Improvement of child survival in Mexico: the diagonal approach

Public health interventions aimed at children in Mexico have placed the country among the seven countries on track to achieve the goal of child mortality reduction by 2015. We analysed census data, mortality registries, the nominal registry of children, national nutrition surveys, and explored temporal association and biological plausibility to explain the reduction of child, infant, and neonatal mortality rates. During the past 25 years, child mortality rates declined from 64 to 23 per 1000 livebirths. A dramatic decline in diarrhoea mortality rates was recorded. Polio, diphtheria, and measles were eliminated. Nutritional status of children improved significantly for wasting, stunting, and underweight. A selection of highly cost-effective interventions bridging clinics and homes, what we called the diagonal approach, were central to this progress. Although a causal link to the reduction of child mortality was not possible to establish, we saw evidence of temporal association and biological plausibility to the high level of coverage of public health interventions, as well as significant association to the investments in women education, social protection, water, and sanitation. Leadership and continuity of public health policies, along with investments on institutions and human resources strengthening, were also among the reasons for these achievements.     

Geospatial distribution and determinants of child mortality in rural western Kenya 2002–2005

Objective To describe local geospatial variation and geospatial risk factors for child mortality in rural western Kenya. Methods We calculated under‐5 mortality rates (U5MR) in 217 villages in a Health and Demographic Surveillance System (HDSS) area in western Kenya from 1 May 2002 through 31 December 2005. U5MRs by village were mapped. Geographical positioning system coordinates of residences at the time of death and distances to nearby locations were calculated. Multivariable Poisson regression accounting for clustering at the compound level was used to evaluate the association of geospatial factors and mortality for infants and children aged 1–4 years. Results Among 54 057 children, the overall U5MR was 56.5 per 1000 person‐years and varied by village from 21 to 177 per 1000 person‐years. High mortality villages occurred in clusters by location and remained in the highest mortality quintile over several years. In multivariable analysis, controlling for maternal age and education as well as household crowding, higher infant mortality was associated with living closer to streams and further from public transport roads. For children 1–4 years, living at middle elevations (1280–1332 metres), living within lower population densities areas, and living in the northern section of the HDSS were associated with higher mortality. Conclusions Childhood mortality was significantly higher in some villages. Several geospatial factors were associated with mortality, which might indicate variability in access to health care or exposure and transmission of infectious diseases. These results are useful in prioritising areas for further study and implementing directed public health interventions.     

Child prostitution: global health burden, research needs, and interventions

Child prostitution is a significant global problem that has yet to receive appropriate medical and public health attention. Worldwide, an estimated 1 million children are forced into prostitution every year and the total number of prostituted children could be as high as 10 million. Inadequate data exist on the health problems faced by prostituted children, who are at high risk of infectious disease, pregnancy, mental illness, substance abuse, and violence. Child prostitution, like other forms of child sexual abuse, is not only a cause of death and high morbidity in millions of children, but also a gross violation of their rights and dignity. In this article we estimate morbidity and mortality among prostituted children, and propose research strategies and interventions to mitigate such health consequences. Our estimates underscore the need for health professionals to collaborate with individuals and organisations that provide direct services to prostituted children. Health professionals can help efforts to prevent child prostitution through identifying contributing factors, recording the magnitude and health effects of the problem, and assisting children who have escaped prostitution. They can also help governments, UN agencies, and non-governmental organisations (NGOs) to implement policies, laws, and programmes to prevent child prostitution and mitigate its effects on children's health.     

Applying an equity lens to child health and mortality: more of the same is not enough

Gaps in child mortality between rich and poor countries are unacceptably wide and in some areas are becoming wider, as are the gaps between wealthy and poor children within most countries. Poor children are more likely than their better-off peers to be exposed to health risks, and they have less resistance to disease because of undernutrition and other hazards typical in poor communities. These inequities are compounded by reduced access to preventive and curative interventions. Even public subsidies for health frequently benefit rich people more than poor people. Experience and evidence about how to reach poor populations are growing, albeit largely through small-scale case studies. Successful approaches include those that improve geographic access to health interventions in poor communities, subsidized health care and health inputs, and social marketing. Targeting of health interventions to poor people and ensuring universal coverage are promising approaches for improvement of equity, but both have limitations that necessitate planning for child survival and effective delivery at national level and below. Regular monitoring of inequities and use of the resulting information for education, advocacy, and increased accountability among the general public and decision makers is urgently needed, but will not be sufficient. Equity must be a priority in the design of child survival interventions and delivery strategies, and mechanisms to ensure accountability at national and international levels must be developed.     

A reversal in reductions of child mortality in western Kenya, 2003-2009

We report and explore changes in child mortality in a rural area of Kenya during 2003-2009, when major public health interventions were scaled-up. Mortality ratios and rates were calculated by using the Kenya Medical Research Institute/Centers for Disease Control and Prevention Demographic Surveillance System. Inpatient and outpatient morbidity and mortality, and verbal autopsy data were analyzed. Mortality ratios for children less than five years of age decreased from 241 to 137 deaths/1,000 live-births in 2003 and 2007 respectively. In 2008, they increased to 212 deaths/1,000 live-births. Mortality remained elevated during the first 8 months of 2009 compared with 2006 and 2007. Malaria and/or anemia accounted for the greatest increases in child mortality. Stock-outs of essential antimalarial drugs during a time of increased malaria transmission and disruption of services during civil unrest may have contributed to increased mortality in 2008-2009. To maintain gains in child survival, implementation of good policies and effective interventions must be complemented by reliable supply and access to clinical services and essential drugs.     

Maternal and child health in Brazil: progress and challenges

In the past three decades, Brazil has undergone rapid changes in major social determinants of health and in the organisation of health services. In this report, we examine how these changes have affected indicators of maternal health, child health, and child nutrition. We use data from vital statistics, population censuses, demographic and health surveys, and published reports. In the past three decades, infant mortality rates have reduced substantially, decreasing by 5·5% a year in the 1980s and 1990s, and by 4·4% a year since 2000 to reach 20 deaths per 1000 livebirths in 2008. Neonatal deaths account for 68% of infant deaths. Stunting prevalence among children younger than 5 years decreased from 37% in 1974-75 to 7% in 2006-07. Regional differences in stunting and child mortality also decreased. Access to most maternal-health and child-health interventions increased sharply to almost universal coverage, and regional and socioeconomic inequalities in access to such interventions were notably reduced. The median duration of breastfeeding increased from 2·5 months in the 1970s to 14 months by 2006-07. Official statistics show stable maternal mortality ratios during the past 10 years, but modelled data indicate a yearly decrease of 4%, a trend which might not have been noticeable in official reports because of improvements in death registration and the increased number of investigations into deaths of women of reproductive age. The reasons behind Brazil's progress include: socioeconomic and demographic changes (economic growth, reduction in income disparities between the poorest and wealthiest populations, urbanisation, improved education of women, and decreased fertility rates), interventions outside the health sector (a conditional cash transfer programme and improvements in water and sanitation), vertical health programmes in the 1980s (promotion of breastfeeding, oral rehydration, and immunisations), creation of a tax-funded national health service in 1988 (coverage of which expanded to reach the poorest areas of the country through the Family Health Program in the mid-1990s); and implementation of many national and state-wide programmes to improve child health and child nutrition and, to a lesser extent, to promote women's health. Nevertheless, substantial challenges remain, including overmedicalisation of childbirth (nearly 50% of babies are delivered by caesarean section), maternal deaths caused by illegal abortions, and a high frequency of preterm deliveries.     

Health and demographic surveillance in rural western Kenya: a platform for evaluating interventions to reduce morbidity and mortality from infectious diseases

We established a health and demographic surveillance system in a rural area of western Kenya to measure the burden of infectious diseases and evaluate public health interventions. After a baseline census, all 33,990 households were visited every four months. We collected data on educational attainment, socioeconomic status, pediatric outpatient visits, causes of death in children, and malaria transmission. The life expectancy at birth was 38 years, the infant mortality rate was 125 per 1000 live births, and the under-five mortality rate was 227 per 1,000 live births. The increased mortality rate in younger men and women suggests high human immunodeficiency virus/acquired immunodeficiency syndrome-related mortality in the population. Of 5,879 sick child visits, the most frequent diagnosis was malaria (71.5%). Verbal autopsy results for 661 child deaths (1 month to <12 years) implicated malaria (28.9%) and anemia (19.8%) as the most common causes of death in children. These data will provide a basis for generating further research questions, developing targeted interventions, and evaluating their impact.     

Psychological functioning among vertically infected HIV-positive children and their primary caregivers

The current study sought to explore the association between primary caregiver depressive symptoms and the psychological functioning in children vertically infected with human immunodeficiency virus (HIV) living in Eastern Cape, South Africa. A cross-sectional data were collected using the Beck Depression Inventory and Strength and Difficulties Questionnaire in a sample of 152 caregiver/child dyads. The results revealed that poorer psychological functioning in children was significantly associated with depressive symptoms in caregivers. This relationship existed whether or not the child was raised by a biological or non-biological caregiver as well as for both genders. Younger children's psychological functioning was more negatively influenced than that of older children raised by a caregiver with depressive symptoms. In the context of a large treatment gap for common mental disorders in South Africa, there is a need for interventions to address maternal mental health in families infected and affected by the HIV/AIDS pandemic as a mental health promotion strategy given that HIV-infected children are a particularly vulnerable population for poor mental and behavioural health outcomes.     

Somalia: supporting the child survival agenda when routine health service is broken

Somalia, one of the most unstable countries in the world, has been without a permanent government for nearly 2 decades. With a health system in total disarray, coverage of basic health interventions remains low and, maternal and child mortality is among the highest in the world. Health partners jointly outlined an integrated package of critical child survival interventions to be delivered through a population-based delivery strategy known as Child Health Days (CHDs), to reduce child mortality. Using this strategy, key child survival interventions are delivered to the community with an objective of reaching children <5 years and women of childbearing age in all districts of Somalia every 6 months. Through this strategy, immunization services were reached in remote areas, and coverage disparity between the urban and rural areas was reduced from 17% (42% urban and 25% rural) to 10% (50% urban and 60% rural). In addition, infants were reached with a third dose of diphtheria-pertussis-tetanus vaccine, achieving 51% coverage during 2009 and 66% in 2010. This paper summarizes the challenges of scaling up child interventions in the troubled context of Somalia by reviewing the planning, implementation, and achievements of CHDs as well as reflecting on challenges for the future of child survival in Somalia.     

How many child deaths can we prevent this year?

This is the second of five papers in the child survival series. The first focused on continuing high rates of child mortality (over 10 million each year) from preventable causes: diarrhoea, pneumonia, measles, malaria, HIV/AIDS, the underlying cause of undernutrition, and a small group of causes leading to neonatal deaths. We review child survival interventions feasible for delivery at high coverage in low-income settings, and classify these as level 1 (sufficient evidence of effect), level 2 (limited evidence), or level 3 (inadequate evidence). Our results show that at least one level-1 intervention is available for preventing or treating each main cause of death among children younger than 5 years, apart from birth asphyxia, for which a level-2 intervention is available. There is also limited evidence for several other interventions. However, global coverage for most interventions is below 50%. If level 1 or 2 interventions were universally available, 63% of child deaths could be prevented. These findings show that the interventions needed to achieve the millennium development goal of reducing child mortality by two-thirds by 2015 are available, but that they are not being delivered to the mothers and children who need them.     

Youth violence prevention, what works?

Violence is currently considered to be both an epidemic problem and a public health problem among youth and adolescents, who represent 31.6% and 20.3% of the overall population of the Americas region, respectively. This paper analyzes the scientific literature on violence prevention as it relates to successful interventions among these populations. Some of the most successful interventions are those related to active engagement of adults with children and adolescents and programs oriented toward early child development and adequate educational practices among parents. The latter is one of the most cost-effective violence prevention interventions for children and adolescents. Efforts to disarm civilian populations during critical periods have also been shown to be effective.     

Mortality in Brazilian children with HIV/AIDS: the role of non-AIDS-related conditions after highly active antiretroviral therapy introduction

AIDS-related mortality has been significantly reduced in areas that systematically adopted highly active antiretroviral therapy (HAART). In Brazil, despite advances in control policy, there is still a lack of evidence about trends in children on causes of death related or not related to HIV/AIDS. We evaluate temporal trends in mortality due to non-HIV-related causes of death in relation to HIV/AIDS-related conditions among children with and without HIV infection. This nationwide study included all deaths in children reported from 1999 to 2007. Mortality odds ratios (MOR) and rates were calculated to assess time trends of death in children with or without HIV/AIDS. These data were analyzed by calendar year, as obtained from official national database. A total of 680,763 deaths occurred in Brazilian children under 13 years of age; of these, 2191 (0.32%) had causes related to HIV/AIDS listed on the death certificate. The mortality rate from HIV/AIDS-related causes in Brazilian children ranged from 0.72 per 100,000 children in 1999 to 0.40 per 100,000 children in 2007, while for selected nonrelated causes the rate of death among HIV-infected children was stable at 0.08 per 100,000 Brazilian children. In children with HIV/AIDS, the MOR of having selected conditions unrelated to HIV/AIDS as a cause of death in 2007 (compared to 1999) was 1.85 (95% confidence interval [CI] = 1.11-3.08, p = 0.02), but without a significant temporal trend (p = 0.413) through the analyzed period. In Brazil, deaths related to HIV/AIDS mortality in children significantly decreased, while the unrelated causes in HIV-infected children maintained a stable trend. These data reinforce the success of national public health policies and the need to offer comprehensive care to children with HIV/AIDS.     

Geographical variations in all-cause mortality in Thailand

In this study, we examined age-specific death rates among men and women from various districts in Thailand using mortality data from 1999 to 2001. A Poisson generalized linear model was used for analysis. To adjust for large variations in resident populations among districts, the 926 districts in Thailand were reduced to 235 "superdistricts" based on a minimum population of 200,000. The Poisson model incorporating additive factors for age-group and superdistrict generally provided a good fit for these data. The fitted mortality rates among the 235 superdistricts were compared with the overall means for each gender (637 per 100,000 for males and 415 per 100,000 for females). Thematic maps were created with three different colors signifying each superdistrict's mortality rate compared to the mean. Northeastern Thailand had higher than average mortality for both males and females. Lower than average death rates were found in southern Thailand with the exception of Phuket and Narathiwat, and in Bangkok, except for females in the superdistrict containing Nong Chok and Lat Krabang Districts. This modeling and mapping approach is a useful preliminary tool enabling public health planners to determine statistically valid geographical variations in mortality and to develop effective interventions.     

Changes in the pattern of infant and childhood mortality in Upper River Division, The Gambia, from 1989 to 1993

A surveillance system was used to detect births and deaths in children in a large, rural, West African population from 1989 to 1993. Cause of death was investigated using post‐mortem questionnaires. Overall infant (age 0–11 months) and child (age 1–4 years) mortality rates of 80.1 and 18.8 per 1000 per year were recorded. These were reasonably consistent over the period of surveillance. The most frequent cause of death in infants was acute respiratory infection (ARI), whereas in children it was malaria: these two conditions accounted for 41% of the deaths in children under 5 years old. Other leading causes of death were acute gastroenteritis, malnutrition, and septicaemia. Deaths attributed to ARI decreased over the 5‐year period, but mortality rates from other causes were either unchanged or increased slightly. Mortality from all causes peaked in the rainy season and was slightly higher in villages which were part of a primary health care programme than in those which were not. There were also no differences between male and female mortality rates beyond one year of age. Despite the introduction of a number of health interventions, there has been no major change in the overall pattern of mortality in children in a rural area of The Gambia. Malaria and ARI remain the main causes of death.     

Health outcomes associated with methamphetamine use among young people: a systematic review

Objectives Methamphetamine (MA) use among young people is of significant social, economic and public health concern to affected communities and policy makers. While responses have focused upon various perceived severe harms of MA use, effective public health interventions require a strong scientific evidence base. Methods We conducted a systematic review to identify scientific studies investigating health outcomes associated with MA use among young people aged 10–24 years. The International Classification of Diseases (ICD‐10) was used to categorize outcomes and determine the level of evidence for each series of harms. Results We identified 47 eligible studies for review. Consistent associations were observed between MA use and several mental health outcomes, including depression, suicidal ideation and psychosis. Suicide and overdose appear to be significant sources of morbidity and mortality among young MA users. Evidence for a strong association between MA use and increased risk of human immunodeficiency virus (HIV) and other sexually transmitted infections is equivocal. Finally, we identified only weak evidence of an association between MA use and dental diseases among young people. Conclusions Available evidence indicates a consistent relationship between MA use and mental health outcomes (e.g. depression, psychosis) and an increased risk of mortality due to suicide and overdose. We found insufficient evidence of an association between MA use and other previously cited harms, including infectious diseases and dental outcomes. As such, future research of higher methodological quality is required to further investigate possible associations. Current interventions should focus attention upon MA‐related health outcomes for which sound scientific evidence is available.     

Sickle cell disease: Reducing the global disease burden

Sickle cell disease has been largely an invisible global health issue, especially in regions of high incidence mainly due to lack of awareness among both the local health policy makers and the public. Public health interventions, such as screening of newborns, provision of prophylaxis against bacterial infections, and immunizations against pneumococcal infections can have the greatest impact. Family education on assessment of spleen size and subsequent detection of splenic sequestration and promptness to seek medical attention for a febrile child is also important in the control of the morbidity and mortality of children with SCD living in resource‐poor countries. In addition to these affordable interventions, hydroxyurea therapy is necessary to decrease both the acute and chronic complications of sickle cell anemia. Sickle cell disease has been recognized to have global health significance by key institutions including the World Health Organization in 2006 and the United Nation is 2008. In 2010, the WHO released national health care management goals and set targets to be achieved by the countries in sub‐Saharan Africa for the control and management of SCD. These are yet to be translated into action. To do, this would require active and sustainable public‐private partnerships for sustainable program development in these regions. Effective interventions should be integrated into existing health systems, the best examples linking primary healthcare facilities to specialized sickle cell disease centers in regional and tertiary healthcare institutions.     

Are long-term trends in child maltreatment decreasing in England and Wales? A time-series analysis of official record data, 1858–2016

Background

Child maltreatment can result in serious immediate and long-term consequences for the child, family, and society. With mounting pressure from media scrutiny and public debate, establishing whether rates of child maltreatment are increasing or decreasing in England and Wales is a public health priority.

Decreasing child mortality,spatial clustering and decreasing disparity in North‐Western Burkina Faso

Within relatively small areas, there exist high spatial variations of mortality between villages. In rural Burkina Faso, with data from 1993 to 1998, clusters of particularly high child mortality were identified in the population of the Nouna Health and Demographic Surveillance System (HDSS), a member of the INDEPTH Network. In this paper, we report child mortality with respect to temporal trends, spatial clustering and disparity in this HDSS from 1993 to 2012. Poisson regression was used to describe village‐specific child mortality rates and time trends in mortality. The spatial scan statistic was used to identify villages or village clusters with higher child mortality. Clustering of mortality in the area is still present, but not as strong as before. The disparity of child mortality between villages has decreased. The decrease occurred in the context of an overall halving of child mortality in the rural area of Nouna HDSS between 1993 and 2012. Extrapolated to the Millennium Development Goals target period 1990–2015, this yields an estimated reduction of 54%, which is not too far off the aim of a two‐thirds reduction.