Lessons From the West Africa Ebola Epidemic: A Systematic Review of Epidemiological and Social and Behavioral Science Research Priorities.

This systematic literature review compared the epidemiological (EPI) research and the qualitative social and behavioral science (SBS) research published during the West Africa Ebola virus disease (EVD) epidemic. Beginning with an initial capture of over 2000 articles, we extracted 236 EPI and 171 SBS studies to examine how disciplinary priorities affected research conducted during the EVD response, with implications for epidemic response effectiveness. Building on this research, we set forth a roadmap for the closer integration of EPI and SBS research in all aspects of epidemic preparedness and response that incorporates the lessons of the West Africa EVD outbreak. Key priorities include the following: (1) developing the capacity to systematically quantify qualitative sociocultural variables; (2) establishing interdisciplinary collaborations to improve "risk segmentation" practices; (3) creating and prepositioning qualitative indicators and composite sociocultural indexes for rapid deployment in outbreaks; (4) integrating novel systems with community resources; (5) developing new techniques for modeling social mobilization and community engagement; (6) prioritizing good data and complex analyses early in emergencies; and (7) learning from past experiences. Our findings support a program of action that situates data collection and analysis in real-time, recursive, integrated efforts to move community attitudes, behaviors, and responses into epidemiological research. We offer recommendations to improve coordinated, multidisciplinary approaches to health emergencies.

Public Health and International Partnerships in the Democratic People's Republic of Korea.

David Hipgrave and colleagues argue that sustained collaboration is required to improve population health and health services in North Korea.

Effect of Home-Based Complementary Food Fortification on Prevalence of Anemia Among Infants and Young Children Aged 6 to 23 Months in Poor Rural Regions of China.

Following the 2008 Wenchuan earthquake, the Chinese government instituted an infant and young and child nutrition program that included promotion of in-home fortification of complementary food with ying yang bao (YYB), a soy-based powder containing iron, 2.5 mg as iron-EDTA and 5 mg as ferrous fumarate, and other micronutrients. Ying yang bao was provided to participating families in 8 poor rural counties in Sichuan, Shaanxi, and Gansu provinces by the Ministry of Health. We assessed hemoglobin levels among infants and young children (IYC) aged 6 to 23 months at baseline in May 2010 (n = 1290) and during follow-up in November 2010 (n = 1142), May 2011 (n = 1118), and November 2011 (n = 1040), using the Hemocue method. Interviewers collected basic demographic information and child feeding practices from the children's caretakers. Altitude-adjusted hemoglobin level averaged 10.8 g/dL, and total anemia prevalence was 49.5% at baseline. Average hemoglobin was 11.3 g/dL at 6 months, 11.6 g/dL at 12 months, and 11.7 g/dL at 18 months after introduction of YYB. Moderate anemia (hemoglobin: 70-99 g/dL) decreased from 20.3% at baseline to 7.5%, 5.8%, and 7.3% after 6, 12, and 18 months of home fortification, respectively (P < .001), whereas mild anemia (hemoglobin: 100-110 g/dL) decreased from 29.0% to 16.7%, 18.1%, and 15.4%, respectively (P < .001). Among infants aged 6 to 23 months, 95% had regularly been fed YYB during the observation period. Regression analysis showed that the duration of YYB consumption and number of sachets consumed per week correlated positively with hemoglobin levels and negatively with anemia rates. Home food fortification with YYB is feasible and effective for nutrition promotion among IYC in high-risk regions of China.

Cause of death among infants in rural western China: a community-based study using verbal autopsy.

OBJECTIVES: To determine the causes of death among infants in high-mortality areas of western China with the use of globally recognized methods. STUDY DESIGN: A survey of all infant deaths identified over 1 year in 4 counties in Yunnan and Xinjiang in which combined verbal autopsy was combined with a physician's diagnosis of the cause to calculate the local infant mortality rate. RESULTS: Among 470 completed investigations, a cause of death was assigned to 423 cases (90%). Overall, pneumonia (34.5%), preterm birth complications (16.5%), diarrhea (10.4%), birth asphyxia (10.3%), and congenital abnormalities (8.5%) were the main causes, with 56.6% of deaths occurring in the neonatal period. Deaths were attributable predominantly to prematurity or birth asphyxia in the early neonatal period, whereas infection accounted for more than 60% and 80% of deaths in the late and postneonatal periods, respectively. Calculated infant mortality was 21.9 in 1000 live births. CONCLUSIONS: The pattern of infant mortality observed in the surveyed counties differs markedly from that reported previously at the national level, with a high proportion the result of causes that may be preventable with globally recommended interventions. Financial and political support is needed to promote improved cause of death surveillance and newborn and infant health care in China's western region.

Maternal deaths among rural-urban migrants in China: a case-control study.

BACKGROUND: Disparity in maternal mortality exists between rural-urban migrant and urban resident women in China, but little research has provided evidence for related policy development. The objective of this study was to identify associations with and risks for maternal death among rural-urban migrant women in order to improve health services for migrant women and reduce maternal mortality in China. METHODS: We conducted a prospective case-control study in urban areas of Guangdong, Zhejiang and Fujian provinces and Beijing municipality. In each, migrant women who died between July 1, 2010 and October 1, 2011 were identified through reports from China's Maternal and Child Mortality Surveillance System. For each, four matched controls were selected from migrant women who delivered in local hospitals during the same period. We compared socio-demographic characteristics, health status and health service variables between cases and controls, and used bivariate and multivariate conditional logistic regression analyses to determine associations with and risk factors for maternal death. RESULTS: 109 cases and 436 controls were assessed. Family income <2000 yuan per month (OR = 4.5; 95% CI 1.7-11.7) and lack of health insurance (OR = 1.3; 95% CI 1.1-1.6) were more common amongst women who died, as were lack of antenatal care (ANC) (OR = 22.3; 95% CI 4.3-116.0) and attending ANC only 1-4 times (OR = 5.0; 95% CI 1.6-15.5). Knowledge of danger signs during delivery was less common in this group (OR = 0.3; 95% CI 0.1-0.8). CONCLUSION: Differences existed between migrant women who died in pregnancy and surviving controls. The identified risk factors suggest strategies for health sector and community action on reducing maternal mortality among migrant women in China. A systematic approach to maternity care for rural-urban migrant women is recommended.

Intensification of integrated immunization services to recover routine vaccination coverage and bring COVID-19 vaccine to the population of Iraq in 2022.

INTRODUCTION: COVID-19 seriously impacted routine immunization (RI) in Iraq. Coverage declined to a 6-year low in 2021, and COVID-19 vaccination uptake was slow. In response, government implemented intensification of integrated immunization services (3IS), a nationwide approach comprising regular outreach sessions of COVID-19 vaccination and RI for children who had either missed doses or never commenced scheduled vaccination (zero-dose children). We describe the 3IS and its impact on vaccination coverage in Iraq. METHODS: 3IS comprised new outreach sessions for urban and rural communities where administrative data suggested there were gaps in coverage. Groups of six personnel from each of 1,321 primary healthcare centres implemented six outreach sessions per month during February-November 2022. Community engagement was an integral component. We compared RI administrative data (2019-2022) and data reported during 3IS activities to assess its impact. RESULTS: In total 4,189,859 vaccine doses were administered during 72,495 3IS outreach sessions, over one-fifth of 19,106,849 vaccine doses administered in Iraq over these 10 months. Among them, 957,874 (22.9 %) were COVID-19 vaccines, adding slightly to national coverage, and 3,231,985 (77.1 %) were RI vaccines, dramatically reducing zero-dose children, adding 18 %, 25 %, 21 %, and 31 % to 2022 penta1, penta3, measles first-dose and MMR1 vaccine coverage, and contributing to national coverage of 102.2 %, 94.5 %, 91.8 % and 96.3 % for these vaccines during February-November, respectively. Moreover, 3IS sessions delivered 133,528 doses of tetanus toxoid, 16,353 doses of adult HepB vaccine, and 315,032 vitamin A doses to eligible individuals. CONCLUSION: In the context of global encouragement to integrate vaccination services, Iraq's 3IS approach enabled dramatic improvements in RI coverage, virtual elimination of zero-dose status among children born during the pandemic, and small improvements in COVID-19 and adult vaccination. Our findings provide lessons for future integrated primary care towards universal health coverage in Iraq, and for other countries yet to undertake integration.

Breastfeeding rates in central and western China in 2010: implications for child and population health.

OBJECTIVE: To describe breastfeeding practices in rural China using globally recommended indicators and to compare them with practices in neighbouring countries and large emerging economies. METHODS: A community-based, cross-sectional survey of 2354 children younger than 2 years in 26 poor, rural counties in 12 central and western provinces was conducted. Associations between indicators of infant and young child feeding and socioeconomic, demographic and health service variables were explored and rates were compared with the most recent data from China and other nations. FINDINGS: Overall, 98.3% of infants had been breastfed. However, only 59.4% had initiated breastfeeding early (i.e. within 1 hour of birth); only 55.5% and 9.4% had continued breastfeeding for 1 and 2 years, respectively, and only 28.7% of infants younger than 6 months had been exclusively breastfed. Early initiation of breastfeeding was positively associated with at least five antenatal clinic visits (adjusted odds ratio, aOR: 3.48; P < 0.001) and negatively associated with delivery by Caesarean (aOR: 0.53; P < 0.001) or in a referral-level facility (aOR: 0.6; P = 0.014). Exclusive breastfeeding among children younger than 6 months was positively associated with delivery in a referral-level facility (aOR: 2.22; P < 0.05). Breastfeeding was not associated with maternal age or education, ethnicity or household wealth. Surveyed rates of exclusive and continued breastfeeding were mostly lower than in other nations. CONCLUSION: Despite efforts to promote breastfeeding in China, rates are very low. A commitment to improve infant and young child feeding is needed to reduce mortality and morbidity.

Considering equity and cost-effectiveness in assessing a parenting intervention to promote early childhood development in rural Vietnam.

Considering equity in early childhood development (ECD) is important to ensure healthy development for every child. Equity-informative cost-effectiveness analysis can further guide decision makers to maximize outcomes with limited resources while promoting equity. This cost-effectiveness study aimed to examine the equity impacts of a multicomponent ECD intervention in rural Vietnam. We estimated the cost-effectiveness of the intervention with a 30-month time horizon from the service provider and household perspectives with equity considerations. Data were from a cluster-randomized controlled trial comparing the intervention with the local standard of care. The incremental cost-effectiveness ratios (ICERs) per child cognitive development score gained were estimated by household wealth quintile and maternal education level, adjusted for cluster effects and baseline characteristics such as maternal parity and age. A 3% discount rate was applied to costs, and non-parametric cluster bootstrapping was used to examine uncertainty around ICERs. Children in the intervention had higher cognitive development scores than those in the control arm across all subgroups. Based on intervention recurrent cost, the ICER per cognitive development score gained was lower in children from the poorest quintile (-US$6) compared to those from the richest quintile (US$16). Similarly, the ICER per cognitive development score gained was lower in children whose mothers had the lowest education level (-US$0.02) than those with mothers who had the highest education level (US$7). Even though our findings should be interpreted with caution due to the insufficient study power, the findings suggest that the intervention could promote equity while improving child cognitive development with greater cost-effectiveness in disadvantaged groups.

Structured, multicomponent, community-based programme for women's health and infant health and development in rural Vietnam: a parallel-group cluster randomised controlled trial.

BACKGROUND: Interventions to improve early childhood development have previously addressed only one or a few risk factors. Learning Clubs is a structured, facilitated, multicomponent programme designed to address eight potentially modifiable risk factors, and offered from mid-pregnancy to 12 months post partum; we aimed to establish whether this programme could improve the cognitive development of children at 2 years of age. METHODS: For this parallel-group cluster-randomised controlled trial, 84 of 116 communes (the clustering unit) in HaNam Province in rural Vietnam were randomly selected and randomly assigned to receive the Learning Clubs intervention (n=42) or usual care (n=42). Women aged at least 18 years who were pregnant (gestational age <20 weeks) were eligible for inclusion. Data sources were standardised, and study-specific questionnaires assessing risks and outcomes were completed in interviews in mid-pregnancy (baseline), late pregnancy (after 32 weeks of gestation), at 6-12 months post partum, and at the end of the study period when children were 2 years of age. Mixed-effects models were used to estimate trial effects, adjusting for clustering. The primary outcome was the cognitive development of children at 2 years of age, assessed by the Bayley Scales of Infant and Toddler Development Third Edition (Bayley-III) cognitive score. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12617000442303). FINDINGS: Between April 28, 2018, and May 30, 2018, 1380 women were screened and 1245 were randomly assigned (669 to the intervention group and 576 to the control group). Data collection was completed on Jan 17, 2021. Data at the end of the study period were contributed by 616 (92%) of 669 women and their children in the intervention group, and by 544 (94%) of 576 women and their children in the control group. Children aged 2 years in the intervention group had significantly higher mean Bayley-III cognitive scores than those in the control group (99·6 [SD 9·7] vs 95·6 [9·4]; mean difference 4·00 [95% CI 2·56-5·43]; p<0·0001). At 2 years of age, 19 (3%) children in the intervention group had Bayley-III scores less than 1 SD, compared with 32 (6%) children in the control group, but this difference was not significant (odds ratio 0·55 [95% CI 0·26-1·17]; p=0·12). There were no significant differences between groups in maternal, fetal, newborn, or child deaths. INTERPRETATION: A facilitated, structured, community-based, multicomponent group programme improved early childhood development to the standardised mean in rural Vietnam and could be implemented in other similarly resource-constrained settings. FUNDING: Australian National Health and Medical Research Council and Grand Challenges Canada Saving Brains Initiative. TRANSLATION: For the Vietnamese translation of the abstract see Supplementary Materials section.

Promoting early childhood development in Viet Nam: cost-effectiveness analysis alongside a cluster-randomised trial.

BACKGROUND: Economic evaluations are critical to ensure effective resource use to implement and scale up child development interventions. This study aimed to estimate the cost-effectiveness of a multicomponent early childhood development intervention in rural Viet Nam. METHODS: We did a cost-effectiveness study alongside a cluster-randomised trial with a 30-month time horizon. The study included 669 mothers from 42 communes in the intervention group, and 576 mothers from 42 communes in the control group. Mothers in the intervention group attended Learning Clubs sessions from mid-pregnancy to 12 months after delivery. The primary outcomes were child cognitive, language, motor, and social-emotional development at age 2 years. In this analysis, we estimated the incremental cost-effectiveness ratios (ICERs) of the intervention compared with the usual standard of care from the service provider and household perspectives. We used non-parametric bootstrapping to examine uncertainty, and applied a 3% discount rate. FINDINGS: The total intervention cost was US$169 898 (start-up cost $133 692 and recurrent cost $36 206). The recurrent cost per child was $58 (1 341 741 Vietnamese dong). Considering the recurrent cost alone, the base-case ICER was $14 and mean ICER of 1000 bootstrap samples was $14 (95% CI -0·48 to 30) per cognitive development score gained with a 3% discount rate to costs. The ICER per language and motor development score gained was $22 and $20, respectively, with a 3% discount rate to costs. INTERPRETATION: The intervention was cost-effective: the ICER per child cognitive development score gained was 0·5% of Viet Nam's gross domestic product per capita, alongside other benefits in language and motor development. This finding supports the scaling up of this intervention in similar socioeconomic settings. FUNDING: Australian National Health and Medical Research Council and Grand Challenges Canada. TRANSLATION: For the Vietnamese translation of the abstract see Supplementary Materials section.

Donated breast milk substitutes and incidence of diarrhoea among infants and young children after the May 2006 earthquake in Yogyakarta and Central Java.

OBJECTIVE: Distribution of breast milk substitutes (BMS) after the 2006 Yogyakarta earthquake was uncontrolled and widespread. We assessed the magnitude of BMS distribution after the earthquake, its impact on feeding practices and the association between consumption of infant formula and diarrhoea among infants and young children. DESIGN: One month after the earthquake, caregivers of 831 children aged 0-23 months were surveyed regarding receipt of unsolicited donations of BMS, and on recent child-feeding practices and diarrhoeal illness. SETTING: Community-level survey in an earthquake-affected district. SUBJECTS: Primary caregivers of surveyed children. RESULTS: In all, 75 % of households with an infant aged 0-5 months and 80 % of all households surveyed received donated infant formula; 76 % of all households received commercial porridge and 49 % received powdered milk. Only 32 % of 0-5-month-old infants had consumed formula before the earthquake, but 43 % had in the 24 h preceding the survey (P < 0·001). Consumption of all types of BMS was significantly higher among those who received donated commodities, regardless of age (P < 0·01). One-week diarrhoea incidence among those who received donated infant formula (25·4 %) was higher than among those who did not (11·5 %; relative risk = 2·12, 95 % CI = 1·34, 3·35). The rate of diarrhoea among those aged 12-23 months was around five times the pre-earthquake rate. CONCLUSIONS: There were strong associations between receipt of BMS and changes in feeding practices, and between receipt of infant formula and diarrhoea. Uncontrolled distribution of infant formula exacerbates the risk of diarrhoea among infants and young children in emergencies.

A rapid assessment of the political economy of health at district level, with a focus on maternal, newborn and child health, in Bangladesh, Indonesia, Nepal and the Philippines.

Low- and middle-income countries (LMICs) face many challenges and competing demands in the health sector, including maternal and newborn mortality. The allocation of financial and human resources for maximum health impact is important for social and economic development. Governments must prioritize carefully and allocate scarce resources to maximum effect, but also in ways that are politically acceptable, financially and institutionally feasible, and sustainable. Political economy analysis (PEA)-that gets what, when and why-can help explain that prioritization process. We used PEA to investigate how four Asian LMICs (Bangladesh, Indonesia, Nepal and the Philippines) allocate and utilize resources for maternal, newborn and child health (MNCH). Using mixed research methods including a literature review, field interviews at national and sub-national level, and policy, process and budget analysis in each country, we examined three political economy issues: (1) do these countries demonstrably prioritize MNCH at policy level; (2) if so, is this reflected in the allocation of financial and other resources and (3) if resources are allocated to MNCH, do they achieve the intended outputs and outcomes through actual programme implementation? We also considered the influence of transnational developments. We found that all four countries demonstrate political commitment to health, including MNCH. However, the health sector receives comparatively low public financing, governments often do not follow through on plans or pronouncements, and capacity for related action varies widely. Poor governance and decentralization, lack of data for monitoring and evaluation of progress, and weak public sector human resource capacity were frequent problems; engagement of the private or non-government sectors is an important consideration. Opportunities exist to greatly improve equity and MNCH outcomes in these nations, using a mix of evidence, improved governance, social engagement and the media to influence decisions, increase resource allocation to and improve accountability in the health sector.

Protocol for an economic evaluation alongside a cluster randomised controlled trial: cost-effectiveness of Learning Clubs, a multicomponent intervention to improve women's health and infant's health and development in Vietnam.

INTRODUCTION: Economic evaluations of complex interventions in early child development are required to guide policy and programme development, but a few are yet available. METHODS AND ANALYSIS: Although significant gains have been made in maternal and child health in resource-constrained environments, this has mainly been concentrated on improving physical health. The Learning Clubs programme addresses both physical and mental child and maternal health. This study is an economic evaluation of a cluster randomised controlled trial of the impact of the Learning Clubs programme in Vietnam. It will be conducted from a societal perspective and aims to identify the cost-effectiveness and the economic and social returns of the intervention. A total of 1008 pregnant women recruited from 84 communes in a rural province in Vietnam will be included in the evaluation. Health and cost data will be gathered at three stages of the trial and used to calculate incremental cost-effectiveness ratios per percentage point improvement of infant's development, infant's health and maternal common mental disorders expressed in quality-adjusted life years gained. The return on investment will be calculated based on improvements in productivity, the results being expressed as benefit-cost ratios. ETHICS AND DISSEMINATION: The trial was approved by Monash University Human Research Ethics Committee (Certificate Number 2016-0683), Australia, and approval was extended to include the economic evaluation (Amendment Review Number 2018-0683-23806); and the Institutional Review Board of the Hanoi School of Public Health (Certificate Number 017-377IDD- YTCC), Vietnam. Results will be disseminated through academic journals and conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12617000442303.