use were measured using the structural equation modelling to test the Andersen behavioural model. The confirmatory Factor Analysis model was also modified based on the DRC context to explore this further. Results: The modified model had the goodness of fit index (GFI) of 0.972, comparative fit index (CFI) of 0.953 and RMSEA of 0.043 (95% CI: 0. 040, 0.047). Health needs (especially diarrhoea) had the largest positive direct effect on healthcare utilisation (standardized regression coefficient [β] = 0.135, P \u3c 0.001), followed by enabling resources (β = 0.051, P = 0.015). Health needs also emerged as a mediator for the positive effect of predisposing on utilisation (indirect effect, β = 0.014; P = 0.009). Conclusion: Access to improved water and improved sanitation, as well as socioeconomic factors like household wealth, were significantly associated with health-seeking behaviours for diarrhoea treatment in the DRC. Besides, caregivers who own higher levels of educational attainments were more inclined to have positive health services uses during the treatments. Efforts are needed to enhance the oral rehydration therapy coupled with educating caregivers on its appropriate use

Factors associated with parenting stress among mothers of children with developmental disabilities: A cross-sectional study

Introduction: Parents of children with developmental disabilities, particularly mothers, are likely to suffer from stress. Nevertheless, the association between parenting stress and the type and extent of disability is far from evident.Methods: To examine the relationship between parenting stress, and type and extent of disability, we collected demographic details and the Parenting Stress Scale from 250 mothers of children with a developmental disability attending special-education schools in Karachi. Type and extent of disability were diagnosed by the school’s psychologist based on DSM criteria. Adjusted beta-coefficients along with a 95% confidence interval were reported using multiple linear regression.Results: The overall mean parenting stress score among mothers was found to be 43.2 (95% CI: 42.3–44.1). A total of 80 mothers (32%) had a child with Intellectual disability (ID), 60 (24%) with Attention deficit hyperactivity disorder (ADHD), 41 (16%) with Autism, and 69 (28%) with Down syndrome. A large proportion of these children (41%) had mild symptoms and around 26% had severe disability. Multivariable analysis showed that the estimated mean parenting stress score was higher for mothers of children with severe autism (β: 8.09, 95% CI: 3.07, 13.11), severe ID (β: 7.45, 95% CI: 3.71, 11.19) and severe ADHD (β: 7.03, 95% CI: 2.62, 11.44) compared to mothers of children with mild autism, ID, and ADHD.Conclusion: Nurturing a child with special care needs is challenging for mothers. Appropriate clinical services aiming to support parents of children with various disabilities should offer resources to educate and enable mothers to manage their child’s disabilities and needs. Tailored parenting interventions must also be introduced to reduce the levels of stress among mothers