Exposure to household air pollution from solid cookfuels and childhood stunting: a population-based, cross-sectional study of half a million children in low- and middle-income countries

BACKGROUND: Household air pollution from the incomplete combustion of solid cookfuels in low- and middle-income countries (LMICs) has been largely ignored as a potentially important correlate of stunting. Our objective was to examine the association between solid cookfuel use and stunting in children aged <5 y. METHODS: We used data from 59 LMICs' population-based cross-sectional demographic and health surveys; 557 098 children aged <5 y were included in our analytical sample. Multilevel logistic regression was used to examine the association between exposure to solid cookfuel use and childhood stunting, adjusting for child sex, age, maternal education and number of children living in the household. We explored the association across key subgroups. RESULTS: Solid cookfuel use was associated with child stunting (adjusted OR 1.58, 95% CI 1.55 to 1.61). Children living in households using solid cookfuels were more likely to be stunted if they lived in rural areas, the poorest households, had a mother who smoked tobacco or were from the Americas. CONCLUSIONS: Focused strategies to reduce solid cookfuel exposure might contribute to reductions in childhood stunting in LMICs. Trial evidence to assess the effect of reducing solid cookfuel exposure on childhood stunting is urgently needed

Thermoregulatory effects of swaddling in Mongolia: A randomised controlled study

Objective To investigate thermal balance of infants in a Mongolian winter, and compare the effects of traditional swaddling with an infant sleeping-bag in apartments or traditional tents (Gers).Design A substudy within a randomised controlled trial.Setting Community in Ulaanbaatar, Mongolia.Subjects A stratified randomly selected sample of 40 swaddled and 40 non-swaddled infants recruited within 48 h of birth.Intervention Sleeping-bags and baby outfits of total thermal resistance equivalent to that of swaddled babies.Outcome measure Digital recordings of infants’ core, peripheral, environmental and microenvironmental temperatures at 30-s intervals over 24 h at ages 1 month and 3 months.Results In Gers, indoor temperatures varied greatly ( 25°C), but remained between 20°C and 22°C, in apartments. Despite this, heavy wrapping, bed sharing and partial head covering, infant core and peripheral temperatures were similar and no infants showed evidence of significant heat or cold stress whether they were swaddled or in sleeping-bags. At 3 months, infants in sleeping-bags showed the ‘mature’ diurnal pattern of a fall in core temperature after sleep onset, accompanied by a rise in peripheral temperature, with a reverse pattern later in the night, just before awakening. This pattern was not related to room temperature, and was absent in the swaddled infants, suggesting that the mature diurnal pattern may develop later in them.Conclusions No evidence of cold stress was found. Swaddling had no identifiable thermal advantages over sleeping-bags during the coldest times, and in centrally heated apartments could contribute to the risk of overheating during the daytime.Trial registration number ISRTN01992617

Medical device procurement in low- and middle-income settings: protocol for a systematic review

Background: Medical device procurement processes for low- and middle-income countries (LMICs) are a poorly understood and researched topic. To support LMIC policy formulation in this area, international public health organizations and research institutions issue a large body of predominantly grey literature including guidelines, manuals and recommendations. We propose to undertake a systematic review to identify and explore the medical device procurement methodologies suggested within this and further literature. Procurement facilitators and barriers will be identified, and methodologies for medical device prioritization under resource constraints will be discussed. Methods/design: Searches of both bibliographic and grey literature will be conducted to identify documents relating to the procurement of medical devices in LMICs. Data will be extracted according to protocol on a number of pre-specified issues and variables. First, data relating to the specific settings described within the literature will be noted. Second, information relating to medical device procurement methodologies will be extracted, including prioritization of procurement under resource constraints, the use of evidence (e.g. cost-effectiveness evaluations, burden of disease data) as well as stakeholders participating in procurement processes. Information relating to prioritization methodologies will be extracted in the form of quotes or keywords, and analysis will include qualitative meta-summary. Narrative synthesis will be employed to analyse data otherwise extracted. The PRISMA guidelines for reporting will be followed. Discussion: The current review will identify recommended medical device procurement methodologies for LMICs. Prioritization methods for medical device acquisition will be explored. Relevant stakeholders, facilitators and barriers will be discussed. The review is aimed at both LMIC decision makers and the international research community and hopes to offer a first holistic conceptualization of this topic.sch_iih1. Perry L, Malkin R: Effectiveness of medical equipment donations to improve health systems: how much medical equipment is broken in the developing world? Med Biol Eng Comput 2011, 49:719-722. 2. World Health Organization: Medical devices: Managing the Mismatch (An outcome of the Priority Medical Devices project). Geneva: World Health Organization; 2010. 3. World Health Organization: Local Production and Technology Transfer to Increase Access to Medical Devices: Addressing the barriers and challenges in low- and middle-income countries. Geneva: World Health Organization; 2012. 4. World Health Organization: Background paper 8: future public health needs: communalities and differences between high- and low-resource settings in Geneva. In Medical Devices: Managing the Mismatch (An outcome of the Priority Medical Devices Project). 2010. 5. Howitt P, Darzi A, Yang GZ, Ashrafian H, Atun R, Barlow J, Blakemore A, Bull AMJ, Car J, Conteh L, Cooke GS, Ford N, Gregson SJ, Kerr K, King D, Kulendran M, Malkin R, Majeed A, Matlin S, Merrified R, Penfolf H, Reid SD, Smith PC, Stevens MM, Templeton MR, Vincent C, Wilson E: Technologies for global health. Lancet 2012, 380:507-535. 6. National Institute of Health and Care Excellence: Guide to the Methods of Technology Appraisal 2013. 2013, [http://www.nice.org.uk/article/pmg9/ chapter/foreword] 7. World Health Organization: Background Paper 3: Clinical evidence for medical devices: regulatory processes focusing on Europe and the United States of America Geneva. In Medical Devices: Managing the Mismatch (An outcome of the Priority Medical Devices Project). 2010. 8. Australian Government Department of Health and Ageing: HTA policy framework. [http://www.health.gov.au/internet/hta/publishing.nsf/Content/ policy-1] 9. Canadian Health Technology Assessment Task Group: Health technology strategy 1. 0 final report. [http://www.who.int/medical_devices/ survey_resources/health_technology_national_policy_canada.pdf] 10. Fricke FU, Dauben HP: Health technology assessment: a perspective from Germany. Value Health 2009, 12(Suppl 2):S20-S27. 11. World Health Organization: Baseline Country Survey on Medical Devices. Geneva: World Health Organization; 2010. 12. UNAIDS & World Health Organization: Guidelines for Using HIV Testing Technologies in Surveillance. 2009. 13. Rieder HL, Van Deun A, Kam KM, Kim SJ, Chonde RM, Trbucq A, Urbanczik R: Priorities for Tuberculosis Bacteriology Services in Low-Income Countries. Paris: International Union Against Tuberculosis and Lung Disease; 2007. 14. World Health Organization: List of medical devices by health care facility: specialized hospital-diagnostic. 2010, [http://hinfo.humaninfo.ro/gsdl/ whoghp/documents/s17971en/s17971en.pdf] 15. World Health Organization: Background paper 1: a stepwise approach to identify gaps in medical devices (availability matrix and survey methodology), Geneva. In Medical Devices: Managing the Mismatch (An outcome of the Priority Medical Devices Project). 2010. 16. Baltussen R, Niessen L: Priority setting of health interventions: the need for multi-criteria decision analysis. Cost Eff Resour Alloc 2006, 4:14. 17. Glassman A, Chalkidou K, on behalf of the Center for Global Development Priority Setting Institutions for Global Health Working Group: Priority-Setting in Health Building institutions for smarter public spending. Washington: Center for Global Development; 2012. 18. Kapiriri L, Martin DK: A strategy to improve priority setting in developing countries. Health Care Anal 2007, 15:159-167. 19. Study Group 1 of the Global Harmonization Task Force: Definition of the terms medical device- and in vitro diagnostic (IVD) medical device. 2012, [http://www.imdrf.org/docs/ghtf/final/sg1/technical-docs/ghtf-sg1- n071-2012-definition-of-terms-120516.docx]. 20. WHO, UNFPA, UNAIDS & FHI: The TCu380A Intrauterine Contraceptive Device (IUD): Specification, Prequalification and Guidelines for Procurement. Geneva: World Health Organization; 2011. 21. World Health Organization: Procuring Single-Use Injection Equipment and Safety Boxes: A practical Guide for Pharmacists, Physicians, Procurement Staff and Programme Managers. Geneva: World Health Organization; 2003. 22. Ross S, Weijer C, Gafni A, Ducey A, Thompson C, Lafreniere R: Ethics, economics and the regulation and adoption of new medical devices: case studies in pelvic floor surgery. BMC Med Ethics 2010, 11:14. 23. Anderson BO, Cazap E, El Saghir NS, Yip CH, Khaled HM, Otero IV, Adebamovo C, Badwe R, Harford JB: Optimisation of breast cancer management in low-resource and middle-resource countries: executive summary of the Breast Health Global Initiative consensus 2010. Lancet Oncol 2011, 12:387-398. 24. Porto JP, Mantese OC, Arantes A, Freitas C, Pinto P, Filho G: Nosocomial infections in a pediatric intensive care unit of a developing country: NHSN surveillance. Rev Soc Bras Med Trop 2012, 45:475-479. 25. Kalifa G, Bouras A, Reymond-Yeni A, Gendrel D: Imaging in pediatrics. Strategy and economic implications for the Third World. Annales de Pediatrie 1992, 39(2):67-70 [French]. 26. Malkin R, Anand V: A novel phototherapy device . IEEE Eng Med Biol Mag 2010, 29(2):37-43. 27. World Health Organization: Medical Device Regulations: Global Overview and Guiding Principles. Geneva: World Health Organization; 2003. 28. Sandelowski M, Barroso J, Voils CI: Using qualitative metasummary to synthesize qualitative and quantitative descriptive findings. Res Nurs Heal 2007, 30:99-111. 29. Centre for Reviews and Dissemination at University of York: Systematic Reviews: CRD's Guidance for Undertaking Reviews in Health Care. York, UK: CRD University of York; 2008. 30. PRISMA 2009 Checklist. PRISMA 2009 Checklist [http://www.prismastatement. org/2.1.2%20-%20PRISMA%202009%20Checklist.pdf]. 31. Guindo LA, Wagner M, Baltussen R, Rindress D, Van Til J, Kind P, Goetghebeur M: From efficacy to equity: literature review of decision criteria for resource allocation and healthcare decision making. Cost Eff Resour Alloc 2012, 10:9.3pub4565pub

Ranking hospitals based on preventable hospital death rates:a systematic review with implications for both direct measurement and indirect measurement through standardized mortality rates

Objectives There is interest in monitoring avoidable or preventable deaths measured directly or indirectly through standardized mortality rates (SMRs). We reviewed studies that use implicit case note reviews to estimate the range of preventable death rates observed, the measurement characteristics of those estimates, and the measurement procedures used to generate them. We comment on the implications for monitoring SMRs and illustrate a way to calculate the number of reviews needed to establish a reliable estimate of preventability of one death or the hospital preventable death rate. Design Systematic review of the literature supplemented by re-analysis of authors previously published and un-published data and measurement design calculations. Data source Searches in PubMed, MEDLINE (OvidSP) and Web of Knowledge in June 2012, updated December 2017. Eligibility criteria Studies of hospital-wide admissions from general and acute medical wards where preventable deaths rates are provided or can be estimate and which can provide inter- observer variations. Results Twenty-four studies were included from 1983-2017. Recent larger studies suggest consistently low rates of preventable deaths (3.0-6.5% since 2012). Reliability of a single review for distinguishing between individual cases with regard to the preventability of death had a Kappa rate of 0.27-0.50 for deaths and 0.24-0.76 for adverse events. A Kappa of 0.35 would require an average of 8-17 reviews of a single case to be precise enough to have confidence about high stakes decisions to change care procedures or impose sanctions within a hospital as a result. No study estimated the variation in preventable deaths across hospitals, although we were able to re-analyse one study to obtain an estimate. Based on this estimate, 200-300 total case-note reviews per hospital could be required to reliably distinguish between hospitals. The studies display considerable heterogeneity: 13/24 studies defined preventable with a threshold of ≥4 in a six-category Likert scale; 11/24 involved a two-stage screening process with nurses at the first stage and physicians at the second. Fifteen studies provided expert clinical review support for reviewer disagreements, advice, or quality control. A ‘generalist/internist’ was the modal physician specialty for reviewers and they received 1-3 days of generic tools orientation and case-note review practice. Methods did not consider the influence of human or environmental factors. Conclusions The literature provides limited information about the measurement characteristics of preventable deaths that suggests substantial numbers of reviews may be needed to create reliable estimates of preventable deaths at the individual or hospital level. Any operational program would require population specific estimates of reliability. Preventable death rates are low, which is likely to make it difficult to use SMRs based on all deaths to validly profile hospitals. The literature provides little information to guide improvements in the measurement procedures. Systematic review registration The systematic review was conceived prior to PROSPERO, and so has not been registered

Birth-Related Perineal Trauma in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis.

Introduction Birth-related perineal trauma (BPT) is a common consequence of vaginal births. When poorly managed, BPT can result in increased morbidity and mortality due to infections, haemorrhage, and incontinence. This review aims to collect data on rates of BPT in low- and middle-income countries (LMICs), through a systematic review and meta-analysis. Methods The following databases were searched: Medline, Embase, Latin American and Caribbean Health Sciences Literature (LILACs), and the World Health Organization (WHO) regional databases, from 2004 to 2016. Cross-sectional data on the proportion of vaginal births that resulted in episiotomy, second degree tears or obstetric anal sphincter injuries (OASI) were extracted from studies carried out in LMICs by two independent reviewers. Estimates were meta-analysed using a random effects model; results were presented by type of BPT, parity, and mode of birth. Results Of the 1182 citations reviewed, 74 studies providing data on 334,054 births in 41 countries were included. Five studies reported outcomes of births in the community. In LMICs, the overall rates of BPT were 46% (95% CI 36-55%), 24% (95% CI 17-32%), and 1.4% (95% CI 1.2-1.7%) for episiotomies, second degree tears, and OASI, respectively. Studies were highly heterogeneous with respect to study design and population. The overall reporting quality was inadequate. Discussion Compared to high-income settings, episiotomy rates are high in LMIC medical facilities. There is an urgent need to improve reporting of BPT in LMICs particularly with regards to births taking in community settings

Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data

This study was supported by a grant from the National Institute for Health Research (NIHR) under its Health Technology Assessment programme (reference No 13/03/25, to ARM