Impact on inequities in health indicators: effect of implementing the integrated management of neonatal and childhood illness programme in Haryana, India

Background: A trial to evaluate the Integrated Management of Neonatal and Childhood Illness (IMNCI) strategy showed that the intervention resulted in lower infant mortality and improved infant care practices. In this paper, we present the results of a secondary analysis to examine the effect of the IMNCI strategy on inequities in health indicators. Methods: The trial was a cluster-randomized controlled trial in 18 primary health centre areas. For this analysis, the population was divided into subgroups by wealth status (using Principal Component Analysis), religion and caste, education of mother and sex of the infant. Multiple linear regression analysis was used to examine inequity gradients in neonatal and post-neonatal mortality, care practices and care seeking, and the differences in these gradients between intervention and control clusters. Findings: Inequity in post-neonatal infant mortality by wealth status was lower in the intervention as compared to control clusters (adjusted difference in gradients 2.2 per 1000, 95% confidence interval (CI) 0 to 4.4 per 1000, P = 0.053). The intervention had no effect on inequities in neonatal mortality. The intervention resulted in a larger effect on breastfeeding within one hour of birth in poorer families (difference in inequity gradients 3.0%, CI 1.5 to 4.5, P < 0.001), in lower caste and minorities families, and in infants of mothers with fewer years of schooling. The intervention also reduced gender inequity in care seeking for severe neonatal illness from an appropriate provider (difference in inequity gradients 9.3%, CI 0.4 to 18.2, P = 0.042). Conclusions: Implementation of IMNCI reduced inequities in post-neonatal mortality, and newborn care practices (particularly starting breastfeeding within an hour of birth) and health care-seeking for severe illness. In spite of the intervention substantial inequities remained in the intervention group and therefore further efforts to ensure that health programs reach the vulnerable population subgroups are required

Use of multiple opportunities for improving feeding practices in under-twos within child health programmes

Objectives: In a community randomized trial, we aimed to promote exclusive breastfeeding and appropriate complementary feeding practices in under-twos to ascertain the feasibility of using available channels for nutrition counselling, their relative performance and the relationship between intensity of counselling and behaviour change. We also assessed whether using multiple opportunities to impart nutrition education adversely affected routine activities. Methods: We conducted a community randomized, controlled effectiveness trial in rural Haryana, India, with four intervention and four control communities. We trained health and nutrition workers in the intervention communities to counsel mothers at multiple contacts on breastfeeding exclusively for 6 months and on appropriate complementary feeding practices thereafter. The intervention was not just training health and nutrition workers in counselling but included community and health worker mobilization. Findings: In the intervention group, about 32% of caregivers were counselled by traditional birth attendants at birth. The most frequent sources of counselling from birth to 3 months were immunization sessions (45.1%) and home visits (32.1%), followed closely by weighing sessions (25.5%); from 7 to 12 months, home visits (42.6%) became more important than the other two. An increase in the number of channels through which caregivers were counselled was positively associated with exclusive breastfeeding prevalence at 3 months (p = 0.002), consumption of milk/cereal gruel or mix use at 9 months (p = 0.004) and 18 months (p = 0.003), undiluted milk at 9 months (p < 0.0001) and 24 hour non-breast-milk energy intakes at 18 months (p = 0.023), after controlling for potential confounding factors. Intervention areas, compared with the control, had higher coverage for vitamin A (45% vs. 11.5%) and iron folic acid (45% vs. 0.4%) supplementation. Conclusions: Using multiple available opportunities and workers for counselling caregivers was feasible, resulted in high coverage and impact, and instead of disrupting ongoing services, resulted in their improvement

Diagnostic measures for severe acute malnutrition in Indian infants under 6 months of age: a secondary data analysis

Background Weight for length z-score (WLZ) < − 3 is currently used to define severe acute malnutrition (SAM) among infants. However, this approach has important limitations for infants younger than 6 months of age as WLZ cannot be calculated using WHO growth standards if infant length is < 45 cm. Moreover, length for age z-score (LAZ) and weight for length z-score (WLZ) are least reliable measures, with high chances of variation, and less chances of detecting undernutrition in under 6 months infants. The objective of the current analysis was to compare WLZ with WAZ and LAZ in a cohort of Indian infants in predicting the deaths between 6 weeks and 6 months of age. Methods The data was from an individually randomized trial conducted in slums of Delhi, India in which infants’ weight and length were measured at 6 weeks of age (at the time of the first immunization visit). Vital status of the infants was documented from 6 weeks to 6 months of age. The sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were calculated for WAZ < -3, WLZ < -3, and LAZ < -3 for deaths between 6 weeks and 6 months of age. The receiver operating characteristics curve was calculated for each of the above anthropometric indicators. Results For deaths occurring between 6 weeks to 6 months of age, the specificity ranged between 85.9–95.9% for all three anthropometric indicators. However, the sensitivity was considerably higher for WAZ; it was 64.6% for WAZ < -3, 39.1% for LAZ < -3, and 25.0% for WLZ < -3. WAZ < -3 had higher area under curve (0.75; 95% CI: 0.68, 0.82) and hence, better discriminated deaths between 6 weeks and 6 months of age than WLZ < -3. The adjusted relative risk (RR 10.6, 95% CI 5.9, 18.9) and the population attributable fraction (PAF 57.9, 95% CI 38.8, 71.0%) of mortality was highest for WAZ < -3. Conclusions We found WAZ < -3 at 6 weeks of age to be a better predictor of death in the 6 weeks to 6 months of life in comparison to WLZ < -3 and LAZ < -3 and propose that it should be considered to diagnose SAM in this age group.publishedVersio

Optimal breastfeeding practices and infant and child mortality: A systematic review and meta-analysis

Aim: To synthesise the evidence for effects of optimal breastfeeding on all-cause and infection-related mortality in infants and children aged 0–23 months. Methods: We conducted a systematic review to compare the effect of predominant, partial or nonbreastfeeding versus exclusive breastfeeding on mortality rates in the first six months of life and effect of no versus any breastfeeding on mortality rates between 6 and 23 months of age. A systematic literature search was conducted in PubMed, Cochrane CENTRAL and CABI. Results: The risk of all-cause mortality was higher in predominantly (RR 1.5), partially (RR 4.8) and nonbreastfed (RR14.4) infants compared to exclusively breastfed infants 0– 5 months of age. Children 6–11 and 12–23 months of age who were not breastfed had 1.8- and 2.0-fold higher risk of mortality, respectively, when compared to those who were breastfed. Risk of infection-related mortality in 0–5 months was higher in predominantly (RR 1.7), partially (RR 4.56) and nonbreastfed (RR 8.66) infants compared to exclusive breastfed infants. The risk was twofold higher in nonbreastfed children when compared to breastfed children aged 6–23 months. Conclusion: The findings underscore the importance of optimal breastfeeding practices during infancy and early childhood.publishedVersio

Cameron-Liebler sets of k-spaces in PG(n,q)

Cameron-Liebler sets of k-spaces were introduced recently by Y. Filmus and F. Ihringer. We list several equivalent definitions for these Cameron-Liebler sets, by making a generalization of known results about Cameron-Liebler line sets in PG(n, q) and Cameron-Liebler sets of k-spaces in PG(2k + 1, q). We also present a classification result

Utilisation, equity and determinants of full antenatal care in India: analysis from the National Family Health Survey 4

Objectives: We examined the utilisation, equity and determinants of full antenatal care (ANC), defined as 4 or more antenatal visits, at least one tetanus toxoid (TT) injection and consumption of iron folic acid (IFA) for a minimum of 100 days, in India. Methods: We analysed a sample of 190,898 women from India’s National Family Health Survey 4. Concentration curves and concentration index were used to assess equity in full ANC utilisation. Multivariable logistic regression model was used to examine the factors associated with full ANC utilisation. Results: In India, 21% of pregnant women utilised full ANC, ranging from 2.3–65.9% across states. Overall, 51.6% had 4 or more ANC visits, 30.8% consumed IFA for atleast 100 days, and 91.1% had one or more doses of tetanus toxoid. Full ANC utilisation was inequitable across place of residence, caste and maternal education. Registration of pregnancy, utilisation of government’s Integrated Child Development Services (ICDS) and health insurance coverage were associated with higher odds of full ANC utilisation. Lower maternal education, lower wealth quintile(s), lack of father’s participation during antenatal visits, higher birth order, teenage and unintended pregnancy were associated with lower odds of full ANC utilisation. Conclusions: Full ANC utilisation in India was inadequate and inequitable. Although half of the women did not receive the minimum recommended ANC visits, the utilisation of TT immunisation was almost universal. The positive association of full ANC with ICDS utilisation and child’s father involvement may be leveraged for increasing the uptake of full ANC. Strategies to address the socio-demographic factors associated with low and inequitable utilisation of full ANC are imperative for strengthening India’s maternal health program.publishedVersio

Setting health research priorities using the CHNRI method:I. Involving funders

In 2007 and 2008, the World Health Organization's Department for Child and Adolescent Health and Development commissioned five large research priority setting exercises using the CHNRI (Child Health and Nutrition Research Initiative) method. The aim was to define research priorities related to the five major causes of child deaths for the period up to the year 2015. The selected causes were childhood pneumonia, diarrhoea, birth asphyxia, neonatal infections and preterm birth/low birth weight. The criteria used for prioritization in all five exercises were the “standard” CHNRI criteria: answerability, effectiveness, deliverability, potential for mortality burden reduction and the effect on equity. Having completed the exercises, the WHO officers were left with another question: how “fundable” were the identified priorities, i.e. how attractive were they to research funders

Health equity impact of community-initiated kangaroo mother care: a randomized controlled trial

Background: Kangaroo mother care (KMC) can substantially enhance overall survival of low birthweight babies. In a large randomized controlled trial, we recently showed that supporting mothers to provide community initiated KMC (ciKMC) can reduce mortality among infants up to 180 days of life by 25% (hazard ratio (HR) 0.75). With the current analysis, we aimed to explore if ciKMC promotion leads to increased inequity in survival. Methods: In the trial we randomized 8402 low birthweight babies to a ciKMC (4480 babies) and a control (3922 babies) arm, between 2015 and 2018 in Haryana, India. We estimated the difference in concentration indices, which measure inequality, between babies in the ciKMC and control arms for survival until 180 days of life. Further, we compared the effect of ciKMC promotion across subgroups defined by socioeconomic status, caste, maternal literacy, infant’s sex, and religion. Results: Our intervention did not increase survival inequity, as the concentration index in the ciKMC arm of the trial was 0.05 (95% CI -0.07 to 0.17) lower than in the control arm. Survival impact was higher among those belonging to the lower two wealth quintiles, those born to illiterate mothers and those belonging to religions other than Hindu. Conclusions: We found that ciKMC promotion did not increase inequity in survival associated with wealth. The beneficial impact of ciKMC tended to be larger among vulnerable groups. Supporting mothers to provide KMC at home to low birthweight babies will not increase and could indeed reduce inequities in infant survival.publishedVersio

Evaluation of two experimental three-way hybrids of free-range chickens under two feeding managements

El pollo campero es un ave con menor velocidad de crecimiento y mayor rusticidad que el pollo parrillero industrial, y está destinado a sistemas de producción semi-intensiva que contemplan aspectos vinculados con el bienestar animal. El esquema tradicional de alimentación de estas aves incluye la utilización de tres tipos de alimento –“Iniciador”, “Crecimiento” y “Terminador”- formulados específicamente para cada una de las etapas. Dado que es complejo manejar tres tipos de alimento en explotaciones pequeñas, los productores se plantean la posibilidad de manejar sólo dos: “Iniciador” y “Terminador”. El objetivo de este trabajo fue caracterizar el comportamiento productivo y la calidad física de la carne de machos de dos cruzamientos experimentales de tres vías de pollo campero -Campero Casilda y Campero Pergamino- como alternativas frente al cruzamiento simple Campero INTA, bajo dos manejos de alimentación (a) tradicional de tres raciones y tres dietas y (b) alternativo con sólo dos raciones (iniciador y terminador) y cinco dietas. Los dos cruzamientos experimentales se desempeñaron de manera equivalente en relación con la mayoría de las variables analizadas y presentaron mayor peso que Campero INTA lo que los transforma en opciones válidas para sistemas de avicultura alternativa a la industrial. La ausencia de modificaciones de trascendencia productiva al reemplazar el alimento crecimiento por combinaciones de iniciador y terminador indica la posibilidad de obviar su inclusión en el esquema de alimentación, simplificando así la producción de este tipo de aves.Campero chicken is a type of meat producing bird with a lower body weight gain and a greater rusticity than their industrial broilers counterparts, intended for semi-intensive production systems that prioritizes aspects related to animal welfare. The traditional feeding scheme includes the use of three types of diets specially formulated for this purpose (Starter, Grower and Finisher). Taking into account the complexity of managing three types of food in small farms, the producers consider the possibility of managing only two: “Starter” and “Finisher”. The aim of this work was to characterize the productive behavior and the physical quality of the meat, of males of two threeway experimental hybrids of free range chickens -Campero Casilda y Campero Pergamino- as alternatives to the twoway cross Campero INTA. Both experimental crosses were evaluated under two feeding regimens (a) traditional, with three diets (Starter, Grower and Finisher) and three rations, and (b) alternative, with only two diets (Starter and Finisher) combined in five rations. The experimental crosses performed in an equivalent manner for almost all traits, being both heavier than Campero INTA, which transforms them into valid options for poultry systems alternative to the industrial one. The lack of meaningful productive differences when Grower feed was replaced by three Starter + Finisher combinations, indicates the feasibility of avoiding its inclusion in the feeding scheme, thus simplifying the production of this type of free-range birds.EEA PergaminoFil: Dottavio, Ana María. Universidad Nacional de Rosario. Facultad de Ciencias Veterinarias. Cátedra de Genética; ArgentinaFil: Dottavio, Ana María. Universidad Nacional de Rosario. Facultad de Ciencias Veterinarias. Carrera del Investigador Científico; ArgentinaFil: Fernández, R. Universidad Nacional de Rosario. Facultad de Ciencias Veterinarias. Cátedra de Economía Agraria y Administración Rural; ArgentinaFil: Romera, Bernardo Martín. Universidad Nacional de Rosario. Facultad de Ciencias Veterinarias. Cátedra de Genética; ArgentinaFil: Advínculo, S.A. Universidad Nacional de Rosario. Facultad de Ciencias Veterinarias. Cátedra de Genética; ArgentinaFil: Martines, Araceli. Universidad Nacional de Rosario. Facultad de Ciencias Veterinarias. Cátedra de Genética; ArgentinaFil: Librera, José Ernesto. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Pergamino.; ArgentinaFil: Librera, José Ernesto. Universidad Nacional de Rosario. Facultad de Ciencias Veterinarias. Cátedra de Genética; ArgentinaFil: Canet, Zulma Edith. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Pergamino; ArgentinaFil: Canet, Zulma Edith. Universidad Nacional de Rosario. Facultad de Ciencias Veterinarias. Cátedra de Genética; ArgentinaFil: Di Masso, Ricardo José. Universidad Nacional de Rosario. Facultad de Ciencias Veterinarias. Cátedra de Genética; ArgentinaFil: Di Masso, Ricardo José. Universidad Nacional de Rosario. Facultad de Ciencias Veterinarias. Carrera del Investigador Científico; Argentin