An analysis of factors associated with neonatal, post-neonatal and child mortality in Haiti, including breastfeeding as a time-dependent variable.

AIM: The main objective of the study was to identify factors associated with neonatal, post-neonatal and child mortality. The study also investigated breastfeeding status as a time-dependent variable. METHODS: The 2016-2017 Haitian Demographic and Health Survey was analysed. The analysis was done on 6530 live births. Time-constant and time-dependent multivariable Royston-Parmar spline models were used to identify associated factors for all three age groups. Restricted mean survival times were calculated for the different levels of the breastfeeding variable for each age group. RESULTS: Neonates and post-neonates who were not breastfed were associated with increased mortality, hazard ratio (HR) 22.13 (95% confidence interval (CI), 16.40-29.87) and HR 4.99 (95% CI, 3.29-7.56), respectively. Males in the child age group were associated with increased mortality, HR 2.04 (95% CI, 1.29-3.23) and HR 2.03 (95% CI, 1.28-3.21) under the time-constant and time-dependent models, respectively. CONCLUSIONS: Early initiation of breastfeeding and breastfeeding throughout the post-neonatal period is recommended. Outreach programmes that provide support and education for vulnerable families are also recommended.

Determinants of neonatal, post-neonatal and child mortality in Afghanistan using frailty models.

BACKGROUND: Afghanistan has one of the highest under-five mortality rates in South Asia, 70.4 per 1000 live births. Determinants need to be identified to reduce this rate. Knowledge of the existence of familial and community frailty will also assist in the reduction of under-five mortality. METHODS: The 2015 Afghanistan Demographic Health Survey, including 32,712 live births, was analysed. Under-five mortality was disaggregated into neonatal, post-neonatal and child mortality and piecewise traditional Cox proportional hazard, variance-corrected and frailty models were developed. All the models identified determinants and the two frailty models examined the existence of familial and community frailty for each age group. RESULTS: There was statistically significant evidence of community frailty. Breastfeeding status was a highly significant determinant under univariable and multivariable analysis for neonatal and post-neonatal mortality. Post-neonates of employed mothers also experienced increased mortality, particularly those whose mother worked in agriculture where the hazard ratio was 2.77 (95% CI 2.10, 3.65). Birth order 5+ was associated with increased mortality for all three age groups. CONCLUSION: The Afghanistan Ministry of Public Health should identify frail communities. Support, such as daycare facilities, should be provided and early initiation of breastfeeding and breastfeeding throughout the post-neonatal period should also be encouraged. IMPACT: The study identified determinants of neonatal, post-neonatal and child mortality. The study also established the presence of community frailty with respect to under-five mortality in Afghanistan. The study shows that the association of not breastfeeding and mortality is more acute in the early neonatal age group and it extends into the post-neonatal age group. The study identified the association of high birth order and mortality in the neonatal, post-neonatal and child age groups in Afghanistan. Policies should be implemented that encourage early initiation of breastfeeding to continue throughout the post-neonatal period and support for vulnerable families should be provided.

Association of Place of Residence and Under-Five Mortality in Middle- and Low-Income Countries: A Meta-Analysis.

This review evaluated the association of place of residence (urban/rural) and under-five mortality in middle- and low-income countries. Both English and Spanish language studies conducted during the Millennium Development Goal (MDG) period (1990 to 2015) were reviewed. Twenty-six cross-sectional studies, all in the English language, were selected for further review. Published data were used for this analysis. A funnel plot was produced to ascertain the presence of publication bias. The combined relative risk for under-five mortality was estimated using a random-effects model and a meta-regression was conducted on 15 of the 26 studies. The studies had a combined effect size of 1.47 (95% confidence interval, 1.27–1.67). The results of the meta-regression showed a positive association between the relative risk and the percentage of the rural population for the various regions/countries. The coefficient for the variable rural population percentage was 0.007, indicating that for every one percent increase in the rural population percentage, there was a 0.007 increase in the relative risk for under-five mortality. However, this was not significant (p-value = 0.3). Rural disadvantage persists in middle- and low-income countries. This is important to evaluate policies and programmes designed to remove the gap in under-five mortality rates between urban and rural areas.

Conditional cash transfers and the double burden of malnutrition among children in Colombia: a quasi-experimental study.

Conditional cash-transfer (CCT) programmes have been shown to improve the nutritional and health status of children from poor families. However, CCT programmes may have unintended and not fully known consequences by increasing the risk of overweight and obesity. We examined the impact of Familias en Acción (FA), a large CCT programme in Colombia, on the double burden of malnutrition among pre-school and school-aged children. Height and weight were measured before programme enrolment and during follow-ups in 1290 children from thirty-one treatment municipalities, being compared with 1584 children from sixty-two matched control municipalities. We used a difference-in-differences approach to evaluate the effect of FA on children's stunting, BMI z-scores, thinness, overweight and obesity, controlling for individual and municipality-level confounders. At baseline, the prevalences of stunting and overweight were 30·3 and 15·4 %, respectively, in treatment municipalities and 27·9 and 17·4 % in control municipalities. FA was associated with reduced odds of thinness (OR 0·26; 95 % CI 0·09, 0·75) and higher BMI-for-age z-scores (BMI z-scores) (ß 0·14; 95 % CI 0·00, 0·27; P<0·05), although the latter was of small clinical significance. The prevalence of stunting, overweight and obesity decreased over time, but the effect of FA on these outcomes was not significant. The CCT programme in Colombia reduced the odds of thinness, but had no effect on stunting, a more prevalent outcome. The FA programme had no effect on overweight or obesity, although BMI z-scores were higher for children under treatment, raising the possibility of an increase of small clinical significance on BMI among pre-school and school-aged children.

Measuring the effect of Choosing Wisely: an integrated framework to assess campaign impact on low-value care.

The Choosing Wisely campaign began in the USA in 2012 to encourage physicians and patients to discuss inappropriate and potentially harmful tests, treatments and procedures. Since its inception, the campaign has grown substantially and has been adopted by 12 countries around the world. Of great interest to countries implementing the campaign, is the effectiveness of Choosing Wisely to reduce overutilisation. This article presents an integrated measurement framework that may be used to assess the impact of a Choosing Wisely campaign on physician and provider awareness and attitudes on low-value care, provider practice behaviour and overuse of low-value services.

Resolving the challenges in the international comparison of health systems: the must do's and the trade-offs.

Countries are increasingly publishing health system performance statistics alongside those of their peers, to identify high performers and achieve a continuously improving health system. The aim of the paper is to identify, and discuss resolution of, some key methodological challenges, which arise when comparing health system performance. To illustrate the issues, we focus on two OECD flagship initiatives: the System of Health Accounts (SHA) and the Health Care Quality Indicators (HCQI) project and refer to two main actors: a coordinating agency, which proposes and collates performance data and second, data correspondents in constituent health systems, who submit data to the coordinating centre. Discussion is structured around two themes: a set of must-do's (legitimacy of the coordinating centre, validity of proposed indicators, feasibility of data collection and technical support for data correspondents) and a set of trade-offs (depth vs. breadth in the number of system elements compared, aggregation vs. granularity of data, flexibility vs. consistency of indicator definitions and inclusion criteria). Robust fulfillment of the must-do's and transparent resolution of the trade-offs both depend upon effective collaboration between the coordinating centre and data correspondents, and a close working relationship between a technical secretariat and a body of experts.

Socio-economic inequalities in malnutrition among children and adolescents in Colombia: the role of individual-, household- and community-level characteristics.

OBJECTIVE: To examine socio-economic inequalities in malnutrition among Colombian children and adolescents, and to assess the contribution of individual-, household- and community-level factors to those inequalities. DESIGN: Cross-sectional data were used from two sources: 2005 Colombian Demographic and Health Survey and 2005 Colombian census. Malnutrition outcomes included stunting and overweight. Multilevel Poisson models were used to estimate the association between individual, household and contextual characteristics and malnutrition. Changes in prevalence ratios of the poorest quintile (v. richest) were compared to assess the contribution of different characteristics to inequalities in malnutrition. SETTING: Population-based, representative of Colombia. SUBJECTS: Children and adolescents <18 years of age (n 30 779) from the Colombian Demographic and Health Survey. RESULTS: Children and adolescents living in the poorest households were close to five times more likely to be stunted, while those from the richest households were 1.3­2.8 times more likely than their poorest counterparts to be overweight. Care practices and household characteristics, particularly mother's education, explained over one-third of socio-economic inequalities in stunting. The proportion explained by access to services was not negligible (between 6% and 14 %). Access to sanitation was significantly associated with a lower prevalence of stunting for all age groups. Between 14% and 32% of socio-economic disparities in overweight were explained by maternal and household characteristics. Mother's overweight was positively associated with overweight of the child. CONCLUSION: Socio-economic inequalities in stunting and overweight coexist among children and adolescents in Colombia. Malnutrition inequalities are largely explained by household characteristics, suggesting the need for targeted interventions.

Elective surgical referral guidelines--background educational material or essential shared decision making tool? A survey of GPs' in England.

BACKGROUND: To investigate general practitioners' (GPs') attitudes to guidelines for elective surgical referral in England. To understand their use of guidelines, and attitudes to shared decision making in the referral decision. METHODS: A questionnaire was developed which investigated attitudes to and use of guidelines. It was given to a stratified random sample 30% (n = 310) drawn from GP lists of 10 English health districts (primary care trusts (PCTs)). GPs were invited to respond online, by telephone, fax or post. Data were analysed using descriptive statistics and backwards stepwise logistic regression. RESULTS: Responses were representative of GPs in England, but (despite up to 6 contacts per non-responder) the overall response rate was 41.6% (n = 129; with the range across PCTs of 25-61%). Most responding GPs indicated support for referral guidelines but 18% reported that they had never used them. Less than three per cent reported use for most or all referral decisions. The odds of using guidelines decreased with increasing age, with a ten year increase in age associated with halving odds of use (OR = 0.53, 95%CI = 0.29-0.90). Over 50% of GPs wanted good access to electronic guidelines with expert information and advice on guideline availability. Almost all (>89%) GPs agreed with sharing referral decisions with patients. Female doctors (OR = 5.2, 95%CI: 1.02-26.3) were more likely to agree with this than male GPs as were those working in larger compared to small or single handed practices (OR = 5.3, 95%CI: 1.4-19.9). CONCLUSIONS: This group of responding GPs was supportive of guidelines but used them in different ways. Referral guidelines should have an educational component for background reading; include key messages for internalisation and application; and incorporate mechanisms to facilitate accessibility and appropriate shared decision making with patients.

Using conditionality as a solution to the problem of low uptake of essential services among disadvantaged communities: a social determinants view.

Conditional cash transfer schemes, which use cash to incentivize uptake of basic health and educational services, are well established among social planners inlow- and middle-income countries and are now taking hold in high-income countries. We appraised these schemes within a social determinants framework and found some encouraging signs in their first decade of operation. Success, however, has been inconsistent, and it is unclear whether conditional cash transfer schemes can reliably secure meaningful improvements in participants' health and nutritional status or educational attainment. Conditional cash transfer schemes' objectives will not be met unless they are transformed in 3 ways: transferring power as well as resources, emphasizing entitlements alongside conditionality, and avoiding the trap of incoherent or residualized policy.

Socioeconomic and ethnic differences in use of lipid-lowering drugs after deregulation of simvastatin in the UK: the Whitehall II prospective cohort study.

BACKGROUND: We examined socioeconomic and ethnic differences in use of lipid-lowering drugs after deregulation of simvastatin in the UK for adults with moderate or high risk of coronary heart disease. METHODS: 3631 participants in the Whitehall II cohort study (mean age 62.7 years, 91% white) were informed of their risk of coronary heart disease, based on Framingham score, before deregulation (2002-2004). The use of prescribed lipid-lowering drugs and use of over-the-counter simvastatin were analysed as outcome variables, after deregulation (2005-2007). RESULTS: 2451 participants were at high risk and 1180 at moderate risk. 20% moderate-risk and 44% high-risk participants reported using prescribed lipid-lowering drugs although no over-the-counter simvastatin was used. Prescribing rates did not differ between employment grades (an index of socioeconomic position), but was higher among South Asian high-risk compared with White high-risk participants (odds ratio 1.64, 95% CI 1.21-2.23). Of the high-risk participants, 44% recalled their increased coronary heart disease risk. South Asian high-risk participants were less likely to recall than White high-risk participants (odds ratio 0.65, 95% CI 0.46-0.93). Furthermore, high risk participants with middle (odds ratio 0.74, 95% CI 0.61-0.89) and low (odds ratio 0.52, 95% CI 0.37-0.74) employment grades were less likely to recall than those with high grades. CONCLUSION: Socioeconomic and ethnic differences in reported use of lipid-lowering drugs were small, but the use of these drugs in general was much lower than recommended and the participants did not utilise over-the-counter statins. Ethnic minorities and lower socioeconomic position groups were less likely to be aware of their increased coronary risk.