Determinants of child survival, health care seeking and nutritional status in a rural district of Pakistan

Ph.DDOCTOR OF PHILOSOPH

Are pre-school girls more likely to be under-nourished in rural Thatta, Pakistan?-a cross-sectional study.

BACKGROUND: Pakistan ranks third lowest on a global gender index (2013) and 13(th) highest on the prevalence of underweight among under-five children (2010). Through this population-based study, we examined gender differentials in the prevalence of stunting, wasting and under-weight defined by World Health Organization (WHO) Growth Standard among rural pre-school Pakistani children. METHODS: We performed secondary analysis of data collected through a cross-sectional survey of Thatta district during 1992-93. Prevalence ratios were calculated for 1051 children aged 0-35 months from 95 randomly selected villages of rural Pakistan using a clustered adjusted log binomial model. Level 1 variables included child and household characteristics and level 2 included village characteristics. RESULTS: Based on the new WHO growth reference, a major proportion of children were stunted (52.9 %), wasted (22.9 %) and under-weight (46.5 %). In a two-level model, compared to boys, girls had significantly greater risk of stunting [Prevalence Ratio (PR) (95 % C.I.) = 1.18 (1.03, 1.36)] and under-weight [P.R. (95 % C.I.) 1.14 (1.03, 1.26)], after adjustment of maternal literacy and village variables. Risk of wasting did not differ with gender [P.R. (95 % C.I.) = 1.04 (0.99, 1.15)]. Mothers of stunted and underweight children were respectively, 21 and 20 % more likely to be illiterate than those of normally nourished children. Sick children were at 16 % greater risk of wasting than those not reported ill. CONCLUSION: Greater prevalence of stunting and under-weight among girls suggests adoption of a gender sensitive approach in nutritional intervention programmes. Prompt management of childhood illnesses may reduce prevalence of wasting. Better literacy among rural mothers may reduce prevalence of stunting and under-weight. Whether gender differences in nutrition status are an underlying pathway for excessive girl mortality in rural Thatta needs further examination

The efficacy of a personalized mhealth coaching program during pregnancy on maternal diet, supplement use, and physical activity: Protocol for a parallel-group randomized controlled trial

Background: Adequate intake of macro- and micronutrients and adoption of an active lifestyle during pregnancy are essential for optimum maternal and fetal health and offspring development. Dietary counseling and advice regarding adequate physical activity are integral components of antenatal care. Personalized coaching through the use of mobile health (mHealth) that supports behavior modification is an innovative approach that needs exploration.Objective: Our primary aim is to assess the efficacy of an mHealth program in improving diet, supplement use, and physical activity during pregnancy. Secondary objectives include evaluation of the program\u27s effect on maternal and offspring health outcomes and assessment of its compliance and usability.Methods: A randomized controlled trial was initiated at the Aga Khan University Hospital in Karachi, Pakistan, in January 2020. We aim to recruit 300 pregnant women in their first trimester who have smartphones, do not have comorbidities, and are not taking medications. The intervention group will be trained to use an mHealth app called PurUmeed Aaghaz. Through this app, the subjects will report information about their diet, supplement use, and physical activity and will receive personalized advice and three push messages as weekly reminders. The research assistant will obtain similar information from the control group via a paperless questionnaire; this group will receive standard face-to-face counseling regarding diet, supplement use, and physical activity. Data will be collected at enrollment and during four follow-up sessions scheduled 6 weeks apart. Primary study outcomes include improvements in diet (ie, change in mean dietary risk score from baseline to each follow-up), supplement use (ie, changes in mean supplement use score and biochemical levels of folic acid, iron, calcium, and vitamin D on a study subset), and mean duration of reported physical activity (minutes). Secondary study outcomes relate to maternal health (ie, gestational diabetes mellitus, gestational hypertension, pre-eclampsia, and gestational weight gain), newborn health (ie, birth weight and length and gestational age at delivery), and infant health (ie, BMI and blood pressure at 1 year of age). Compliance will be determined by the proportion of participants who complete the 6-month coaching program. Usability will be assessed based on features related to design, interface, content, coaching, perception, and personal benefit.Results: The study was approved by the Ethics Review Committee of the Aga Khan University in 2017. The recruitment of study participants was completed in September 2021. All follow-ups and outcome assessments are expected to be completed by March 2023 and analysis is expected to be completed by June 2023. We expect the results to be published by the end of 2023.Conclusions: This study will be an important step toward evaluating the role of mHealth in improving behaviors related to a healthy diet, supplement use, and promotion of physical activity during pregnancy, as well as in influencing maternal and offspring outcomes. If proven effective, mHealth interventions can be scaled up and included in antenatal care packages at tertiary care hospitals of low- and middle-income countries.Trial registration: ClinicalTrials.gov NCT04216446; https://clinicaltrials.gov/ct2/show/NCT04216446.International registered report identifier (irrid): DERR1-10.2196/31611

Using mobile phones to improve young people\u27s sexual and reproductive health in low- and middle-income countries: A systematic review protocol to identify barriers, facilitators and reported interventions

Background: Due to a growing reliance on mobile phone technology and decreasing mobile phone costs, the use of mobile phones is on the rise, especially among the youth population. Young people are responsive and enthusiastic to use novel approaches such as mHealth to access sexual and reproductive health information and services. Globally, reproductive health programs have used mHealth to provide sexual and reproductive health education and services to young people, through diverse communication channels. However, few attempts have been made to systematically review the mHealth programs for young people sexual and reproductive health (SRH) in low- and middle-income countries (LMICs). In addition, very little is known regarding the potential barriers and facilitators to the uptake of mobile phone interventions for improving young people SRH. This review aims to highlight facilitators and inhibitors to implementing and increasing uptake of mHealth interventions for young people\u27s SRH, in LMICs specifically. Additionally, the review will identify the range of mHealth solutions which can be used for improving young people\u27s SRH in LMICs.Methods: The review will focus on comparing the various types of mHealth interventions/strategies that are used to improve young people\u27s SRH services in LMICs. PubMed, CINAHL Plus, Science Direct, Cochrane, and gray literature will be explored using a detailed search strategy. The studies involving young people (adolescents and youth) aged 10-24 years to which mHealth interventions were delivered for improving their SRH outcomes will be included in this review. LMICs will be selected according to the World Bank\u27s (WB) 2018 Country Classification list. Studies published between January 2005 and March 2018 will be included as the field of mHealth has emerged over the last decade. English language articles will be included as the authors are proficient in this language.Discussion: The systematic review will assist researchers and SRH professionals in understanding facilitators and barriers to implementing and increasing the uptake of mHealth interventions for SRH in LMICs. Finally, this review will provide more detailed information about embracing the use of mobile phones at different levels of the healthcare system for improving young people\u27s SRH outcomes

Comparison of estimates of under-nutrition for pre-school rural Pakistani children based on the WHO standard and the National Center for Health Statistics (NCHS) reference

Objective: To compare estimates of under-nutrition among pre-school Pakistani children using the WHO growth standard and the National Center for Health Statistics (NCHS) reference. Design: Prevalence of stunting, wasting and underweight as defined by WHO and NCHS standards are calculated and compared. Setting: The data are from two cross-sectional surverys conducted in the early 1990s, the time frame for setting the baseline for the Millennium Development Goals: (i) National Health Survey of Pakistan (NHSP) assessed the health status of a nationally representative sample and (ii) Thatta Health System Research Project (THSRP) was a survey in Thatta, a rural district of Sindh Province. Subejcts: In all, 1533 and 1051 children aged 0-35 months from national and Thatta surveys, respectively. Results: WHO standard gave a significantly higher prevalence of stunting for both national [36.7 (95% CI 33.2, 40.2)] and Thatta surveys [52.9 (95% CI 48.9, 56-9)] compared to the NCHS reference [national 29.1 (95% CI 25.9, 32.2) and Thatta: 44.8 (95% CI 41.1, 48.5), respectively]. It also gave significantly higher prevalence of wasting for the Thatta survey [22.9 (95% CI 20.3, 25.5)] compared to the NCHS reference [15.7 (95% CI 13.5, 17.8)]. Differences due to choice of standard were pronounced during infancy and for severely wasted and severely stunted children. Conclusions: Pakistan should switch to the robustly constructed and up-to-date WHO growth standard for assessing under-nutrition. New growth charts should be introduced along with training for health workers. This has implications for nutritional intervention programmes, for resetting the country\u27s targets for Millennium Development Goal 1 and for monitoring nutritional trends

Pakistan developmental origins of health and disease (DOHaD) society: Addressing the \u27DO\u27 component of DOHaD

Adverse intrauterine environment could serve as an important stimulus for postnatal altered health status and for increased susceptibility to long-term non-communicable diseases (NCDs). The notion is now recognized as the Developmental Origins of Health and Disease (DOHaD), which was first proposed by Sir David Barker. Since then, several scientific disciplines have strived to measure the magnitude of the early fetal programming and later risk of diseases. Pakistan, with striking figures of morbidity and mortality from NCDs, is currently tackling with double burden of diseases and requires planned efforts to counteract the threat of NCDs. Considering the growing needs and available evidences, Pakistan DOHaD Society was officially instigated in September 2016. The Society aims to explicitly address the association of life in utero with future health and disease and to endorse early screening and interventions to reduce the burden of NCDs, mental health issues and learning disorders along the life course. It has shown significant progress toward investigating the influence of adverse in utero environment such as diabetes, maternal under-nutrition and pre-eclampsia on fetal programming under two major research lines, that is, cardiovascular and cerebrovascular programming. The Society has been successful in disseminating its research findings through several esteemed international scientific conferences. Pakistan DOHaD Society encourages scientific community for collaborative research aimed at improving the quality of life during early childhood, adolescence and adulthood through provision of appropriate pre-pregnancy and antenatal interventions targeted to address at-risk in utero conditions

Prenatal detection of impaired corpus callosum growth using two-dimensional neurosonography in growth-restricted fetuses: potential indicator of fetal brain remodeling in-utero

Objectives: Fetal corpus callosum (CC) serves as a sensitive indicator for brain development and maturation. This largest white-matter-fiber-bundle is important for inter-hemispheric communication of sensory, motor and higher-order information. Its altered development in preterm-infants suggests white-matter-injury and its possible association with delayed cognitive and motor development. We aim to compare the growth of CC in appropriate-for-gestational-age (AGA) and growth-restricted-fetuses (GRFs) using two-dimensional-neuroimaging. Methods: 42 pregnant women were examined in the third-trimester (25-37 weeks) from October- December 2013. Inclusion criteria were singleton fetuses with no structural or chromosomal abnormalities and pregnant women with no medical complications. Fetal brain was examined in the mid-sagittal plane. Length of the CC was measured across outer-outer and inner-inner diameters along with its area. Mean of three measurements recorded in millimeters was included in the analysis. Results: Out of 42 fetuses examined, 31 were identified as AGA and 11 as GRFs based on their estimated-fetal-weight. Mid-sagittal view was successfully obtained in all except for 4 AGA fetuses (90%). Mean maternal age, mean gestational age (GA) and mean area of CC did not differ between the groups (p-value \u3e 0.05). Mean outer-outer and mean inner-inner diameters of CC were significantly lower for GRFs [37.12 (S.D. = 4.6) and 31.27 (S.D. = 4)] compared to AGA fetuses [41.2 (S.D. = 3.4) and 35.8 (S.D. = 2.4)] (p-values: 0.006 and 0.001), respectively. However, both the diameters showed a positive correlation with GA in AGA and GRFs. Conclusions: GRFs show a diminished growth of CC. This may be an indicator of fetal brain remodeling in-utero as an adaptation to compromised intra-uterine environment. Further studies with larger sample size and with inclusion of additional neural biomarkers are needed to validate our findings and to evaluate the effect of reduced fetal CC growth on cognitive and motor development during early childhood. Keywords: corpus callosum, two-dimensional neurosonography, growth restricted fetuses, brain remodelin

Influence of intrauterine growth status on aortic intima-media thickness and aortic diameter in near-term fetuses: A comparative cross-sectional study

Intrauterine undernutrition may lead to fetal vascular programming. We compared abdominal aortic intima-media thickness (aIMT) and aortic diameter (aD) between appropriate for gestational age (AGA) and growth-restricted fetuses (GRF). We recruited 136 singleton fetuses at 34-37 weeks of gestation from Fetal Medicine Unit of Aga Khan University Hospital, Karachi (January-November 2017). Subjects were classified as AGA (n = 102) and GRF (n = 34) using INTER-GROWTH 21st growth reference and standard ultrasound protocol. Their far- and near-wall aIMT and aD were compared after adjustment of maternal age, first-trimester body mass index, fetal gender, hypertension and hyperglycemia in pregnancy. As the severity of growth restriction increased in GRF, aIMT and aD showed an increasing and a decreasing trend, respectively. Both far- and near-wall aIMT in GRF [(adj. β = 0.082, 95% confidence interval [CI] 0.042-0.123) and (adj. β = 0.049, 95% CI 0.010-0.089)] were significantly greater with reference to AGA fetuses. GRF subgroup analysis into small for gestational age (SGA) fetuses and intrauterine growth restricted (IUGR) revealed highly significant difference between AGA and IUGR for far (0.142 mm, P-value \u3c 0.001) and near-wall aIMT (0.115 mm, P-value \u3c 0.001) and marginally significant aD difference (0.51 mm, P-value 0.05). These findings suggest that the extent of fetal aortic remodelling is influenced by the severity of growth restriction. Hence, the targeted interventions for the cardiovascular health promotion of IUGR and SGA born neonates are desirable during early childhood, particularly in set ups with high prevalence of low birth weight babies