Reasons for Being "Zero-Dose and Under-Vaccinated" among Children Aged 12-23 Months in the Democratic Republic of the Congo.

(1) Introduction: The Democratic Republic of the Congo (DRC) has one of the largest cohorts of un- and under-vaccinated children worldwide. This study aimed to identify and compare the main reasons for there being zero-dose (ZD) or under-vaccinated children in the DRC. (2) Methods: This is a secondary analysis derived from a province-level vaccination coverage survey conducted between November 2021 and February 2022; this survey included questions about the reasons for not receiving one or more vaccines. A zero-dose child (ZD) was a person aged 12-23 months not having received any pentavalent vaccine (diphtheria-tetanus-pertussis-Hemophilus influenzae type b (Hib)-Hepatitis B) as per card or caregiver recall and an under-vaccinated child was one who had not received the third dose of the pentavalent vaccine. The proportions of the reasons for non-vaccination were first presented using the WHO-endorsed behavioral and social drivers for vaccination (BeSD) conceptual framework and then compared across the groups of ZD and under-vaccinated children using the Rao-Scott chi-square test; analyses were conducted at province and national level, and accounting for the sample approach. (3) Results: Of the 51,054 children aged 12-23 m in the survey sample, 19,676 ZD and under-vaccinated children were included in the study. For the ZD children, reasons related to people's thinking and feelings were cited as 64.03% and those related to social reasons as 31.13%; both proportions were higher than for under-vaccinated children (44.7% and 26.2%, respectively, p < 0.001). Regarding intentions to vaccinate their children, 82.15% of the parents/guardians of the ZD children said they wanted their children to receive "none" of the recommended vaccines, which was significantly higher than for the under-vaccinated children. In contrast, "practical issues" were cited for 35.60% of the ZD children, compared to 55.60% for the under-vaccinated children (p < 0.001). The distribution of reasons varied between provinces, e.g., 12 of the 26 provinces had a proportion of reasons for the ZD children relating to practical issues that was higher than the national level. (4) Conclusions: reasons provided for non-vaccination among the ZD children in the DRC were largely related to lack of parental/guardian motivation to have their children vaccinated, while reasons among under-vaccinated children were mostly related to practical issues. These results can help inform decision-makers to direct vaccination interventions.

"Zero Dose" Children in the Democratic Republic of the Congo: How Many and Who Are They?

(1) Background: The Democratic Republic of the Congo (DRC) is one of the countries with the highest number of never vaccinated or "zero-dose" (ZD) children in the world. This study was conducted to examine the proportion of ZD children and associated factors in the DRC. (2) Methods: Child and household data from a provincial-level vaccination coverage survey conducted between November 2021-February 2021 and 2022 were used. ZD was defined as a child aged 12 to 23 months who had not received any dose of pentavalent (diphtheria-tetanus-pertussis-Haemophilus influenzae type b (Hib)-Hepatitis B) vaccine (by card or recall). The proportion of ZD children was calculated and associated factors were explored using logistic regression, taking into account the complex sampling approach. (3) Results: The study included 51,054 children. The proportion of ZD children was 19.1% (95%CI: 19.0-19.2%); ZD ranged from 62.4% in Tshopo to 2.4% in Haut Lomami. After adjustment, being ZD was associated with low level of maternal education and having a young mother/guardian (aged ≤ 19 years); religious affiliation (willful failure to disclose religious affiliation as the highest associated factor compared to being Catholic, followed by Muslims, revival/independent church, Kimbanguist, Protestant); proxies for wealth such as not having a telephone or a radio; having to pay for a vaccination card or for another immunization-related service; not being able to name any vaccine-preventable disease. A child's lack of civil registration was also associated with being ZD. (4) Conclusions: In 2021, one in five children aged 12-23 months in DRC had never been vaccinated. The factors associated with being a ZD child suggest inequalities in vaccination that must be further explored to better target appropriate interventions.

Infection, nutritional status, and body composition: Associations at birth and 6 months postnatally in Soweto, South Africa.

INTRODUCTION: The impact of infection on infant nutritional status, body size, and growth is well documented. However, research into the impact of infection on infant body composition is limited. Greater understanding is, therefore, needed on the effects of infection in early life. METHODS: Associations between a composite morbidity index consisting of the sum of the cumulative tallies for a range of symptoms representing infection and morbidity in the infants and nutritional status (height-for-age (HAZ), and weight-for-height (WHZ)), and body composition (fat-free mass (FFM), fat mass (FM), fat-free mass index (FFMI), and fat mass index (FMI)) at 6 months of age were investigated using hierarchical regression analysis. RESULTS: The sample comprised data between birth and 6 months postnatally, of 156 infants who were a priori born healthy in Soweto, South Africa. Morbidity, over the cumulative period of birth to 6 months, was associated with lower FMI (ß = -1.77) and lower FM (ß = -0.61), and conversely with higher FFM (ß = 0.94), in infants at 6 months. No associations were found between the morbidity index and FFMI, HAZ, and WHZ. Increased birthweight was associated with a higher FFM (ß = 0.66), HAZ (ß = 1.14), and WHZ (ß = 0.87). Finally, safely managed sanitation facilities, representative of reduced environmental exposure to fecal-oral transmission pathways were associated with a higher HAZ (ß = 1.21). DISCUSSION: Reduction in FMI and FM and exposure to inflammatory cytokines associated with mounting an immune response could alter phenotypic trajectories during to this period of plasticity. From a public health perspective, these results imply that it is important to intensify efforts to prevent infection in infants in the first 6 months postnatally, and that these efforts should concentrate on access to safely managed sanitation facilities.

Body size preferences for women and adolescent girls living in Africa: a mixed-methods systematic review.

OBJECTIVE: To synthesise evidence on body size preferences for females living in Africa and the factors influencing these. DESIGN: Mixed-methods systematic review including searches on Medline, CINHAL, ASSIA, Web of Science and PsycINFO (PROSPERO CRD42015020509). A sequential-explanatory approach was used to integrate quantitative and qualitative findings. SETTING: Urban and rural Africa. PARTICIPANTS: Studies of both sexes providing data on body size preferences for adolescent girls and women aged ≥10 years. RESULTS: Seventy-three articles from twenty-one countries were included: fifty quantitative, fifteen qualitative and eight mixed methods. Most studies reported a preference for normal or overweight body sizes. Some studies of adolescent girls/young women indicated a preference for underweight. Factors influencing preferences for large(r) body sizes included: socio-demographic (e.g. education, rural residency), health-related (e.g. current BMI, pubertal status), psycho-social (e.g. avoiding HIV stigma) and socio-cultural factors (e.g. spouse's preference, social standing, cultural norms). Factors influencing preferences for slim(mer) body sizes included: socio-demographic (e.g. higher socioeconomic status, urban residency, younger age), health-related (e.g. health knowledge, being nulliparous), psycho-social (e.g. appearance, body size perception as overweight/obese) and socio-cultural factors (e.g. peer pressure, media). CONCLUSIONS: Preference for overweight (not obese) body sizes among some African females means that interventions need to account for the array of factors that maintain these preferences. The widespread preference for normal weight is positive in public health terms, but the valorisation of underweight in adolescent girls/young women may lead to an increase in body dissatisfaction. Emphasis needs to be placed on education to prevent all forms of malnutrition.

Association Between Household and Maternal Socioeconomic Factors with Birth Outcomes in the Democratic Republic of Congo and South Africa: A Comparative Study.

OBJECTIVE: To assess and compare the associations between household socioeconomic (SES) factors with birth outcomes (low birth weight (LBW), small-for-gestational age (SGA) and preterm birth (PTB)) in the Democratic Republic of Congo (DRC) and South Africa (SA). METHODS: Cross-sectional data of mother-newborn pairs collected in 2017 in the DRC were compared with mother-newborn pairs data from the SA Soweto first 1000-days pregnancy cohort study (2013-2016). Country-specific and pooled multivariable logistic regressions analyses assessed the associations between maternal education, marital status, and housing with LBW, SGA, and PTB adjusted for maternal anthropometry and obstetric factors. RESULTS: 1084 mother-newborn pairs were recruited (DRC: 256; SA: 828). The rates of LBW, PTB and SGA were, 11.5%, 17.1% and 32.8% in the DRC and 15.9%, 10.5% and 20.1% in SA. SES factors differed between countries and sex. In the DRC, being married decreased the odds of having LBW and PTB children by 86% and 80%, respectively. In SA, being a mother with secondary level of education and above was associated with 86% reduced odds of SGA. In the pooled analyses, women with secondary level of education and above had a 2.2-fold increase in odds of giving birth to a PTB newborn. Country of residence and maternal nutritional status were stronger predictors of birth outcomes than SES factors. CONCLUSION FOR PRACTICE: In sub-Saharan Africa, policies aiming to alleviate women's education combined with improved social support and household SES prior to and during pregnancy are critical to optimal neonatal outcomes and strategic to achieve the Sustainable Development Goals.

The association between household socio-economic status, maternal socio-demographic characteristics and adverse birth and infant growth outcomes in sub-Saharan Africa: a systematic review.

Adverse birth outcomes and infant undernutrition remain the leading causes of morbidity and mortality in sub-Saharan Africa (SSA). Impaired infant growth and development, which often begins during foetal development, may persist during the first 2 years of life and has been associated with higher risks of cardiometabolic diseases. This systematic review assessed the associations between maternal demographic characteristics and household socio-economic status (SES), and preterm birth (PTB), small for gestational age, low birth weight (LBW), stunting, wasting and underweight in children under 2 years of age in SSA countries. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, we searched for publications in three electronic databases (PubMed, Scopus and ScienceDirect). Eleven studies on children under 2 years of age, in four SSA regions, published in English between 1990 and 2018, were included. All the studies were observational in design (cross-sectional or cohort studies). Maternal education was the most commonly explored exposure. Most studies (63.3%) focused on undernutrition during the first 2 years of life: LBW, PTB and stunting. Lower maternal education, maternal unemployment and lower household wealth index were the SES factors most commonly associated with adverse birth outcomes and infant undernutrition. Maternal marital status was not associated with any infant outcomes. The definitions of the SES varied, which may explain discrepancies between studies. Nutrition intervention programs in SSA need to promote education and poverty alleviation in women at reproductive age, starting from pre-pregnancy, to optimise infant growth and development and prevent the increase in the prevalence of cardiometabolic diseases.

Exclusive breastfeeding policy, practice and influences in South Africa, 1980 to 2018: A mixed-methods systematic review.

BACKGROUND: In 2011, South Africa committed to promoting exclusive breastfeeding (EBF) for six months for all mothers, regardless of HIV status, in line with World Health Organization recommendations. This was a marked shift from earlier policies, and with it, average EBF rates increased from less than 10% in 2011 to 32% by 2016. OBJECTIVES: The aim of this mixed-methods systematic review was to describe EBF practices in South Africa and their multi-level influences over four policy periods. METHODS: We applied PRISMA guidelines according to a published protocol (Prospero: CRD42014010512). We searched seven databases [Africa-Wide, PubMed, Popline, PsychINFO, CINAHL, Global Health, and The Cochrane Library] and conducted hand searches for eligible articles (all study designs, conducted in South Africa and published between 1980-2018). The quality of articles was assessed using published tools, as appropriate. Separate policy analysis was conducted to delineate four distinct policy periods. We compared EBF rates by these periods. Then, applying a three-level ecological framework, we analysed EBF influences concurrently by method. Finally, the findings were synthesized to compare breastfeeding influences by policy period, maintaining an ecological framework. RESULTS: From an initial sample of 20,226 articles, 72 unique articles were reviewed, three of which contributed to both quantitative and qualitative analysis. Despite the large sample, several provinces were poorly represented (if at all) and many studies were assessed as low to moderate quality. Despite these limitations, our historical lens enabled us to explore why South African progress on increasing EBF practices has been slow. The review reflects a context that increasingly supports EBF, but falls short in accounting for family, community, and workplace influences. The findings also highlight the unintended damage caused by rapidly adopting and introducing global guidelines to an unsupported health workforce. CONCLUSIONS: From a South African perspective, we identified geographic and methodological biases, as well as gaps in our understanding and potential explanations of inequities in EBF. Our recommendations relate to policy, programming, and research to inform changes that would be required to further improve EBF practice rates in South Africa. While our review is South Africa-specific, our findings have broader implications for investing in multi-level interventions and limiting how often infant feeding guidelines are changed.