Solid fuel and child health in Africa : a causal analysis of social determinants

This thesis uses causal diagrams to describe and quantify the associations between social conditions - such as wealth, education and occupation; proximal health risks - in particular indoor air pollution from solid fuel use; and acute lower respiratory infections (ALRI) among African children. The aim is to delineate different pathways that translate lower socio-economic status into poorer health outcomes. A conceptual causal diagram is used to org?????????????anise a 'series of a priori hypotheses, which are operationalised and tested using Demographic and Health Survey data for Benin, Ethiopia, Kenya and Namibia and, for the solid fuel use pathway, a pooled set of World Health Survey data for sixteen African countries. In doing so, this thesis employs a variety of statistical techniques, including cluster analysis, logistic and ordered logistic regression, survival analysis and Bayesian multileyel and spatial modelling. ?????????????The results suggest that solid fuel use across sub-Saharan Africa is particularly strongly structured by wealth, maternal education and, to a lesser extent, paternal education as partially independent determinants. Heterogeneity at community and districtlevels'strongly influences fuel choice; in some countries this variation is spatially structured~With an'adjusted hazard ratio of 2.35 (1.22; .4.52) cooking with solid fuels is confirmed as a major risk for ALRI mortality. However, socio-economic gradients in ALRI mortality are weak, and are not primarily mediated' by smoke-producing cooking practices. Instead, across much of the social spectrum indoor air pollution appears to exert its effect on child health largely independently of p6~erty;~rlack of education. This thesis illustrates how the rigorous application of causal diagrams combined with standard statistical methods can characterise a complex web of interactions between distal and proximal causes of disease. The ALRI mortality risk associated with traditional fuel use points to a large potential for preventive interventions to reduce c::h.i1d. mor~!d.itY-and mortality.Imperial Users onl

Cooking and Season as Risk Factors for Acute Lower Respiratory Infections in African Children: A Cross-Sectional Multi-Country Analysis

Background Acute lower respiratory infections (ALRI) are a leading cause of death among African children under five. A significant proportion of these are attributable to household air pollution from solid fuel use. Methods We assessed the relationship between cooking practices and ALRI in pooled datasets of Demographic and Health Surveys conducted between 2000 and 2011 in countries of sub-Saharan Africa. The impacts of main cooking fuel, cooking location and stove ventilation were examined in 18 (n = 56, 437),9 (n = 23, 139) and 6 countries (n = 14, 561) respectively. We used a causal diagram and multivariable logistic mixed models to assess the influence of covariates at individual, regional and national levels. Results Main cooking fuel had a statistically significant impact on ALRI risk (p<0.0001),with season acting as an effect modifier (p = 0.034). During the rainy season, relative to clean fuels, the odds of suffering from ALRI were raised for kerosene (OR 1.64;CI: 0.99, 2.71),coal and charcoal (OR 1.54;CI: 1.21, 1.97),wood (OR 1.20;CI: 0.95, 1.51) and lower-grade biomass fuels (OR 1.49;CI: 0.93, 2.35). In contrast, during the dry season the corresponding odds were reduced for kerosene (OR 1.23;CI: 0.77, 1.95),coal and charcoal (OR 1.35;CI: 1.06, 1.72) and lower-grade biomass fuels (OR 1.07;CI: 0.69, 1.66) but increased for wood (OR 1.32;CI: 1.04, 1.66). Cooking location also emerged as a season-dependent statistically significant (p = 0.0070) determinant of ALRI, in particular cooking indoors without a separate kitchen during the rainy season (OR 1.80;CI: 1.30, 2.50). Due to infrequent use in Africa we could, however, not demonstrate an effect of stove ventilation. Conclusions We found differential and season-dependent risks for different types of solid fuels and kerosene as well as cooking location on child ALRI. Future household air pollution studies should consider potential effect modification of cooking fuel by season

Cooking and Season as Risk Factors for Acute Lower Respiratory Infections in African Children: A Cross-Sectional Multi-Country Analysis

Background Acute lower respiratory infections (ALRI) are a leading cause of death among African children under five. A significant proportion of these are attributable to household air pollution from solid fuel use. Methods We assessed the relationship between cooking practices and ALRI in pooled datasets of Demographic and Health Surveys conducted between 2000 and 2011 in countries of sub-Saharan Africa. The impacts of main cooking fuel, cooking location and stove ventilation were examined in 18 (n = 56, 437),9 (n = 23, 139) and 6 countries (n = 14, 561) respectively. We used a causal diagram and multivariable logistic mixed models to assess the influence of covariates at individual, regional and national levels. Results Main cooking fuel had a statistically significant impact on ALRI risk (p<0.0001),with season acting as an effect modifier (p = 0.034). During the rainy season, relative to clean fuels, the odds of suffering from ALRI were raised for kerosene (OR 1.64;CI: 0.99, 2.71),coal and charcoal (OR 1.54;CI: 1.21, 1.97),wood (OR 1.20;CI: 0.95, 1.51) and lower-grade biomass fuels (OR 1.49;CI: 0.93, 2.35). In contrast, during the dry season the corresponding odds were reduced for kerosene (OR 1.23;CI: 0.77, 1.95),coal and charcoal (OR 1.35;CI: 1.06, 1.72) and lower-grade biomass fuels (OR 1.07;CI: 0.69, 1.66) but increased for wood (OR 1.32;CI: 1.04, 1.66). Cooking location also emerged as a season-dependent statistically significant (p = 0.0070) determinant of ALRI, in particular cooking indoors without a separate kitchen during the rainy season (OR 1.80;CI: 1.30, 2.50). Due to infrequent use in Africa we could, however, not demonstrate an effect of stove ventilation. Conclusions We found differential and season-dependent risks for different types of solid fuels and kerosene as well as cooking location on child ALRI. Future household air pollution studies should consider potential effect modification of cooking fuel by season

When complexity matters: a step-by-step guide to incorporating a complexity perspective in guideline development for public health and health system interventions

Background Guidelines on public health and health system interventions often involve considerations beyond effectiveness and safety to account for the impact that these interventions have on the wider systems in which they are implemented. This paper describes how a complexity perspective may be adopted in guideline development to facilitate a more nuanced consideration of a range of factors pertinent to decisions regarding public health and health system interventions. These factors include acceptability and feasibility, and societal, economic, and equity and equality implications of interventions. Main message A 5-step process describes how to incorporate a complexity perspective in guideline development with examples to illustrate each step. The steps include: (i) guideline scoping, (ii) formulating questions, (iii) retrieving and synthesising evidence, (iv) assessing the evidence, and (v) developing recommendations. Guideline scoping using stakeholder consultations, complexity features, evidence mapping, logic modelling, and explicit decision criteria is emphasised as a key step that informs all subsequent steps. Conclusions Through explicit consideration of a range of factors and enhanced understanding of the specific circumstances in which interventions work, a complexity perspective can yield guidelines with better informed recommendations and facilitate local adaptation and implementation. Further work will need to look into the methods of collecting and assessing different types of evidence beyond effectiveness and develop procedural guidance for prioritising across a range of decision criteria

Understanding child stunting in India: a comprehensive analysis of socio-economic, nutritional and environmental determinants using quantile boosting

BACKGROUND: Most attempts to address undernutrition, responsible for one third of global child deaths, have fallen behind expectations. This suggests that the assumptions underlying current modelling and intervention practices should be revisited. OBJECTIVE: We undertook a comprehensive analysis of the determinants of child stunting in India, and explored whether the established focus on linear effects of single risks is appropriate. DESIGN: Using cross-sectional data for children aged 0–24 months from the Indian National Family Health Survey for 2005/2006, we populated an evidence-based diagram of immediate, intermediate and underlying determinants of stunting. We modelled linear, non-linear, spatial and age-varying effects of these determinants using additive quantile regression for four quantiles of the Z-score of standardized height-for-age and logistic regression for stunting and severe stunting. RESULTS: At least one variable within each of eleven groups of determinants was significantly associated with height-for-age in the 35% Z-score quantile regression. The non-modifiable risk factors child age and sex, and the protective factors household wealth, maternal education and BMI showed the largest effects. Being a twin or multiple birth was associated with dramatically decreased height-for-age. Maternal age, maternal BMI, birth order and number of antenatal visits influenced child stunting in non-linear ways. Findings across the four quantile and two logistic regression models were largely comparable. CONCLUSIONS: Our analysis confirms the multifactorial nature of child stunting. It emphasizes the need to pursue a systems-based approach and to consider non-linear effects, and suggests that differential effects across the height-for-age distribution do not play a major role

Cinemeducation in medicine: a mixed methods study on students’ motivations and benefits

BACKGROUND: Cinemeducation courses are used to supplement more standard teaching formats at medical schools and tend to emphasise biopsychosocial aspects of health. The purpose of this paper is to explore why medical students attend the cinemeducation course M23 Cinema (M23C) at LMU Munich and whether a film screening with a subsequent expert and peer discussion benefits their studies and their future careers as medical doctors. METHODS: An exploratory sequential mixed methods study design was used. Qualitative research, i.e. three focus groups, four expert interviews, one group interview and one narrative interview, was conducted to inform a subsequent quantitative survey. Qualitative data was analysed using qualitative content analysis and quantitative data was analysed descriptively. The findings were integrated using the “following a thread” protocol. RESULTS: In total, 28 people were interviewed and 503 participants responded to the survey distributed at seven M23C screenings. Participants perceive the M23C as informal teaching where they learn about perspectives on certain health topics through the combination of film and discussion while spending time with peers. The reasons for and reported benefits of participation varied with educational background, participation frequency and gender. On average, participants gave 5.7 reasons for attending the M23C. The main reasons for participating were the film, the topic and the ability to discuss these afterwards as well as to spend an evening with peers. Attending the M23C was reported to support the students’ memory with regards to certain topics addressed in the M23C when the issues resurface at a later stage, such as during university courses, in the hospital, or in their private life. CONCLUSIONS: The M23C is characterised by its unique combination of film and discussion that encourages participants to reflect upon their opinions, perspectives and experiences. Participating in the M23C amplified the understanding of biopsychosocial aspects of health and illness in students. Thus, cinemeducative approaches such as the M23C may contribute to enabling health professionals to develop and apply humane, empathetic and relational skills. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12909-022-03240-x

Diagram-based Analysis of Causal Systems (DACS): elucidating inter-relationships between determinants of acute lower respiratory infections among children in sub-Saharan Africa.

Effective interventions require evidence on how individual causal pathways jointly determine disease. Based on the concept of systems epidemiology, this paper develops Diagram-based Analysis of Causal Systems (DACS) as an approach to analyze complex systems, and applies it by examining the contributions of proximal and distal determinants of childhood acute lower respiratory infections (ALRI) in sub-Saharan Africa

Neonatal health in Nepal: analysis of absolute and relative inequalities and impact of current efforts to reduce neonatal mortality

Background: Nepal has made substantial progress in reducing under-five mortality and is on track to achieve Millennium Development Goal 4, but advances in neonatal health are less encouraging. The objectives of this study were to assess relative and absolute inequalities in neonatal mortality over time, and to review experience with major programs to promote neonatal health. Methods: Using four nationally representative surveys conducted in 1996, 2001, 2006 and 2011, we calculated neonatal mortality rates for Nepal and for population groups based on child sex, geographical and socio-economic variables using a true cohort log probability approach. Inequalities based on different variables and years were assessed using rate differences (rd) and rate ratios (rr); time trends in neonatal mortality were measured using the annual rate of reduction. Through literature searches and expert consultation, information on Nepalese policies and programs implemented since 1990 and directly or indirectly attempting to reduce neonatal mortality was compiled. Data on timeline, coverage and effectiveness were extracted for major programs. Results: The annual rate of reduction for neonatal mortality between 1996 and 2011 (2.8 percent per annum) greatly lags behind the achievements in under-five and infant mortality, and varies across population groups. For the year 2011, stark absolute and relative inequalities in neonatal mortality exist in relation to wealth status (rd = 21.4, rr = 2.2); these are less pronounced for other measures of socio-economic status, child sex and urban-rural residence, ecological and development region. Among many efforts to promote child and maternal health, three established programs and two pilot programs emerged as particularly relevant to reducing neonatal mortality. While these were designed based on national and international evidence, information about coverage of different population groups and effectiveness is limited. Conclusion: Neonatal mortality varies greatly by socio-demographic variables. This study clearly shows that much remains to be achieved in terms of reducing neonatal mortality across different socio-economic, ethnic and geographical population groups in Nepal. In moving forward it will be important to scale up programs of proven effectiveness, conduct in-depth evaluation of promising new approaches, target unreached and hard-to-reach populations, and maximize use of financial and personnel resources through integration across programs

Factors Influencing Household Uptake of Improved Solid Fuel Stoves in Low- and Middle-Income Countries: A Qualitative Systematic Review

Household burning of solid fuels in traditional stoves is detrimental to health, the environment and development. A range of improved solid fuel stoves ( IS) are available but little is known about successful approaches to dissemination. This qualitative systematic review aimed to identify factors that influence household uptake of IS in low- and middle-income countries. Extensive searches were carried out and studies were screened and extracted using established systematic review methods. Fourteen qualitative studies from Asia, Africa and Latin-America met the inclusion criteria. Thematic synthesis was used to synthesise data and findings are presented under seven framework domains. Findings relate to user and stakeholder perceptions and highlight the importance of cost, good stove design, fuel and time savings, health benefits, being able to cook traditional dishes and cleanliness in relation to uptake. Creating demand, appropriate approaches to business, and community involvement, are also discussed. Achieving and sustaining uptake is complex and requires consideration of a broad range of factors, which operate at household, community, regional and national levels. Initiatives aimed at IS scale up should include quantitative evaluations of effectiveness, supplemented with qualitative studies to assess factors affecting uptake, with an equity focus