Climate change-induced shifts in the food systems and diet-related non-communicable diseases in sub-Saharan Africa: a scoping review and a conceptual framework.

OBJECTIVES: To determine the relationship between climate change, food systems and diet-related non-communicable diseases (DR-NCDs) in sub-Saharan Africa (SSA) and propose a conceptual framework for food systems in SSA. DESIGN: A scoping review. ELIGIBILITY CRITERIA: Studies included investigated the relationship between climate change and related systemic risks, food systems, DR-NCDs and its risk factors in SSA. Studies focusing on the association between climate change and DR-NCDs unrelated to food systems, such as social inequalities, were excluded. SOURCES OF EVIDENCE: A comprehensive search was conducted in ProQuest (nine databases), Google Scholar and PubMed in December 2022. CHARTING METHODS: Data extracted from studies included author, study type, country of study, climate change component, DR-NCD outcomes and risk factors, and impacts of climate change on DR-NCDs. A narrative approach was used to analyse the data. Based on the evidence gathered from SSA, we modified an existing food system conceptual framework. RESULTS: The search retrieved 19 125 studies, 10 of which were included in the review. Most studies used a cross-sectional design (n=8). Four explored the influence of temperature on liver cancer through food storage while four explored the influence of temperature and rainfall on diabetes and obesity through food production. Cross-sectional evidence suggested that temperature is associated with liver cancer and rainfall with diabetes. CONCLUSION: The review highlights the vulnerability of SSA's food systems to climate change-induced fluctuations, which in turn affect dietary patterns and DR-NCD outcomes. The evidence is scarce and concentrates mostly on the health effects of temperature through food storage. It proposes a conceptual framework to guide future research addressing climate change and DR-NCDs in SSA.

Is health expenditure on immunisation associated with immunisation coverage in sub-Saharan Africa? A multicountry analysis, 2013-2017.

OBJECTIVES: The designing of contextually tailored sustainable plans to finance the procurement of vaccines and the running of appropriate immunisation programmes are necessary to address the high burden of vaccine-preventable diseases and low immunisation coverage in sub-Saharan Africa (SSA). We sought to estimate the minimum fraction of a country's health budget that should be invested in national immunisation programmes to achieve national immunisation coverage of 80% or greater depending on the context, with and without donors' support. DESIGN: Multicountry analysis of secondary data using retrieved publicly available data from the WHO, Global Alliance for Vaccines and Immunization (GAVI) and World Bank databases. SETTING: Data on 24 SSA countries, between 2013 and 2017. METHODS: We model the variations in immunisation coverage across the different SSA countries using a fractional logit model. Three different generalised linear models were fitted to explore how various explanatory variables accounted for the variability in each of the three different vaccines-measles-containing vaccine (MCV)1, diphtheria, pertussis, tetanus (DPT3) and BCG. RESULTS: We observed an association between current health expenditure (as a percentage of gross domestic product) and immunisation coverage for BCG (OR=1.01, 95% CI: 1.01 to 1.04, p=0.008) and DPT3 (OR=1.01, 95% CI: 1.0 to 1.02, p=0.020) vaccines. However, there was no evidence to indicate that health expenditure on immunisation (as a proportion of current health expenditure) could be a strong predictor of immunisation coverage (DPT, OR 0.96 (95% CI 0.78 to 1.19; p=0.702); BCG, OR 0.91 (0.69 to 1.19; p=0.492); MCV, OR 0.91 (0.69 to 1.19; p=0.482)). We demonstrate in selected countries that to achieve the GAVI target of 80% in the countries with low DPT3 coverage, health expenditure would need to be increased by more than 45%. CONCLUSIONS: There is a need to facilitate the development of strategies that support African countries to increase domestic financing for national immunisation programmes towards achieving 2030 targets for immunisation coverage.

Adjustments in purchasing arrangements to support the COVID-19 health sector response: evidence from eight middle-income countries.

The COVID-19 pandemic has triggered several changes in countries' health purchasing arrangements to accompany the adjustments in service delivery in order to meet the urgent and additional demands for COVID-19-related services. However, evidence on how these adjustments have played out in low- and middle-income countries is scarce. This paper provides a synthesis of a multi-country study of the adjustments in purchasing arrangements for the COVID-19 health sector response in eight middle-income countries (Armenia, Cameroon, Ghana, Kenya, Nigeria, Philippines, Romania and Ukraine). We use secondary data assembled by country teams, as well as applied thematic analysis to examine the adjustments made to funding arrangements, benefits packages, provider payments, contracting, information management systems and governance arrangements as well as related implementation challenges. Our findings show that all countries in the study adjusted their health purchasing arrangements to varying degrees. While the majority of countries expanded their benefit packages and several adjusted payment methods to provide selected COVID-19 services, only half could provide these services free of charge. Many countries also streamlined their processes for contracting and accrediting health providers, thereby reducing administrative hurdles. In conclusion, it was important for the countries to adjust their health purchasing arrangements so that they could adequately respond to the COVID-19 pandemic, but in some countries financing challenges resulted in issues with equity and access. However, it is uncertain whether these adjustments can and will be sustained over time, even where they have potential to contribute to making purchasing more strategic to improve efficiency, quality and equitable access in the long run.

The impact of growth monitoring and promotion on health indicators in children under five years of age in low- and middle-income countries.

BACKGROUND: Undernutrition in the critical first 1000 days of life is the most common form of childhood malnutrition, and a significant problem in low- and middle-income countries (LMICs). The effects of undernutrition in children aged under five years are wide-ranging and include increased susceptibility to and severity of infections; impaired physical and cognitive development, which diminishes school and work performance later in life; and death. Growth monitoring and promotion (GMP) is a complex intervention that comprises regular measurement and charting of growth combined with promotion activities. Policymakers, particularly in international aid agencies, have differing and changeable interpretations and perceptions of the purpose of GMP. The effectiveness of GMP as an approach to preventing malnutrition remains a subject of debate, particularly regarding the added value of growth monitoring compared with promotion alone. OBJECTIVES: To evaluate the effectiveness of child growth monitoring and promotion for identifying and addressing faltering growth, improving infant and child feeding practices, and promoting contact with and use of health services in children under five years of age in low- and middle-income countries. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 3 November 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs), cohort studies, and controlled before-after studies that compared GMP with standard care or nutrition education alone in non-hospitalised children aged under five years. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods to conduct a narrative synthesis. Our primary outcomes were anthropometric indicators, infant and child feeding practices, and health service usage. Secondary outcomes were frequency and severity of childhood illnesses, and mortality. We used GRADE to assess the certainty of evidence for each primary outcome. MAIN RESULTS: We included six studies reported in eight publications. We grouped the findings according to intervention. Community-based growth monitoring and promotion (without supplementary feeding) versus standard care We are unsure if GMP compared to standard care improves infant and child feeding practices, as measured at 24 months by the proportion of infants who have fluids other than breast milk introduced early (49.7% versus 70.5%; 1 study; 4296 observations; very low-certainty evidence). We are unsure if GMP improves health service usage, as measured at 24 months by the proportion of children who receive vitamin A (72.5% versus 62.9%; 1 study; 4296 observations; very low-certainty evidence) and the proportion of children who receive deworming (29.2% versus 14.6%; 1 study; 4296 observations; very low-certainty evidence). No studies reported selected anthropometric indicators (weight-for-age z-score or height-for-age z-score) at 12 or 24 months, infant and child feeding practices at 12 months, or health service usage at 12 months. Community-based growth monitoring and promotion (with supplementary feeding) versus standard care Two studies (with 569 participants) reported the mean weight-for-age z-score at 12 months, providing very low-certainty evidence: in one study, there was little or no difference between GMP and standard care (mean difference (MD) -0.07, 95% confidence interval (CI) -0.19 to 0.06); in the other study, mean weight-for-age z-score worsened in both groups, but we were unable to calculate a relative effect. GMP versus standard care may make little to no difference to the mean height-for-age z-score at 12 months (MD -0.15, 95% CI -0.34 to 0.04; 1 study, 337 participants; low-certainty evidence). Two studies (with 564 participants) reported a range of outcome measures related to infant and child feeding practices at 12 months, showing little or no difference between the groups (very low-certainty evidence). No studies reported health service usage at 12 or 24 months, feeding practices at 24 months, or selected anthropometric indicators at 24 months. AUTHORS' CONCLUSIONS: There is limited uncertain evidence on the effectiveness of GMP for identifying and addressing faltering growth, improving infant and child feeding practices, and promoting contact with and use of health services in children aged under five years in LMICs. Future studies should explore the reasons for the apparent limited impact of GMP on key child health indicators. Reporting of GMP interventions and important outcomes must be transparent and consistent.

Stunting of Growth in Developing Countries.

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Are children on track with their routine immunization schedule in a fragile and protracted conflict state of South Sudan? A community-based cross-sectional study.

OBJECTIVES: The objective of this study was to assess if children aged 0-23 months in a conflict-affected state of South Sudan were on track with their immunization schedule and to identify predisposing factors that affected this study population from being on track with their routine immunization schedule. DESIGN: Community-based cross-sectional study using a semi-structured questionnaire. The binary outcome of interest was defined as being on or off track with routine vaccination schedule. Multivariable logistic regression was used to analyze for the association between the predisposing factors surveyed and being off track with one's routine immunization schedule. SETTING: Rural communities in four counties (Rumbek Center, Rumbek North, Rumbek East and Wulu) of the Western Lakes state in South Sudan during January 10, 2020 to June 10, 2020. PARTICIPANTS: We surveyed 428 children aged 0-23 months and their mothers/caregivers who lived in either of the four counties in the Western Lakes State. Participants were selected using random ballot sampling. RESULTS: More than three-quarters of the children surveyed (75.5%) were off track with their vaccination schedule. Children with an immunization card had 71% reduced odds of being off track with their immunization (AOR = 0.29; 95% CI 0.10-0.83, p-value = 0.021) compared to children without immunization cards. Children who reside near health facilities and do not require transportation to facilities had 87% reduced odds of being off track with their immunization compared to those who lived far and required transport to facilities. Giving an adequate immunization notice before conducting immunization outreach visits to communities was also associated with reduced odds (AOR = 0.27; 95% CI 0.09-0.78. p-value = 0.016) of children being off track with their immunization. CONCLUSION: This study revealed that most children were off track with their vaccination schedule in South Sudan, which is not only influenced by maternal characteristics but mainly by community- and state-level immunization service delivery mechanisms. Policies and interventions to improve child immunization uptake should prioritize these contextual characteristics.

Impact evaluation of immunisation service integration to nutrition programmes and paediatric outpatient departments of primary healthcare centres in Rumbek East and Rumbek Centre counties of South Sudan.

OBJECTIVE: To evaluate the impact of immunisation service integration to nutrition programmes and under 5-year-old paediatric outpatient departments of primary healthcare centres in Rumbek East and Rumbek Centre counties of South Sudan. DESIGN: Retrospective intervention study. SETTING: Three primary healthcare centres in Rumbek East county and three primary healthcare centres in Rumbek Centre county of Lakes state in South Sudan. PARTICIPANT: We extracted the data for the uptake of pentavalent vaccine (first, second and third dose) given to children aged between 6 weeks and 23 months from immunisation records for January-June 2019 before immunisation service integration and July-December 2019 after immunisation service integration from the District Health Information System 2 website to estimate the immunisation uptake ratios and drop-out rates. RESULTS: The uptake of the first dose of the pentavalent vaccine improved from 61% to 96% (p<0.001) after immunisation service integration into the nutrition programmes of the primary healthcare centres in Rumbek Centre county. The uptake of the second pentavalent dose improved from 37% to 69% (p<0.001) and for the third pentavalent dose from 36% to 62% (p<0.001), while the drop-out rate reduced from 57% to 40% (p<0.001). While in Rumbek East county, the uptake of the first dose of the pentavalent vaccine improved from 55% to 77% (p<0.001) after immunisation service integration into the under 5-year-old paediatric outpatient departments. The uptake of the second dose improved from 36% to 62% (p<0.001) and for the third dose from 44% to 63% (p<0.001), while the drop-out rate reduced from 40% to 28% (p<0.001). Children were 23% more likely (RR 1.23, 95% CI 1.12 to 1.36, p<0.001) to be immunised with the first dose of the pentavalent vaccine on immunisation service integration into the nutrition programmes of primary healthcare centres of Rumbek Centre county in comparison to integration into under 5-year-old outpatient departments of Rumbek East county. CONCLUSION: Integration of immunisation service delivery to nutrition sites and children's outpatient departments improved the immunisation coverage and decreased drop-out rates in the Rumbek East and Rumbek Centre counties of South Sudan. This evidence of positive impact should encourage the stakeholders of the Expanded Programme on Immunisation to focus on the sustainability and scale-up of this intervention to other counties in South Sudan, as logistically as possible.