Poor Child Health Outcomes Research Articles

A Protocol for Concretizing and Contextualizing a Critical Realist “Theory of Neighbourhood Context, Stress, Depression, and the Developmental Origins of Health and Disease (DOHD)”, Sydney Australia

Introduction: This research protocol has been developed as part of an integrated care initiative for vulnerable families in Sydney, Australia. The aim is to develop “whole-of-government” interventions that break intergenerational cycles of disadvantage and poor life outcomes. A realist methodology will be described for the translation of empirically ‘data derived’ causal middle-range theories of social mechanisms, into health and social programme theories, whose theoretical propositions can be operationalized and studied in concrete situations using collective theory driven approaches. Theory/Methods: The research settings are in metropolitan Sydney, Australia. The design will be a longitudinal, multi-level, mixed method realist evaluation of applied programme interventions that seek to break the intergenerational cycle of social disadvantage and poor child health and developmental outcomes. The programme of research will consist of three components: 1) Operationalization of the theory and designing of programme initiatives for implementation; 2) Evaluation of the translated programme and implementation theory using Theory of Change and Realistic Evaluation; and 3) Theory Testing of realist hypotheses using both intensive and extensive critical realist research methods including realist structural modelling. Results: No applicable Discussion: The proposed programme of research will assist in translating empirical explanatory theory building to theory driven interventions. The research will be situated in socially disadvantaged regions of Sydney where the local child and family interagencies will collaborate to design and implement new initiatives that address significant disparities in early childhood development and adolescent outcomes attributed to neighbourhood circumstances, family stress and intergenerational cycles of disadvantage and poor mental health. Conclusions: Central to this protocol is the development of programme theory. Much of the theory driven and realist evaluation literature begins with existing interventions. The first task in those situations is to identify the underlying programme theory. In preparing this programme of work we were faced with the translation of causal theory to programme and implementation theory. We have proposed as a first step in this protocol the formal translation of the middle-range ‘causal’ theory into a middle-range ‘programme theory’ followed by an intervention design process based on Theory of Change approaches. Lessons learned: In preparing the protocol we have identified extensive debate concern the nature of implementation theory and programme theory. There is also on-going critical analysis of the nature of context (c), mechanisms (M) and outcomes (o) and how these might be defined and measured. Limitations: The application of realist methodologies to population health interventions is relatively new and there is little extant literature on the translational process from causal theory to programme theory. The study protocol is thus breaking new ground and it is anticipated that the approaches described will require modification. Suggestions for future research: The protocol development identified a need for further clarification of the nature of causal mechanism and programme mechanisms among the integrated care and evaluation research communities.

A model to facilitate collaborative social support for pregnant students in secondary schools.

Pregnancy among secondary school students remains a public health problem and is associated with school dropout as well as poor maternal and child health outcomes. Schools in South Africa no longer expel pregnant students as was the case before 2000. Instead, the government encourages them to remain in class to complete their education, but pregnant students often face stigma, and some drop out of school as a result. To remain in class and access antenatal care, pregnant students require social support from teachers, parents and professional nurses. Unfortunately, teachers, parents and professional nurses support pregnant students on an ad hoc basis, and this calls for a model to facilitate collaborative social support. The purpose of this paper is to present and describe a model to facilitate collaborative social support for pregnant students attending secondary schools in South Africa, using the model description steps of Chinn and Kramer. The model is designed as a tool to enable pregnant students to remain in school, attend antenatal care and in the end, deliver healthy babies. The professional nurse, as a member and leader of the school health team which visits secondary schools to provide a package of school health services, is the agent or facilitator of the model.

Let's Talk About Breastfeeding: The Importance of Delivering a Message in a Home Visiting Program.

To examine the potential impact of paraprofessional home visitors in promoting breastfeeding initiation and continuation among a high-risk population. A secondary analysis of program data from a statewide home visitation program. Thirty-six Healthy Families New York sites across New York State. A total of 3521 pregnant mothers at risk of poor child health and developmental outcomes. Home visitors deliver a multifaceted intervention that includes educating high-risk mothers on benefits of breastfeeding, encouraging them to breastfeed and supporting their efforts during prenatal and postnatal periods. Home visitor-reported content and frequency of home visits, participant-reported breastfeeding initiation and duration, and covariates (Kempe Family Stress Index, race and ethnicity, region, nativity, marital status, age, and education). Logistic regression. Breastfeeding initiation increased by 1.5% for each 1-point increase in the percentage of prenatal home visits that included breastfeeding discussions. Breastfeeding continuation during the first 6 months also increased with the percentage of earlier home visits that included breastfeeding discussions. Additionally, if a participant receives 1 more home visit during the third month, her likelihood of breastfeeding at 6 months increases by 11%. Effect sizes varied by months postpartum. Delivering a breastfeeding message consistently during regular home visits is important for increasing breastfeeding rates. Given that home visiting programs target new mothers least likely to breastfeed, a more consistent focus on breastfeeding in this supportive context may reduce breastfeeding disparities.

Factors Associated with Smokeless Tobacco Use among Pregnant Women in Rural Areas of the Southern Terai, Nepal

Tobacco use among women during pregnancy leading to poor maternal and child health outcomes has been well documented. However, factors influencing use of smokeless tobacco in Nepal has not yet been well established. This study aims at exploring the factors related to smokeless tobacco use among pregnant women in rural southern Terai of Nepal. A community-based cross-sectional study was performed at 52 wards within 6 Village Development Committee in Dhanusha district of Nepal. A total of 426 expectant mothers in their second trimester were selected using a multistage cluster sampling method. Descriptive and regression analyses were done to explore the factors that influence smokeless tobacco use. In a total of 426 pregnant mothers, one in five used tobacco in any form. Among the users, 13.4% used smokeless tobacco. Pregnant mothers who were smoking tobacco (AOR 6.01; 95% CI (1.88-19.23), having alcohol consumption (AOR 3.86; 95% CI (1.23-12.08), stressed (AOR 5.04; 95% CI (1.81-14.03), non-vegetarian (AOR 3.31;(1.84-13.03), not attending regular mothers' group meetings (AOR 4.63; (1.41-15.19), and not-exposed to mass media (AOR 5.02; (1.89-13.33) were significantly associated with smokeless tobacco use. Similarly, mothers of age group 20-34 years, dalit, aadibasi and janajati, hill origin, no education and primary education were more likely to use smokeless tobacco than their counterparts. Factors such as smoking tobacco, alcohol consumption, stress, and poor education were found to be significantly associated with smokeless tobacco use among pregnant women in southern Terai of Nepal. This requires an immediate attention develop an effective strategy to prevent and control smokeless tobacco use among pregnant women in southern Terai of Nepal.

Pediatric Residents’ Recognition and Dissemination of Resources for Unmet Social Needs (USN) and Adverse Childhood Experiences (ACE) (QI Abstract)

ACE are recognized risk factors for poor health outcomes in children. The American Academy of Pediatrics recently recommended routine screening of USN and targeted ACE screening in the primary care setting. However, most residents receive little to no training in asking ACE and USN type questions and providing resources if positives are elicited. The Child and Youth Center serves a diverse population made of about 50% African Americans and 35% Latinos. We focus on outreach to the underserved but the amount of USN and ACE are unknown. Aim Statement Increase the dissemination of resources by 20% to families that indicated they need assistance from implementation on October 2, 2016 to January 31, 2017. Interventions We implemented routine screening for USN and ACE for all children, presenting for a well child visit in our pediatric resident clinic. Residents dispensed resources to families who indicated they needed assistance. The first intervention was resident education regarding the new screening tool and location of resources on a website. The second intervention was outreach to individual providers if they did not provide resources but the parents had asked for assistance. The third intervention was printing the three most commonly needed resources and having them readily accessible for residents to give to parents. Measures We used PDSA cycles and QI methodology in a rapid cycle to improve distribution of resources. We calculated the percentage of resources given before and after each intervention.

Poor early childhood outcomes attributable to maternal depression in Mexican women.

We aimed to estimate the population fraction of poor early child health and developmental outcomes attributable to maternal depressive symptoms (DS) contrasting it between low- and middle/high-income households. We used a nationally representative probabilistic sample of 4240 children younger than 5years old and their mothers, derived from the Mexican National Health and Nutrition Survey Data (ENSANUT 2012). Complex survey design, sampling, and analytic weights were taken into account in analyses. DS was measured by CESD-7. Child outcomes were as follows: breastfeeding, attending well-child check-ups, respiratory disease, diarrhea and general health problems, immunization, accidents, growth, obesity, and food insecurity. Prevalence of DS among mothers was 21.36%. In low-SES households, DS was associated with higher risk of never being breastfed (RR=1.77; p<.05), health problems (RR=1.37; p<.05), acute respiratory disease (RR=1.51; p<.05), accidents requiring child hospitalization (RR=2.16; p<.01), and moderate or severe food insecurity (RR=1.58; p<.001). In medium- or high-SES households, DS was associated with higher risk of never attending a developmental check-up (RR=2.14; p<.05) and moderate or severe food insecurity (RR=1.75; p<.01). Population risks attributable to DS ranged from 2.30 to 17.45%. Prevention of DS could lead to reduction of problematic early childhood outcomes in both low and medium/high SES.

Characterizing Social Determinants of Health for Adolescent Mothers during the Prenatal and Postpartum Periods

PurposeSignificant racial disparities and continuing poor birth outcomes make adolescent pregnancy a significant public health concern in the United States despite declining pregnancy rates. Social determinants of health are associated with increased likelihood of pregnancy and poor maternal and child health outcomes. This study aims to characterize specific elements of social determinants of health in a cohort of predominantly Latina adolescent mothers. MethodsBetween February 2007 and August 2008, 106 pregnant adolescents participated in a study with assessments at 20 to 24 weeks of gestation, and at 3 and 6 months postpartum. Survey questions addressed residential mobility, financial support and childcare, and perceived need for and use of community resources. Comparative analysis assessed differences between adolescents by age (<16 vs. ≥16 years old) and ethnicity (Latina vs. non-Latina). FindingsAdolescent mothers experienced high rates of residential mobility, with 59.4% moving at least once in the year before their prenatal survey. Participants relied primarily on public aid (94–96%) and their parents (81–85%) for financial support. Latina participants were more likely than non-Latinas to rely on public aid. Although many participants reported needing financial support and housing, few used available services. Younger adolescents relied less often on the father of the baby for support than older adolescents. ConclusionsAdolescent mothers' high rates of residential mobility and increasing reliance on public assistance highlight resource gaps that potentially put them and their children at risk for poor outcomes. Targeted efforts to augment systemic support in these domains are a critical component of addressing health disparities for this population.

Poor health outcomes in moderate and late preterm children at 2 years of age

Poor health outcomes in moderate and late preterm children at 2 years of age

Trends and Analysis of Child Anthropometric Indices for India

This paper based on National Family Health Survey-4 studies the prevalence of anthropometric indices like stunting, wasting, and underweight in India, with especial reference to the districts of Bihar, West Bengal and Madhya Pradesh. Though prevalence of stunting and underweight has declined in all states, yet seven out of thirteen states actually witnessed an increase in rates of wasting. Mother’s health, availability of adequate balanced diet, drinking water, institutional delivery and exposure to immunization programs are found to have been associated with the observed outcomes. In some parts of India, active left winged extremism are hypothesized to have stalled development process in these regions, which have translated to poor child health outcomes. Food and nutrition insecurity need to be tackled in these areas. Finally this paper advocates for changes in policy prescriptions taking into account geopolitical constraints, for ameliorating the twin problems of food insecurity and under-nutrition.

Increased household financial strain, the Great Recession and child health—findings from the UK Millennium Cohort Study

BackgroundThere is a growing body of evidence associating financial strain (FS) with poor health but most of this research has been cross-sectional and adult-focused. During the ‘Great Recession’ many UK...

Knowledge and Preconception Care Seeking Practices among Reproductive-age Diabetic Women in Zambia

Background and Objectives: Pre-existing diabetes is associated with poor pregnancy outcomes, yet much is unknown about knowledge of preconception care among diabetic women. Preconception Care (PCC) is the health interventions to women and couples before conception to reduce poor maternal and child health outcomes. The objective of this study was to examine the knowledge and preconception care seeking practices of diabetic women in the reproductive age. Methods: The study was conducted at the University Teaching Hospital and Levy Mwanawasa General Hospital in Lusaka, Zambia. A cross- sectional hospital based study of 114 diabetic women between 15-45 years old was conducted between March and May 2017. Data were collected using structured questionnaires during face-toface interviews. Data were entered using Microsoft Excel and then exported to SPSS version 20 for analysis. The Chi-square test was used to determine the association between knowledge levels and identified factors; these were further analyzed using binary logistic regression to determine the adjusted odds of poor knowledge. Results: The findings showed that 52.6% of diabetic women that participated in the study had poor knowledge of preconception care. The identified independent factors associated with poor knowledge on preconception care were women receiving a level of education up to primary education only [Adjusted Odds Ratio (AOR) 4.54, 95% Confidence Interval (CI) (2.23, 9.27)], and women that had ≤ 1 year duration of diabetes diagnosis [AOR 3.21 95% (1.35, 7.65)]. About 67% of the participants with a history of being pregnant after diagnosis of diabetes did not seek preconception care. Conclusion and Implications for Translation: The study indicated poor knowledge level as well as poor practice of seeking preconception care within diabetic women attending the University Teaching Hospital and Levy Mwanawasa General Hospital in Lusaka, Zambia. There is a need to explore the establishment of clinical guidelines and policies that will allow the dissemination of pregnancy related advise to diabetic women. As soon as women of the reproductive age were diagnosed with diabetes they should be aware of the PCC, and information dissemination through health centers is vital to encourage women to seek PCC when pregnancy is desired.

Integrating Maternal Mental Health Care in the Pediatric Medical Home: Treatment Engagement and Child Outcomes.

Maternal depression is associated with an array of poor child health outcomes, and low-income women face many barriers to accessing treatment. In this pilot study, we assessed treatment engagement in a maternal mental health clinic staffed by a case manager and psychiatrist in an urban pediatric practice. We also examined factors associated with engagement as well as child health outcomes and health care use. Nearly half of the women enrolled attended at least 4 sessions with a psychiatrist in 6 months. Text messaging with the case manager was associated with a greater compliance with psychiatrist sessions. Comparing index children with their siblings prior to enrollment, a higher percentage had immunizations up to date at 1 year of age (82% vs 43%, P = .01), and well-child visit compliance trended toward significance (65% vs 35%, P = .06). The pediatric setting holds promise as an innovative venue to deliver maternal mental health care.

The effectiveness of Technology-assisted Cascade Training and Supervision of community health workers in delivering the Thinking Healthy Program for perinatal depression in a post-conflict area of Pakistan - study protocol for a randomized controlled trial.

BackgroundRates of perinatal depression in low and middle income countries are reported to be very high. Perinatal depression not only has profound impact on women’s health, disability and functioning, it is associated with poor child health outcomes such as pre-term birth, under-nutrition and stunting, which ultimately have an adverse trans-generational impact. There is strong evidence in the medical literature that perinatal depression can be effectively managed with psychological treatments delivered by non-specialists. Our previous research in Pakistan led to the development of a successful perinatal depression intervention, the Thinking Healthy Program (THP). The THP is a psychological treatment delivered by community health workers. The burden of perinatal depression can be reduced through scale-up of this proven intervention; however, training of health workers at scale is a major barrier. To enhance access to such interventions there is a need to look at technological solutions to training and supervision.Methods/designThis is a non-inferiority, single-blinded randomized controlled trial. Eighty community health workers called Lady Health Workers (LHWs) working in a post-conflict rural area in Pakistan (Swat) will be recruited through the LHW program. LHWs will be randomly allocated to Technology-assisted Cascade Training and Supervision (TACTS) or to specialist-delivered training (40 in each group). The TACTS group will receive training in THP through LHW supervisors using a tablet-based training package, whereas the comparison group will receive training directly from mental health specialists. Our hypothesis is that both groups will achieve equal competence. Primary outcome measure will be competence of health workers at delivering THP using a modified ENhancing Assessment of Common Therapeutic factors (ENACT) rating scale immediately post training and after 3 months of supervision. Independent assessors will be blinded to the LHW allocation status.DiscussionWomen living in post-conflict areas are at higher risk of depression compared to the general population. Implementation of evidence-based interventions for depression in such situations is a challenge because health systems are weak and human resources are scarce. The key innovation to be tested in this trial is a Technology-assisted Cascade Training and Supervision system to assist scale-up of the THP.Trial registrationRegistered with ClinicalTrials.gov as GCC-THP-TACTS-2015, Identifier: NCT02644902.

Obesity Prevention Programs in Children: Impact on Weight, Shape and Food Concern.

Childhood overweight and obesity have an estimated prevalence of 10 % globally. High body mass index (BMI) is a known major predictor of body dissatisfaction, problem eating, low self-esteem, bullying and poor social and health outcomes for children. Childhood is also a time when lifelong habits are established, and as such is a time where prevention efforts have a high chance of success if implemented appropriately. Obesity prevention in children also has the potential to create weight, shape and food concerns in children and as such programs should focus on the principle first, do no harm. This paper canvasses existing literature and intervention program data to make the following recommendations for effective childhood obesity prevention: Programs should be educative for both children and their parents, programs should be inclusive of the whole family, there should be a focus on health and growth, not weight, and parents, schools and children should all be involved.

Breastfeeding and Child Health in Uganda

The study sets out to estimate the effect of breastfeeding and health knowledge on child mortality and stunting. We used a nationally representative UDHS data of 2011 merged with the community section of the UNHS 2011 in order to bring on board community variables, such as distance to the health facility, that are potential instrumental variables. We employed various techniques; OLS, IV and control function during the analysis. We find that breastfeeding and health knowledge reduce child mortality but not child stunting irrespective of the analytical technique employed. Just as previous literature documents, the OLS estimate of the coefficient on breastfeeding and health knowledge is biased downwards compared to the IV and control function estimates. Government efforts towards sensitizing the masses about the importance of breastfeeding should be strengthened. Additionally, government needs to prioritize health knowledge impartation to women of reproductive age that are no longer in school. Additionally school curricular should be improved to include the impartation of health knowledge to students at an early stage of education in order to mitigate poor child health outcomes for the future generation. Keywords: Breastfeeding, child mortality, child stunting, Uganda

No evidence that polygynous marriage is a harmful cultural practice in northern Tanzania

Polygyny is cross-culturally common and a topic of considerable academic and policy interest, often deemed a harmful cultural practice serving the interests of men contrary to those of women and children. Supporting this view, large-scale studies of national African demographic surveys consistently demonstrate that poor child health outcomes are concentrated in polygynous households. Negative population-level associations between polygyny and well-being have also been reported, consistent with the hypothesis that modern transitions to socially imposed monogamy are driven by cultural group selection. We challenge the consensus view that polygyny is harmful, drawing on multilevel data from 56 ethnically diverse Tanzanian villages. We first demonstrate the vulnerability of aggregated data to confounding between ecological and individual determinants of health; while across villages polygyny is associated with poor child health and low food security, such relationships are absent or reversed within villages, particularly when children and fathers are coresident. We then provide data indicating that the costs of sharing a husband are offset by greater wealth (land and livestock) of polygynous households. These results are consistent with models of polygyny based on female choice. Finally, we show that village-level negative associations between polygyny prevalence, food security, and child health are fully accounted for by underlying differences in ecological vulnerability (rainfall) and socioeconomic marginalization (access to education). We highlight the need for improved, culturally sensitive measurement tools and appropriate scales of analysis in studies of polygyny and other purportedly harmful practices and discuss the relevance of our results to theoretical accounts of marriage and contemporary population policy.

Opportunities for Nurses to Increase Parental Health Literacy: A Discussion Paper

Most families can access a range of health information and advice. Information and advice sources often include nurses, the Internet, social media, books, as well as family and friends. While the immediate aim may be to find information, it can also be to assist with parenting skills, solve parenting problems or as part of decision-making processes about their child’s health. These processes are strongly influenced by the parent’s level of health literacy. Health literacy describes a person’s capacity to obtain and utilize health related information. Although there are numerous health literacy definitions all have clearly defined steps. These steps are: obtaining relevant information; then understanding this information; and finally being able to use the information to achieve the expected outcome. Previous research has linked low levels of parental health literacy with poorer child health outcomes. Given this link, increasing health literacy levels would be advantageous for both families and health services. Nurses working with families are in a position to support the family to increase their health literacy through the use of a variety of strategies. This article outlines how health literacy can influence the way parents seek help when they are concerned about child health issues, the relevance of parental health literacy for nurses and suggests some tools that could be used to support the increase of health literacy.

Laboratory Determined Sugar Content and Composition of Commercial Infant Formulas, Baby Foods and Common Grocery Items Targeted to Children.

Excess added sugar consumption is tied to poor health outcomes in children. The sugar content of beverages and foods children are exposed to is mostly unknown, yet this information is imperative for understanding potential risks from overconsumption of sugars in early life. We determined actual sugar content by conducting a blinded laboratory analysis in infant formulas, breakfast cereals, packaged baked goods and yogurts. One hundred samples were sent to an independent laboratory for analysis via gas chromatography. Sugar content and composition was determined and total sugar was compared against nutrition labels. Of the 100 samples analyzed, 74% contained ≥20% of total calories per serving from added sugars. Nutrient label data underestimated or overestimated actual sugars and ~25% of all samples had actual total sugar values that were either <10% or >10% of labeled total sugar. Many products that are frequently marketed to and consumed by infants and young children contain sugars in amounts that differ from nutrition labels and often in excess of recommended daily levels. These findings provide further support for adding more comprehensive sugar labeling to food and beverage products, specifically those marketed to, or commonly consumed by, children.

"Do You Wanna Breathe or Eat?": Parent Perspectives on Child Health Consequences of Food Insecurity, Trade-Offs, and Toxic Stress.

ObjectivesThis study among 51 parents of young children under age four investigated how parents that report marginal, low and very low food security characterize how trade-offs associated with food insecurity affect parents’ mental health and child well-being.MethodsWe carried out 51 semi-structured audio-recorded interviews after participants responded to a survey regarding food security status and maternal depressive symptoms. Each interview was transcribed. Through a content analysis, we coded “meaning units” in each manuscript and organized them by themes in ATLAS.ti. Among participants reporting both food insecurity and depressive symptoms, we identified three primary areas of concern: trade-offs, mental health, and child well-being.ResultsParents described how trade-offs associated with food insecurity have a profound relationship with their mental health and home environment that strongly affects young children. Descriptions of hardships include anxiety and depression related to overdue bills and shut-off notices, strains with housing costs, and safety. Parents described how their own frustration, anxiety, and depression related to economic hardship have a negative impact on their children’s physical health, and their social and emotional development.ConclusionsParents in food insecure households recognize that trade-offs between food and other basic necessities are associated with their personal stress and poor mental health that, in turn, affects their children’s health and development. Partnerships between healthcare providers, policymakers, and parents are essential to successfully address and prevent the poor child health outcomes of toxic stress associated with food insecurity and poverty.

Bridging the Gap: using an interrupted time series design to evaluate systems reform addressing refugee maternal and child health inequalities.

BackgroundThe risk of poor maternal and perinatal outcomes in high-income countries such as Australia is greatest for those experiencing extreme social and economic disadvantage. Australian data show that women of refugee background have higher rates of stillbirth, fetal death in utero and perinatal mortality compared with Australian born women. Policy and health system responses to such inequities have been slow and poorly integrated. This protocol describes an innovative programme of quality improvement and reform in publically funded universal health services in Melbourne, Australia, that aims to address refugee maternal and child health inequalities.Methods/designA partnership of 11 organisations spanning health services, government and research is working to achieve change in the way that maternity and early childhood health services support families of refugee background. The aims of the programme are to improve access to universal health care for families of refugee background and build organisational and system capacity to address modifiable risk factors for poor maternal and child health outcomes. Quality improvement initiatives are iterative, co-designed by partners and implemented using the Plan Do Study Act framework in four maternity hospitals and two local government maternal and child health services.Bridging the Gap is designed as a multi-phase, quasi-experimental study. Evaluation methods include use of interrupted time series design to examine health service use and maternal and child health outcomes over a 3-year period of implementation. Process measures will examine refugee families’ experiences of specific initiatives and service providers’ views and experiences of innovation and change.DiscussionIt is envisaged that the Bridging the Gap program will provide essential evidence to support service and policy innovation and knowledge about what it takes to implement sustainable improvements in the way that health services support vulnerable populations, within the constraints of existing resources.