Assessment of Childhood Stunting Prevalence over Time and Risk Factors of Stunting in the Healthy Village Programme Areas in Bangladesh.

Childhood stunting is a significant public health concern in Bangladesh. This study analysed the data from the Healthy Village programme, which aims to address childhood stunting in southern coastal Bangladesh. The aim was to assess childhood stunting prevalence over time and explore the risk factors in the programme areas. A cross-sectional, secondary data analysis was conducted for point-prevalence estimates of stunting from 2018 to 2021, including 132,038 anthropometric measurements of under-five children. Multivariate logistic regression analyses were conducted for risk factor analysis (n = 20,174). Stunting prevalence decreased from 51% in 2018 to 25% in 2021. The risk of stunting increased in hardcore poor (aOR: 1.46, 95% CI: 1.27, 1.68) and poor (aOR: 1.50, 95% CI: 1.33, 1.70) versus rich households, children with mothers who were illiterate (aOR: 1.25, 95% CI: 1.09, 1.44) and could read and write (aOR: 1.35, 95% CI: 1.16, 1.56) versus mothers with higher education, and children aged 1-2 years compared with children under one year (aOR: 1.32, 95% CI: 1.20, 1.45). The stunting rate was halved over three years in programme areas, which is faster than the national trend. We recommend addressing socioeconomic inequalities when tackling stunting and providing targeted interventions to mothers during the early weaning period.

Embedded implementation research in programming at scale - the new normal to be!

If you want to run faster, don't just buy a new pair of shoes; also consider your training methods and where you run.This supplement examines six countries that have run faster than others in reducing under-five mortality, taking an implementation research approach, with country case studies done with local researchers and local institutions. Key generalizable learnings are to choose and adapt implementation strategies to context, design strategies to target the most vulnerable, systematically learn from implementation experience, and to leverage non-health-sector contributions.Embedding implementation research in programming has the potential to greatly improve and accelerate the contextualization and implementation of evidence-based child survival interventions to improve equity in coverage and overall effectiveness in reducing under-five mortality. It is now time to build such capacity in local institutions at scale, and incentives for concerned stakeholders to make this the new normal. Regional institutions should now take the lead in making this happen, not just in individual institutions and countries, but across entire regions, supported by global partners.Trial registration N/A.

Child health and the implementation of Community and District-management Empowerment for Scale-up (CODES) in Uganda: a randomised controlled trial.

INTRODUCTION: Uganda's district-level administrative units buttress the public healthcare system. In many districts, however, local capacity is incommensurate with that required to plan and implement quality health interventions. This study investigates how a district management strategy informed by local data and community dialogue influences health services. METHODS: A 3-year randomised controlled trial (RCT) comprised of 16 Ugandan districts tested a management approach, Community and District-management Empowerment for Scale-up (CODES). Eight districts were randomly selected for each of the intervention and comparison areas. The approach relies on a customised set of data-driven diagnostic tools to identify and resolve health system bottlenecks. Using a difference-in-differences approach, the authors performed an intention-to-treat analysis of protective, preventive and curative practices for malaria, pneumonia and diarrhoea among children aged 5 and younger. RESULTS: Intervention districts reported significant net increases in the treatment of malaria (+23%), pneumonia (+19%) and diarrhoea (+13%) and improved stool disposal (+10%). Coverage rates for immunisation and vitamin A consumption saw similar improvements. By engaging communities and district managers in a common quest to solve local bottlenecks, CODES fostered demand for health services. However, limited fiscal space-constrained district managers' ability to implement solutions identified through CODES. CONCLUSION: Data-driven district management interventions can positively impact child health outcomes, with clinically significant improvements in the treatment of malaria, pneumonia and diarrhoea as well as stool disposal. The findings recommend the model's suitability for health systems strengthening in Uganda and other decentralised contexts. TRIAL REGISTRATION NUMBER: ISRCTN15705788.

Primary health care and nutrition.

Globally, dietary factors are responsible for about one in five deaths. In many low- and middle-income countries different forms of malnutrition (including obesity and undernutrition) can co-exist within the same population. This double burden of malnutrition is placing a disproportional strain on health systems, slowing progress towards universal health coverage (UHC). Poor nutrition also impedes the growth of local economies, ultimately affecting the global economy. In this article, we argue that comprehensive primary health care should be used as a platform to address the double burden of malnutrition. We use a conceptual framework based on human rights and the Astana Declaration on primary health care to examine existing recommendations and propose guidance on how policy-makers and providers of community-oriented primary health care can strengthen the role of nutrition within the UHC agenda. Specifically, we propose four thematic areas for action: (i) bridging narratives and strengthening links between the primary health care and the nutrition agenda with nutrition as a human rights issue; (ii) encouraging primary health-care providers to support local multisectoral action on nutrition; (iii) empowering communities and patients to address unhealthy diets; and (iv) ensuring the delivery of high-quality promotive, preventive, curative and rehabilitative nutrition interventions. For each theme we summarize the available strategies, policies and interventions that can be used by primary health-care providers and policy-makers to strengthen nutrition in primary health care and thus the UHC agenda.

Environ un décès sur cinq dans le monde est dû à des facteurs alimentaires. Dans de nombreux pays à faible et moyen revenu, différentes formes de malnutrition (y compris l'obésité et la dénutrition) peuvent coexister au sein d'une même population. Ce double fardeau de malnutrition exerce une pression démesurée sur les systèmes de santé, ralentissant la progression vers une couverture maladie universelle (CMU). Une mauvaise alimentation entrave également la croissance des économies locales, ce qui en fin de compte affecte l'économie mondiale. Dans cet article, nous estimons qu'il est impératif d'utiliser une approche globale des soins de santé primaires comme plateforme pour s'attaquer au double fardeau de la malnutrition. Nous avons employé un cadre conceptuel fondé sur les droits humains et la Déclaration d'Astana sur les soins de santé primaires. D'une part pour examiner les recommandations existantes, et d'autre part pour fournir un éclairage sur la manière dont les législateurs et les prestataires de soins de santé primaires, implantés au niveau communautaire, peuvent renforcer le rôle de la nutrition dans le programme de CMU. Nous proposons plus exactement quatre champs d'action : (i) aligner les discours et consolider les liens entre les soins de santé primaires et le programme de nutrition, en intégrant ce dernier dans la thématique des droits humains; (ii) encourager les prestataires de soins de santé primaires à soutenir les initiatives locales multisectorielles portant sur la nutrition; (iii) donner aux patients et aux collectivités le pouvoir de lutter contre l'alimentation déséquilibrée; et enfin, (iv) assurer la mise en œuvre d'interventions de qualité pour la promotion, la prévention, le traitement et la réhabilitation en matière de nutrition. Pour chaque champ d'action, nous résumons les stratégies, politiques et interventions à la disposition des législateurs et prestataires de soins de santé primaires pour renforcer le rôle de la nutrition dans les soins de santé primaires et, par conséquent, le programme de CMU.

Los factores alimentarios son responsables de aproximadamente una de cada cinco muertes en todo el mundo. Diferentes tipos de malnutrición (incluidas la obesidad y la desnutrición) pueden coexistir en la misma población de muchos países de ingresos bajos y medios. Esta doble carga de la malnutrición está ejerciendo una presión desproporcionada sobre los sistemas sanitarios, lo que ralentiza los progresos hacia la cobertura sanitaria universal (CSU). Además, la mala nutrición dificulta el crecimiento de las economías locales, lo que en última instancia afecta a la economía global. En este artículo, se argumenta que la atención primaria de salud integral se debería utilizar como plataforma para abordar la doble carga de la malnutrición. Se utiliza un marco conceptual basado en los derechos humanos y en la Declaración de Astaná sobre la atención primaria de salud para analizar las recomendaciones existentes y proponer directrices sobre cómo los responsables de formular las políticas y los proveedores de atención primaria de salud orientada a la comunidad pueden fortalecer la función de la nutrición dentro del programa de la CSU. En concreto, se proponen cuatro áreas temáticas de acción: (i) narrativas de vinculación y fortalecimiento de los vínculos entre la atención primaria de salud y el programa de nutrición en donde la nutrición sea una cuestión de derechos humanos; (ii) alentar a los proveedores de atención primaria de salud a que apoyen la medida multisectorial local sobre la nutrición; (iii) potenciar a las comunidades y a los pacientes para tratar las dietas poco saludables; y (iv) garantizar la realización de intervenciones de nutrición de alta calidad de tipo promocional, preventivo, curativo y de rehabilitación. Para cada tema se resumen las estrategias, políticas e intervenciones disponibles que los proveedores de atención primaria de salud y los responsables de formular las políticas pueden utilizar para fortalecer la nutrición en la atención primaria de salud y, por consiguiente, el programa de la CSU.

Bypassing or successful referral? A population-based study of reasons why women travel far for childbirth in Eastern Uganda.

BACKGROUND: Delivery in a facility with a skilled health provider is considered the most important intervention to reduce maternal and early newborn deaths. Providing care close to people's homes is an important strategy to facilitate equitable access, but many women are known to bypass the closest delivery facility for a higher level one. The aim of this study was to investigate to what extent mothers in rural Uganda bypassed their nearest facility for childbirth care and the determinants for their choice. METHODS: The study used data collected as part of the Expanded Quality Management Using Information power (EQUIP) study in the Mayuge District of Eastern Uganda between 2011 and 2014. In this study, bypassing was defined as delivering in a health facility that was not the nearest childbirth facility to the mother's home. Multilevel logistic regression was used to model the relationship between bypassing the nearest health facility for childbirth and the different independent factors. RESULTS: Of all women delivering in a health facility, 45% (499/1115) did not deliver in the nearest facility regardless of the level of care. Further, after excluding women who delivered in health centre II (which is not formally equipped to provide childbirth care) and excluding those who were referred or had a caesarean section (because their reasons for bypassing may be different), 29% (204/717) of women bypassed their nearest facility to give birth in another facility, 50% going to the only hospital of the district. The odds of bypassing increased if a mother belonged to highest wealth quintile compared to the lowest quintile (AOR 2.24, 95% CI: 1.12-4.46) and decreased with increase of readiness of score of the nearest facility for childbirth (AOR = 0.84, 95% CI: 0.69-0.99). CONCLUSIONS: The extent of bypassing the nearest childbirth facility in this rural Ugandan setting was 29%, and was associated primarily with the readiness of the nearest facility to provide care as well as the wealth of the household. These results suggest inequalities in bypassing for better quality care that have important implications for improving Uganda's maternal and newborn health outcomes.

Disease mapping of early- and late-stage cancer to monitor inequalities in early detection: a study of cutaneous malignant melanoma.

We consider disease mapping of early- and late-stage cancer, in order to identify and monitor inequalities in early detection. Our method is demonstrated by mapping cancer incidence at high geographical resolution using data on 10,302 cutaneous malignant melanoma (CMM) cases within the 3.7 million population of South-West Sweden. The cases were geocoded into small-areas, each with a population size between 600 and 2600 and accessible socio-demographic data. Using the disease mapping application Rapid Inquiry Facility (RIF) 4.0, we produced regional maps to visualise spatial variations in stage I, II and III-IV CMM incidences, complemented by local maps to explore the variations within two urban areas. Pronounced spatial disparities in stage I CMM incidence were revealed by the regional and local maps. Stage I CMM incidence was markedly higher in wealthier small-areas, in particular within each urban area. A twofold higher stage I incidence was observed, on average, in the wealthiest small-areas (upper quintile) than in the poorest small-areas (lower quintile). We identified in the regional map of stage III-IV CMM two clusters of higher or lower than expected late-stage incidences which were quite distinct from those identified for stage I. In conclusion, our analysis of CMM incidences supported the use of this method of cancer stage incidence mapping for revealing geographical and socio-demographic disparities in cancer detection.

Mental Distress and Human Rights Violations During COVID-19: A Rapid Review of the Evidence Informing Rights, Mental Health Needs, and Public Policy Around Vulnerable Populations.

Background: COVID-19 prevention and mitigation efforts were abrupt and challenging for most countries with the protracted lockdown straining socioeconomic activities. Marginalized groups and individuals are particularly vulnerable to adverse effects of the pandemic such as human rights abuses and violations which can lead to psychological distress. In this review, we focus on mental distress and disturbances that have emanated due to human rights restrictions and violations amidst the pandemic. We underscore how mental health is both directly impacted by the force of pandemic and by prevention and mitigation structures put in place to combat the disease. Methods: We conducted a review of relevant studies examining human rights violations in COVID-19 response, with a focus on vulnerable populations, and its association with mental health and psychological well-being. We searched PubMed and Embase databases for studies between December 2019 to July 2020. Three reviewers evaluated the eligibility criteria and extracted data. Results: Twenty-four studies were included in the systematic inquiry reporting on distress due to human rights violations. Unanimously, the studies found vulnerable populations to be at a high risk for mental distress. Limited mobility rights disproportionately harmed psychiatric patients, low-income individuals, and minorities who were at higher risk for self-harm and worsening mental health. Healthcare workers suffered negative mental health consequences due to stigma and lack of personal protective equipment and stigma. Other vulnerable groups such as the elderly, children, and refugees also experienced negative consequences. Conclusions: This review emphasizes the need to uphold human rights and address long term mental health needs of populations that have suffered disproportionately during the pandemic. Countries can embed a proactive psychosocial response to medical management as well as in existing prevention strategies. International human rights guidelines are useful in this direction but an emphasis should be placed on strengthening rights informed psychosocial response with specific strategies to enhance mental health in the long-term. We underscore that various fundamental human rights are interdependent and therefore undermining one leads to a poor impact on the others. We strongly recommend global efforts toward focusing both on minimizing fatalities, protecting human rights, and promoting long term mental well-being.

[Integrated Community Case Management - one piece of the puzzle to achieve the ambitious global goals for child health]. / Lokala hälsoarbetare bidrar till bättre barnhälsa globalt - Nära kontakt mellan samhälle och sjukvård avgörande för att nå globala målen för barnhälsa och Agenda 2030.

Remarkable achievements have been made in global child health, with the global under-five mortality halved between 1990 and 2015. However almost 6 million children die every year before their 5th birthday; mostly due to preventable causes. Acknowledging that the clinical presentation of the sick child is complex and does not match individual guidelines of specific diseases, WHO and Unicef have developed an integrated approach for case management of the sick child by community health workers. The approach, called Integrated Community Case Management (iCCM), is meant to be used in areas lacking access to formal health care in low income settings. The concept has several strengths, such as linking the community to the health facilities, improving quality of care, promoting rational use of drugs, enabling health promotion and has been shown to reduce mortality in studies. However, due to barriers  within the broader health system, iCCM has been difficult to implement in large-scale national programs. With the world stepping up its action to reach the Sustainable Development Goals (SDGs), community-based interventions such as iCCM promise to accelerate the progress when implementation is part of an approach to strengthen health systems.

Using a cross-contextual reciprocal learning approach in a multisite implementation research project to improve self-management for type 2 diabetes.

This paper reports on the use of reciprocal learning for identifying, adopting and adapting a type 2 diabetes self-management support intervention in a multisite implementation trial conducted in a rural setting in a low-income country (Uganda), a periurban township in a middle-income country (South Africa) and socioeconomically disadvantaged suburbs in a high-income country (Sweden). The learning process was guided by a framework for knowledge translation and structured into three learning cycles, allowing for a balance between evidence, stakeholder interaction and contextual adaptation. Key factors included commitment, common goals, leadership and partnerships. Synergistic outcomes were the cocreation of knowledge, interventions and implementation methods, including reverse innovations such as adaption of community-linked models of care. Contextualisation was achieved by cross-site exchanges and local stakeholder interaction to balance intervention fidelity with local adaptation. Interdisciplinary and cross-site collaboration resulted in the establishment of learning networks. Limitations of reciprocal learning relate to the complexity of the process with unpredictable outcomes and the limited generalisability of results.

Patient and Provider Dilemmas of Type 2 Diabetes Self-Management: A Qualitative Study in Socioeconomically Disadvantaged Communities in Stockholm.

Studies comparing provider and patient views and experiences of self-management within primary healthcare are particularly scarce in disadvantaged settings. In this qualitative study, patient and provider perceptions of self-management were investigated in five socio-economically disadvantaged communities in Stockholm. Twelve individual interviews and four group interviews were conducted. Semi-structured interview guides included questions on perceptions of diabetes diagnosis, diabetes care services available at primary health care centers, patient and provider interactions, and self-management support. Data was analyzed using thematic analysis. Two overarching themes were identified: adopting and maintaining new routines through practical and appropriate lifestyle choices (patients), and balancing expectations and pre-conceptions of self-management (providers). The themes were characterized by inherent dilemmas representing confusions and conflicts that patients and providers experienced in their daily life or practice. Patients found it difficult to tailor information and lifestyle advice to fit their daily life. Healthcare providers recognized that patients needed support to change behavior, but saw themselves as inadequately equipped to deal with the different cultural and social aspects of self-management. This study highlights patient and provider dilemmas that influence the interaction and collaboration between patients and providers and hinder uptake of self-management advice.

Private retail drug shops: what they are, how they operate, and implications for health care delivery in rural Uganda.

BACKGROUND: Retail drug shops play a significant role in managing pediatric fevers in rural areas in Uganda. Targeted interventions to improve drug seller practices require understanding of the retail drug shop market and motivations that influence practices. This study aimed at describing the operational environment in relation to the Uganda National Drug Authority guidelines for setup of drug shops; characteristics, and dispensing practices of private retail drug shops in managing febrile conditions among under-five children in rural western Uganda. METHODS: Cross sectional survey of 74 registered drug shops, observation checklist, and 428 exit interviews using a semi-structured questionnaire with care-seekers of children under five years of age, who sought care at drug shops during the survey period. The survey was conducted in Mbarara and Bushenyi districts, South Western Uganda, in May 2013. RESULTS: Up to 90 and 79% of surveyed drug shops in Mbarara and Bushenyi, largely operate in premises that meet National Drug Authority requirements for operational suitability and ensuring medicines safety and quality. Drug shop attendants had some health or medical related training with 60% in Mbarara and 59% in Bushenyi being nurses or midwives. The rest were clinical officers, pharmacists. The most commonly stocked medicines at drug shops were Paracetamol, Quinine, Cough syrup, ORS/Zinc, Amoxicillin syrup, Septrin® syrup, Artemisinin-based combination therapies, and multivitamins, among others. Decisions on what medicines to stock were influenced by among others: recommended medicines from Ministry of Health, consumer demand, most profitable medicines, and seasonal disease patterns. Dispensing decisions were influenced by: prescriptions presented by client, patients' finances, and patient preferences, among others. Most drug shops surveyed had clinical guidelines, iCCM guidelines, malaria and diarrhea treatment algorithms and charts as recommended by the Ministry of Health. Some drug shops offered additional services such as immunization and sold non-medical goods, as a mechanism for diversification. CONCLUSION: Most drug shops premises adhered to the recommended guidelines. Market factors, including client demand and preferences, pricing and profitability, and seasonality largely influenced dispensing and stocking practices. Improving retail drug shop practices and quality of services, requires designing and implementing both supply-side and demand side strategies.