Adjusted effects of domestic violence, tobacco use, and indoor air pollution from use of solid fuel on child mortality

The next 1000 days: building on early investments for the health and development of young children

Following the first 1000 days of life that span from conception to two years of age, the next 1000 days of a child's life from 2-5 years of age offer a window of opportunity to promote nurturing and caring environments, establish healthy behaviours, and build on early gains to sustain or improve trajectories of healthy development. This Series paper, the first of a two-paper Series on early childhood development and the next 1000 days, focuses on the transition to the next 1000 days of the life course, describes why this developmental period matters, identifies the environments of care, risks, and protective factors that shape children's development, estimates the number of children who receive adequate nurturing care, and examines whether current interventions are meeting children's needs. Paper 2 focuses on the cost of inaction and the implications of not investing in the next 1000 days. In low-income and middle-income countries (LMICs), only 62 million children aged 3 and 4 years (25·4%) currently receive adequate nurturing care during the next 1000 days, leaving 181·9 million children exposed to risks that jeopardise their healthy development. Inputs across nurturing care dimensions of health, nutrition, protection, responsive care, and learning vary substantially across countries. In LMICs, although 86·2% of children have a healthy weight in this period, less than one in three children have access to developmental stimulation or are protected from physical punishment, and only 38·8% have access to early childhood care and education services. Intervention research in LMICs in the next 1000 days is scarce. The continuity of developmentally appropriate nurturing care, coordination across health, education, and protection sectors, and the implementation of interventions to support caregivers and improve the quality of education and care remain top priorities in this period. These sectors play key roles in promoting quality early care and education for this age group, which will help maximise developmental potential and opportunities of children globally and help progress towards the achievement of the Sustainable Development Goals.

Association between household air pollution and all-cause and cause-specific mortality: a systematic review and meta-analysis

Recently, a growing number of epidemiological studies have examined the relationship between household air pollution (HAP) and all-cause and cause-specific mortality. While the results were not entirely consistent, the current study followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) protocol to conduct a comprehensive review and meta-analysis. Data sources were PubMed, Web of Science, Embase, and Cochrane Library for studies published up to 12 May 2022. The pooled relative risks (RRs) with 95% confidence intervals (CI) were used to estimate the effect of household air pollution on all-cause and cause-special mortality. Then I square value (I²) was used to assess heterogeneity, and random-effects model was used as the pooling method. Seventeen studies were included in the quantitative analysis. Our results showed a significant association between household air pollution and increased risks of all-cause mortality (RR = 1.12, 95% CI = 1.06-1.19) and cardiovascular disease mortality (RR = 1.13, 95% CI = 1.04-1.24). Similarly, the associations between household air pollution and mortality from other specific causes (respiratory, ischemic heart disease, stroke, and total cancer) were positive, although they were not statistically significant. The study suggests that exposure to household air pollution increases the risk of all-cause mortality and cardiovascular disease mortality. In addition, our results found a trend of increased mortality from the respiratory system, ischemic heart disease, stroke, and total cancer, with household air pollution.

Multilevel Analysis of Lifestyle and Household Environment for Toddlers With Symptoms of Acute Respiratory Infection (ARI) in Indonesia in 2007, 2012, and 2017

Introduction. The morbidity and mortality rate of Acute Respiratory Tract Infection (ARI) in children under 5 is relatively high in Indonesia. Socio-demographic characteristic is considered one of the factors causing ARI in Indonesia. However, no study analyzed the prevalence of ARI among toddlers and the differences among the determinant factors in multiple periods. Thus, this study aimed to analyze the prevalence trends and determinant factors associated with ARI symptoms in children under 5 in Indonesia in 2007, 2012, and 2017. Methods. This study analyzed cross-sectional survey data from the Demographic and Health Survey (DHS) in Indonesia during 2007, 2012, and 2017. Bivariate and multivariate analysis with logistic regression was performed using Stata version 15. The final results were expressed in Adjusted Odds Ratio (AORs) and 95% Confidence Interval (CI). Results. The findings showed a progress in prevalence trends with a decrease in the percentage of children with ARI symptoms from 11.25% (2007), then 5.12% (2012) to 4.22% (2017). Risk factors for toddlers experiencing ARI symptoms were as follows: younger maternal age (OR: 1.13, 95% Cl 0.70-1.81 in 2007, OR: 1.72, 95% Cl 1.03-2.88 in 2012 and OR: 0.98, 95% Cl 0.48-1.97 in 2017), smoking habits of family members (OR: 1.12, 95% Cl 0.85-1.48 in 2012, OR: 1.23, 95% Cl in 2017), poor drinking water quality (OR: 1.12, 95% Cl 0.85-1.48 in 2012 and OR: 1.23, 95% Cl in 2017), unavailable toilet facilities (OR: 1.27, 95% Cl 1.04-1.56 in 2007, OR: 1.24, 95% Cl 0.95-1.63 in 2012 and OR: 1.28, 95% Cl 0.97-1.68 in 2017). Conclusion. There was a decrease in the prevalence of ARI symptoms among children in 2007, 2012, and 2017, with no prominent differences in other related factors. The lifestyle and household environmental factors such as the use of dirty fuel, the presence of smokers in the household, the poor quality of drinking water, unavailable toilet facilities in addition to the maternal age and child age were the determinant factors that must be prioritized and improved. Family self-awareness should also be enhanced for better prospects for toddler survival.

A Systematic Review and Appraisal of Epidemiological Studies on Household Fuel Use and Its Health Effects Using Demographic and Health Surveys

The domestic combustion of polluting fuels is associated with an estimated 3 million premature deaths each year and contributes to climate change. In many low- and middle-income countries (LMICs), valid and representative estimates of people exposed to household air pollution (HAP) are scarce. The Demographic and Health Survey (DHS) is an important and consistent source of data on household fuel use for cooking and has facilitated studies of health effects. However, the body of research based on DHS data has not been systematically identified, nor its strengths and limitations critically assessed as a whole. We aimed to systematically review epidemiological studies using DHS data that considered cooking fuel type as the main exposure, including the assessment of the extent and key drivers of bias. Following PRISMA guidelines, we searched PubMed, Web of Science, Scopus and the DHS publication portal. We assessed the quality and risk of bias (RoB) of studies using a novel tool. Of 2748 records remaining after removing duplicates, 63 were read in full. A total of 45 out of 63 studies were included in our review, spanning 11 different health outcomes and representing 50 unique analyses. In total, 41 of 45 (91%) studies analysed health outcomes in children <5 years of age, including respiratory infections (n = 17), death (all-cause) (n = 14), low birthweight (n = 5), stunting and anaemia (n = 5). Inconsistencies were observed between studies in how cooking fuels were classified into relatively high- and low-polluting. Overall, 36/50 (80%) studies reported statistically significant adverse associations between polluting fuels and health outcomes. In total, 18/50 (36%) of the analyses were scored as having moderate RoB, while 16/50 (32%) analyses were scored as having serious or critical RoB. Although HAP exposure assessment is not the main focus of the DHS, it is the main, often only, source of information in many LMICs. An appreciable proportion of studies using it to analyse the association between cooking fuel use and health have potential for high RoB, mostly related to confounder control, exposure assessment and misclassification, and outcome ascertainment. Based on our findings, we provide some suggestions for ways in which revising the information collected by the DHS could make it even more amenable to studies of household fuel use and health, and reduce the RoB, without being onerous to collect and analyse.

Health effects of household air pollution related to biomass cook stoves in resource limited countries and its mitigation by improved cookstoves

BACKGROUND

Household air pollution (HAP) related to cooking is associated with significant global morbidity and mortality. An estimated three billion people worldwide are exposed to cooking related HAP caused by solid fuel combustion. This exposure is highest for the vulnerable population of women and children resulting in significant cumulative health effects.

METHODS

A literature review was conducted for health effects of household air pollution related to biomass cookstoves in resource limited countries and to evaluate the effect of improved cookstoves on these health effects. We searched PubMed, Embase and Cochrane Library. We conducted searches in January 2018 with a repeat in February 2020. We included only studies conducted in resource limited countries, published in English, irrespective of publication year and studies that examined the health effects of HAP and/or studied the effects of improved cookstove (IC). Two authors independently screened journal article titles, abstracts and full-text articles to identify those that included the following search term: biomass cookstoves and health risks. We also assessed the limitations of IC with barriers to their uptake.

RESULTS

Health effects associated with HAP mostly include increased blood pressure (BP), dyspnea, childhood pneumonia, lung cancer, low birthweight and cardiovascular diseases. Being a global problem with divergent environmental factors including wide variety of fuel used, housing condition, foods prepared, climatic condition and social factors; most solutions though efficient seems inadequate. Improved cookstove (IC) mitigates emissions and improves short term health, though few randomized long-term studies could substantiate its long-standing continuance and health benefits.

CONCLUSION

There is ample data about the health effects of HAP, with some benefit with IC intervention for elevated blood pressure, dyspnea symptoms, mutagenicity and cardiovascular diseases. IC does not have any benefit in pregnancy outcomes or children health.

Perceptions of Health and Illness: A Qualitative Study of Jordanian Mothers

PURPOSE

To explore: 1) the perceptions of Jordanian mothers of their children's health and illness; and 2) the strategies of Jordanian mothers regarding disease prevention and health promotion.

DESIGN AND METHODS

A qualitative descriptive design was used to select a sample of Jordanian mothers (n = 20) of children aged 6 to12 years. Semi-structured interviews generated data to which thematic analysis was applied.

RESULTS

Four central themes emerged for Jordanian mothers' perceptions of their children's health and illness: physical, functional, wellbeing, and coping. Mothers used a variety of biomedical and psychosocial strategies for health promotion and disease prevention for their children.

CONCLUSION

Jordanian mothers' perceptions of health and illness were multidimensional. Mothers used positive strategies to prevent disease and promote the health of their children. The mothers overlooked some important aspects related to promoting children's health, such as minimizing the harm from tobacco and the importance of regular dental checkups.

PRACTICE IMPLICATIONS

Community or school-based health programs that target both children and their parents are needed to address the effect of smoking on children's health, highlight the importance of oral hygiene and regular dental checkups, and emphasize the role of exercise and healthy nutrition on children's health.

Household environment and symptoms of childhood acute respiratory tract infections in Nigeria, 2003-2013: a decade of progress and stagnation

BACKGROUND

Acute respiratory infections (ARIs) remains a disease of public health importance in Nigeria. Though, previous studies have identified factors associated with childhood ARI symptoms, the progress made in reducing the burden of this major childhood morbidity in the past decade in Nigeria has not been quantified. Therefore, this study describes the trends in the prevalence and factors associated with ARI symptoms among under-five (U5) children in Nigeria between years 2003 and 2013.

METHODS

A retrospective cross-sectional analysis of nationally representative data from the Nigeria Demographic and Health Surveys (NDHS) for years 2003, 2008 and 2013 was done. The study sample included women of reproductive age who had U5 children presenting with a cough accompanied with short rapid breaths in the last 2 weeks prior data collection. Data were analysed using complementary log regression model.

RESULTS

Prevalence of ARI symptoms were 10.3, 4.6 and 3.8% for years 2003, 2008 and 2013 respectively. The use of unclean cooking fuel was not associated with ARI symptom in 2003 and 2008, but in 2013 (OR = 2.50, CI: 1.16-5.42). Living in houses built with poor quality materials was associated with higher risk of ARI symptoms in 2008 (OR = 1.34, CI: 1.11-1.61) and 2013 (OR = 1.59, CI: 1.32-1.93). Higher risk of ARI symptoms was also associated with younger child's age, Northern regions and household wealth quintile between 2003 and 2013.

CONCLUSIONS

Though there has been a significant progress in the reduction of the prevalence of ARI symptoms between 2003 and 2013, the same could not be said of household environmental risk factors. Interventions to reduce the contributory effects of these factors to the occurrence of ARI symptoms should be instituted by government and other relevant stakeholders.

Correlates of domestic violence experience among recently-married women residing in slums in Pune, India

The high risk of experiencing domestic violence (DV) among married women in India who reside in slum communities underscores the need for effective, evidence-based, and culturally-tailored primary prevention. To inform such DV primary prevention strategies for this population, we herein aimed to identify correlates of DV experience in early marriage. Utilizing a cross-sectional design, potential correlates of DV experience were explored among a geographically-clustered random sample of 100 recently-married women residing in slums in Pune, India. In multivariable regression, DV experience was associated with less educational attainment by the participant’s spouse (standardized β = -0.281, p = 0.004), less satisfaction of the spouse’s family with the maanpaan (wedding-related gifts provided by the bride’s family) they received at the time of marriage (standardized β = -0.298, p<0.001), poorer conflict negotiation skills (standardized β = -0.308, p<0.001), and greater acknowledgement of DV occurrence in family and friends (standardized β = 0.436, p<0.001). These correlates suggest strategies that could be incorporated into future DV primary prevention interventions for this vulnerable population (i.e. promoting completion of formal education of boys alongside girls, mitigating causes of familial dowry harassment, improving conflict negotiation skills, and challenging norms surrounding DV).

Attributable risk and potential impact of interventions to reduce household air pollution associated with under-five mortality in South Asia

BACKGROUND

Solid fuel use is the major source of household air pollution (HAP) and accounts for a substantial burden of morbidity and mortality in low and middle income countries. To evaluate and compare childhood mortality attributable to HAP in four South Asian countries.

METHODS

A series of Demographic and Health Survey (DHS) datasets for Bangladesh, India, Nepal and Pakistan were used for analysis. Estimates of relative risk and exposure prevalence relating to use of cooking fuel and under-five mortality were used to calculate population attributable fractions (PAFs) for each country. Potential impact fractions (PIFs) were also calculated assessing theoretical scenarios based on published interventions aiming to reduce exposure prevalence.

RESULTS

There are an increased risk of under-five mortality in those exposed to cooking fuel compared to those not exposed in the four South Asian countries (OR = 1.30, 95% CI = 1.07-1.57, P = 0.007). Combined PAF estimates for South Asia found that 66% (95% CI: 43.1-81.5%) of the 13,290 estimated cases of under-five mortality was attributable to HAP. Joint PIF estimates (assuming achievable reductions in HAP reported in intervention studies conducted in South Asia) indicates 47% of neonatal and 43% of under-five mortality cases associated with HAP could be avoidable in the four South Asian countries studied.

CONCLUSIONS

Elimination of exposure to use of cooking fuel in the household targeting valuable intervention strategies (such as cooking in separate kitchen, improved cook stoves) could reduce substantially under-five mortality in South Asian countries.

Neonatal, infant and under-five mortalities in Nigeria: An examination of trends and drivers (2003-2013)

Neonatal (NMR), infant (IMR) and under-five (U5M) mortality rates remain high in Nigeria. Evidence-based knowledge of trends and drivers of child mortality will aid proper interventions needed to combat the menace. Therefore, this study assessed the trends and drivers of NMR, IMR, and U5M over a decade in Nigeria. A nationally representative data from three consecutive Nigeria Demographic and Household Surveys (NDHS) was used. A total of 66,158 live births within the five years preceding the 2003 (6029), 2008 (28647) and 2013 (31482) NDHS were included in the analyses. NMR was computed using proportions while IMR and U5 were computed using life table techniques embedded in Stata version 12. Probit regression model and its associated marginal effects were used to identify the predisposing factors to NMR, IMR, and U5M. The NMR, IMR, and U5M per 1000 live births in 2003, 2008 and 2013 were 52, 41, 39; 100, 75, 69; and 201, 157, 128 respectively. The NMR, IMR, and U5M were consistently lower among children whose mothers were younger, living in rural areas and from richer households. Generally, the probability of neonate death in 2003, 2008 and 2013 were 0.049, 0.039 and 0.038 respectively, the probability of infant death was 0.093, 0.071 and 0.064 while the probability of under-five death was 0.140, 0.112 and 0.092 for the respective survey years. While adjusting for other variables, the likelihood of infant and under-five deaths was significantly reduced across the survey years. Maternal age, mothers' education, place of residence, child's sex, birth interval, weight at birth, skill of birth attendant, delivery by caesarean operation or not significantly influenced NMR, IMR, and U5M. The NMR, IMR, and U5M in Nigeria reduced over the studied period. Multi-sectoral interventions targeted towards the identified drivers should be instituted to improve child survival.

Household air pollution from use of cooking fuel and under-five mortality: The role of breastfeeding status and kitchen location in Pakistan

Household air pollution (HAP) mainly from cooking fuel is one of the major causes of respiratory illness and deaths among young children in low and middle-income countries like Pakistan. This study investigates for the first time the association between HAP from cooking fuel and under-five mortality using the 2013 Pakistan Demographic and Health Survey (PDHS) data. Multi-level logistic regression models were used to examine the association between HAP and under-five mortality in a total of 11,507 living children across four age-groups (neonatal aged 0-28 days, post-neonatal aged 1-11 months, child aged 12-59 months and under-five aged 0-59 months). Use of cooking fuel was weakly associated with total under-five mortality (OR = 1.22, 95%CI = 0.92-1.64, P = 0.170), with stronger associations evident for sub-group analyses of children aged 12-59 months (OR = 1.98, 95%CI = 0.75-5.25, P = 0.169). Strong associations between use of cooking fuel and mortality were evident (ORs >5) in those aged 12-59 months for households without a separate kitchen using polluting fuels, and in children whose mother never breastfed. The results of this study suggest that HAP from cooking fuel is associated with a modest increase in the risk of death among children under five years of age in Pakistan, but particularly in those aged 12-59 months, and those living in poorer socioeconomic conditions. To reduce exposure to cooking fuel which is a preventable determinant of under-five mortality in Pakistan, the challenge remains to promote behavioural interventions such as breastfeeding in infancy period, keeping young children away from the cooking area, and improvements in housing and kitchen design.

Housing materials as predictors of under-five mortality in Nigeria: evidence from 2013 demographic and health survey

BACKGROUND

Nigeria is among countries with high Under-Five Mortality (U5M) rates worldwide. Both maternal and childhood factors have been linked to U5M in the country. However, despite the growing global recognition of the association between housing and quality of life, the role of housing materials as predictors of U5M remain largely unexplored in Nigeria. This study, therefore, investigated the relationship between housing materials and U5M in Nigeria.

METHODS

The study utilised the 2013 Nigeria Demographic and Health Survey data. A representative sample of 40,680 households was selected for the survey. The sample included 18,516 women of reproductive age who had given birth in the past 5 years prior the survey; with attention on the survival status of the index child (the most recent delivery). Data were analysed using descriptive statistics, Chi-square, Cox-proportional hazard and Brass 2-parameter models (α = 0.05).

RESULTS

The hazard ratio of U5M was 1.46 (C.I = 1.02-1.47, p < 0.001) and 1.23 (C.I = 1.24-1.71, p < 0.001) higher among children who lived in houses built with inadequate and moderate housing materials respectively than those in good housing materials. Under-five deaths show a downward trend (slope = -0.4871) relative to the housing materials assessment score. The refined U5M rate was 143.5, 127.0 and 90.8 per 1000 live birth among women who live in houses built with inadequate, moderate and adequate housing materials respectively. Other predictors of U5M were; the size of the child at birth, preceding birth interval, prenatal care provider, residence and education. Under-five death reduces with increasing maternal level of; education, wealth quintile, media exposure and housing material type and mostly experienced by Muslim women (6.0%), rural women (6.5%) and women residence in the North-West geopolitical zones (6.9%).

CONCLUSIONS

Living in houses built with poor housing materials promoted U5M in Nigeria. Provision of sustainable housing by the government and the maintenance of existing housing stock to healthful conditions will play a significant role in reducing the burden of U5M in Nigeria.

Independent and combined effects of maternal smoking and solid fuel on infant and child mortality in sub-Saharan Africa

OBJECTIVE

To estimate the independent and combined risks of infant and child mortality associated with maternal smoking and use of solid fuel in sub-Saharan Africa.

METHODS

Pooled weighted data on 143 602 under-five children in the most recent demographic and health surveys for 15 sub-Saharan African countries were analysed. The synthetic cohort life table technique and Cox proportional hazard models were employed to investigate the effect of maternal smoking and solid cooking fuel on infant (age 0-11 months) and child (age 12-59 months) mortality. Socio-economic and other confounding variables were included as controls.

RESULTS

The distribution of the main explanatory variable in households was as follows: smoking + solid fuel - 4.6%; smoking + non-solid fuel - 0.22%; no smoking + solid fuel - 86.9%; and no smoking + non-solid fuel - 8.2%. The highest infant mortality rate was recorded among children exposed to maternal smoking + solid fuel (72 per 1000 live births); the child mortality rate was estimated to be 54 per 1000 for this group. In full multivariate models, the risk of infant death was 71% higher among those exposed to maternal smoking + solid fuel (HR = 1.71, CI: 1.29-2.28). For ages 12 to 59 months, the risk of death was 99% higher (HR = 1.99, CI: 1.28-3.08).

CONCLUSIONS

Combined exposures to cigarette smoke and solid fuel increase the risks of infant and child mortality. Mothers of under-five children need to be educated about the danger of smoking while innovative approaches are needed to reduce the mortality risks associated with solid cooking fuel.

Household air pollution and under-five mortality in India (1992-2006)

BACKGROUND

Household air pollution (HAP) - predominantly from cooking fuel is a major public health hazard and one of the leading causes of respiratory illness and deaths among children under-five years in India. This study investigates the association between HAP from cooking fuel and under-five mortality using India's National Family and Health Survey (NFHS) datasets over the period 1992-2006 (total of 166,382 children), and the extent to which the association differed by environmental and behavioral factors affecting level of exposure.

METHODS

The association between HAP and under-five mortality of three age-groups (neonatal age between 0-28 days, post-neonatal age between 1-11 months and children aged between 12-59 months) was examined using multi-level logistic regression models.

RESULTS

HAP was associated with mortality among children aged under-five (OR = 1.30, 95%CI = 1.18-1.43, P < 0.001) and was more strongly associated in sub-group analyses of post-neonatal mortality (OR = 1.42, 95%CI = 1.19-1.71, P < 0.001) and child mortality (OR = 1.42, 95%CI = 1.05-1.91, P = 0.021) than neonatal mortality (OR = 1.23, 95%CI = 1.09-1.39, P = 0.001). The association was stronger for households in rural areas and for households without a separate kitchen using polluting fuel, and in women who had never breastfed for all age-groups.

CONCLUSION

Use of cooking fuel in the household is associated with increased risk of mortality in children aged under-five years. Factors relating to access to clean fuels, improvements in infrastructure and household design and behavioral factors are discussed, and can result in further declines in under-five mortality in India.

The Development and Validation of the Indian Family Violence and Control Scale

The high prevalence of domestic violence (DV) among married women in India and associated negative health repercussions highlight the need for effective prevention strategies and tools to measure the efficacy of such interventions. Literature supporting differing manifestations of DV by culture underscores the need for a culturally-tailored scale to more effectively measure DV in the Indian context. We therefore aimed to develop and validate such a tool, the Indian Family Violence and Control Scale (IFVCS), through a mixed-methods study. The psychometric development of IFVCS is herein discussed. After field pre-testing and expert review, a 63-item questionnaire was administered to a random sample of 630 married women from May-July 2013 in Pune, India. The item response theory approach for binary data to explore the IFVCS structure suggested that IFVCS is reliable, with the majority of items having high (>0.5) and significant factor loadings. Concurrent validity, assessed by comparing responses to IFVCS with the validated, abridged Conflict Tactics Scale-2, was high (r = 0.899, p<0.001) as was the construct validity, demonstrated by its significant association with several established DV correlates. Therefore, initial assessment of the IFVCS psychometric properties suggests that it is an effective tool for measuring DV among married women in India and speaks to its capacity for enhancing understanding of DV epidemiology and for evaluating the effectiveness of future DV interventions.

Household Air Pollution and Under-Five Mortality in Bangladesh (2004-2011)

Household air pollution (HAP) is one of the leading causes of respiratory illness and deaths among children under five years in Bangladesh. This study investigates the association between HAP from cooking fuel and under-five mortality using Bangladesh Demographic and Health Survey (BDHS) datasets over the period 2004–2011 (n = 18,308 children), and the extent to which this association differed by environmental and behavioral factors affecting level of exposure. The association between HAP and neonatal (age between 0–28 days), infant (age between 0 and 11 months) and under–five (age between 0 and 59 months) mortality was examined using multilevel logistic regression models. HAP was not strongly associated with overall neonatal (OR = 1.49, 95% CI = 1.01–2.22, p = 0.043), infant (OR = 1.27, 95% CI = 0.91–1.77, p = 0.157) or under-five mortality (OR = 1.14, 95% CI = 0.83–1.55, p = 0.422) in the context of overall decreasing trends in under-five mortality. The association was stronger for households with an indoor kitchen using polluting fuels, and in women who had never breastfed. Reductions in exposure to pollution from cooking fuel, given it is a ubiquitous and modifiable risk factor, can result in further declines in under-five mortality with household design and behavioural interventions.

Consequences of household air pollution on child survival: evidence from demographic and health surveys in 47 countries

BACKGROUND

Over one-third of the world's population is exposed to household air pollution (HAP) but the separate effects of cooking with solid fuel and kerosene on childhood mortality are unclear.

OBJECTIVES

To evaluate the effects of both solid fuels and kerosene on neonatal (0-28 days) and child (29 days-59 months) mortality.

METHODS

We used Demographic and Health Surveys from 47 countries and calculated adjusted relative risks (aRR) using Poisson regression models.

RESULTS

The aRR of neonatal and child mortality in households exposed to solid fuels were 1.24 (95% CI: 1.14, 1.34) and 1.21 (95% CI: 1.12, 1.30), respectively, and the aRR for neonatal and child mortality in households exposed to kerosene were 1.34 (95% CI: 1.18, 1.52) and 1.12 (95% CI: 0.99, 1.27), controlling for individual, household, and country-level predictors of mortality.

CONCLUSIONS

Kerosene should not be classified as a clean fuel. Neonates are at risk for mortality from exposure to solid fuels and kerosene.

How well does the World Health Organization definition of domestic violence work for India?

Domestic violence (DV) is reported by 40% of married women in India and associated with substantial morbidity. An operational research definition is therefore needed to enhance understanding of DV epidemiology in India and inform DV interventions and measures. To arrive at a culturally-tailored definition, we aimed to better understand how definitions provided by the World Health Organization and the 2005 India Protection of Women from Domestic Violence Act match the perceptions of behaviors constituting DV among the Indian community. Between September 2012 and January 2013, 16 key informant interviews with experts in DV and family counseling and 2 gender-concordant focus groups of lay community members were conducted in Pune, India to understand community perceptions of the definition of DV, perpetrators of DV, and examples of DV encountered by married women in Pune, India. Several key themes emerged regarding behaviors and acts constituting DV including 1) the exertion of control over a woman's reproductive decision-making, mobility, socializing with family and friends, finances, and access to food and nutrition, 2) the widespread acceptance of sexual abuse and the influences of affluence on sexual DV manifestations, 3) the shaping of physical abuse experiences by readily-available tools and the presence of witnesses, 4) psychological abuse for infertility, dowry, and girl-children, and 5) the perpetration of DV by the husband and other members of his family. Findings support the need for a culturally-tailored operational definition that expands on the WHO surveillance definition to inform the development of more effective DV intervention strategies and measures.

The effect of solid fuel use on childhood mortality in Nigeria: evidence from the 2013 cross-sectional household survey

BACKGROUND

In Nigeria, approximately 69% of households use solid fuels as their primary source of domestic energy for cooking. These fuels produce high levels of indoor air pollution. This study aimed to determine whether Nigerian children residing in households using solid fuels at <5 years of age were at higher risk of death.

METHODS

The 2013 Nigeria Demographic and Health Survey data were analysed in Cox regression analyses to examine the effects of solid fuel use on deaths of children aged 0-28 days (neonatal), 1-11 months (post-neonatal), and 12-59 months (child).

RESULTS

The results indicated that approximately 0.8% of neonatal deaths, 42.9% of post-neonatal deaths, and 36.3% of child deaths could be attributed to use of solid fuels. The multivariable analyses found that use of solid fuel was associated with post-neonatal mortality (hazard ratio [HR] =1.92, 95% confidence interval [CI]: 1.42-2.58) and child mortality (HR = 1.63, CI: 1.09-2.42), but was not associated with neonatal mortality (HR = 1.01, CI: 0.73-1.26). Living in rural areas and poor households were associated with an increased risk of death during the three mortality periods.

CONCLUSION

Living in a rural area and poor households were strongly associated with an increased risk of a child > 1 to < 60 months dying due to use of solid fuels. The health effects of household use of solid fuels are a major public health threat that requires increased research and policy development efforts. Research should focus on populations in rural areas and low socioeconomic households so that child survival in Nigeria can be improved.

Intimate partner violence against women during and after pregnancy: a cross-sectional study in Mumbai slums

Background

At least one-third of women in India experience intimate partner violence (IPV) at some point in adulthood. Our objectives were to describe the prevalence of IPV during pregnancy and after delivery in an urban slum setting, to review its social determinants, and to explore its effects on maternal and newborn health.

Methods

We did a cross-sectional study nested within the data collection system for a concurrent trial. Through urban community surveillance, we identified births in 48 slum areas and interviewed mothers ~6 weeks later. After collecting information on demographic characteristics, socioeconomic indicators, and maternal and newborn care, we asked their opinions on the justifiability of IPV and on their experience of it in the last 12 months.

Results

Of 2139 respondents, 35% (748) said that violence was justifiable if a woman disrespected her in-laws or argued with her husband, failed to provide good food, housework and childcare, or went out without permission. 318 (15%, 95% CI 13, 16%) reported IPV in the year that included pregnancy and the postpartum period. Physical IPV was reported by 247 (12%, 95% CI 10, 13%), sexual IPV by 35 (2%, 95% CI 1, 2%), and emotional IPV by 167 (8%, 95% CI 7, 9). 219 (69%) women said that the likelihood of IPV was either unaffected by or increased during maternity. IPV was more likely to be reported by women from poorer families and when husbands used alcohol. Although 18% of women who had suffered physical IPV sought clinical care for their injuries, seeking help from organizations outside the family to address IPV itself was rare. Women who reported IPV were more likely to have reported illness during pregnancy and use of modern methods of family planning. They were more than twice as likely to say that there were situations in which violence was justifiable (odds ratio 2.6, 95% CI 1.7, 3.4).

Conclusions

One in seven women suffered IPV during or shortly after pregnancy. The elements of the violent milieu are mutually reinforcing and need to be taken into account collectively in responding to both individual cases and framing public health initiatives.

Determinants of better health: a cross-sectional assessment of positive deviants among women in West Bengal

Background

Rural women in West Bengal have been found to have low rates of formal education, poor health knowledge, high rates of malnutrition and anemia, and low levels of empowerment. Despite these difficult circumstances, some women have positive health outcomes compared to women with similarly disadvantaged backgrounds. The purpose of this study is to identify factors associated with positive health outcomes among women with primary education or less.

Methods

Multivariable regression models were built for outcomes of positive deviance to better characterize the factors in a woman’s life that most impact her ability to deviate from the status quo.

Results

Positive deviants in this context are shown to be women who are able to earn an income, who have access to information through media sources, and who, despite little schooling, have marginally higher levels of formal education that lead to improved health outcomes.

Conclusions

Study findings indicate that positive deviant women in disadvantaged circumstances can achieve positive outcomes amidst a host of contextual barriers that would predict poor health outcomes. Focusing on areas such as enhancing access to media sources, facilitating self-help groups for married women, and promoting prolonged education and delayed marriage for girls may improve health knowledge and behavior among married women with low levels of education.