Statistical modelling of determinants of child stunting using secondary data and Bayesian networks: a UKRI Global Challenges Research Fund (GCRF) Action Against Stunting Hub protocol paper

INTRODUCTION

Several factors have been implicated in child stunting, but the precise determinants, mechanisms of action and causal pathways remain poorly understood. The objective of this study is to explore causal relationships between the various determinants of child stunting.

METHODS AND ANALYSIS

The study will use data compiled from national health surveys in India, Indonesia and Senegal, and reviews of published evidence on determinants of child stunting. The data will be analysed using a causal Bayesian network (BN)-an approach suitable for modelling interdependent networks of causal relationships. The model's structure will be defined in a directed acyclic graph and illustrate causal relationship between the variables (determinants) and outcome (child stunting). Conditional probability distributions will be generated to show the strength of direct causality between variables and outcome. BN will provide evidence of the causal role of the various determinants of child stunning, identify evidence gaps and support in-depth interrogation of the evidence base. Furthermore, the method will support integration of expert opinion/assumptions, allowing for inclusion of the many factors implicated in child stunting. The development of the BN model and its outputs will represent an ideal opportunity for transdisciplinary research on the determinants of stunting.

ETHICS AND DISSEMINATION

Not applicable/no human participants included.

Whole of government approaches to accelerate adolescent success: efficiency and financing considerations

The multiple domains of development covered by the Sustainable Development Goals (SDGs) present a practical challenge for governments. This is particularly acute in highly resource-constrained settings which use a sector-by-sector approach to structure financing and prioritization. One potentially under-prioritized solution is to implement interventions with the potential to simultaneously improve multiple outcomes across sectors, what United Nations Development Programme refer to as development 'accelerators'. An increasing number of accelerators are being identified in the literature. There are, however, challenges associated with the evaluation and implementation of accelerators. First, as accelerators have multiple benefits, possibly in different sectors, they will be undervalued if the priority setting is conducted sector-by-sector. Second, even if their value is recognized, accelerators may not be adopted if doing so clashes with any of the multiple competing interests policymakers consider, of which efficiency/social desirability is but one. To illustrate the first challenge, and outline a possible solution, we conduct a cost-effectiveness analysis comparing the implementation of three sector-specific interventions to an accelerator, first using a sector-by-sector planning perspective, then a whole of government approach. The case study demonstrates how evaluating the cost-effectiveness of interventions sector-by-sector can lead to suboptimal efficiency rankings and overlook interventions that are efficient from a whole of government perspective. We then examine why recommendations based on a whole of government approach to evaluation are unlikely to be heeded. To overcome this second challenge, we outline a menu of existing and novel financing mechanisms that aim to address the mismatch between political incentives and logistical constraints in the priority setting and the economic evaluation evidence for cost-effective accelerators. These approaches to financing accelerators have the potential to improve efficiency, and in doing so, progress towards the SDGs, by aligning political incentives more closely with recommendations based on efficiency rankings.

Home learning environments and children's language and literacy skills: A meta-analytic review of studies conducted in low- and middle-income countries

A robust finding from research in high-income countries is that children living in resource-poor homes are vulnerable to difficulties with language and literacy but less is known about this association in low- and middle-income (LMI) countries. We present a meta-analysis of 6,678 correlations from studies in 43 LMI countries. Overall, the results indicate a small but significant association (r = .08) between home language and literacy environment and children's language and literacy skills. After examining a range of moderators, adult literacy practices and books-at-home had a significantly larger association with children's language and literacy skills than did home tutoring. Studies using customized measures demonstrated a more marked association between home attributes and children's outcomes (r = .14) than studies using a common measure across multiple sites (r = .06). Published studies showed significantly larger associations than unpublished studies, and countries with greater income inequality showed a larger association than relatively egalitarian societies. We conclude that the small overall association should not be taken as support for the absence of, or a vanishingly small relationship between the home learning environment and children's language and literacy skills in LMI countries. Rather, an important factor in detecting this relationship is that assessments must better reflect the nature of homes in different cultures to capture true variation in the population. Such contextually situated measurement would lead to an inclusive conceptualization of home learning environments and can better inform intervention programs to enhance children's educational success, a critical target for many LMI countries. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Different Instruments, Same Content? A Systematic Comparison of Child Maltreatment and Harsh Parenting Instruments

Child maltreatment and harsh parenting both include harmful actions by parents toward children that are physical (e.g., spanking, slapping) or emotional (e.g., threatening, yelling). The distinction between these two constructs, in meaning and measurement, is often unclear, leading to inconsistent research and policy. This study systematically identified, reviewed, and compared parent-reported child maltreatment (N = 7) and harsh parenting (N = 18) instruments. The overlap in parenting behaviors was 73%. All physical behaviors that were measured in harsh parenting instruments (e.g., spanking, beating up) were also measured in child maltreatment instruments. Unique physical behaviors measured in maltreatment instruments include twisting body parts and choking. All emotional behaviors in maltreatment instruments were included in harsh parenting instruments, and vice versa. Our findings suggest similar, but not identical, operationalizations of child maltreatment and harsh parenting. Our findings can help guide discussions on definitions, operationalizations, and their consequences for research on violence against children.

Research evaluating the effectiveness of dementia interventions in low- and middle-income countries: A systematic mapping of 340 randomised controlled trials

OBJECTIVES

More people with dementia live in low- and middle-income countries (LMICs) than in high-income countries, but best-practice care recommendations are often based on studies from high-income countries. We aimed to map the available evidence on dementia interventions in LMICs.

METHODS

We systematically mapped available evidence on interventions that aimed to improve the lives of people with dementia or mild cognitive impairment (MCI) and/or their carers in LMICs (registered on PROSPERO: CRD42018106206). We included randomised controlled trials (RCTs) published between 2008 and 2018. We searched 11 electronic academic and grey literature databases (MEDLINE, EMBASE, PsycINFO, CINAHL Plus, Global Health, World Health Organization Global Index Medicus, Virtual Health Library, Cochrane CENTRAL, Social Care Online, BASE, MODEM Toolkit) and examined the number and characteristics of RCTs according to intervention type. We used the Cochrane risk of bias 2.0 tool to assess the risk of bias.

RESULTS

We included 340 RCTs with 29,882 (median, 68) participants, published 2008-2018. Over two-thirds of the studies were conducted in China (n = 237, 69.7%). Ten LMICs accounted for 95.9% of included RCTs. The largest category of interventions was Traditional Chinese Medicine (n = 149, 43.8%), followed by Western medicine pharmaceuticals (n = 109, 32.1%), supplements (n = 43, 12.6%), and structured therapeutic psychosocial interventions (n = 37, 10.9%). Overall risk of bias was judged to be high for 201 RCTs (59.1%), moderate for 136 (40.0%), and low for 3 (0.9%).

CONCLUSIONS

Evidence-generation on interventions for people with dementia or MCI and/or their carers in LMICs is concentrated in just a few countries, with no RCTs reported in the vast majority of LMICs. The body of evidence is skewed towards selected interventions and overall subject to high risk of bias. There is a need for a more coordinated approach to robust evidence-generation for LMICs.

Reducing dementia-related stigma and discrimination among community health workers in Brazil: protocol for a randomised controlled feasibility trial

INTRODUCTION

Stigma and discrimination among healthcare workers can hinder diagnosis and the provision of appropriate care in dementia. This study is aimed at developing, delivering and evaluating the feasibility of a group antistigma intervention to improve knowledge, attitudes and behaviours in relation to people living with dementia among community health workers (CHWs).

METHODS AND ANALYSIS

This will be a randomised controlled feasibility trial conducted with 150 CHWs from 14 primary care units (PCUs) in São Paulo, Brazil. PCUs will be randomly allocated (1:1) in two parallel groups-experimental group or control group. Participants from PCUs allocated to the experimental group will receive a 3-day group intervention involving audio-visual and printed materials as well as elements of social contact. The control group will keep their usual routine. Knowledge, attitude and intended behaviour stigma-based outcomes will be assessed at baseline and at follow-up (30 days after intervention) to both groups, with additional questions on feasibility for the experimental group at follow-up. Around 10-15 participants will take part in follow-up semistructured interviews to further explore feasibility. Quantitative analyses will follow an 'intention to treat' approach. Qualitative data will be analysed using content analysis.

ETHICS AND DISSEMINATION

This study was approved by the National Commission for Ethics in Research in Brazil (n. 5.510.113). Every participant will sign a consent form. Results will be disseminated through academic journals and events related to dementia. The intervention materials will be made available online.

Beyond growth and density: Recentring the demographic drivers of urban health and risk in the global south

Debates within urban studies concerning the relationship between urbanisation and infectious disease focus on issues of urban population growth, density, migration and connectivity. However, an effective long-term risk and wellbeing agenda, without which the threat of future pandemics cannot be mitigated, must also take account of demographic forces and changes as critical drivers of transmission and mortality risk within and beyond cities. A better understanding of the dynamics of fertility, mortality and changing age structures – key determinants of urban decline/growth in addition to migration – provides the foundation upon which healthier cities and a healthy global urban system can be developed. The study of how basic demographic attributes and trends are distributed in space and how they interact with risks, including those of infectious disease, must be incorporated as a priority into a post-COVID-19 urban public health agenda. This perspective concurs with recent debates in urban studies emphasising the demographic drivers of urban change. Moreover, it raises critical questions about the microbial and environmental emphasis of much research on the interface of urban health and governance.

Evaluating the dissemination and scale-up of two evidence-based parenting interventions to reduce violence against children: study protocol

Background

Eliminating violence against children is a prominent policy goal, codified in the Sustainable Development Goals, and parenting programs are one approach to preventing and reducing violence. However, we know relatively little about dissemination and scale-up of parenting programs, particularly in low- and middle-income countries (LMICs). The scale-up of two parenting programs, Parenting for Lifelong Health (PLH) for Young Children and PLH for Parents and Teens, developed under Creative Commons licensing and tested in randomized trials, provides a unique opportunity to study their dissemination in 25 LMICs.

Methods

The Scale-Up of Parenting Evaluation Research (SUPER) study uses a range of methods to study the dissemination of these two programs. The study will examine (1) process and extent of dissemination and scale-up, (2) how the programs are implemented and factors associated with variation in implementation, (3) violence against children and family outcomes before and after program implementation, (4) barriers and facilitators to sustained program delivery, and (5) costs and resources needed for implementation.Primary data collection, focused on three case study projects, will include interviews and focus groups with program facilitators, coordinators, funders, and other stakeholders, and a summary of key organizational characteristics. Program reports and budgets will be reviewed as part of relevant contextual information. Secondary data analysis of routine data collected within ongoing implementation and existing research studies will explore family enrolment and attendance, as well as family reports of parenting practices, violence against children, child behavior, and child and caregiver wellbeing before and after program participation. We will also examine data on staff sociodemographic and professional background, and their competent adherence to the program, collected as part of staff training and certification.

Discussion

This project will be the first study of its kind to draw on multiple data sources and methods to examine the dissemination and scale-up of a parenting program across multiple LMIC contexts. While this study reports on the implementation of two specific parenting programs, we anticipate that our findings will be of relevance across the field of parenting, as well as other violence prevention and social programs.

Violence prevention accelerators for children and adolescents in South Africa: A path analysis using two pooled cohorts

BACKGROUND

The INSPIRE framework was developed by 10 global agencies as the first global package for preventing and responding to violence against children. The framework includes seven complementary strategies. Delivering all seven strategies is a challenge in resource-limited contexts. Consequently, governments are requesting additional evidence to inform which 'accelerator' provisions can simultaneously reduce multiple types of violence against children.

METHODS AND FINDINGS

We pooled data from two prospective South African adolescent cohorts including Young Carers (2010-2012) and Mzantsi Wakho (2014-2017). The combined sample size was 5,034 adolescents. Each cohort measured six self-reported violence outcomes (sexual abuse, transactional sexual exploitation, physical abuse, emotional abuse, community violence victimisation, and youth lawbreaking) and seven self-reported INSPIRE-aligned protective factors (positive parenting, parental monitoring and supervision, food security at home, basic economic security at home, free schooling, free school meals, and abuse response services). Associations between hypothesised protective factors and violence outcomes were estimated jointly in a sex-stratified multivariate path model, controlling for baseline outcomes and socio-demographics and correcting for multiple-hypothesis testing using the Benjamini-Hochberg procedure. We calculated adjusted probability estimates conditional on the presence of no, one, or all protective factors significantly associated with reduced odds of at least three forms of violence in the path model. Adjusted risk differences (ARDs) and adjusted risk ratios (ARRs) with 95% confidence intervals (CIs) were also calculated. The sample mean age was 13.54 years, and 56.62% were female. There was 4% loss to follow-up. Positive parenting, parental monitoring and supervision, and food security at home were each associated with lower odds of three or more violence outcomes (p < 0.05). For girls, the adjusted probability of violence outcomes was estimated to be lower if all three of these factors were present, as compared to none of them: sexual abuse, 5.38% and 1.64% (ARD: -3.74% points, 95% CI -5.31 to -2.16, p < 0.001); transactional sexual exploitation, 10.07% and 4.84% (ARD: -5.23% points, 95% CI -7.26 to -3.20, p < 0.001); physical abuse, 38.58% and 23.85% (ARD: -14.72% points, 95% CI -19.11 to -10.33, p < 0.001); emotional abuse, 25.39% and 12.98% (ARD: -12.41% points, 95% CI -16.00 to -8.83, p < 0.001); community violence victimisation, 36.25% and 28.37% (ARD: -7.87% points, 95% CI -11.98 to -3.76, p < 0.001); and youth lawbreaking, 18.90% and 11.61% (ARD: -7.30% points, 95% CI -10.50 to -4.09, p < 0.001). For boys, the adjusted probability of violence outcomes was also estimated to be lower if all three factors were present, as compared to none of them: sexual abuse, 2.39% to 1.80% (ARD: -0.59% points, 95% CI -2.24 to 1.05, p = 0.482); transactional sexual exploitation, 6.97% to 4.55% (ARD: -2.42% points, 95% CI -4.77 to -0.08, p = 0.043); physical abuse from 37.19% to 25.44% (ARD: -11.74% points, 95% CI -16.91 to -6.58, p < 0.001); emotional abuse from 23.72% to 10.72% (ARD: -13.00% points, 95% CI -17.04 to -8.95, p < 0.001); community violence victimisation from 41.28% to 35.41% (ARD: -5.87% points, 95% CI -10.98 to -0.75, p = 0.025); and youth lawbreaking from 22.44% to 14.98% (ARD -7.46% points, 95% CI -11.57 to -3.35, p < 0.001). Key limitations were risk of residual confounding and not having information on protective factors related to all seven INSPIRE strategies.

CONCLUSION

In this cohort study, we found that positive and supervisory caregiving and food security at home are associated with reduced risk of multiple forms of violence against children. The presence of all three of these factors may be linked to greater risk reduction as compared to the presence of one or none of these factors. Policies promoting action on positive and supervisory caregiving and food security at home are likely to support further efficiencies in the delivery of INSPIRE.