Implementation research for promoting access and rational use of antibiotics for children: lessons learnt from Tanzania.

Implementation research (IR) has proved to be a potential catalyst in facilitating the uptake of evidence-based innovations into routine practices and thereby maximizing public health outcomes. IR not only focuses on the effectiveness of the innovations but also identifies and addresses the barriers and facilitators to maximize their uptake into routine practices. This article describes the processes undertaken to implement a research project aimed at promoting access and rational use of antibiotics for children (PARAC). It also provides an overview of the lessons learnt during its implementation in Tanzanian hospital and community settings.

Profiling of antimicrobial dispensing practices in accredited drug dispensing outlets in Tanzania: a mixed-method cross-sectional study focusing on pediatric patients.

BACKGROUND: The emergency of antimicrobial resistance due to irrational antimicrobial use has put public health under threat. Accredited Drug Dispensing Outlets (ADDOs) play an important role in enhancing availability and accessibility of antimicrobials, however, there is a scarcity of studies assessing antimicrobial dispensing practices in these outlets, focusing on children in Tanzania. OBJECTIVE: This study was conducted to assess the antimicrobial dispensing practices among ADDO dispensers and explore the factors influencing the use of antimicrobials for children in Tanzania. METHODS: A community-based cross-sectional study utilizing both qualitative (interviews) and quantitative (simulated clients) methods was conducted between June and September 2020 in seven zones and 14 regions in Tanzania. RESULTS: The study found inappropriate dispensing and use of antimicrobials for children, influenced by multiple factors such as patient's and dispenser's knowledge and attitude, financial constraints, and product-related factors. Only 8% (62/773) of dispensers asked for prescriptions, while the majority (90%) were willing to dispense without prescriptions. Most dispensers, 83% (426/513), supplied incomplete doses of antimicrobials and only 60.5% (345/570) of the dispensers gave proper instructions for antimicrobial use to clients. Over 75% of ADDO dispensers displayed poor practice in taking patient history. CONCLUSION: ADDO dispensers demonstrated poor practices in dispensing and promoting rational antimicrobial use for children. Training, support, and regulatory interventions are required to improve antimicrobial dispensing practices in community drug outlets.

Closing the know-do gap for child health: UNICEF's experiences from embedding implementation research in child health and nutrition programming.

UNICEF operates in 190 countries and territories, where it advocates for the protection of children's rights and helps meet children's basic needs to reach their full potential. Embedded implementation research (IR) is an approach to health systems strengthening in which (a) generation and use of research is led by decision-makers and implementers; (b) local context, priorities, and system complexity are taken into account; and (c) research is an integrated and systematic part of decision-making and implementation. By addressing research questions of direct relevance to programs, embedded IR increases the likelihood of evidence-informed policies and programs, with the ultimate goal of improving child health and nutrition.This paper presents UNICEF's embedded IR approach, describes its application to challenges and lessons learned, and considers implications for future work.From 2015, UNICEF has collaborated with global development partners (e.g. WHO, USAID), governments and research institutions to conduct embedded IR studies in over 25 high burden countries. These studies focused on a variety of programs, including immunization, prevention of mother-to-child transmission of HIV, birth registration, nutrition, and newborn and child health services in emergency settings. The studies also used a variety of methods, including quantitative, qualitative and mixed-methods.UNICEF has found that this systematically embedding research in programs to identify implementation barriers can address concerns of implementers in country programs and support action to improve implementation. In addition, it can be used to test innovations, in particular applicability of approaches for introduction and scaling of programs across different contexts (e.g., geographic, political, physical environment, social, economic, etc.). UNICEF aims to generate evidence as to what implementation strategies will lead to more effective programs and better outcomes for children, accounting for local context and complexity, and as prioritized by local service providers. The adaptation of implementation research theory and practice within a large, multi-sectoral program has shown positive results in UNICEF-supported programs for children and taking them to scale.

Quality antenatal care protects against low birth weight in 42 poor counties of Western China.

Limited data exist related to low birth weight (LBW) incidence and risk factors in Western China. This paper aims to assess LBW and its relationship with antenatal care (ANC) in the poor counties of Western China. A community-based study in rural Western China was conducted in 2011. A kernel distribution was used to estimate the adjusted LBW incidence, and associations between LBW and socio-demographic or maternal factors were examined using multilevel logistic regression. Among 8,964 participants, 65.7% were weighed at birth. Crude LBW incidence was 6.6% and the adjusted rate was 9.3%. The study revealed that risk factors of LBW are being female, raised within a minority group, and with a family income below the national poverty line. For maternal risk factors, LBW was positively associated with not attending at least five or eight ANC visits, not receiving any ANC during the first trimester, and not having access to assess certain ANC content (weight, blood pressure, blood test, urine test, B-scan ultrasound, and folic acid supplement). There is urgent need to promote quality ANC in poor and rural areas of Western China and to prioritize vulnerable women and children who will benefit from quality ANC.

Coverage of Haemophilus influenzae Type b Conjugate Vaccine for Children in Mainland China: Systematic Review and Meta-analysis.

BACKGROUND: Use of Haemophilus influenzae type b conjugate vaccine is effective in reducing the disease burden, but its coverage in China is unclear. The aim of this meta-analysis is to assess the coverage of Hib conjugate vaccines in children in Mainland China. METHODS: We systematically searched Pubmed, Web of Science, Medline, CNKI and Wanfang to identify studies assessing the coverage of Hib vaccine in Chinese children. Random-effects models were used to obtain pooled estimates for Hib vaccine coverage and analyzed heterogeneity with meta-regression and subgroup analyses. RESULTS: Thirty-three studies that included 7,227,480 subjects in 12 provinces met our inclusion criteria. The pooled overall coverage of Hib conjugate vaccine was 54.9% [95% confidence interval (CI): 52.9-57.0]. The pooled coverage for the nonlocal population (54.3%; 95% CI: 52.4-56.3) was lower than that for the local residents (62.0%; 95% CI: 58.4-65.6). The region-pooled coverage was higher in the east of China (59.7%; 95% CI: 57.3-62.1) than in the central and west parts of the country (48.5%; 95% CI: 40.6-56.4). Overall, 26.7% (95% CI: 20.1-33.2) had 1 dose only, 14.8% (95% CI: 10.0-19.6%) had 2 doses, 13.5% (95% CI: 9.1-17.8) had 3 doses and 14.3% (95% CI: 9.7-18.9) had 4 doses. CONCLUSIONS: We found a low coverage of Hib conjugate vaccine, particularly for the nonlocal children and those living in the central and west parts of China. Including Hib vaccine into the national immunization program is recommended to reduce disparities in vaccination coverage.

Vaccine-preventable disease control in the People's Republic of China: 1949-2016.

BACKGROUND: China's immunization program is one of the oldest and largest in the world. Rates of vaccine-preventable diseases (VPD) are comparable to those in high-income countries. The program's evolution has been characterized by ambitious target setting and innovative strategies that have not been widely described. METHODS: We reviewed national and provincial health department archives; analyzed disease surveillance, vaccination coverage, and serosurvey data from 1950 through 2016; and, conducted in-depth interviews with senior Chinese experts involved early VPD control efforts. RESULTS: Widespread immunization began in the 1950s with smallpox, diphtheria, and Bacillus-Calmette Guerin vaccines, and in the 1960s with pertussis, tetanus, polio, measles, and Japanese encephalitis (JE) vaccines. The largest drops in absolute VPD burden occurred in the 1970s with establishment of the Rural Cooperative Medical System and a cadre of trained peasant health workers whose responsibilities included vaccinations. From 1970 to 1979, incidence per 100,000 population dropped 48% from 3.3 to 1.75 for diphtheria, 50% from 152.2 to 49.4 for pertussis, 77% from 2.5 to 0.6 for polio, 60% from 450.5 to 178.3 for measles, and 72% from 18.0 to 5.1 for JE, averting an average of 4 million VPD cases each year. Until the early 1980s, vaccines were delivered through annual winter campaigns using a coordinated 'rush-relay' system to expedite transport while leveraging vaccine thermostability. Establishment of the cold chain system during in the 1980s allowed bi-monthly vaccination rounds and more timely vaccination resulting in rates of diphtheria, pertussis, measles and meningitis falling over 90% from 1980 to 1989, while polio and JE rates fell 40-50%. In the 1990s, progress stalled as financing for public health was weakened by broad market reforms. Large investments in public health and immunizations by the central government since 2004 has led to further declines in VPD burden and increased equity. During 2011-2016, the incidence per 100,000 population was <2.0 for measles and <0.2 for pertussis, JE, meningococcal meningitis, and hepatitis A. From 1992 to 2014, the prevalence of chronic hepatitis B infection in children <5 years fell from 9.7% to 0.3%, a 97% decline. China was certified polio-free in 2000 and diphtheria was last reported in 2006. CONCLUSIONS: Long-term political commitment to immunizations as a basic right, ambitious targets, use of disease incidence as the primary metric to assess program performance, and nationwide scale-up of successful locally developed strategies that optimized use of available limited resources have been critical to China's success in controlling vaccine-preventable diseases.

Factors influencing developmental delay among young children in poor rural China: a latent variable approach.

OBJECTIVES: The aims of the study were to determine the prevalence of suspected developmental delay in children living in poor areas of rural China and to investigate factors influencing child developmental delay. DESIGN: A community-based, cross-sectional survey was conducted.Eighty-three villages in Shanxi and Guizhou Provinces, China. PARTICIPANTS: A total of 2514 children aged 6-35 months and their primary caregivers. OUTCOME MEASURES: Suspected child developmental delay was evaluated using the Ages & Stages Questionnaires-Chinese version. Caregivers' education and age, wealth index, child feeding index, parent-child interaction, number of books and Zung Self-Rating Depression Scale were reported by the primary caregivers. Haemoglobin levels were measured using a calibrated, automated analyser. Birth weight was obtained from medical records. RESULTS: Overall, 35.7% of the surveyed children aged 6-35 months demonstrated suspected developmental delay. The prevalence of suspected developmental delay was inversely associated with age, with the prevalence among young children aged 6-11 months being almost double that of children aged 30-35 months (48.0% and 22.8%, respectively). Using a structural equation model, it was demonstrated that caregiver's care and stimulus factors and child's haemoglobin level were directly correlated, while caregiver's sociodemographic factors were indirectly associated with suspected developmental delay. CONCLUSIONS: The prevalence of suspected developmental delay is high in poor rural areas of China, and appropriate interventions to improve child development are needed.

Comparison of text messaging data collection vs face-to-face interviews for public health surveys: a cluster randomized crossover study of care-seeking for childhood pneumonia and diarrhoea in rural China.

BACKGROUND: To compare text messaging and face-to-face interviews to conduct a survey on childhood diarrhoea and pneumonia. METHODS: Caregivers of young children able to send text messages in Zhao County in rural China were included in this crossover study. Villages (clusters) were randomized into two groups using the ratio 1:1.6 to account for an expected higher drop-out in group 2. In group 1, participants first completed the face-to-face and then text messaging survey; this order was reversed in group 2. We determined data equivalence of 17 questions that were answered by participants who were the same person in both surveys. For the text messaging survey, we assessed the overall and item response rate. RESULTS: We included 1014 participants between 16 and 28 March 2013: 371 in 15 villages in group 1 and 643 in 27 villages in group 2. A total of 662 (65.3%) out of 1014 participants responded (first text message question) and a significantly higher proportion who did not respond were from rural areas (P = 0.005). Of 651 participants willing to participate, 356 (54.7%) completed the text messaging survey, which was marginally significantly different between the groups (P = 0.05). In total, 409 participants took part in both surveys: 183 in group 1 and 226 in group 2. There was a significantly higher proportion of caregivers from rural areas in Zhao County in the non-responder group compared to the responder group (P = 0.004). Kappas were substantial for six (0.61-0.80), moderate for two (0.58 and 0.60), and fair for three questions (0.31, 0.35 and 0.37). The proportion of agreement was >90% for five questions; 80.0%-90.0% for five questions; 70.0%, 65.0% and 45.5%. The remaining questions had too small numbers to calculate these values. CONCLUSIONS: This study shows that text messaging data collection produces data similar to data from face-to-face interviews in a middle-income setting, but the response rate was insufficient for use in public health surveys. Improving the response rate is important, because text message surveys could be of greater value in rural remote areas due to the cost-saving potential.

Relaxation of the one child policy and trends in caesarean section rates and birth outcomes in China between 2012 and 2016: observational study of nearly seven million health facility births.

OBJECTIVE: To examine how the relaxation of the one child policy and policies to reduce caesarean section rates might have affected trends over time in caesarean section rates and perinatal and pregnancy related mortality in China. DESIGN: Observational study. SETTING: China's National Maternal Near Miss Surveillance System (NMNMSS). PARTICIPANTS: 6 838 582 births at 28 completed weeks or more of gestation or birth weight ≥1000 g in 438 hospitals in the NMNMSS between 2012 and 2016. MAIN OUTCOME MEASURES: Obstetric risk was defined using a modified Robson classification. The main outcome measures were changes in parity and age distributions and relative frequency of each Robson group, crude and adjusted trends over time in caesarean section rates within each risk category (using Poisson regression with a robust variance estimator), and trends in perinatal and pregnancy related mortality over time. RESULTS: Caesarean section rates declined steadily between 2012 and 2016 (crude relative risk 0.91, 95% confidence interval 0.89 to 0.93), reaching an overall hospital based rate of 41.1% in 2016. The relaxation of the one child policy was associated with an increase in the proportion of multiparous births (from 34.1% in 2012 to 46.7% in 2016), and births in women with a uterine scar nearly doubled (from 9.8% to 17.7% of all births). Taking account of these changes, the decline in caesarean sections was amplified over time (adjusted relative risk 0.82, 95% confidence interval 0.81 to 0.84). Caesarean sections declined noticeably in nulliparous women (0.75, 0.73 to 0.77) but also declined in multiparous women without a uterine scar (0.65, 0.62 to 0.77). The decrease in caesarean section rates was most pronounced in hospitals with the highest rates in 2012, consistent with the government's policy of targeting hospitals with the highest rates. Perinatal mortality declined from 10.1 to 7.2 per 1000 births over the same period (0.87, 0.83 to 0.91), and there was no change in pregnancy related mortality over time. CONCLUSIONS: China is the only country that has succeeded in reverting the rising trends in caesarean sections. China's success is remarkable given that the changes in obstetric risk associated with the relaxation of the one child policy would have led to an increase in the need for caesarean sections. China's experience suggests that change is possible when strategies are comprehensive and deal with the system level factors that underpin overuse as well as the various incentives at work during a clinical encounter.

Exclusive Breastfeeding Rate and Complementary Feeding Indicators in China: A National Representative Survey in 2013.

Appropriate infant and young child feeding could reduce morbidity and mortality and could improve cognitive development of children. However, nationwide data on exclusive breastfeeding and complementary feeding status in China are scarce. The aim of this study was to assess current exclusive breastfeeding and complementary feeding status in China. A national representative survey (Chinese National Nutrition and Health Survey) of children aged under 6 years was done in 2013. Stratified multistage cluster sampling was used to select study participants. World Health Organization (WHO) infant and young child feeding indicators were firstly used to assess exclusive breastfeeding and complementary feeding practice nationwide. In total, 14,458 children aged under two years (0 to <730 days) were studied from 55 counties in 30 provinces in China. The crude exclusive breastfeeding rate under 6 months was 20.7% (908/4381) and the weighted exclusive breastfeeding rate was 18.6%. The crude prevalence of minimum dietary diversity, minimum meal frequency and minimum acceptable diet were 52.5% (5286/10,071), 69.8% (7027/10,071), and 27.4% (2764/10,071) among children aged 6-23 months, respectively. The weighted rate was 53.7%, 69.1%, and 25.1%, respectively. Residential area, household income and maternal education were positively associated with the three complementary feeding indicators. The exclusive breastfeeding rate under 6 months was low and complementary feeding practice was not optimal in China. Residential area, household income and maternal education might be used to target infants and young children to improve complementary feeding practice.

[Effectiveness of integrated early childhood development intervention on nurturing care for children aged 0-35 months in rural China].

Objective: To explore whether Integrated Early Childhood Development (IECD) program has effectively improved the nurturing care for children aged 0-35 months in rural China. Methods: IECD has been implemented by the government of China with support from the United Nations Children's Fund (UNICEF) in four poverty-stricken rural counties since 2014. The interventions targeting the five key components of nurturing care (i.e. child and caregiver health, child nutrition, early learning support, child protection and social security) were delivered through the IECD program to children aged 0 to 35 months and their caregivers. A population-based intervention trial was designed to evaluate intervention effectiveness with data collected in 2013 (baseline) and 2016 (mid-term). The changes of nurturing care in the intervention and control group were analyzed by using a difference-in-differences (DID) model. This approach provided adjustment for sociodemographic and other confounding factors. Results: The baseline and mid-term survey enrolled 1 468 and 1 384 children in the intervention group, and 1 485 and 1 361 in the control group. After two years of implementation, the prevalence of caregiver's depression in the intervention group showed a decrease of 9.1% (mid-term 34.8% (479/1 377) vs. baseline 43.9% (621/1 414)), whereas that in control group showed a decrease of 1.6% (mid-term 34.3% (464/1 353) vs. baseline 35.9% (509/1 419)). With the confounding adjusted in the difference-in-differences model, the decrease of the caregiver's depression prevalence in the intervention group was 7.0% greater than that in the control group (P=0.008). The qualified rate of minimum meal frequency in the intervention group showed an increase of 10.4% (mid-term 69.0% (532/771) vs. baseline 58.6% (481/821)), whereas the qualified rate in the intervention group showed an increase of 2.9% (mid-term 66.4% (469/706) vs. baseline 63.5% (508/800)). With the confounding adjusted in the difference-in-differences model, the increase of the qualified rate in the intervention group was 8.2% greater than that in the control group (P=0.021). The proportion of violent discipline by caregivers in the intervention group showed a decrease of 6.2% (mid-term 49.1% (478/973) vs. baseline 55.3% (554/1 001)), whereas the proportion in control group showed an increase of 4.5% (mid-term 58.4% (560/959) vs. baseline 53.9% (558/1 036)), and with the confounding adjusted in the difference-in-differences model, the difference in increase rate between two groups was 11.0% (P=0.001). The proportion of families with three or more children's books in the intervention group showed an increase of 12.7% (mid-term 42.7% (588/1 378) vs. baseline 30.0% (432/1 440)), whereas the proportion of the control group showed an increase of 4.2% (mid-term 25.7% (349/1 357) vs. baseline 21.5% (298/1 388)), and with the confounding adjusted in the difference-in-differences model, the difference in increase rate between two groups was 6.1% (P=0.007). Conclusions: The IECD intervention strategy implemented in rural China effectively improved the mental health of caregivers, optimizes families' child feeding and early stimulation behaviors, while reducing violent discipline and other risk factors. IECD provides better nurturing care for the early development of children aged 0-35 months in rural China.

Utilization pattern of Haemophilus influenza type b vaccine in eight provinces of China.

OBJECTIVE: In China, Hib vaccine is a private-sector vaccine that is an option for parents to select to give to their children; it must be paid for out-of-pocket because it is not included in the government's Expanded Program on Immunization (EPI). We evaluated utilization patterns of Hib vaccine to provide evidence in support of development of a national Hib vaccination strategy. METHODS: We obtained lists of children from immunization information systems (IIS) of counties or districts in 8 provinces of China. Using these lists, we selected 10 children at random from each birth cohort from 2008 through 2012. We obtained Hib vaccination dates from official vaccination certificates. The target sample size was 1,000 children. RESULTS: We were able to obtain records for 978 subjects of the selected subjects; of these, 44.79% had received at least 1 dose of Hib vaccine, and 15.54%, 5.83%, 12.27%, and 11.15% had received one, two, three, and four doses, respectively. Per capita GDP was positively correlated with receipt of at least one dose of Hib vaccine. Among the 438 subjects who received Hib vaccine, 27% received 1 dose after 12 months of age; 15%, 7%, and 23% received one of three other patterns of Hib vaccination recommended by the World Health Organization (WHO) [a 3-dose primary series; 2 primary series doses and 1 booster; or 3 primary series doses and 1 booster]. The other 28% of subjects received patterns of Hib vaccination not recommended by WHO. Considering protection from Hib disease as receipt of a WHO-recommended Hib vaccine schedule, 29% of subjects could be considered protected after 12 months of age, 52% could be considered protected during infancy and beyond, and 19% could be considered to not have been protected adequately, despite being vaccinated. CONCLUSIONS: Coverage with Hib vaccine was low. There were significant differences between WHO recommendations and actual patterns of use of Hib vaccine, with half of vaccine recipients receiving no protection during infancy and one fifth receiving non-protective Hib vaccination patterns. Inclusion of Hib vaccine into China's EPI system, which provides vaccine at no charge to parents and makes specific vaccination schedule standards, has potential to make more effective use of Hib vaccine.

The dietary diversity and stunting prevalence in minority children under 3 years old: a cross-sectional study in forty-two counties of Western China.

As a key indicator of childhood malnutrition, few studies have focused on stunting in relation to various socio-economic factors in which disadvantaged groups face in China. We conducted a community-based cross-sectional study incorporating forty-two rural counties in seven western provinces of China in 2011. In total, 5196 children aged 6-23 months were included. We used Poisson regression to examine risk factors for inadequate minimum dietary diversity (MDD) and stunting status, respectively. Overall, the proportion of children not meeting MDD was 44·5 %. Children aged 6-11 months (adjusted risk ratio (ARR)=1·39; 95 % CI 1·31, 1·49), with two siblings (ARR=1·09; 95 % CI 1·02, 1·17), delivered at home (ARR=1·30; 95 % CI 1·20, 1·41), within Yi (ARR=1·15; 95 % CI 1·04, 1·28) or Uighur groups (ARR=1·52; 95 % CI 1·36, 1·71), with an illiterate caregiver (ARR=2·12; 95 % CI 1·52, 2·96), receiving lowest income (ARR=1·32; 95 % CI 1·17, 1·50), and with breast-feeding in the last day (ARR=1·55; 95 % CI 1·44, 1·66) were more likely to have inadequate MDD. Moreover, inadequate MDD was positively associated with stunting (ARR=1·15; 95 % CI 1·01, 1·31). Other determinants for stunting were age, sex, place of delivery, minority group and income. The stunting prevalence and proportion of inadequate MDD remained high in Western China; to reduce stunting rates of ethnic minorities, further efforts addressing appropriate dietary feeding practices are needed, especially within these groups.

Inequality in early childhood neurodevelopment in six poor rural counties of China: a decomposition analysis.

BACKGROUND: Previous studies about inequality in children's health focused more on physical health than the neurodevelopment. In this study, we aimed to evaluate the inequality in early childhood neurodevelopment in poor rural China and explore the contributions of socioeconomic factors to the inequality. METHOD: Information of 2120 children aged 0 to 35 months and their households in six poor rural counties of China was collected during July - September, 2013. Age and Stages Questionnaire-Chinese version, concentration index and decomposition analysis were used to assess the neurodevelopment of early childhood, measure its inequality and evaluate the contributions of socioeconomic factors to the inequality, respectively. RESULT: The prevalence of suspected developmental delay in children under 35 months of age in six poor rural counties of China was nearly 40%, with the concentration index of -0.0877. Household economic status, caregivers' depressive symptoms, learning material and family support for learning were significantly associated with children's suspected developmental delay, and explained 34.1, 14.1, 8.9 and 7.0% of the inequality in early childhood neurodevelopment, respectively. CONCLUSION: The early childhood neurodevelopment in the surveyed area is poor and unfair. Factors including household economic status, caregivers' depressive symptoms, learning material and family support for learning are significantly associated with children's suspected developmental delay and early developmental inequality. The results highlight the urgent need of monitoring child neurodevelopment in poor rural areas. Interventions targeting the caregivers' depressive symptoms, providing learning material and developmental appropriate stimulating activities may help improve early childhood neurodevelopment and reduce its inequality.

Haemophilus influenzae type b carriage and burden of its related diseases in Chinese children: Systematic review and meta-analysis.

BACKGROUND: Haemophilus influenzae type b (Hib) is an important cause of invasive bacterial disease in children worldwide. The limited awareness of disease burden is a major barrier to the introduction of Hib vaccine into China's National Immunization Program. Therefore, we conducted a systematic review and meta-analysis to estimate carriage of Hib and burden of its related diseases in Chinese children. METHODS: We systematically searched Pubmed, Web of Science, Ovid, Chinese National Knowledge Infrastructure (CNKI), and Wanfang databases for studies published up to December 31, 2016, reporting Hib carriage and burden of Hib diseases among children in Mainland China. Pooled estimates were obtained using random-effects models. RESULTS: We included 27 studies with 15783 children across 14 provinces. The pooled carriage of Hib was 5.87% (95% CI 3.42-8.33) for healthy children. The pooled proportion of disease due to Hib were 4.06% (95% CI 3.29-4.83) for acute lower respiratory tract infection (ALRI) and 27.32% (95% CI 0.41-54.24) for bacterial meningitis. The proportion of ALRI caused by Hib was higher in northern China than that in the south. Significant heterogeneity was noted across and within regions (P<0.001). After the induction of Hib vaccine, meta-regression showed that carriage of Hib changed little (P=0.725), but the proportion of ALRI caused by Hib in children decreased (P<0.001). CONCLUSIONS: Hib carriage persists at low levels among children in China. The proportion of ALRI due to Hib infection decreased with year. Incorporation of Hib vaccine into the National Immunization Program could reduce the burden of Hib disease in China.

Monitoring and evaluating the adherence to a complementary food supplement (Ying Yang Bao) among young children in rural Qinghai, China: a mixed methods evaluation study.

BACKGROUND: Large investments are currently made in community-based complementary food supplement (Ying Yang Bao, YYB) programs to improve nutrition of young children in rural areas in China. However, there is a lack of knowledge about the experience and challenges of implementing YYB programs in China. We aimed to: 1) monitor distribution of YYB; 2) assess children's adherence to and acceptability of YYB; and 3) evaluate community-based strategies to improve the program. METHODS: This mixed methods evaluation study combined data from surveys and focus groups that took place during a controlled interventional evaluation trial. The trial aimed to evaluate the effectiveness of community-based YYB distribution on improving children's health status in rural areas in China. We conducted five cross-sectional surveys with caregivers of children aged 6-23 months (baseline survey (N = 1804) in August 2012 and four follow-up cross-sectional surveys: 1) N = 494 in January 2013; 2) N = 2187 in August 2013; 3) N = 504 in January 2014; and 4) N = 2186 in August 2014) in one rural county in Qinghai Province. We used a two-stage cluster sampling technique to select mothers with eligible children for each survey. Information was collected from caregivers on household characteristics, YYB consumption and acceptability in the surveys. High adherence in each survey was defined as children who consumed at least four YYB sachets during the previous week. A logistic regression model was developed to obtain odds ratios (OR) with 95% confidence intervals of factors associated with high adherence. Also, we conducted 10 focus groups with73 caregivers and health workers involved in the YYB distribution. Content analysis was used to explore qualitative findings, which were used to gain deeper insight into the quantitative results. RESULTS: Around 90% of caregivers had ever received YYB and more than 80% of children ever took YYB. Caregivers mainly knew about YYB through their village doctors. High adherence to YYB increased from 49.4% in the first follow-up survey (January 2013) to 81.4% in the last follow-up survey (August 2014; P < 0.0001). Repeated training sessions with village doctors could increase adherence. However, due to unplanned YYB stock-out, caregivers did not receive YYB for six months, which may have led to a decrease of high adherence from 64.1% in the second follow-up survey (August 2013) to 53.6% in the third follow-up survey (January 2014; P < 0.0001). Self-reported acceptability increased from 43.2% to 71.8%, partly due to improving the taste of YYB, which was the main reason that children disliked taking YYB. Unfortunately, more than 60% of caregivers did not perceive positive health improvement in their children after taking YYB. Multivariate analysis showed that children with diarrhea (OR = 1.216, 95% CI 1.025-1.442), cough or fever (OR = 1.222, 95% CI 1.072-1.393) during the past two weeks had significantly lower adherence. CONCLUSIONS: This evaluation study showed that program monitoring in rural West China was critically important for understanding program implementation and adherence trends. This led to strategic changes to the intervention over time: improving the taste of YYB; strengthening health education of village doctors and caregivers; and ensuring continuity of YYB supply. Future programs need to monitor program implementation in other settings in China and elsewhere.

What could cognitive capital mean for China's children?

Cognitive capital is an emerging paradigm that captures the criticality of investing in children whilst neural proliferation and development of brain architecture are at their peak. Distinct from financial capital, cognitive capital represents investment in future human potential from interventions in nutrition, health, education, child protection, and social welfare systems that optimize brain development. The return on investment is significant given the plasticity of the developing brain in response to positive stimuli. Investment in brain development results in improved health and well-being, educational outcomes, skills, employment, and quality of life. The inverse is also true. Negative stimuli lead to depreciating cognitive capital, poorer mental and physical health and educational outcomes, and decreased life chances. Cognitive capital could be an organizing framework for China's next phase of development to ensure the building of a prosperous society. Through significant commitment from the government, China has seen remarkable improvements in under-five mortality, literacy rates, access to basic education, life expectancy, and gross domestic product in the past few decades as the result of an expansion of publicly funded social services. Yet, inequities remain within and across communities and regions. In 2015, China had a country ranking of 97 for gross national income per capita, highlighting remaining challenges across the whole population. Cognitive capital relies on a package of forward-looking policies that lead to equitable, efficient, and effective use of existing and future resources. This is consistent with the United Nations Convention on the Rights of the Child. Investments in interventions that maximize optimal brain development in children, realize children's rights, and contribute to future economic growth, defined as "cognitive capital," represent a significant opportunity for improving children's lives, nation-building, and future economic growth in China.

Eliminating Iodine Deficiency in China: Achievements, Challenges and Global Implications.

The prevention of iodine deficiency through salt iodization has been recognized as a global success story, and China stands at the forefront of this achievement with one of the most successful programs in the world. High level political commitment, national mandatory legislation, a state-managed edible salt industry and a complex and highly sophisticated surveillance system have facilitated the success of the program. Challenges have arisen however, including: (i) concern that adequate iodine status in pregnant women cannot be achieved without causing above adequate iodine intakes in children; (ii) declining iodine intake as a result of reductions in salt consumption and increased consumption of processed foods, which may not be made with iodized salt; (iii) the existence of areas with high iodine content in the water; and (iv) declines in household use of iodized salt due to concerns about excess iodine intake and thyroid disease. This article reviews the achievements and challenges of the Chinese Iodine Deficiency Disorders (IDD) Elimination Program and reflects on lessons learned and implications for other national salt iodization programs.

Child feeding and stunting prevalence in left-behind children: a descriptive analysis of data from a central and western Chinese population.

OBJECTIVES: To examine the effect of parental rural-to-urban internal migration on nutritional status of left-behind children and how this is related to guardianship. METHODS: We used UNICEF China's maternal and child health survey data to investigate stunting prevalence and feeding practices in children left behind by rural-to-urban internal migrant parents. We also assessed the effects of primary guardianship which is related closely with parental migration. RESULTS: Of 6136 children aged 0-3 years, over one-third was left behind by one or both parents. About 13 % were left behind by mothers, leaving guardianship primarily to grandmothers. Left-behind status was not associated with stunting, yet children who were cared for primarily by their fathers had a 32 % increase of stunting compared to children cared for by the mothers [adjusted odds ratio (aOR) = 1.32; 95 % confidence interval = 1.04-1.67]. Children with migrant mothers were less likely to receive age-appropriate breastfeeding (aOR = 0.04;0.02-0.10) and a minimum acceptable diet (aOR = 0.56;0.39-0.79) compared with non-left-behind children. CONCLUSIONS: Guardian's feeding behaviours varied, and was inappropriate for both children affected and not affected by parent's rural-to-urban internal migration. Community-based infant and young child feeding counselling and support should be provided to all caregivers.