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

Solid fuel use and cooking practices as a major risk factor for ALRI mortality among African children

Background: Almost half of global child deaths due to acute lower respiratory infections (ALRIs) occur in sub-Saharan Africa, where three-quarters of the population cook with solid fuels. This study aims to quantify the impact of fuel type and cooking practices on childhood ALRI mortality in Africa, and to explore implications for public health interventions. Methods: Early-release World Health Survey data for the year 2003 were pooled for 16 African countries. Among 32 620 children born during the last 10 years, 1455 (4.46%) were reported to have died prior to their fifth birthday. Survival analysis was used to examine the impact of different cooking-related parameters on ALRI mortality, defined as cough accompanied by rapid breathing or chest indrawing based on maternal recall of symptoms prior to death. Results: Solid fuel use increases the risk of ALRI mortality with an adjusted hazard ratio of 2.35 (95% CI 1.22 to 4.52); this association grows stronger with increasing outcome specificity. Differences between households burning solid fuels on a well-ventilated stove and households relying on cleaner fuels are limited. In contrast, cooking with solid fuels in the absence of a chimney or hood is associated with an adjusted hazard ratio of 2.68 (1.38 to 5.23). Outdoor cooking is less harmful than indoor cooking but, overall, stove ventilation emerges as a more significant determinant of ALRI mortality. Conclusions: This study shows substantial differences in ALRI mortality risk among African children in relation to cooking practices, and suggests that stove ventilation may be an important means of reducing indoor air pollution

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

How can we adapt complex population health interventions for new contexts? Progressing debates and research priorities

Introduction: The UK Medical Research Council and National Institute for Health Research have funded the ADAPT study (2018–2020), to develop methodological guidance for the adaptation of complex population health interventions for new contexts. While there have been advances in frameworks, there are key theoretical and methodological debates to progress. The ADAPT study convened a panel meeting to identify and enrich these debates. This paper presents the panel’s discussions and suggests directions for future research. Methods: Sixteen researchers and one policymaker convened for a 1-day meeting in July 2019. The aim was to reflect on emerging study findings (systematic review of adaptation guidance; scoping review of case examples; and qualitative interviews with funders, journal editors, researchers and policymakers), progress theoretical and methodological debates, and consider where innovation may be required to address research gaps. Discussion: Despite the proliferation of adaptation frameworks, questions remain over the definition of basic concepts (eg, adaptation). The rationale for adaptation, which often focuses on differences between contexts, may lead to adaptation hyperactivity. Equal emphasis should be placed on similarities. Decision-making about intervention modification currently privileges the concept of ‘core components’, and work is needed to progress the use and operationalisation of ‘functional fidelity’. Language and methods must advance to ensure meaningful engagement with diverse stakeholders in adaptation processes. Further guidance is required to assess the extent of re-evaluation required in the new context. A better understanding of different theoretical perspectives, notably complex systems thinking, implementation science and realist evaluation may help in enhancing research on adaptation

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

Considerations of complexity in rating certainty of evidence in systematic reviews:a primer on using the GRADE approach in global health

Public health interventions and health technologies are commonly described as 'complex', as they involve multiple interacting components and outcomes, and their effects are largely influenced by contextual interactions and system-level processes. Systematic reviewers and guideline developers evaluating the effects of these complex interventions and technologies report difficulties in using existing methods and frameworks, such as the Grading of Recommendations Assessment, Development and Evaluation (GRADE). As part of a special series of papers on implications of complexity in the WHO guideline development, this paper serves as a primer on how to consider sources of complexity when using the GRADE approach to rate certainty of evidence. Relevant sources of complexity in systematic reviews, health technology assessments and guidelines of public health are outlined and mapped onto the reported difficulties in rating the estimates of the effect of these interventions. Recommendations on how to address these difficulties are further outlined, and the need for an integrated use of GRADE from the beginning of the review or guideline development is emphasised. The content of this paper is informed by the existing GRADE guidance, an ongoing research project on considering sources of complexity when applying the GRADE approach to rate certainty of evidence in systematic reviews and the review authors' own experiences with using GRADE