Setting priorities for development of emerging interventions against childhood diarrhoea

Prevalence of drinking or eating more than usual and associated factors during childhood diarrhea in East Africa: a multilevel analysis of recent demographic and health survey

Background

Diarrhea is the second most common cause of death in under-five children. Fluid and food replacement during diarrheal episodes have a paramount effect to avert morbidity and mortality. However, there is limited information about feeding practices. This study aimed to assess the prevalence of drinking or eating more and associated factors during diarrhea among under-five children in East Africa using demographic and health surveys (DHSs).

Methods

Secondary data analysis was done on DHSs 2008 to 2018 in 12 East African Countries. Total weighted samples of 20,559 mothers with their under-five children were included. Data cleaning, coding, and analysis were performed using Stata 16. Multilevel binary logistic regression were performed to identify factors associated with drinking or eating more during diarrheal episodes. Adjusted Odds Ratio (AOR) with a 95% CI, and p-value < 0.05 were used to declare statistical significance.

Results

Prevalence of drinking or eating more than usual during diarrhea disease in East Africa was 26.27%(95% CI: 25.68–26.88). Mothers age > 35 years (AOR: 1.14, 95% CI: (1.03, 1.26), mothers primary education (AOR: 1.17, 95% CI: 1.06,1.28), secondary education (AOR: 1.43,95% CI: 1.27,1.61), and higher education (AOR: 1.42,95% CI: 1.11,1.81), occupation of mothers (agriculture, AOR: 2.2, 95% CI: 1.3–3.6), sales and services, AOR = 1.20, CI:1.07,1.34), manual, AOR =1.28,95% CI: 1.11,1.44), children age 1–2 years (AOR =1.34,95% CI: 1.22,1.46) and 3–4 years (AOR =1.36,95% CI: 1.20,1.55), four and more antenatal visits (AOR: 1.14,95% CI: 1.03,1.27), rich wealth status (AOR:1.27,95% CI: 1.16,1.40), birth in health facility (AOR = 1.19, 95%CI: 1.10, 1.30) and visit health facility (AOR = 1.12, 95%CI: 1.03, 1.22) were associated with drinking or eating more.

Conclusion

The prevalence of drinking or eating more is low in East Africa. Maternal age, occupation, antenatal care visit, marital status, educational status, wealth status, place of delivery, visiting health facility, and child age were significantly associated with drinking or eating more during diarrheal episodes. Health policy and programs should focus on educating mothers, improving the household wealth status, encouraging women to contact health facilities for better feeding practices of children during diarrheal episodes.

Setting global research priorities for private sector child health service delivery: Results from a CHNRI exercise

Background

The private health sector is an important source of sick child care, yet evidence gaps persist in best practices for integrated management of private sector child health services. Further, there is no prioritized research agenda to address these gaps. We used a Child Health and Nutrition Research Initiative (CHNRI) process to identify priority research questions in response to these evidence gaps. CHNRI is a consultative approach that entails prioritizing research questions by evaluating them against standardized criteria.

Methods

We engaged geographically and occupationally diverse experts in the private health sector and child health. Eighty-nine experts agreed to participate and provided 150 priority research questions. We consolidated submitted questions to reduce duplication into a final list of 50. We asked participants to complete an online survey to rank each question against 11 pre-determined criteria in four categories: (i) answerability, (ii) research feasibility, (iii) sustainability/equity, and (iv) importance/potential impact. Statistical data analysis was conducted in SAS 9.4 (SAS Institute Inc, Cary NC, USA). We weighted all 11 evaluation criteria equally to calculate the research priority score and average expert agreement for each question. We disaggregated results by location in high-income vs low- and middle-income countries.

Results

Forty-nine participants (55.1%) completed the online survey, including 33 high-income and 16 low- and middle-income country respondents. The top, prioritized research question asks whether accreditation or regulation of private clinical and non-clinical sources of care would improve integrated management of childhood illness services. Four of the top ten research priorities were related to adherence to case management protocols. Other top research priorities were related to training and supportive supervision, digital health, and infant and newborn care. Research priorities among high-income and low- and middle-income country respondents were highly correlated.

Conclusion

To our knowledge, this is the first systematic exercise conducted to define research priorities for the management of childhood illness in the private sector. The research priorities put forth in this CHNRI exercise aim to stimulate interest from policy makers, program managers, researchers, and donors to respond to and help close evidence gaps hindering the acceleration of reductions in child mortality through private sector approaches.

Assessment of Poor Home Management Practice of Diarrhea and Associated Factors among Caregivers of Under-Five Years Children in Urban and Rural Residents of Doba Woreda, Ethiopia: Comparative Cross-Sectional Study

Background

Diarrhea is the first cause of illness and the second cause of death in under-five children. Home interventions can prevent 57% of mortality related to diarrhea. However, malpractices were common and the reason for this underutilization was unclear. Thus, this study was aimed at assessing poor home management practice of Diarrhea and associated factors among caregivers of under-five years children in urban and rural residents.

Methods

The community-based comparative cross-sectional study was conducted in Doba woreda, Ethiopia, from February 25 to March 15, 2017. Multistage cluster sampling technique was used to study 559 caregivers. An interviewer administered pretested structured questionnaire was used to collect data. Collected data were entered into Epi Info version 3.5.1 and exported to statistical package for social sciences (SPSS) version 20.0 for analysis. The binary logistic regression model was used. In bivariate analysis p-value<0.25 was taken into multivariable analysis. Adjusted odds ratios with their corresponding 95% of CI were used to report results with a significance level of p-value<0.05.

Result

184 urban and 375 rural caregivers were included in the study. Poor home management practice was 55.8% of urban and 85.6% of rural residents. Knowledge level (AOR=2.7(CI[1.3, 6.5]) and AOR=13.4(CI[5.3, 34.0]) and difficulty in preparing oral rehydration salt (AOR=4.0CI[1.4, 11.0]) and AOR=2.4(1.3, 5.3)) were associated factors for both urban and rural residents, respectively. Caregivers of male index child (AOR=2.3(1.2, 4.7)) and age of the caregivers (AOR=0.26(0.09, 0.8)) were associated with poor home practice for urban residents. In rural residents, inaccessibility to zinc supplementation (AOR=2.4(1.2, 5.0)) was among associated factors.

Conclusion

Poor home management practice of diarrhea was high in both urban and rural residents. It was higher in rural compared to urban residents. Poor practice was associated with knowledge level, age of the caregivers, sex of the index child, and accessibility of zinc. Health education and community mobilization on home management of diarrhea are important to increase awareness and improve practice level.

Feeding Practice during Diarrheal Episode among Children Aged between 6 to 23 Months in Mirab Abaya District, Gamo Gofa Zone, Southern Ethiopia

Background

Diarrheal disease is one of the main causes of childhood malnutrition. In developing countries 30% of pediatric beds are occupied with children having diarrheal disease. Fluid replacement, continued feeding, and increasing appropriate fluid at home during the diarrhea episodes are the cornerstone of treatment package. The purpose of this study was to assess feeding practice during diarrheal episodes among children aged 6 to 23 months in Mirab Abaya district, Gamo Gofa Zone, South Ethiopia.

Methods

Community-based cross-sectional study design was conducted from February to March 2016 among children aged 6 to 23 months. A multistage sampling technique was used to select the study participants. A total of 661 participants were included in our study. Data were entered into Epi data version 3.1 and exported to SPSS 20.0 statistical software for analysis. Bivariate and multivariable analysis were done to assess factors associated with feeding practices during a diarrheal episode. Odds ratio with 95% CI was used to identify a statistically significant association between independent variables and feeding practice during diarrheal episode.

Result

The proportion of proper feeding practice during diarrheal episode was 467 (70.7%). Boy children were about 1.6 times [AOR; 1.62 (95%CI=1.04, 2.50)] more likely to receive increased food and fluid than girl children. Mothers who have one under-five child were 2 times [AOR 2.11 (95% CI =1. 38, 3.23)] more likely to have proper feeding practice during diarrheal episode as compared to those have two and more under-five children. The likelihood of increasing food and fluid during diarrheal episodes was 2 times [AOR 2.46 (95% CI=1. 55, 3.88)] higher among children from maternal age of 30-39 years than those from 20-29 years. Mothers who get information about feeding practices during diarrheal episodes were 2 times [AOR 2.19 (95% CI=1. 43, 3.36)] more likely to increase food and fluid to their child compared to their counterparts.

Conclusion

In this study educational status, number of antenatal care visits, sex, number of under-5 children, maternal age, and mothers information about feeding practice were independently associated with feeding practices during a diarrheal episode. Therefore, intensive intervention programme should focus on these determinants to reduce child mortality and morbidity and realize sustainable development goals.

Setting an implementation research agenda for Canadian investments in global maternal, newborn, child and adolescent health: a research prioritization exercise

BACKGROUND

Improving global maternal, newborn, child and adolescent health (MNCAH) is a top development priority in Canada, as shown by the $6.35 billion in pledges toward the Muskoka Initiative since 2010. To guide Canadian research investments, we aimed to systematically identify a set of implementation research priorities for MNCAH in low- and middle-income countries.

METHODS

We adapted the Child Health and Nutrition Research Initiative method. We scanned the Child Health and Nutrition Research Initiative literature and extracted research questions pertaining to delivery of interventions, inviting Canadian experts on MNCAH to generate additional questions. The experts scored a combined list of 97 questions against 5 criteria: answerability, feasibility, deliverability, impact and effect on equity. These questions were ranked using a research priority score, and the average expert agreement score was calculated for each question.

RESULTS

The overall research priority score ranged from 40.14 to 89.25, with a median of 71.84. The average expert agreement scores ranged from 0.51 to 0.82, with a median of 0.64. Highly-ranked research questions varied across the life course and focused on improving detection and care-seeking for childhood illnesses, overcoming barriers to intervention uptake and delivery, effectively implementing human resources and mobile technology, and increasing coverage among at-risk populations. Children were the most represented target population and most questions pertained to interventions delivered at the household or community level.

INTERPRETATION

Investing in implementation research is critical to achieving the Sustainable Development Goal of ensuring health and well-being for all. The proposed research agenda is expected to drive action and Canadian research investments to improve MNCAH.

Research Priorities on the Relationship between Wasting and Stunting

Background

Wasting and stunting are global public health problems that frequently co-exist. However, they are usually separated in terms of policy, guidance, programming and financing. Though both wasting and stunting are manifestations of undernutrition caused by disease and poor diet, there are critical gaps in our understanding of the physiological relationship between them, and how interventions for one may affect the other. The aim of this exercise was to establish research priorities in the relationships between wasting and stunting to guide future research investments.

Methods and Findings

We used the CHNRI (Child Health and Nutrition Research Initiative) methodology for setting research priorities in health. We utilised a group of experts in nutrition, growth and child health to prioritise 30 research questions against three criteria (answerability, usefulness and impact) using an online survey. Eighteen of 25 (72%) experts took part and prioritised research directly related to programming, particularly at the public health level. The highest-rated questions were: “Can interventions outside of the 1000 days, e.g. pre-school, school age and adolescence, lead to catch-up in height and in other developmental markers?”; “What timely interventions work to mitigate seasonal peaks in both wasting and stunting?”; and “What is the optimal formulation of ready-to-use foods to promote optimal ponderal growth and also support linear growth during and after recovery from severe acute malnutrition?” There was a high level of agreement between experts, particularly for the highest ranking questions.

Conclusions

Increased commitment to rigorous evaluations of treatment and prevention interventions at the public health level, addressing questions of the timing of intervention, and the extent to which impacts for both wasting and stunting can be achieved, is needed to inform global efforts to tackle undernutrition and its consequences.

Alberta Provincial Pediatric EnTeric Infection TEam (APPETITE): epidemiology, emerging organisms, and economics

Background

Each year in Canada there are 5 million episodes of acute gastroenteritis (AGE) with up to 70 % attributed to an unidentified pathogen. Moreover, 90 % of individuals with AGE do not seek care when ill, thus, burden of disease estimates are limited by under-diagnosing and under-reporting. Further, little is known about the pathogens causing AGE as the majority of episodes are attributed to an “unidentified” etiology. Our team has two main objectives: 1) to improve health through enhanced enteric pathogen identification; 2) to develop economic models incorporating pathogen burden and societal preferences to inform enteric vaccine decision making.

Methods/Design

This project involves multiple stages: 1) Molecular microbiology experts will participate in a modified Delphi process designed to define criteria to aid in interpreting positive molecular enteric pathogen test results. 2) Clinical data and specimens will be collected from children aged 0–18 years, with vomiting and/or diarrhea who seek medical care in emergency departments, primary care clinics and from those who contact a provincial medical advice line but who do not seek care. Samples to be collected will include stool, rectal swabs (N = 2), and an oral swab. Specimens will be tested employing 1) stool culture; 2) in-house multiplex (N = 5) viral polymerase chain reaction (PCR) panel; and 3) multi-target (N = 15) PCR commercially available array. All participants will have follow-up data collected 14 days later to enable calculation of a Modified Vesikari Scale score and a Burden of Disease Index. Specimens will also be collected from asymptomatic children during their well child vaccination visits to a provincial public health clinic. Following the completion of the initial phases, discrete choice experiments will be conducted to enable a better understanding of societal preferences for diagnostic testing and vaccine policy. All of the results obtained will be integrated into economic models.

Discussion

This study is collecting novel samples (e.g., oral swabs) from previously untested groups of children (e.g., those not seeking medical care) which are then undergoing extensive molecular testing to shed a new perspective on the epidemiology of AGE. The knowledge gained will provide the broadest understanding of the epidemiology of vomiting and diarrhea of children to date.

Recent advances in understanding the long-term sequelae of childhood infectious diarrhea

Worldwide, early childhood infectious diarrhea continues to be a significant concern. Diarrheal illness affects the world's youngest and most vulnerable citizens disproportionately. Estimates are that over 70 % of deaths from diarrhea occur in people younger than 24 months of age. Diarrhea and environmental enteropathy have been associated with growth failure and stunting. In addition, the burden of enteric disease also leads to cognitive and academic losses, thus resulting in loss of human capital and economic productivity. While considerable progress has been made on preventing and treating childhood diarrheal illness, the mortality and morbidity still remain unacceptably high. This paper reviews recent (mainly from 2013) publications surrounding the global burden of childhood diarrhea and the implications for long-term sequelae.

Interventions to address deaths from childhood pneumonia and diarrhoea equitably: what works and at what cost?

Global mortality in children younger than 5 years has fallen substantially in the past two decades from more than 12 million in 1990, to 6·9 million in 2011, but progress is inconsistent between countries. Pneumonia and diarrhoea are the two leading causes of death in this age group and have overlapping risk factors. Several interventions can effectively address these problems, but are not available to those in need. We systematically reviewed evidence showing the effectiveness of various potential preventive and therapeutic interventions against childhood diarrhoea and pneumonia, and relevant delivery strategies. We used the Lives Saved Tool model to assess the effect on mortality when these interventions are applied. We estimate that if implemented at present annual rates of increase in each of the 75 Countdown countries, these interventions and packages of care could save 54% of diarrhoea and 51% of pneumonia deaths by 2025 at a cost of US$3·8 billion. However, if coverage of these key evidence-based interventions were scaled up to at least 80%, and that for immunisations to at least 90%, 95% of diarrhoea and 67% of pneumonia deaths in children younger than 5 years could be eliminated by 2025 at a cost of $6·715 billion. New delivery platforms could promote equitable access and community platforms are important catalysts in this respect. Furthermore, several of these interventions could reduce morbidity and overall burden of disease, with possible benefits for developmental outcomes.