Iniqüidades sociais na saúde e nutrição de crianças em países de renda baixa e média

OBJECTIVE: To describe the effects of social inequities on the health and nutrition of children in low and middle income countries. METHODS: We reviewed existing data on socioeconomic disparities within-countries relative to the use of services, nutritional status, morbidity, and mortality. A conceptual framework including five major hierarchical categories affecting inequities was adopted: socioeconomic context and position, differential exposure, differential vulnerability, differential health outcomes, and differential consequences. The search of the PubMed database since 1990 identified 244 articles related to the theme. Results were also analyzed from almost 100 recent national surveys, including Demographic Health Surveys and the UNICEF Multiple Indicator Cluster Surveys. RESULTS: Children from poor families are more likely, relative to those from better-off families, to be exposed to pathogenic agents; once they are exposed, they are more likely to become ill because of their lower resistance and lower coverage with preventive interventions. Once they become ill, they are less likely to have access to health services and the quality of these services is likely to be lower, with less access to life-saving treatments. As a consequence, children from poor family have higher mortality rates and are more likely to be undernourished. CONCLUSIONS: Except for child obesity and inadequate breastfeeding practices, all the other adverse conditions analyzed were more prevalent in children from less well-off families. Careful documentation of the multiple levels of determination of socioeconomic inequities in child health is essential for understanding the nature of this problem and for establishing interventions that can reduce these differences.OBJETIVO: Describir el efecto de las iniquidades sociales sobre la nutrición y salud de niños de países de renta baja y media. MÉTODOS: Fueron revisadas informaciones disponibles sobre disparidades socioeconómicas intra-países, relativas al uso de servicios de salud, estado nutricional, morbilidad y mortalidad. Se adoptó un modelo conceptual con cinco categorías jerárquicas en la producción de inequidades: contexto y posición socioeconómica, diferencias en la exposición, en la vulnerabilidad, en los hechos de salud y en las consecuencias. En investigación realizada en la base PubMed, en el período de 1990-2007 fueron encontrados 244 artículos relacionados al tema. Fueron también analizados los resultados de cerca de 100 pesquisas de ámbito nacional recientes, incluyendo Pesquisas Nacionales de Demografía y Salud y Pesquisas por Conglomerados de Múltiples Indicadores, del Fondo de las Naciones Unidas para la Infancia. RESULTADOS: Niños de familias pobres, en comparación con aquellas de familias más ricas, son más susceptibles a la exposición a agentes patogénicos; una vez expuestas, tienen un riesgo aumentado de enfermar, debido a su menor resistencia y menor cobertura de medidas preventivas. Una vez que se toman enfermos, tienen menor acceso a servicios de salud, la calidad de los servicios que logran utilizar tiende a ser inferior, con menor acceso a tratamientos médicos que garanticen su sobrevivencia. Como consecuencia, niños de familias más pobres presentan mayores tasas de mortalidad y mayor riesgo de ser subnutridas. CONCLUSIONES: Excepto obesidad infantil y prácticas inadecuadas de amamantamiento, todas las otras condiciones adversas analizadas tuvieron mayor prevalencia entre los niños de familias menos favorecidas. La documentación cuidadosa de los múltiples niveles de determinantes de las inequidades socioeconómicas en salud infantil es esencial para el entendimiento de la naturaleza del problema, y para el establecimiento de intervenciones que puedan reducir estas diferencias.OBJETIVO: Descrever o efeito das iniqüidades sociais sobre a nutrição e saúde de crianças de países de renda baixa e média. MÉTODOS: Foram revisadas informações disponíveis sobre disparidades socioeconômicas intra-países, relativas a uso de serviços de saúde, estado nutricional, morbidade e mortalidade. Adotou-se um modelo conceitual com cinco categorias hierárquicas na produção de iniqüidades: contexto e posição socioeconômica, diferenças na exposição, na vulnerabilidade, nos desfechos de saúde e nas conseqüências. Em pesquisa realizada na base PubMed, no período de 1990-2007 foram encontrados 244 artigos relacionados ao tema. Foram também analisados os resultados de cerca de 100 inquéritos de âmbito nacional recentes, incluindo Pesquisas Nacionais de Demografia e Saúde e Inquéritos por Conglomerados de Múltiplos Indicadores, do Fundo das Nações Unidas para a Infância. RESULTADOS: Crianças de famílias pobres, em comparação com aquelas de famílias mais ricas, são mais suscetíveis à exposição a agentes patogênicos; uma vez expostas, têm um risco aumentado de adoecer, devido à sua menor resistência e menor cobertura de medidas preventivas. Uma vez que se tornam doentes, têm menor acesso a serviços de saúde, a qualidade dos serviços que logram utilizar tende a ser inferior, com menor acesso a tratamentos médicos que garantam sua sobrevivência. Como conseqüência, crianças de famílias mais pobres apresentam maiores taxas de mortalidade e maior risco de serem subnutridas. CONCLUSÕES: Exceto obesidade infantil e práticas inadequadas de aleitamento materno, todas as outras condições adversas analisadas tiveram maior prevalência entre as crianças de famílias menos favorecidas. A documentação cuidadosa dos múltiplos níveis de determinantes das iniqüidades socioeconômicas em saúde infantil é essencial para o entendimento da natureza do problema, e para o estabelecimento de intervenções que possam reduzir estas diferenças

mHealth Series: Text messaging data collection of infant and young child feeding practice in rural China – a feasibility study

Face–to–face interviews by trained field workers are commonly used in household surveys. However, this data collection method is labor–intensive, time–consuming, expensive, prone to interviewer and recall bias and not easily scalable to increase sample representativeness. The study explored the feasibility of using text messaging to collect information on infant and young child feeding practice in rural China

Social, economic, political and health system and program determinants of child mortality reduction in China between 1990 and 2006: A systematic analysis

Between 1990 and 2006, China reduced its under-five mortality rate (U5MR) from 64.6 to 20.6 per 1000 live births and achieved the fourth United Nation’s Millennium Development Goal nine years ahead of target. This study explores the contribution of social, economic and political determinants, health system and policy determinants, and health programmes and interventions to this success

Relaxation of the one child policy and trends in caesarean section rates and birth outcomes in China between 2012 and 2016: observational study of nearly seven million health facility births.

OBJECTIVE: To examine how the relaxation of the one child policy and policies to reduce caesarean section rates might have affected trends over time in caesarean section rates and perinatal and pregnancy related mortality in China. DESIGN: Observational study. SETTING: China's National Maternal Near Miss Surveillance System (NMNMSS). PARTICIPANTS: 6 838 582 births at 28 completed weeks or more of gestation or birth weight ≥1000 g in 438 hospitals in the NMNMSS between 2012 and 2016. MAIN OUTCOME MEASURES: Obstetric risk was defined using a modified Robson classification. The main outcome measures were changes in parity and age distributions and relative frequency of each Robson group, crude and adjusted trends over time in caesarean section rates within each risk category (using Poisson regression with a robust variance estimator), and trends in perinatal and pregnancy related mortality over time. RESULTS: Caesarean section rates declined steadily between 2012 and 2016 (crude relative risk 0.91, 95% confidence interval 0.89 to 0.93), reaching an overall hospital based rate of 41.1% in 2016. The relaxation of the one child policy was associated with an increase in the proportion of multiparous births (from 34.1% in 2012 to 46.7% in 2016), and births in women with a uterine scar nearly doubled (from 9.8% to 17.7% of all births). Taking account of these changes, the decline in caesarean sections was amplified over time (adjusted relative risk 0.82, 95% confidence interval 0.81 to 0.84). Caesarean sections declined noticeably in nulliparous women (0.75, 0.73 to 0.77) but also declined in multiparous women without a uterine scar (0.65, 0.62 to 0.77). The decrease in caesarean section rates was most pronounced in hospitals with the highest rates in 2012, consistent with the government's policy of targeting hospitals with the highest rates. Perinatal mortality declined from 10.1 to 7.2 per 1000 births over the same period (0.87, 0.83 to 0.91), and there was no change in pregnancy related mortality over time. CONCLUSIONS: China is the only country that has succeeded in reverting the rising trends in caesarean sections. China's success is remarkable given that the changes in obstetric risk associated with the relaxation of the one child policy would have led to an increase in the need for caesarean sections. China's experience suggests that change is possible when strategies are comprehensive and deal with the system level factors that underpin overuse as well as the various incentives at work during a clinical encounter

Sociodemographic and obstetric characteristics of stillbirths in China: a census of nearly 4 million health facility births between 2012 and 2014

Background Very little is known about the burden and determinants of stillbirths in China. We used data from a national surveillance system for health facility births to compute a stillbirth rate representative of all facility births in China and to explore sociodemographic and obstetric factors associated with variation in the stillbirth rate. Methods We used data from China’s National Maternal Near Miss Surveillance System between Jan 1, 2012, and Dec 31, 2014, which covers 441 hospitals in 326 urban districts and rural counties. The surveillance aimed to enumerate all maternal deaths and near misses in health facilities, and collected data prospectively for all pregnant or post-partum women admitted to the obstetric department. We restricted the analysis to births of 28 or more completed weeks of gestation or 1000 g or heavier birthweight. We examined the strength of association between sociodemographic characteristics, gestational age, and obstetric complications and stillbirths using logistic regression, taking account of the sampling strategy and clustering of births within hospitals and in cases of more than one birth per woman. Findings There were 3 956 836 births and 37 855 stillbirths, giving a stillbirth rate of 8·8 per 1000 births (95% CI 8·8–8·9). The stillbirth rate was particularly high for women younger than 15 years of age (59·9 stillbirths per 1000 births), those who had not sought antenatal care (38·3 per 1000), the unmarried (32·5 per 1000), those with no education (26·9 per 1000), or those who had had four or more births (23·2 per 1000). A high proportion (29 319 [78·2%] of 37 514) of stillbirths occurred at gestational ages of younger than 37 weeks, and about two thirds (24 787 [66·1%] of 37 514) were in women without any maternal complication at the time of birth. Of babies born at normal gestations (37–41 weeks), maternal complications substantially increased the risk of stillbirth (odds ratio comparing antepartum or intrapartum complications with no complication 3·96 [95% CI 3·66–4·29]), but only a small proportion (1638 [4·4%] of 37 514) of stillbirths fell into this group. Interpretation Our analysis of nearly 4 million births in 441 health facilities in China suggests a stillbirth rate of 8·8 per 1000 births between 2012 and 2014. Stillbirths do not feature in the Chinese Government’s 5 year plans and most information systems do not include stillbirths. The Government need to start paying attention to stillbirths and invest strategically in antenatal care, particularly for the most disadvantaged women, including the very young, unmarried, and illiterate, and those at high parity

Text Messaging Data Collection for Monitoring an Infant Feeding Intervention Program in Rural China: Feasibility Study

BACKGROUND: An effective data collection method is crucial for high quality monitoring of health interventions. The traditional face-to-face data collection method is labor intensive, expensive, and time consuming. With the rapid increase of mobile phone subscribers, text messaging has the potential to be used for evaluation of population health interventions in rural China. OBJECTIVE: The objective of this study was to explore the feasibility of using text messaging as a data collection tool to monitor an infant feeding intervention program. METHODS: Participants were caregivers of children aged 0 to 23 months in rural China who participated in an infant feeding health education program. We used the test-retest method. First, we collected data with a text messaging survey and then with a face-to-face survey for 2 periods of 3 days. We compared the response rate, data agreement, costs, and participants’ acceptability of the two methods. Also, we interviewed participants to explore their reasons for not responding to the text messages and the reasons for disagreement in the two methods. In addition, we evaluated the most appropriate time during the day for sending text messages. RESULTS: We included 258 participants; 99 (38.4%) participated in the text messaging survey and 177 (68.6%) in the face-to-face survey. Compared with the face-to-face survey, the text messaging survey had much lower response rates to at least one question (38.4% vs 68.6%) and to all 7 questions (27.9% vs 67.4%) with moderate data agreement (most kappa values between .5 and .75, the intraclass correlation coefficients between .53 to .72). Participants who took part in both surveys gave the same acceptability rating for both methods (median 4.0 for both on a 5-point scale, 1=disliked very much and 5=liked very much). The costs per questionnaire for the text messaging method were much lower than the costs for the face-to-face method: ¥19.7 (US $3.13) versus ¥33.9 (US$5.39) for all questionnaires, and ¥27.1 (US $4.31) versus ¥34.4 (US$5.47) for completed questionnaires. The main reasons for not replying were that participants did not receive text messages, they were too busy to reply, or they did not see text messages in time. The main reasons for disagreement in responses were that participants forgot their answers in the text messaging survey and that they changed their minds. We found that participants were more likely to reply to text messages immediately during 2 time periods: 8 AM to 3 PM and 8 PM to 9 PM. CONCLUSIONS: The text messaging method had reasonable data agreement and low cost, but a low response rate. Further research is needed to evaluate effectiveness of measures that can increase the response rate, especially in collecting longitudinal data by text messaging

Child feeding and stunting prevalence in left-behind children: a descriptive analysis of data from a central and western Chinese population

Objectives: To examine the effect of parental rural-to-urban internal migration on nutritional status of left-behind children and how this is related to guardianship. Methods: We used UNICEF China’s maternal and child health survey data to investigate stunting prevalence and feeding practices in children left behind by rural-to-urban internal migrant parents. We also assessed the effects of primary guardianship which is related closely with parental migration. Results: Of 6,136 children aged 0-3 years, over one third was left behind by one or both parents. About 13% were left behind by mothers, leaving guardianship primarily to grandmothers. Left-behind status was not associated with stunting, yet children who were cared for primarily by their fathers had a 32% increase of stunting compared to children cared for by the mothers (adjusted odds ratio[aOR]=1.32;95% confidence interval=1.04-1.67). Children with migrant mothers were less likely to receive age-appropriate breastfeeding (aOR=0.04;0.02-0.10) and a minimum acceptable diet (aOR=0.56;0.39-0.79) compared with non-left-behind children. Conclusions: Guardian’s feeding behaviours varied, and was inappropriate for both children affected and not affected by parent’s rural-to-urban internal migration. Community-based infant and young child feeding counselling and support should be provided to all caregivers

Closing the know-do gap for child health: UNICEF's experiences from embedding implementation research in child health and nutrition programming.

UNICEF operates in 190 countries and territories, where it advocates for the protection of children's rights and helps meet children's basic needs to reach their full potential. Embedded implementation research (IR) is an approach to health systems strengthening in which (a) generation and use of research is led by decision-makers and implementers; (b) local context, priorities, and system complexity are taken into account; and (c) research is an integrated and systematic part of decision-making and implementation. By addressing research questions of direct relevance to programs, embedded IR increases the likelihood of evidence-informed policies and programs, with the ultimate goal of improving child health and nutrition.This paper presents UNICEF's embedded IR approach, describes its application to challenges and lessons learned, and considers implications for future work.From 2015, UNICEF has collaborated with global development partners (e.g. WHO, USAID), governments and research institutions to conduct embedded IR studies in over 25 high burden countries. These studies focused on a variety of programs, including immunization, prevention of mother-to-child transmission of HIV, birth registration, nutrition, and newborn and child health services in emergency settings. The studies also used a variety of methods, including quantitative, qualitative and mixed-methods.UNICEF has found that this systematically embedding research in programs to identify implementation barriers can address concerns of implementers in country programs and support action to improve implementation. In addition, it can be used to test innovations, in particular applicability of approaches for introduction and scaling of programs across different contexts (e.g., geographic, political, physical environment, social, economic, etc.). UNICEF aims to generate evidence as to what implementation strategies will lead to more effective programs and better outcomes for children, accounting for local context and complexity, and as prioritized by local service providers. The adaptation of implementation research theory and practice within a large, multi-sectoral program has shown positive results in UNICEF-supported programs for children and taking them to scale

A realist synthesis of randomised control trials involving use of community health workers for delivering child health interventions in low and middle income countries

<p>Abstract</p> <p>Background</p> <p>A key constraint to saturating coverage of interventions for reducing the burden of childhood illnesses in Low and Middle Income Countries (LMIC) is the lack of human resources. Community health workers (CHW) are potentially important actors in bridging this gap. Evidence exists on effectiveness of CHW in management of some childhood illnesses (IMCI). However, we need to know how and when this comes to be. We examine evidence from randomized control trials (RCT) on CHW interventions in IMCI in LMIC from a realist perspective with the aim to see if they can yield insight into the working of the interventions, when examined from a different perspective.</p> <p>Methods</p> <p>The realist approach involves educing the mechanisms through which an intervention produced an outcome in a particular context. 'Mechanisms' are reactions, triggered by the interaction of the intervention and a certain context, which lead to change. These are often only implicit and are actually hypothesized by the reviewer. This review is limited to unravelling these from the RCTs; it is thus a hypothesis generating exercise.</p> <p>Results</p> <p>Interventions to improve CHW performance included 'Skills based training of CHW', 'Supervision and referral support from public health services', 'Positioning of CHW in the community'. When interventions were applied in context of CHW programs embedded in local health services, with beneficiaries who valued services and had unmet needs, the interventions worked if following mechanisms were triggered: anticipation of being valued by the community; perception of improvement in social status; sense of relatedness with beneficiaries and public services; increase in self esteem; sense of self efficacy and enactive mastery of tasks; sense of credibility, legitimacy and assurance that there was a system for back-up support. Studies also showed that if context differed, even with similar interventions, negative mechanisms could be triggered, compromising CHW performance.</p> <p>Conclusion</p> <p>The aim of this review was to explore if RCTs could yield insight into the working of the interventions, when examined from a different, a realist perspective. We found that RCTs did yield some insight, but the hypotheses generated were very general and not well refined. These hypotheses need to be tested and refined in further studies.</p