Determinants of child survival in Ghana: A multi-level survival analysis of individual and contextual factors

Purpose: The aim of this study was to evaluate overall survival and treatment-related mortality in children with acute leukemia treated in a middle-income healthcare setting and to test the hypothesis that early treatment response and sex independently predict survival outcomes. Materials and Methods: We retrospectively analyzed 105 pediatric patients diagnosed with acute leukemia between February 2021 and May 2023 at the Health Sciences University, Adana City Training and Research Hospital, Turkey. Data were obtained from institutional electronic medical records. Overall and event-free survival were estimated using the Kaplan–Meier method and compared using the log-rank test. Results: The median age was 9 years. Acute lymphoblastic leukemia was diagnosed in 91 patients, acute myeloid leukemia in 13, and mixed-phenotype acute leukemia in one. The overall survival rate was 62.6%. Survival was higher in girls than in boys (80% vs. 48%). Patients with a favorable day-8 steroid response demonstrated substantially higher survival than poor responders (83% vs. 35%). In multivariate analysis, early steroid response was independently associated with a marked reduction in mortality risk. Conclusion: In this single-center cohort from a middle-income country, female sex and early steroid response were associated with improved survival in pediatric acute leukemia. However, treatment-related mortality remained substantial, underscoring the need to strengthen supportive care, infection control, and access to modern risk-stratified monitoring. Incorporation of early response assessment and molecular follow-up into routine clinical practice may further improve outcomes, although the lack of minimal residual disease data limited more refined prognostic stratification.

Trials have demonstrated that azithromycin mass drug administration (MDA) to children 1-59months old reduces mortality but increases antimicrobial resistance (AMR). The World Health Organization recommends that programs include mortality and AMR monitoring. Niger is expanding the azithromycin MDA for child survival program nationwide. To establish program monitoring and leverage the infrastructure to evaluate other community health interventions, AVENIR II is designed as a cluster-randomized adaptive platform trial with monitoring and re-randomization every 2years. The initial focus is to monitor under-5 mortality, AMR, implementation, and safety as the azithromycin program expands in Niger. All eligible primary health center catchment areas (Centre de Santé Intégrés, CSIs) will be included in biannual oral azithromycin MDA to children 1-59months old. A subset will be randomized to delay MDA for the first 2years, after which they will receive MDA. Another subset will then be randomized to stop MDA for the next 2years. The proportion randomized to delay or stop will be determined using an adaptive algorithm including (1) results of prior azithromycin MDA mortality trials, (2) expert opinion on the appropriate ethical balance between delivering the program and monitoring AMR, and (3) statistical power to detect a programmatically relevant difference between arms. We anticipate 5-10% of CSIs will be randomized to delay or stop at each randomization. Mortality and AMR will be monitored at baseline and every 2years. Implementation and safety outcomes will be monitored continuously. To enable ongoing monitoring while ensuring program access, CSIs receiving MDA will be re-randomized using the adaptive algorithm updated with new mortality results, and no CSI will go without MDA for more than 2years. In this platform design, additional arms may be added or dropped based on information from other studies, updates to guidelines, or preferences of Niger policymakers, and other interventions may be evaluated. The risk of AMR has led to caution in the implementation of azithromycin MDA. We present a design that enables continued rigorous evaluation of program impact on key outcomes, with flexibility to evaluate other interventions as well. ClinicalTrials.gov NCT06358872. Registered on April 2024.

Survivors of childhood, adolescent, and young adult cancers (CAYA) experience unique survivorship needs that are often unaddressed. We characterized young adult CAYA survivors' perspectives on the acceptability and utility of a novel model for routinely identifying and addressing their needs in survivorship care. Our onco-primary care program implemented routine needs-based care using age-appropriate needs and distress screening at survivorship visits. Survivors completed a screener and ranked their top three concerns for discussion, and clinicians discussed and addressed survivors' prioritized concerns. Research personnel recruited English-speaking survivors ages 18-39 with a history of cancer during their clinic visit. Twelve survivors completed semi-structured interviews about their needs-based care experience. We conducted iterative thematic content analysis to identify themes. The sample was 41.7% male and included some diversity of race and ethnicity (e.g., 16.7% Asian American, 25.0% Hispanic). We defined five themes: (1) Being asked relevant, age-appropriate questions made survivors feel "seen" and enhanced connection to the care team. (2) The model helped survivors identify their concerns and overcome barriers to talking about them with the clinician. (3) Prioritizing concerns was challenging but facilitated focus in the visit. (4) Completing the assessment at the visit and at every visit was acceptable. (5) Survivors were satisfied with communication and how their needs were addressed. Young adult CAYA survivors had positive perceptions of routine age-appropriate needs assessment followed by clinician discussion in survivorship. This model was relevant, useful, and acceptable, and enhanced their perceptions of providers and satisfaction with care.

This study evaluates UNICEF’s communication-for-development (C4D) strategies aimed at reducing six major childhood mortality diseases (measles, poliomyelitis, diphtheria, pertussis, tetanus, and tuberculosis) in Plateau State, Nigeria. Using a cross-sectional survey design, 400 questionnaires were distributed across the three senatorial districts, and 367 valid responses were recovered (response rate 91.8%). Data was collected using a structured questionnaire with seven-point Likert items and analysed using frequency and percentage distributions. Results indicate high awareness of the six diseases (90.7%) and substantial reach of UNICEF campaigns (81.0% awareness of campaigns). Respondents reported that mass media, interpersonal communication (health workers/community volunteers), and engagement with religious/traditional leaders were effective strategies, with 84.6% agreeing that multiple communication channels are used and 87.7% indicating improved disease awareness. However, gaps remain in consistent application across localities and in digital engagement. Based on findings, we recommend strengthening local language content, formalising community volunteer training, piloting SMS/WhatsApp reminders in targeted LGAs, and expanding monitoring and feedback mechanisms. These findings provide actionable guidance for UNICEF and state health actors seeking to optimise communication strategies for immunisation and child survival.

Lay Summary Clinical trials are essential to improving treatment and survival for children with brain and spinal tumors. However, nearly 90% of these trials happen in high-income countries, while most affected children live in low- and middle-income countries, where trials are scarce. These trials also tend to be smaller and focus more on supportive care. Expanding global trial access is critical to developing treatments that work for all children, improving care standards, and building lasting research capacity. Greater international collaboration can help address these gaps and ensure advances benefit children everywhere.

Anemia and undernutrition are major public health concerns affecting child growth, development, and survival, particularly in low-resource settings like East Africa. These conditions often occur together and exacerbate the health and developmental challenges of young children. Despite their high prevalence, no research has explored their co-occurrence and the spatial variations across East African countries. Hence, this study aimed to analyze the spatial distribution and identify predictors of the co-existence of anemia and under-nutrition among children aged 6-59 months in East Africa, utilizing recent Demographic and Health Survey data. Understanding the burden and factors affecting their co-occurrence is crucial for mapping geographic hotspot areas and identifying location-specific factors, which guide policymakers in developing targeted interventions. This study analyzed the latest Demographic and Health Survey data from East African countries, focusing on children aged 6-59 months. It included those with complete outcome and geospatial data while excluding those with missing or inaccurate survey coverage. The primary outcome was the co-occurrence of anemia and undernutrition, which was defined as the presence of anemia together with at least one form of undernutrition, including stunting, wasting, or underweight. The data was managed and analyzed using STATA version 17, ArcGIS version 10.7.1, SaTScan v10.1, and MGWR version 2.2 software. Hotspot analysis was performed to identify high or low prevalence, and ordinary kriging was utilized for interpolation. Furthermore, the Bernoulli-based model was used to identify the most likely clusters of co-occurrences of these conditions by SaTScan analysis. Finally, the geographical weighted regression with the multiscale geographical weighted regression extension analysis was fitted to identify the spatially varying determinants. The overall prevalence of co-occurrence of anemia and undernutrition was 26.08% (95% CI: 25.70-26.46%). The spatial analysis revealed that the distribution was non-random (p-value<0.001), with significant hotspot areas identified in northeast Ethiopia, northern and northwest Uganda, most parts of Burundi, northeast Tanzania, northern Zambia, central to southern Malawi, eastern Mozambique, and southern Madagascar. The primary clusters were concentrated in Burundi and southern Rwanda (RR = 3.48, LLR = 82.53; p-value <0.001). Spatial regression analysis identified several key predictors with geographic variation, including young maternal age (15-24 years), maternal anemia, no maternal education, poor household wealth, lack of health insurance, maternal tobacco use, multiple births, recent child diarrhea and fever, lack of Vitamin A supplementation, and smaller perceived birth size. The study highlights significant geographic disparities in the co-occurrence of anemia and undernutrition, with multiple maternal, child, and household factors contributing to the burden. These findings emphasize the need for region-specific public health interventions and future longitudinal research should explore additional confounders and refine regionally tailored approaches.

Although there has been a substantial drop in the global under-five mortality rate over time, Sub-Saharan African countries, such as Mozambique, are still experiencing a significant burden. Therefore, this study evaluated the determinants of under-five mortality in Mozambique. This study used weighted data from 9668 live births in Mozambique’s Demographic and Health Survey. A mixed-effect logistic regression model identified determinants of under-five mortality, with statistical significance based on adjusted odds ratios and 95% confidence intervals. An under-five mortality rate of 48 per 1000 live births was significantly associated with being female, twin, small at birth, high birth order, and having a short birth interval. While under-five mortality is declining nationally, Mozambique still faces high child deaths. Key determinants include the child’s sex, twin births, higher birth order, small birth size, and short birth intervals. Targeted interventions addressing these factors are needed to meet Sustainable. Development Goal targets for child survival.

Introduction Despite significant advancements over the previous three decades, under-five mortality is still a significant public health concern in East Africa. Sustainable Development Goal (SDG) 3.2 calls for a reduction in under-five mortality to 25 deaths per 1,000 live births by 2030. Recent evaluations show that the area is not on course to attain the SDG objective, despite considerable declines in Kenya, Rwanda, Tanzania, and Uganda. This study compares the forecasting performance of Autoregressive Integrated Moving Average (ARIMA), Autoregressive Frictionally Integrated Moving Average (ARFIMA), and hybrid models for predicting under-five mortality rates (U5MR) in four East African countries and assesses their projected progress toward SDG 3.2. Methods Annual U5MR data for 1995–2022 were obtained from the World Bank. Differencing was used to attain stationarity after initial Augmented Dickey-Fuller (ADF) tests revealed non-stationarity in all four nations. ARIMA, ARFIMA, and hybrid models tailored to each country were fitted and assessed using AIC, BIC, RMSE, MAE, MAPE, and R 2 . The Ljung-Box test was used to determine residual independence. The best-performing models were used to create forecasts for 2023 to 2030. Results In every country, ARIMA models performed better than ARFIMA and hybrid models, exhibiting the best residual diagnostics and the lowest error metrics. Through 2030, U5MR is expected to continue declining, although none of the four nations are expected to meet the SDG 3.2 objective. Discussion To achieve SDG 3.2 in East Africa, child survival initiatives and healthcare systems must be strengthened. Conclusion In every country, ARIMA models performed better than other models, showing the best residual diagnostics and the lowest error metrics. Although U5MR is expected to continue declining through 2030, none of the four nations is expected to meet the SDG 3.2 objective.

Testicular relapse constitutes one of the most frequent extramedullary recurrences in pediatric acute lymphoblastic leukemia (ALL), yet its clinical management remains incompletely characterized. This study assessed treatment outcomes and long-term survival in children with testicular relapse following initial therapy under the CCCG-ALL-2015 study (ChiCTR-IPR-14005706, http://www.chictr.org.cn). In total, 66 patients from 13 medical centers were retrospectively analyzed. Clinical characteristics and survival outcomes were compared across salvage treatment modalities. The median interval from initial diagnosis to testicular relapse was 37 months. Among 59 patients who received post-relapse therapy, the 2-year overall survival (OS) rate was 86.1% after a median follow-up of 33 months. Patients treated with chimeric antigen receptor T-cell (CAR-T) therapy showed a 2-year OS of 90.7%, compared to 81.7% in those managed with conventional regimens, such as chemotherapy, orchiectomy, or hematopoietic stem-cell transplantation (P > 0.05). Among 37 children with isolated testicular relapse, 18 underwent CAR-T therapy and 10 underwent orchiectomy, achieving 2-year OS rates of 92.3% and 100%, respectively (P > 0.05). Testicular relapse typically emerged approximately 3 years after initial diagnosis. CAR-T therapy proved to be both safe and effective, providing survival comparable to conventional regimens and offering potential advantages in preserving life quality among long-term survivors.

Therapeutic benefits of intravenous immunoglobulin (IVIG) and steroids remain inconclusive in optimizing treatment strategies for acute myocarditis. PubMed, EMBASE, Cochrane databases, and Web of Science were searched for studies evaluating the effectiveness of adjunctive IVIG, steroids, or both with standard heart failure treatment in pediatric acute myocarditis. A random-effects network meta-analysis was conducted using frequentist and Bayesian approaches. Effect sizes were calculated as risk ratio (RR) and mean difference (MD). P-scores provided a ranking of treatments. Thirteen studies comprising 2850 participants were involved. Compared with standard treatment, IVIG reduced in-hospital mortality (RR, 0.52; 95% CI, 0.35-0.76), long-term mortality (RR, 0.5; 95% CI, 0.27-0.98), overall mortality (RR, 0.52; 95% CI, 0.34-0.76), and better composite outcome (RR, 0.61; 95% CI, 0.43-0.88). IVIG was optimal for reducing in-hospital and overall mortality and improving the composite outcome (P-scores = 0.993, 0.999, 0.986). Steroids or their combination with IVIG showed no significant benefit. IVIG improved cardiac function by increasing left ventricular ejection fraction (MD, 6.00%; 95% CI, 0.94-11.06) and reducing left ventricular end-diastolic diameter (MD, -3.77; 95% CI, -7.02 to -0.52). Integrating IVIG into standard treatment may significantly enhance outcomes in children with complicated acute myocarditis. This systematic review and network meta-analysis addresses the gap between clinical trial efficacy and real-world effectiveness in pediatric clinical practice. This study suggests that adding IVIG to standard heart failure therapy may improve survival and cardiac function in children with acute complicated myocarditis. The routine use of steroids requires the cautious clinical application. High-quality randomized controlled trials are needed to inform guidelines and optimize therapy.

Studies have shown strong relationships between the presence of kin and children's survival outcomes in historical and contemporary low-income contexts. However, this relationship has never been studied among an enslaved population, who encountered extremely harsh living conditions. Examining this relationship among different populations may reveal similarities and differences across contexts. The present study addresses this gap by examining the life courses of children born between 1830 and 1863 and enslaved in Suriname (n = 19,095 children) and their mothers. For the period 1848‒1863, we can also observe matrilineal kin, including grandmothers, aunts, and uncles (n = 12,020 children). The relationships of matrilineal kin's presence and children's hazard of death from ages 6 months to 12 years were analyzed with Cox proportional hazards models. Experiencing maternal death was related to an increased hazard of death for children throughout childhood, but particularly during infancy (ages 6 months to 1 year; hazard ratio: 6.24, 95% confidence interval: 3.34‒11.66), and it decreased as children aged. The presence of grandmothers was related to a decreased hazard of death among children aged 1‒5, and the presence of aunts and uncles was beneficial to survival for children aged 5‒12. Mothers were especially important to children's survival, particularly during infancy, likely due to the importance of maternal care and breastfeeding on survival. During childhood, however, it appears that the presence of extended kin was also important, implying that children's care could have been provided by other family members once children were weaned. These findings closely align with those of other studies and reflect the importance of extended kin networks on childhood survival across time and space.

Endocrine late-effects in survivors of childhood and adolescence cancer: clinical management.

Adult cancer survivors are likely to be hospitalised with chronic illnesses, although evidence for childhood and AYA survivors is limited. This study quantified hospitalisations and the costs of health services used by survivors of childhood, adolescent, and young adult (AYA) cancers with and without chronic conditions. We assessed long-term survivors (≥5years past diagnosis) of childhood and AYA cancers diagnosed at ages 0-39years between 1997 and 2011 in Queensland, Australia. Utilising a linked administrative dataset, we determined the prevalence of chronic conditions from hospital records using classification codes (ICD-10-AM) and quantified hospitalisations and associated costs in 2024 Australian dollars (AU$). Generalised linear regression modelling was used to examine how chronic conditions affected healthcare costs, controlling for clinical and socio-demographic factors. Of 14,422 participants, 16% (n=2286) were hospitalised with at least one chronic disease, with hypertension (n=675, 4.7%) and depression (n=463, 3.2%) being the most common. Inpatient admissions were significantly higher for survivors withchronic conditions (mean 3, SD=10) compared to those without chronic conditions (mean 1, SD=4). The mean annual costs were highest for those with chronic kidney disease (AU$26,428, SD=AU$30,331), schizophrenia (AU$22,835, SD=AU$37,204), epilepsy (AU$22,361, SD=AU$37,224), paralysis (AU$22,051, SD=AU$32,165) and chronic heart failure (AU$21,912 SD=AU$38,763). Hypertension (AU$5.4 million) and depression (AU$4.3 million) incurred the highest total costs over the follow-up period. Implementing targeted survivorship care and preventative measures for high-cost conditions such as schizophrenia and chronic kidney disease may optimise healthcare resource use and reduce the economic burden for this population.

Undernutrition or obesity: relationship with long-term survival in children with acute lymphoblastic leukemia in an upper-middle income country: a multicenter cohort study.

Building an "Abdomen-First" multidisciplinary system for pediatric polytrauma with major abdominal injuries: A decade of surgical evolution and outcomes.

The last 40 years have seen a substantial improvement in overall survival from cancer in children and young people. There is limited information on psychiatric wellbeing in female survivors of cancer at a young age. In this 40-year population-based linkage study, we set out to determine the incidence of first psychiatric admission compared with a non-exposed age-matched control. Scottish cancer registry records from 1981 to 2012 were linked to psychiatric admissions, maternity and death records from January 1981 to September 2018 using the unique personal Community Health Index number allocated to each person in Scotland. For each exposed subject, three age and deprivation matched controls from the population were selected. The primary exposed group was all females with a cancer diagnosis at age <25 years and no previous pregnancy and no psychiatric admission before cancer diagnosis. The main outcome measure is admission to a psychiatric hospital with a mental health diagnosis. Female cancer survivors had a significantly lower cumulative incidence of first psychiatric admissions than matched controls over the 38 years of follow-up for the cohort (p<0.05). The relative risk of a first psychiatric admission at 25 years from cancer diagnosis was 0.72 (0.56-0.89). Overall, we have shown that young cancer survivors are less likely than age-matched controls to have a psychiatric admission after cancer diagnosis. In particular, psychiatric admissions for mood disorders, neuroses, personality disorders and substance use are significantly less likely in the cancer survivors. The experience of cancer treatment and survival in young females may reduce the risk of psychiatric admission in later life.

Child mortality continues to pose a major public health challenge across Asia. This study examines trends in under-5, infant and neonatal mortality and identifies key determinants, spatial risk patterns and projections through 2030 using spatiotemporal modelling. We used national-level data from 41 Asian countries, representing over 80% of Asia's population, between 2000 and 2022, incorporating 26 health, environmental and sociodemographic indicators. A hierarchical Bayesian model using Integrated Nested Laplace Approximation, incorporating fixed effects, spatially structured and unstructured random effects, and temporal smoothing, was used. Model performance was assessed via the Deviance Information Criterion, Watanabe-Akaike Information Criterion, coefficient of determination (R²), root mean squared error (RMSE) and mean absolute error metrics. Under-5 mortality decreased significantly (p<0.001) from 46.73 to 18.53 per 1000 live births. Strong negative associations were observed between child mortality and vaccination coverage-rubella (r=-0.79), Diphtheria, Tetanus, and Pertussis (DTP) (r=-0.74), hepatitis B (r=-0.58) and rotavirus (r=-0.20). Female literacy (r=-0.20) and life expectancy (r=-0.30) also contributed to improved outcomes. Spatial analyses identified Afghanistan (under-5: 77.12), Bangladesh (57.12) and Myanmar (63.16) as high-risk hotspots, while Japan, Sri Lanka and the UAE maintained low predicted rates (≈0). Neonatal mortality patterns were flatter across time and space, peaking in Bangladesh (6.30), Indonesia (5.08) and Azerbaijan (5.00). Predictive accuracy was highest for neonatal mortality (R²=0.99; RMSE=1.93). Some countries, such as Yemen and the UAE, displayed near-zero or negative forecasts, suggesting sensitivity to spatial priors in sparse-data contexts. The study highlights the critical role of immunisation and maternal education in reducing mortality, and the need for more targeted neonatal interventions. The white-box modelling framework enables both interpretability and reliable forecasting, supporting data-driven policy planning toward achieving advanced, equitable child survival, as outlined in Sustainable Development Goal 3.2.

BackgroundBreastfeeding is one of the most cost-effective public health interventions to improve child survival and development. A key determinant of breastfeeding initiation and continuation is maternal self-efficacy, defined as a mother's confidence in her ability to breastfeed. The Breastfeeding Self-Efficacy Scale–Short Form (BSES-SF) is one of the most widely used instruments internationally to assess this construct. However, no validation studies have been conducted in Ecuador, and evidence from Latin America remains limited, particularly regarding advanced psychometric analyses.ObjectiveTo validate the Spanish version of the BSES-SF in Ecuadorian mothers with previous breastfeeding experience, examining its factorial structure, factorial invariance, reliability, and convergent validity.MethodsAn instrumental psychometric study was conducted with 325 mothers recruited from public and private health centers in Loja, Ecuador, who had breastfeeding experience during the child's first two years of life. Confirmatory factor analysis (CFA) was used to compare competing factorial models, and multi-group CFA tested factorial invariance across maternal age groups. Reliability was assessed using Cronbach's alpha and McDonald's omega. Convergent validity was examined through correlations with psychological capital (PCQ-12) and positive mental health (PMH-9).ResultsA second-order four-factor model showed the best fit to the data (χ²/df = 1.39; CFI = 0.998; TLI = 0.997; SRMR = 0.043; RMSEA = 0.035) and demonstrated full factorial invariance across age groups. Convergent validity was generally adequate, although one dimension showed average variance extracted values below the recommended threshold. The scale showed excellent overall reliability (α = 0.915; ω = 0.929) and significant positive correlations with psychological capital and positive mental health.ConclusionThe Spanish version of the BSES-SF is a valid and reliable instrument for assessing breastfeeding self-efficacy in Ecuadorian mothers. Clinically, it supports early identification of women at risk of low breastfeeding self-efficacy, facilitating timely and targeted breastfeeding support. From a public health and policy perspective, this psychometrically robust and culturally adapted instrument can inform breastfeeding promotion programs, equity-focused maternal health interventions, and monitoring of nutrition and health-related Sustainable Development Goals.

Background Advances in cancer treatment have increased survival among childhood and adolescent patients, yet many survivors experience long-term psychosocial and health challenges. Structural factors such as health insurance and geographic location influence access to survivorship care, but little is known about their combined impact. Methods Secondary data were analyzed from 470 childhood and adolescent cancer survivors who completed the Impact of Cancer–Childhood Survivors (IOC-CS) questionnaire during visits to a survivorship clinic in the US Pacific Northwest. Hierarchical OLS regression examined predictors of positive and negative psychosocial impacts, including demographic, clinical, and environmental variables (geographic location and insurance type), and their interaction. Results The interaction between rural residence and public insurance significantly predicted higher negative impact scores (β = 0.13, p = .05) after controlling for covariates, indicating compounded risk for psychosocial distress. Public insurance independently predicted higher negative impact and lower positive impact scores. Rurality alone was not a significant predictor after accounting for interaction effects. Conclusions Survivors with both rural residence and public insurance face intersecting structural barriers that amplify psychosocial challenges. Future research should explore tailored interventions and policy strategies to reduce disparities in survivorship care access and outcomes.