Global core indicators for measuring WHO's paediatric quality-of-care standards in health facilities: development and expert consensus.

BACKGROUND: There are currently no global recommendations on a parsimonious and robust set of indicators that can be measured routinely or periodically to monitor quality of hospital care for children and young adolescents. We describe a systematic methodology used to prioritize and define a core set of such indicators and their metadata for progress tracking, accountability, learning and improvement, at facility, (sub) national, national, and global levels. METHODS: We used a deductive methodology which involved the use of the World Health Organization Standards for improving the quality-of-care for children and young adolescents in health facilities as the organizing framework for indicator development. The entire process involved 9 complementary steps which included: a rapid literature review of available evidence, the application of a peer-reviewed systematic algorithm for indicator systematization and prioritization, and multiple iterative expert consultations to establish consensus on the proposed indicators and their metadata. RESULTS: We derived a robust set of 25 core indicators and their metadata, representing all 8 World Health Organization quality standards, 40 quality statements and 520 quality measures. Most of these indicators are process-related (64%) and 20% are outcome/impact indicators. A large proportion (84%) of indicators were proposed for measurement at both outpatient and inpatient levels. By virtue of being a parsimonious set and given the stringent criteria for prioritizing indicators with "quality measurement" attributes, the recommended set is not evenly distributed across the 8 quality standards. CONCLUSIONS: To support ongoing global and national initiatives around paediatric quality-of-care programming at country level, the recommended indicators can be adopted using a tiered approach that considers indicator measurability in the short-, medium-, and long-terms, within the context of the country's health information system readiness and maturity. However, there is a need for further research to assess the feasibility of implementing these indicators across contexts, and the need for their validation for global common reporting.

Understanding mother and child health-seeking behavior in urban Pakistan.

Pakistan has long held one of the highest rates in the world for mother and child mortality, albeit the leading causes of death are largely preventable. Unlike many other low and middle-income countries (LMIC), however, limited research has been conducted within conflict-ridden LMIC like Pakistan on health-seeking behavior. Even less is known about more developed localities within these nations. Between May and June 2016, a pre-tested cross-sectional pilot study was conducted in Islamabad. Seventy mothers were surveyed, and data were used to run descriptive analyses and generate multivariable regression models to evaluate a mother's desire to solicit medical attention. Mothers had higher self-health seeking behavioral scores if they were more likely to pursue care for their children and vice versa. In situations that potentially warranted medical intervention, they were also 1.84 times more likely to solicit care for their children than for themselves. While most women were inclined to take their children to an established provider for a variety of illnesses, many still faced prominent barriers to accessing healthcare. To improve population health in developing nations like Pakistan, evidence-based methods should be adopted that increase healthcare accessibility, improve health awareness, and prioritize the health status of everyone in the family.

Adolescent sexual and reproductive health in sub-Saharan Africa: who is left behind?

Adolescent sexual and reproductive health (ASRH) continues to be a major public health challenge in sub-Saharan Africa where child marriage, adolescent childbearing, HIV transmission and low coverage of modern contraceptives are common in many countries. The evidence is still limited on inequalities in ASRH by gender, education, urban-rural residence and household wealth for many critical areas of sexual initiation, fertility, marriage, HIV, condom use and use of modern contraceptives for family planning. We conducted a review of published literature, a synthesis of national representative Demographic and Health Surveys data for 33 countries in sub-Saharan Africa, and analyses of recent trends of 10 countries with surveys in around 2004, 2010 and 2015. Our analysis demonstrates major inequalities and uneven progress in many key ASRH indicators within sub-Saharan Africa. Gender gaps are large with little evidence of change in gaps in age at sexual debut and first marriage, resulting in adolescent girls remaining particularly vulnerable to poor sexual health outcomes. There are also major and persistent inequalities in ASRH indicators by education, urban-rural residence and economic status of the household which need to be addressed to make progress towards the goal of equity as part of the sustainable development goals and universal health coverage. These persistent inequalities suggest the need for multisectoral approaches, which address the structural issues underlying poor ASRH, such as education, poverty, gender-based violence and lack of economic opportunity.

Using a peer mentorship approach improved the use of neonatal continuous positive airway pressure and related outcomes in Malawi.

AIM: This study evaluated whether peer mentorship was an effective and sustainable way of improving and maintaining knowledge and skills on neonatal continuous positive airway pressure (CPAP) in a low-resource setting with a high turnover of healthcare providers. METHODS: The Malawi Ministry of Health recruited five nurses with considerable CPAP experience and provided them with mentorship training from July to August 2014. The mentors then provided 1-week on-site mentorship for 113 colleagues at 10 secondary and one tertiary hospital where gaps in neonatal CPAP use had been identified. CPAP competencies and outcomes were compared 3 months before and after each mentorship. RESULTS: In the 3 months before and after mentorship, the average CPAP competency score increased from 32 ± 4% to 97 ± 2%, while CPAP usage increased from 7% to 23% among eligible neonates. Survival following CPAP mentorship increased from 23% to 35%, but this was not significant due to the small sample size. Both mentees and mentors reported useful transfers of knowledge and skills when using CPAP. CONCLUSION: Mentorship effectively bridged the knowledge and skills gaps among health workers and increased CPAP use, competency scores and survival rates.

Maternal short stature and under-weight status are independent risk factors for preterm birth and small for gestational age in rural Bangladesh.

BACKGROUND/OBJECTIVES: To estimate the risks of term-small for gestational age (SGA), preterm-appropriate for gestational age (AGA), and preterm SGA associated with maternal height and body mass index (BMI) and to calculate the population attributable fractions (PAF) of term SGA, preterm AGA, and preterm SGA associated with maternal short stature. SUBJECTS/METHODS: A population-based cohort of 13,230 women with pre-pregnancy height and weight followed from 2012 to 2016 in Sylhet, Bangladesh. We analyzed data of 2655 singleton live born infants. The babies born <37 weeks of gestation were considered preterm and weight <10th percentile of Intergrowth sex-specific gestational age were considered SGA. Risk factors for term SGA, preterm AGA, and preterm SGA were examined using multinomial logistic regression that estimated relative risk ratios (RRR) and 95% confidence intervals (CI). RESULTS: Maternal short stature <145 cm was significantly associated with term SGA (RRR 1.88, 95% CI 1.37, 2.58; p < 0.001), preterm AGA (RRR 1.45, 95% CI 1.02, 2.05; p < 0.05), and preterm SGA (RRR 14.40, 95% CI 1.82, 113.85; p < 0.05). Maternal underweight status (BMI < 18.5 kg/m2) was significant predictor of term SGA (RRR 1.32, 95% CI 1.10, 1.59; p < 0.01), and preterm AGA (RRR 1.39, 95% CI 1.12, 1.71; p < 0.01). PAF for maternal short stature were 23.2, 7.3, and 73.9% for term SGA, preterm AGA, and preterm SGA, respectively. CONCLUSIONS: To address the problem of undernutrition, Bangladesh needs to strengthen implementation of its multi-sectoral nutrition program comprising nutrition specific and sensitive interventions. Implementation of the program with high coverage and quality would improve maternal nutrition and perinatal outcomes including preterm births and SGA.

Differences in prevalence and determinants of hypertension according to rural-urban place of residence among adults in Bangladesh.

This cross-sectional study analysed Bangladesh Demographic and Health Survey 2011 data with the aim of investigating the prevalence of, and risk factors for, hypertension in individuals aged over 35 by rural-urban place of residence. After estimation of the stratified prevalence of hypertension by background characteristics, multivariable logistic regression analysis was conducted to calculate the adjusted odds (AORs) and 95% confidence intervals (CIs) for selected factors. Of the 7839 participants, 1830 were from urban areas and 6009 from rural areas. The overall prevalence of hypertension was 32.6% (95% CI: 30.5-34.8) in urban areas and 23.6% (95% CI: 22.5-24.7) in rural areas. The prevalence and odds of hypertension increased with increasing age, female sex, concomitant diabetes and overweight/obesity and richer wealth status in both urban and rural regions. Although residence in Khulna and Rangpur divisions and higher education level were associated with increased odds of hypertension in urban regions, this was not the case in rural regions (p>0.05). Residence in Sylhet and Chittagong divisions had lower odds of hypertension in rural regions. Furthermore, the proportions of overweight/obese, diabetic and higher wealth status participants were higher in urban than in rural regions. The prevalence and odds of hypertension were found to be associated with several common factors after stratifying by place of residence. Some of these factors are more concentrated in urban regions, so urban residents with these risk factors need to be made more aware of these in order to control hypertension in Bangladesh. Public health programmes also need to be tailored differently for urban and rural regions, based on the different distribution of these significant factors in the two areas.

Sex differences in prevalence and associated factors of prehypertension and hypertension among Bangladeshi adults.

Globally, complications of raised blood pressure are fundamental public health issues. There has been limited research if prevalence and risk factors vary by sex in many countries, including Bangladesh. We stratified the prevalence and associated factors of prehypertension and hypertension according to sex in Bangladesh. This cross-sectional study analyzed the Bangladesh Demographic and Health Survey 2011 data. After estimating prevalence according to sex, multilevel logistic regression was applied to obtain associated factors. This study analyzed data of 3876 males and 3962 females aged ≥35 years. The prevalence of hypertension was 19.4% (95% confidence interval [CI]: 18.0-21.0) among males and 31.9% (95% CI: 30.1-33.6) among females. Among both males and females, prevalence and odds of hypertension increased with age, overweight/obesity, diabetes, upper wealth status, and residence in some divisions. Education level was a significant positive correlate of hypertension for males only. Males and females had similar prevalence of prehypertension, 27.2% (95% CI: 25.6-28.8) and 27.6% (95% CI: 26.0-29.2), respectively. Characteristics such as older age, overweight/obesity, and diabetes were associated with higher prevalence and odds of prehypertension among females; prehypertension among males was associated with advancing age, overweight/obesity, education level, wealth status, and division of residence. In Bangladesh, almost half of the males and females could have increased risks of complications resulting from hypertension and prehypertension. Addressing the characteristics associated with higher prevalence or odds of these conditions is crucial. Several common risk factors indicate that a common prevention and control strategy could work for both sexes.

Determinants of hypertension among adults in Bangladesh as per the Joint National Committee 7 and 2017 American College of Cardiology/American Hypertension Association hypertension guidelines.

We investigated determinants of hypertension in Bangladesh using both Joint National Committee 7 (JNC7) and 2017 American College of Cardiology/American Hypertension Association (2017 ACC/AHA) guidelines. After reporting background characteristics, odds ratios (ORs) were obtained by multilevel logistic regression. Among 7839 respondents aged ≥35 years, 25.7% (n = 2016) and 48.0% (n = 3767) respondents had hypertension as per the JNC7 and 2017 ACC/AHA guidelines, respectively. The following factors were significant according to the 2017 ACC/AHA guideline: ≥65 years (adjusted OR [AOR]: 2.4, 95% confidence interval [CI]: 2.2-3.0), 55-64 years (AOR: 1.6, 95% CI: 1.4-1.9), and 45-54 years (AOR: 1.4, 95% CI: 1.3-1.6) age groups, females (AOR: 2.0, 95% CI: 1.7-2.2), overweight/obesity (AOR: 2.4, 95% CI: 2.0-2.8), diabetes (AOR: 1.4, 95% CI: 1.2-1.6), secondary (AOR: 1.2, 95% CI: 1.1-1.4), or college education level (AOR: 1.8, 95% CI: 1.4-2.3), middle (AOR: 1.3, 95% CI: 1.1-1.6), richer (AOR: 1.5, 95% CI: 1.2-1.8) or richest (AOR: 2.0, 95% CI: 1.6-2.4) wealth quintiles, residence in Khulna (AOR: 1.5, 95% CI: 1.2-1.9), and Rangpur (AOR: 1.7, 95% CI: 1.3-2.2) divisions. All factors were significant as per the JNC7 guideline too. Both guidelines found similar determinants. Prevention and control programs should prioritize increasing awareness among people with higher likelihood of hypertension.

Levels and correlates of nutritional status of women of childbearing age in rural Bangladesh.

OBJECTIVE: The present study examined the prevalence of and risk factors for malnutrition in a population-based cohort of women of childbearing age in rural Bangladesh. DESIGN: A cross-sectional study that collected pre-pregnancy weight, height, and data on selected risk factors for nutritional status of women. SETTING: The study was conducted in Sylhet District of Bangladesh. SUBJECTS: Study subjects included 13 230 non-pregnant women of childbearing age. Women were classified into underweight (<18·5 kg/m2), normal (18·5-24·9 kg/m2) and overweight/obese (≥25·0 kg/m2) using BMI; and into moderate to severe stunting (<150 cm), mild stunting (150-<155 cm) and normal (≥155 cm) using height. Two multinomial logistic regression models were fitted for BMI: model 1 examined individual and household factors associated with BMI, and model 2 additionally examined the association of community variables. The same analysis was conducted for height. RESULTS: Prevalence of underweight, overweight/obesity and moderate to severe stunting was 37·0, 7·2 and 48·6 %, respectively. Women's education and household wealth were inversely related to both underweight status and stunting. Underweight rate was significantly lower in the post-harvest season. Women with any education and who belonged to households with higher wealth were more likely to be overweight/obese. CONCLUSIONS: The study documented high underweight and stunting, and moderate overweight/obesity rates among rural Bangladeshi women; and recommends design and implementation of a multidimensional intervention programme based on individual-, household- and community-level risk factors that can address underweight, stunting and overweight/obesity to improve the nutritional status of women of childbearing age in Bangladesh.

The new 2017 ACC/AHA guideline for classification of hypertension: changes in prevalence of hypertension among adults in Bangladesh.

We analyzed the Bangladesh Demographic and Health Survey 2011 data to examine absolute differences in hypertension prevalence according to the hypertension definition of the "2017 American College of Cardiology/American Heart Association (2017 ACC/AHA) Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults" and "Seventh Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC7)" 2003 guidelines. Among 7839 participants ≥35 years, the JNC7 and 2017 ACC/AHA classified 25.7% (95% confidence interval (CI): 24.5-27.0%) and 48.0% (95% CI: 46.4-49.7%) people hypertensive, respectively. The JNC7 prevalence was 19.4% (95% CI: 18.0-21.0%) among males and 31.9% (95% CI: 30.1-33.6%) among females. The prevalence was 41.4% (95% CI: 39.4-43.5%) among males and 54.5% (95% CI: 52.4-56.4%) among females as per the 2017 ACC/AHA guideline. From JNC7 to 2017 ACC/AHA, the overall difference in prevalence was 22.3% (95% CI: 19.8-24.8%). Males and females had similar differences, 22.0% (95% CI: 18.3-25.7%) and 22.6% (95% CI: 19.4-26.0%), respectively. As per the 2017 ACC/AHA guideline, >50% prevalence was observed among people with body mass index ≥25 kg/m2, college-level education, co-morbid diabetes, richest wealth quintile, females, age ≥55 years, urban residence, or living in Khulna, Rangpur or Dhaka divisions; the absolute difference was >20% in most categories. We found a substantial increase in the prevalence of hypertension due to change in blood pressure thresholds as per the 2017 ACC/AHA guideline. We recommend conducting more comprehensive population-based studies to estimate the recent burden of hypertension in Bangladesh. Future studies should estimate similar prevalence in other countries.

Determinants of early neonatal mortality in Afghanistan: an analysis of the Demographic and Health Survey 2015.

BACKGROUND: Neonatal mortality is declining slowly compared to under-five mortality in many developing countries including Afghanistan. About three-fourths of these deaths occur in the early neonatal period (i.e., the first week of life). Although a number of studies investigated determinants of early neonatal mortality in other countries, there is a lack of evidence regarding this in Afghanistan. This study investigated determinants of early neonatal mortality in Afghanistan. METHODS: Data from the Afghanistan Demographic and Health Survey 2015 (AfDHS 2015) were analyzed. After reporting the weighted frequency distributions of selected factors, a multilevel logistic regression model revealed adjusted associations of factors with early neonatal mortality. RESULTS: A total of 19,801 weighted live-births were included in our analysis; 266 (1.4%) of the newborns died in this period. Multivariable analysis found that multiple gestations (adjusted odds ratio (AOR): 9.3; 95% confidence interval (CI): 5.7-15.0), larger (AOR: 2.9; 95% CI: 2.2-3.8) and smaller (AOR: 1.8; 95% CI: 1.2-2.6) than average birth size, maternal age ≤ 18 years (AOR: 1.8; 95% CI: 1.1-3.2) and ≥ 35 years (AOR: 1.7; 95% CI: 1.3-2.3), and birth interval of < 2 years (AOR: 2.6; 95% CI: 1.4-4.9) had higher odds of early neonatal mortality. On the other hand, antenatal care by a skilled provider (AOR: 0.7; 95% CI: 0.5-0.9), facility delivery (AOR: 0.7; 955 CI: 0.5-0.9), paternal higher education level (AOR: 0.7; 95% CI: 0.5-1.0), living in north-western (AOR: 0.3; 95% CI: 0.1-0.6), central-western regions (AOR: 0.5; 95% CI: 0.3-0.9) and in a community with higher maternal education level (AOR: 0.4; 95% CI: 0.2-0.9) had negative association. CONCLUSIONS: Several individual, maternal and community level factors influence early neonatal deaths in Afghanistan; significance of the elements of multiple levels indicates that neonatal survival programs should follow a multifaceted approach to incorporate these associated factors. Programs should focus on birth interval prolongation with the promotion of family planning services, utilization of antenatal care and institutional delivery services along with management of preterm and sick infants to prevent this large number of deaths in this period.

A comparison of practices, distributions and determinants of birth attendance in two divisions with highest and lowest skilled delivery attendance in Bangladesh.

BACKGROUND: Delivery by skilled birth attendants (SBAs) is strongly recommended to reduce maternal and neonatal mortality. The percentage of births attended by SBAs is low in Bangladesh (42% in 2014), though this rate varies widely by divisions, with the highest 58% in Khulna and only 27% in Sylhet. Comparing and critically analyzing the practices, distributions and determinants of delivery attendance in two divisions with the highest and lowest SBA attendance could help to understand the differences and to employ the findings of the high-performing division to the low-performing division. METHODS: The 7th Bangladesh Demographic and Health Survey (BDHS 2014) data were analyzed. After reporting the types of delivery attendants, logistic regression analyses were applied to calculate the odds ratios of determinants of deliveries attended by SBAs. RESULTS: SBAs attended 225 (58.6%) and 128 (27.4%) deliveries in Khulna and Sylhet, respectively. Khulna had higher birth attendance by qualified doctors (42.5%, n = 163) than Sylhet (15.8%, n = 74). Sylhet had higher attendance by traditional attendants (60.8%, n = 285) than Khulna (33.7%, n = 129). In both regions, attendance by community skilled birth attendants (CSBAs) was very low (< 1%). Khulna had higher percentages of women with higher education level, husbands' higher education, antenatal care (ANC) visits by SBAs, and higher wealth quintiles than Sylhet. In multivariable analyses, higher education level (adjusted odds ratio (AOR): 8.4; 95% confidence interval (CI): 1.9-36.7), ANC visits (AOR: 3.6; 95% CI: 2.0-6.5), family planning workers' visit (AOR: 3.0; 95% CI: 1.6-5.4), and belonging to richer (AOR: 2.6; 95% CI: 1.4-5.1) or richest (AOR: 3.8; 95% CI: 1.9-7.6) household wealth quintiles had significant positive associations with deliveries by SBAs in Sylhet. Similarly, ANC visits (AOR: 2.5; 95% CI: 1.4-4.6) and higher wealth quintile (AOR: 4.7; 95% CI: 1.9-11.5) were positive predictors in Khulna. CONCLUSIONS: The higher proportion of educated women and their husbands, wealth status and ANC visits were associated with higher SBA utilization in Khulna compared to Sylhet. Improvement of socioeconomic status, increasing birth attendant awareness programs, providing ANC services, and family-planning workers' visits could increase the proportion of SBA-attended deliveries in Sylhet Division. CSBA program should be re-evaluated for both divisions.