The effect of a community-based, integrated and nurturing care intervention on early childhood development in rural China.

OBJECTIVES: This study investigated whether an integrated, community-based and nurturing care intervention led to a reduction in the prevalence of suspected neurodevelopmental delay in children. The study also considered how the programme could be sustained to promote early development in children aged under 3 years in the poorest areas of rural China. STUDY DESIGN: A quasi-experimental design was applied, with data collection before and after a 2-year programme implementation, in both intervention and comparison (control) areas. METHODS: From July 2014, the Integrated Early Childhood Development (IECD) programme was implemented in poverty-stricken areas in four counties of China. Nurturing care intervention focusing on five components (child health, nutrition, responsive care, protection and early learning support) was delivered mainly by the village early childhood development centre and township/village clinic. Another two counties of similar per capita gross domestic product, geographical characteristics, under-five mortality rate, under-five underweight prevalence and ethnicity to the four programme counties were selected as the comparison and received no IECD programme intervention. The Ages & Stages Questionnaire was used to evaluate the neurodevelopmental outcome of children; the overall suspected developmental delay (SDD) referred to any developmental delay in the communication, gross-motor, fine-motor or problem-solving or personal-social domains of the questionnaire. Children underwent anthropometric measurements and haemoglobin concentration testing through peripheral blood. Face-to-face interviews of caregivers were conducted to collect intervention use, cognitive stimulation and child-protection behaviours. A difference-in-differences regression approach, adjusting for confounding factors, was applied to estimate intervention impact on the neurodevelopmental outcomes in the children. Path analysis was employed to examine the mediating effects of growth, nutrition status, cognitive stimulation and child-protection behaviours through which the IECD intervention predicted children's developmental health. RESULTS: In total, 2953 children aged under 3 years and their caregivers were enrolled at baseline, and 2745 child-caregiver pairs completed the postintervention assessment. Prevalence of overall SDD was reduced by 18% (from 37% at baseline to 19% at postintervention) in intervention counties, which is a significant difference compared with the 10% reduction in control counties (from 30% to 20%), with an adjusted odds ratio of 0.69 (95% confidence interval: 0.54-0.89). Consistent findings were found across domains. Path analysis indicated that the effect of the intervention on promoting developmental health was mediated by multiple nurturing care-associated factors, including cognitive stimulation frequency, positive discipline, length-for-age growth and haemoglobin concentration. CONCLUSIONS: The community-based integrated intervention could significantly prevent developmental delay in children aged under 3 years in rural China.

Effects of early comprehensive interventions on child neurodevelopment in poor rural areas of China: a moderated mediation analysis.

OBJECTIVES: To examine the effects of early comprehensive interventions on home environment and child neurodevelopment among children younger than 3 years in poor rural areas of China, as well as the underlying mediating and moderating mechanisms. STUDY DESIGN: Non-randomized intervention study was conducted among 216 children aged 0-3 years in Shanxi province of China. Based on a 2 × 2 factor design, children in Lin and Fenxi County were assigned to an intervention group with duration less than 1 year (n = 26) or an intervention group with duration longer than 1 year (n = 82), while children in Fangshan County served as a control group with duration less than 1 year (n = 30) or a control group with duration longer than 1 year (n = 78). METHODS: The control group received national public health services (NPHS), while the intervention group received NPHS plus comprehensive interventions covering health, nutrition, early psychosocial stimulation, and child protection. Home environment (Infant-Toddler Home Observation for Measurement of the Environment [HOME]) and child neurodevelopment (Ages and Stages Questionnaire [ASQ]) were measured by observation and interview with mothers after the intervention program. RESULTS: The intervention group showed significantly higher overall HOME, organization, learning materials, and involvement than the control group, only for a duration longer than 1 year. Children in the intervention group performed better in overall ASQ, fine motor, problem-solving, and personal-social than children in the control group. Moderated mediation analyses indicated that there were significantly indirect effects of treatment on overall ASQ through overall HOME, organization, and involvement only when the duration was longer than 1 year. CONCLUSIONS: Early comprehensive interventions longer than 1 year improve home environment and promote child neurodevelopment among children younger than 3 years in poor rural areas. What is more, effects of early comprehensive interventions longer than 1 year on child neurodevelopment were mediated by home environment.

High prevalence of developmental delay among children under three years of age in poverty-stricken areas of China.

OBJECTIVES: Poverty and its associated factors put children at risk for developmental delay. The aim of this study was to describe the neurodevelopment of children under three years of age in poverty-stricken areas of China and explore possible associated factors. STUDY DESIGN: A cross-sectional survey was conducted among 2837 children aged 1-35 months in poverty-stricken areas of China. METHODS: Characteristics of the child, caregiver, and family were collected through face-to-face caregiver interviews. Developmental delay was explored with the five-domain, structured, parent-completed Ages and Stages Questionnaire. The Zung Self-rating Depression Scale was used to assess depressive symptoms of the caregivers. The Chi-squared test and multivariate logistic regression analyses were used to explore associated factors. RESULTS: Of the children, 39.7% (95% confidence interval, 37.9-41.5) had developmental delay in at least one of the five domains. For the domains of communication, gross motor, fine motor, problem solving, and personal-social skills, the prevalence was 11.5%, 18.5%, 21.4%, 18.4%, and 17.9%, respectively. Significant predictors of increased odds of developmental delay included the child having no toys (odds ratio [OR] = 2.31), the caregiver having depression (OR = 2.24), insufficient learning activities (OR = 1.65), and more children in the family (OR = 1.16). CONCLUSIONS: The high prevalence of developmental delay in children younger than three years in poverty-stricken areas of China and the presence of risk factors for developmental delay such as inadequate learning resources and activities in the home, caregiver depression, and low family income highlight the need for early identification and interventions.

Poor complementary feeding practices and high anaemia prevalence among infants and young children in rural central and western China.

BACKGROUND/OBJECTIVES: Infant and young child feeding (IYCF) has not been documented in central and western China, where anaemia is prevalent. To support policy advocacy, we assessed IYCF and anaemia there using standardized methods. SUBJECTS/METHODS: A community-based, cross-sectional survey of 2244 children aged 6-23 months in 26 counties of 12 provinces. Analysis of associations between haemoglobin concentration (HC), IYCF indicators and other variables using crude and multivariate techniques. RESULTS: Only 41.6% of those surveyed consumed a minimum acceptable diet. Fewer still-breastfeeding than non-breastfeeding children consumed the recommended minimum dietary diversity (51.7 versus 71.9%; P<0.001), meal frequency (57.7% v. 81.5%; P<0.001) or iron-rich food (63.3% v. 78.9%; P<0.001). Anaemia (51.3% overall) fell with age but was significantly associated with male sex, extreme poverty, minority ethnicity, breastfeeding and higher altitude. Dietary diversity, iron intake, growth monitoring and being left behind by out-migrating parents were protective against anaemia. A structural equation model demonstrated associations between IYCF, HC and other variables. Meal frequency, iron intake and altitude were directly and positively associated with HC; dietary diversity was indirectly associated. Health service uptake was not associated. Continued breastfeeding was directly associated with poor IYCF and indirectly with reduced HC, as were having a sibling and poor maternal education. CONCLUSION: Infant and young child anaemia is highly prevalent and IYCF is poor in rural central and western China. Continued breastfeeding and certain other variables indicate risk of poor IYCF and anaemia. Major policy commitment to reducing iron deficiency and improving IYCF is needed for China's rural poor.

Are health interventions implemented where they are most needed? District uptake of the integrated management of childhood illness strategy in Brazil, Peru and the United Republic of Tanzania.

OBJECTIVE: To describe geographical patterns of implementation of the Integrated Management of Childhood Illness (IMCI) strategy in three countries and to assess whether the strategy was implemented in areas with the most pressing child health needs. METHODS: We conducted interviews with key informants at the national and district levels in Brazil, Peru and the United Republic of Tanzania, and an ecological study of factors associated with health worker training in IMCI. Explanatory factors included district population, distance from the capital, human development index, other socioeconomic indicators and baseline mortality rates in children younger than five years. FINDINGS: In line with recommendations by WHO, early implementation districts were characterized by proximity to the capital and suitable training sites, presence of motivated health managers and a functioning health system. In the expansion phase, IMCI tended to be adopted by other districts with similar characteristics. In Brazil, uptake by poor and small municipalities and those further away from the state capital was significantly lower. In Peru, there was no association with distance from Lima, and a non-significant trend for IMCI adoption by small and poor departments. In the United Republic of Tanzania, the only statistically significant finding was a lower uptake by remote districts. Implementation was not associated with baseline mortality levels in any country studied. CONCLUSION: Whereas clear and reasonable guidelines are provided for selection of early use districts, no criteria for promoting IMCI expansion had been issued, and areas of greatest need were not prioritized. Equity analyses based on the geographical deployment of new programmes and strategies can contribute to assessing whether they are reaching those who need them most.

Implementing global knowledge in local practice: a WHO lung health initiative in Nepal.

Clinical practice guidelines are used widely to improve the quality of primary health care in different health systems, including those of low-income countries. Often developed at international level and adapted to national contexts to increase the feasibility of effective uptake, guideline initiatives aim to transfer global scientific knowledge into local practice. The WHO's Practical Approach to Lung Health (PAL) is an example of such an initiative and is currently being developed to improve the quality of care for youths and adults with respiratory diseases. We assessed ex-ante the feasibility of successful implementation of PAL in a pilot programme in rural Nepal, studying three components: the quality of the innovation (i.e. the guidelines), the effectiveness of the implementation strategy (i.e. training) and the receptiveness of the social system of health staff at all levels (i.e. social and organizational characteristics). We assessed the guideline innovation with the AGREE instrument for guidelines, the intended implementation strategy by critical comparison with literature on effective strategies, and the social system with both a stakeholder analysis and a descriptive analysis of the health care system at district level. This ex-ante assessment of an adaptive local implementation of international WHO guidelines showed that in July 2002 the 'implementability' of the package was challenged on the three components studied. To increase the chances of successful implementation, the national guideline development process should be improved and the implementation strategy needs to be upgraded. In order to successfully transfer global knowledge into local practice, we need to develop additional multifactorial sustained interventions that tackle other culture-specific and health system-specific barriers as well. The primary health workers are key informants for these barriers.

Towards an integrated approach to lung health in adolescents in developing countries.

The World Health Organization strategies, Integrated Management of Childhood Illness and Practical Approach to Lung health provide assessment and management guidelines for health workers in developing countries. We reviewed issues important to lung health in adolescents to highlight whether differences in factors such as adolescent behaviour have consequences for the development of case management guidelines, to form a bridge between guidelines for younger children and for adults and to make suggestions for further study. Pneumonia, asthma and tuberculosis are the leading lung health problems in adolescents. As countries industrialise, the importance of asthma mortality and morbidity increases as that of pneumonia and pulmonary tuberculosis decreases. Guidelines for managing pneumonia and asthma in children and adults in developing and developed countries should be adaptable for use in adolescents in developing countries, although more information is needed on predictors of severity such as respiratory rate cut-offs, level of fever, hypotension, malnutrition and level of consciousness. The effectiveness of low-cost treatment for asthma should be explored further. HIV and the global resurgence of tuberculosis pose significant challenges for improving adolescent lung health, and prevention of smoking initiation during adolescence is a priority goal of any integrated approach to improving lung health.

[Buruli ulcer (Mycobacterium ulcerans infection); report from the International Congress in Yamoussoukro, Ivory Coast]. / Buruli-ulcus (infectie met Mycobacterium ulcerans); verslag van een internationaal congres in Yamoussoukro, Ivoorkust.

Mycobacterium ulcerans infection (Buruli ulcer) is the third important mycobacterial disease world-wide in immunocompetent humans, after tuberculosis and leprosy. M. ulcerans is an environmental mycobacterium which has now been recovered from water and soil in swampy areas, and transmission to man occurs presumably through minor skin traumas. Endemic foci are known throughout the world, predominantly in tropical rain forest areas. The clinical presentation varies between a papule, a nodule or an ulceration with typically undermined edges. Surgery is the only effective treatment. BCG vaccination has a moderate protective effect. An association with HIV infection has not been demonstrated so far. Poor communities, with limited access to health care, and especially children are affected. The medical and socioeconomic burden imposed by the disease is tremendous. During the last decade the incidence of the disease has increased dramatically, particularly in West Africa. Possibly this is connected with changes in the natural ecosystem. The Yamoussoukro declaration on Buruli ulcer, adopted July 6, 1998, is the basis of improvement of awareness, health education, treatment, and research on M. ulcerans infection. Support by the international community is urgently needed.

Effects of oestradiol-17 beta and LRH upon the two fractions of pituitary follicle-stimulating hormone separated by concanavalin-A chromatography.

The effects of oestradiol-17 beta (E2) and LRH upon the two fractions of pituitary follicle stimulating hormone (FSH) obtained by concanavalin A (Con A) chromatography were studied. Anterior pituitary glands were removed from adult intact rats at different times throughout the oestrous cycle, and from long-term ovariectomized (Ovx) rats after specific endocrine treatments. The presence, relative ratio and biological activity of each Con A separable FSH fraction were assessed by a specific radioimmunoassay and by an in vitro bioassay. After separation by concanavalin A chromatography, glands from intact rats sacrificed during the days of oestrus, dioestrus 1 and dioestrus 2, exhibited constant relative ratios (U:B FSH ratio) of the two FSH fractions so separated (Con A unbound and bound FSH), whereas donors sacrificed at the morning and early afternoon (13.00-15.00 h) of the day of pro-oestrus, showed the highest U:B FSH ratio; this ratio abruptly declined at the time of the FSH surge, after 15.00 h of pro-oestrus. Ovx rats exhibited lower ratios than intact animals. Pituitary extracts from Ovx donors under short-term (20 h) E2 exposure (condition which decreased pituitary sensitivity to LRH), showed the lowest U:B FSH ratio, whereas glands from Ovx rats exposed to conditions which caused increased pituitary LRH exposure (immediately before the oestradiol-induced FSH surge or after injection of 100 ng of LRH) showed an increase in their U:B FSH ratio, as compared with Ovx and Ovx + E2 (20 h) rats.(ABSTRACT TRUNCATED AT 250 WORDS)