Changes in behavior and quality of life in German young children during the COVID-19 pandemic-results from the COVID kids bavaria study.

Introduction: The COVID-19 pandemic with its containment measures such as closures of schools and daycare facilities led to numerous restrictions in daily life, putting developmental opportunities and health-related quality of life in children at risk. However, studies show that not every family was impacted equally by the pandemic and that this exceptional health and societal situation reinforced pre-existing health inequalities among the vulnerable. Our study aimed at analyzing changes in behavior and health-related quality of life of children attending elementary schools and daycare facilities in Bavaria, Germany in spring 2021. We also sought to identify associated factors contributing to inequalities in quality of life. Methods: Data from a multi-center, open cohort study ("COVID Kids Bavaria") conducted in 101 childcare facilities and 69 elementary schools across all electoral districts of Bavaria were analyzed. Children attending these educational settings (aged 3-10 years) were eligible for participation in a survey on changes in behavior and health-related quality of life. The KINDLR questionnaire (based on children's self-report and parental report) was administered about one year after the onset of the pandemic (spring 2021). Descriptive and logistic regression analyses and comparisons to pre-pandemic KiGGS (German Health Interview and Examination Survey for Children and Adolescents) data were undertaken. Results: Among respondents, a high percentage of parents reported changes in their children's eating and sleeping behavior, sports and outdoor activities as well as altered screen time. Health-related quality of life in KINDLR analyses compared to pre-pandemic population averages were lower in all age groups (for 3-6-year-old KINDLR-total score: COVID Kids Bavaria MD 74.78 ± 10.57 vs KiGGS data 80.0 ± 8.1; 7-10 years-old KINDLR-total score: COVID Kids Bavaria MD 73.88 ± 12.03 vs KiGGS data 79.30 ± 9.0). No significant differences were detected with regard to associated factors, namely type of institution, sex of the child, migration background, household size and parental education. Conclusion: These findings suggest a relevant impact of the COVID-19 pandemic on children's behavior and health-related quality of life one year after the onset of the pandemic. Further analyses in large-scale longitudinal studies are needed to determine the effects of specific pandemic or crisis associated factors contributing to health inequalities.

Using GRADE Evidence to Decision frameworks to support the process of health policy-making: an example application regarding taxation of sugar-sweetened beverages.

BACKGROUND: Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) frameworks are well-known tools that enable guideline panels to structure the process of developing recommendations and making decisions in healthcare and public health. To date, they have not regularly been used for health policy-making. This article aims to illustrate the application of the GRADE EtD frameworks in the process of nutrition-related policy-making for a European country. METHODS: Based on methodological guidance by the GRADE Working Group and the findings of our recently published scoping review, we illustrate the process of moving from evidence to recommendations, by applying the EtD frameworks to a fictitious example. Sugar-sweetened beverage (SSB) taxation based on energy density was chosen as an example application. RESULTS: A fictitious guideline panel was convened by a national nutrition association to develop a population-level recommendation on SSB taxation aiming to reduce the burden of overweight and obesity. Exemplary evidence was summarized for each EtD criterion and conclusions were drawn based on all judgements made in relation to each criterion. As a result of the high priority to reduce the burden of obesity and because of the moderate desirable effects on health outcomes, but considering scarce or varying research evidence for other EtD criteria, the panel made a conditional recommendation for SSB taxation. Decision-makers may opt for conducting a pilot study prior to implementing the policy on a national level. CONCLUSIONS: GRADE EtD frameworks can be used by guideline panels to make the process of developing recommendations in the field of health policy more systematic, transparent and comprehensible.

Health sector readiness for the prevention and control of non-communicable diseases: A multi-method qualitative assessment in Nepal.

In Nepal, deaths attributable to NCDs have increased in recent years. Although NCDs constitute a major public health problem, how best to address this has not received much attention. The objective of this study was to assess the readiness of the Nepalese health sector for the prevention and control of NCDs and their risk factors. The study followed a multi-method qualitative approach, using a review of policy documents, focus group discussions (FGDs), and in-depth interviews (IDIs) conducted between August and December 2020. The policy review was performed across four policy categories. FGDs were undertaken with different cadres of health workers and IDIs with policy makers, program managers and service providers. We performed content analysis using the WHO health system building blocks framework as the main categories. Policy documents were concerned with the growing NCD burden, but neglect the control of risk factors. FGDs and IDIs reveal significant perceived weaknesses in each of the six building blocks. According to study participants, existing services were focused on curative rather than preventive interventions. Poor retention of all health workers in rural locations, and of skilled health workers in urban locations led to the health workers across all levels being overburdened. Inadequate quantity and quality of health commodities for NCDs emerged as an important logistics issue. Monitoring and reporting for NCDs and their risk factors was found to be largely absent. Program decisions regarding NCDs did not use the available evidence. The limited budget dedicated to NCDs is being allocated to curative services. The engagement of non-health sectors with the prevention and control of NCDs remained largely neglected. There is a need to redirect health sector priorities towards NCD risk factors, notably to promote healthy diets and physical activity and to limit tobacco and alcohol consumption, at policy as well as community levels.

Advancing the WHO-INTEGRATE Framework as a Tool for Evidence-Informed, Deliberative Decision-Making Processes: Exploring the Views of Developers and Users of WHO Guidelines.

BACKGROUND: Decision-making on matters of public health and health policy is a deeply value-laden process. The World Health Organization (WHO)-INTEGRATE framework was proposed as a new evidence-to-decision (EtD) framework to support guideline development from a complexity perspective, notably in relation to public health and health system interventions, and with a foundation in WHO norms and values. This study was conducted as part of the development of the framework to assess its comprehensiveness and usefulness for public health and health policy decision-making. METHODS: We conducted a qualitative study comprising nine key informant interviews (KIIs) with experts involved in WHO guideline development and four focus group discussions (FGDs) with a total of forty health decision-makers from Brazil, Germany, Nepal and Uganda. Transcripts were analyzed using MAXQDA12 and qualitative content analysis. RESULTS: Most key informants and participants in the FGDs appreciated the framework for its relevance to real-world decision-making on four widely differing health topics. They praised its broad perspective and comprehensiveness with respect to new or expanded criteria, notably regarding societal implications, equity considerations, and acceptability. Some guideline developers questioned the value of the framework beyond current practice and were concerned with the complexity of applying such a broad range of criteria in guideline development processes. Participants made concrete suggestions for improving the wording and definitions of criteria as well as their grouping, for covering missing aspects, and for addressing overlap between criteria. CONCLUSION: The framework was well-received by health decision-makers as well as the developers of WHO guidelines and appears to capture all relevant considerations discussed in four distinct real-world decision processes that took place on four different continents. Guidance is needed on how to apply the framework in guideline processes that are both transparent and participatory. A set of suggestions for improvement provides a valuable starting point for advancing the framework towards version 2.0.

Simulation Modeling for the Economic Evaluation of Population-Based Dietary Policies: A Systematic Scoping Review.

Simulation modeling can be useful to estimate the long-term health and economic impacts of population-based dietary policies. We conducted a systematic scoping review following the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) guideline to map and critically appraise economic evaluations of population-based dietary policies using simulation models. We searched Medline, Embase, and EconLit for studies published in English after 2005. Modeling studies were mapped based on model type, dietary policy, and nutritional target, and modeled risk factor-outcome pathways were analyzed. We included 56 studies comprising 136 model applications evaluating dietary policies in 21 countries. The policies most often assessed were reformulation (34/136), taxation (27/136), and labeling (20/136); the most common targets were salt/sodium (60/136), sugar-sweetened beverages (31/136), and fruit and vegetables (15/136). Model types included Markov-type (35/56), microsimulation (11/56), and comparative risk assessment (7/56) models. Overall, the key diet-related risk factors and health outcomes were modeled, but only 1 study included overall diet quality as a risk factor. Information about validation was only reported in 19 of 56 studies and few studies (14/56) analyzed the equity impacts of policies. Commonly included cost components were health sector (52/56) and public sector implementation costs (35/56), as opposed to private sector (18/56), lost productivity (11/56), and informal care costs (3/56). Most dietary policies (103/136) were evaluated as cost-saving independent of the applied costing perspective. An analysis of the main limitations reported by authors revealed that model validity, uncertainty of dietary effect estimates, and long-term intervention assumptions necessitate a careful interpretation of results. In conclusion, simulation modeling is widely applied in the economic evaluation of population-based dietary policies but rarely takes dietary complexity and the equity dimensions of policies into account. To increase relevance for policymakers and support diet-related disease prevention, economic effects beyond the health sector should be considered, and transparent conduct and reporting of model validation should be improved.

The WHO-INTEGRATE evidence to decision framework version 1.0: integrating WHO norms and values and a complexity perspective.

INTRODUCTION: Evidence-to-decision (EtD) frameworks intend to ensure that all criteria of relevance to a health decision are systematically considered. This paper, part of a series commissioned by the WHO, reports on the development of an EtD framework that is rooted in WHO norms and values, reflective of the changing global health landscape, and suitable for a range of interventions and complexity features. We also sought to assess the value of this framework to decision-makers at global and national levels, and to facilitate uptake through suggestions on how to prioritise criteria and methods to collect evidence. METHODS: In an iterative, principles-based approach, we developed the framework structure from WHO norms and values. Preliminary criteria were derived from key documents and supplemented with comprehensive subcriteria obtained through an overview of systematic reviews of criteria employed in health decision-making. We assessed to what extent the framework can accommodate features of complexity, and conducted key informant interviews among WHO guideline developers. Suggestions on methods were drawn from the literature and expert consultation. RESULTS: The new WHO-INTEGRATE (INTEGRATe Evidence) framework comprises six substantive criteria-balance of health benefits and harms, human rights and sociocultural acceptability, health equity, equality and non-discrimination, societal implications, financial and economic considerations, and feasibility and health system considerations-and the meta-criterion quality of evidence. It is intended to facilitate a structured process of reflection and discussion in a problem-specific and context-specific manner from the start of a guideline development or other health decision-making process. For each criterion, the framework offers a definition, subcriteria and example questions; it also suggests relevant primary research and evidence synthesis methods and approaches to assessing quality of evidence. CONCLUSION: The framework is deliberately labelled version 1.0. We expect further modifications based on focus group discussions in four countries, example applications and input across concerned disciplines.

Towards a taxonomy of logic models in systematic reviews and health technology assessments: A priori, staged, and iterative approaches.

The complexity associated with how interventions result-or fail to result-in outcomes and how context matters is increasingly recognised. Logic models provide an important tool for handling complexity, with contrasting uses in programme evaluation and evidence synthesis. To reconcile these, we developed an approach that combines the strengths of both traditions, propose a taxonomy of logic models, and provide guidance on how to choose between approaches and types of logic models in systematic reviews and health technology assessments (HTA). The taxonomy distinguishes 3 approaches (a priori, staged, and iterative) and 2 types (systems-based and process-orientated) of logic models. An a priori logic model is specified at the start of the systematic review/HTA and remains unchanged. With a staged logic model, the reviewer prespecifies several points, at which major data inputs require a subsequent version. An iterative logic model is continuously modified throughout the systematic review/HTA process. System-based logic models describe the system, in which the interaction between participants, intervention, and context takes place; process-orientated models display the causal pathways leading from the intervention to multiple outcomes. The proposed taxonomy of logic models offers an improved understanding of the advantages and limitations of logic models across the spectrum from a priori to fully iterative approaches. Choice of logic model should be informed by scope of evidence synthesis, presence/absence of clearly defined population, intervention, comparison, outcome (PICO) elements, and feasibility considerations. Applications across distinct interventions and methodological approaches will deliver good practice case studies and offer further insights on the choice and implementation of logic modelling approaches.

An approach for setting evidence-based and stakeholder-informed research priorities in low- and middle-income countries.

To derive evidence-based and stakeholder-informed research priorities for implementation in African settings, the international research consortium Collaboration for Evidence-Based Healthcare and Public Health in Africa (CEBHA+) developed and applied a pragmatic approach. First, an online survey and face-to-face consultation between CEBHA+ partners and policy-makers generated priority research areas. Second, evidence maps for these priority research areas identified gaps and related priority research questions. Finally, study protocols were developed for inclusion within a grant proposal. Policy and practice representatives were involved throughout the process. Tuberculosis, diabetes, hypertension and road traffic injuries were selected as priority research areas. Evidence maps covered screening and models of care for diabetes and hypertension, population-level prevention of diabetes and hypertension and their risk factors, and prevention and management of road traffic injuries. Analysis of these maps yielded three priority research questions on hypertension and diabetes and one on road traffic injuries. The four resulting study protocols employ a broad range of primary and secondary research methods; a fifth promotes an integrated methodological approach across all research activities. The CEBHA+ approach, in particular evidence mapping, helped to formulate research questions and study protocols that would be owned by African partners, fill gaps in the evidence base, address policy and practice needs and be feasible given the existing research infrastructure and expertise. The consortium believes that the continuous involvement of decision-makers throughout the research process is an important means of ensuring that studies are relevant to the African context and that findings are rapidly implemented.

Afin de déterminer, à partir d'éléments factuels et avec l'apport des parties prenantes, les priorités de recherche pouvant être mises en œuvre dans les pays d'Afrique, le consortium de recherche international Collaboration for Evidence-Based Health Care and Public Health in Africa (CEBHA+) a élaboré et appliqué une démarche pragmatique. Tout d'abord, une enquête en ligne et une consultation en face à face entre les partenaires du CEBHA+ et les responsables politiques ont permis de mettre en lumière les domaines de recherche prioritaires. Ensuite, des listes documentaires relatives à ces domaines de recherche prioritaires ont permis d'identifier les lacunes ainsi que des questions connexes prioritaires en matière de recherche. Enfin, des protocoles d'étude ont été mis au point en vue d'être intégrés à une proposition de subvention. Des représentants de la mise en œuvre des politiques ont participé à l'ensemble du processus. La tuberculose, le diabète, l'hypertension et les blessures de la route ont été sélectionnés comme domaines de recherche prioritaires. Les listes documentaires portaient sur le dépistage et les modèles de soins du diabète et de l'hypertension, sur la prévention de ces maladies ainsi que sur leurs facteurs de risque au niveau de la population, et sur la prévention et la prise en charge des blessures de la route. L'analyse de ces listes a permis de dégager trois questions de recherche prioritaires portant sur l'hypertension et le diabète et une sur les blessures de la route. Les quatre protocoles d'étude en découlant utilisent toute une série de méthodes de recherche primaire et secondaire; un cinquième favorise une démarche méthodologique intégrée sur l'ensemble des activités de recherche. La démarche du CEBHA+, en particulier la constitution de listes documentaires, a permis de formuler les questions de recherche et les protocoles d'étude qui reviendront aux partenaires africains, de combler les lacunes des bases de données et de répondre aux besoins en matière de politiques et de pratiques; elle s'est également révélée applicable compte tenu de l'expertise et de l'infrastructure de recherche existantes. Pour le consortium, l'implication continue des décisionnaires dans le processus de recherche est un important moyen de garantir que les études soient pertinentes pour les pays africains et que leurs résultats soient rapidement mis en œuvre.

Para obtener las prioridades de investigación documentadas y comunicadas a las partes interesadas para su implementación en África, el consorcio de investigación internacional Asociación de Asistencia Médica Basada en Evidencia en África (CEBHA+, por sus siglas en inglés), desarrolló y aplicó un enfoque pragmático. En primer lugar, una encuesta en línea y una consulta presencial entre socios de la CEBHA+ y responsables políticos originó los sectores de investigación prioritarios. En segundo lugar, unos mapas documentados para estos sectores de investigación prioritarios identificaron disparidades y asuntos relativos a la investigación prioritaria. Por último, se desarrollaron protocolos de estudio para incluirlos dentro de una propuesta de subvención. Los representantes políticos y prácticos participaron durante todo el proceso. Los sectores de investigación prioritarios seleccionados fueron la tuberculosis, la diabetes, la hipertensión y los traumatismos provocados por accidentes de tráfico. Los mapas documentados abordaron el examen y los modelos de asistencia de la diabetes y la hipertensión, la prevención de la diabetes y la hipertensión a nivel de población, sus factores de riesgo y la prevención y gestión de traumatismos provocados por accidentes de tráfico. Los análisis de estos mapas generaron tres asuntos de investigación de prioridades sobre hipertensión y diabetes y uno sobre traumatismos provocados por accidentes de tráfico. Los cuatro protocolos de estudio resultantes emplean una amplia gama de métodos de investigación primarios y secundarios; un quinto presenta un enfoque metodológico integrado a través de todas las actividades de investigación. El enfoque de la CEBHA+, concretamente los mapas documentados, contribuyó a formular cuestiones y protocolos de estudio sobre la investigación que pertenecerían a socios africanos, subsanarían diferencias en la base de pruebas, abordarían las necesidades sobre políticas y prácticas y serían viables gracias a la infraestructura y experiencia de investigación existentes. El consorcio considera que la constante implicación de los responsables de la toma de decisiones a lo largo del proceso de investigación es un medio importante para garantizar que los estudios se correspondan al contexto africano y que los resultados se implementen con rapidez.

Clean fuels for resource-poor settings: A systematic review of barriers and enablers to adoption and sustained use.

BACKGROUND: Access to, and sustained adoption of, clean household fuels at scale remains an aspirational goal to achieve sufficient reductions in household air pollution (HAP) in order to impact on the substantial global health burden caused by reliance on solid fuels. AIM AND OBJECTIVES: To systematically appraise the current evidence base to identify: (i) which factors enable or limit adoption and sustained use of clean fuels (namely liquefied petroleum gas (LPG), biogas, solar cooking and alcohol fuels) in low- and middle-income countries; (ii) lessons learnt concerning equitable scaling-up of programmes of cleaner cooking fuels in relation to poverty, urban-rural settings and gender. METHODS: A mixed-methods systematic review was conducted using established review methodology and extensive searches of published and grey literature sources. Data extraction and quality appraisal of quantitative, qualitative and case studies meeting inclusion criteria were conducted using standardised methods with reliability checking. FINDINGS: Forty-four studies from Africa, Asia and Latin America met the inclusion criteria (17 on biogas, 12 on LPG, 9 on solar, 6 on alcohol fuels). A broad range of inter-related enabling and limiting factors were identified for all four types of intervention, operating across seven pre-specified domains (i.e. fuel and technology characteristics, household and setting characteristics, knowledge and perceptions, financial, tax and subsidy aspects, market development, regulation, legislation and standards, and programme and policy mechanisms) and multiple levels (i.e. household, community, national). All domains matter and the majority of factors are common to all clean fuels interventions reviewed although some are fuel and technology-specific. All factors should therefore be taken into account and carefully assessed during planning and implementation of any small- and large-scale initiative aiming at promoting clean fuels for household cooking. CONCLUSIONS: Despite limitations in quantity and quality of the evidence this systematic review provides a useful starting point for the design, delivery and evaluation of programmes to ensure more effective adoption and use of LPG, biogas, alcohol fuels and solar cooking. FUNDING: This review was funded by the Department for International Development (DfID) of the United Kingdom. The authors would also like to thank the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) for their technical support.

Factors affecting institutional delivery in rural Chitwan district of Nepal: a community-based cross-sectional study.

BACKGROUND: Health facility delivery is considered a critical strategy to improve maternal health. The Government of Nepal is promoting institutional delivery through different incentive programmes and the establishment of birthing centres. This study aimed to identify the socio-demographic, socio-cultural, and health service-related factors influencing institutional delivery uptake in rural areas of Chitwan district, where high rates of institutional deliveries co-exist with a significant proportion of home deliveries. METHODS: This community-based cross-sectional study was conducted in six rural Village Development Committees of Chitwan district, which are characterised by relatively low institutional delivery rates and the availability of birthing centres. The study area represents both hilly and plain areas of Chitwan. A total of 673 mothers who had given birth during a one-year-period were interviewed using a structured questionnaire. Univariate and multivariable logistic regression analysis using stepwise backward elimination was performed to identify key factors affecting institutional delivery. RESULTS: Adjusting for all other factors in the final model, advantaged caste/ethnicity [aOR: 1.98; 95% CI: 1.15-3.42], support for institutional delivery by the husband [aOR: 19.85; 95% CI: 8.53-46.21], the decision on place of delivery taken jointly by women and family members [aOR: 5.43; 95% CI: 2.91-10.16] or by family members alone [aOR: 4.61; 95% CI: 2.56-8.28], birth preparations [aOR: 1.75; 95% CI: 1.04-2.92], complications during the most recent pregnancy/delivery [aOR: 2.88; 95% CI: 1.67-4.98], a perception that skilled health workers are always available [aOR: 2.70; 95% CI: 1.20-6.07] and a birthing facility located within one hour's travelling distance [aOR: 2.15; 95% CI: 1.26-3.69] significantly increased the likelihood of institutional delivery. On the other hand, not knowing about the adequacy of physical facilities significantly decreased the likelihood of institutional delivery [aOR: 0.14; 95% CI: 0.05-0.41]. CONCLUSION: With multiple incentives present, the decision to deliver in a health facility is affected by a complex interplay of socio-demographic, socio-cultural, and health service-related factors. Family decision-making roles and a husband's support for institutional delivery exert a particularly strong influence on the place of delivery, and this should be emphasized in the health policy as well as development and implementation of maternal health programmes in Nepal.

Beyond direct impact: evidence synthesis towards a better understanding of effectiveness of environmental health interventions.

Systematic reviews are a cornerstone of evidence-based public health, and there is much discussion on how this method may need to be modified to do justice to complex interventions, such as environmental health interventions. This paper asserts that intervention effectiveness is influenced by variability in five distinct layers--direct (intrinsic) impact, user compliance, delivery, programming and policy measures--which are embedded in the broader geographical, socio-economic, political and cultural context. The multi-component, multi-sectoral nature of most environmental health interventions results in a complex relationship between these layers of influence, involving systemic interactions. As illustrated with examples, understanding environmental health interventions critically relies on considering all of these layers. These distinct layers of influence can serve as a framework towards the comprehensive analysis of environmental health interventions in systematic reviews, drawing on quantitative and qualitative methods and a variety of disciplines.

Enablers and barriers to large-scale uptake of improved solid fuel stoves: a systematic review.

BACKGROUND: Globally, 2.8 billion people rely on household solid fuels. Reducing the resulting adverse health, environmental, and development consequences will involve transitioning through a mix of clean fuels and improved solid fuel stoves (IS) of demonstrable effectiveness. To date, achieving uptake of IS has presented significant challenges. OBJECTIVES: We performed a systematic review of factors that enable or limit large-scale uptake of IS in low- and middle-income countries. METHODS: We conducted systematic searches through multidisciplinary databases, specialist websites, and consulting experts. The review drew on qualitative, quantitative, and case studies and used standardized methods for screening, data extraction, critical appraisal, and synthesis. We summarized our findings as "factors" relating to one of seven domains-fuel and technology characteristics; household and setting characteristics; knowledge and perceptions; finance, tax, and subsidy aspects; market development; regulation, legislation, and standards; programmatic and policy mechanisms-and also recorded issues that impacted equity. RESULTS: We identified 31 factors influencing uptake from 57 studies conducted in Asia, Africa, and Latin America. All domains matter. Although factors such as offering technologies that meet household needs and save fuel, user training and support, effective financing, and facilitative government action appear to be critical, none guarantee success: All factors can be influential, depending on context. The nature of available evidence did not permit further prioritization. CONCLUSIONS: Achieving adoption and sustained use of IS at a large scale requires that all factors, spanning household/community and program/societal levels, be assessed and supported by policy. We propose a planning tool that would aid this process and suggest further research to incorporate an evaluation of effectiveness.

Neonatal health in Nepal: analysis of absolute and relative inequalities and impact of current efforts to reduce neonatal mortality.

BACKGROUND: Nepal has made substantial progress in reducing under-five mortality and is on track to achieve Millennium Development Goal 4, but advances in neonatal health are less encouraging. The objectives of this study were to assess relative and absolute inequalities in neonatal mortality over time, and to review experience with major programs to promote neonatal health. METHODS: Using four nationally representative surveys conducted in 1996, 2001, 2006 and 2011, we calculated neonatal mortality rates for Nepal and for population groups based on child sex, geographical and socio-economic variables using a true cohort log probability approach. Inequalities based on different variables and years were assessed using rate differences (rd) and rate ratios (rr); time trends in neonatal mortality were measured using the annual rate of reduction. Through literature searches and expert consultation, information on Nepalese policies and programs implemented since 1990 and directly or indirectly attempting to reduce neonatal mortality was compiled. Data on timeline, coverage and effectiveness were extracted for major programs. RESULTS: The annual rate of reduction for neonatal mortality between 1996 and 2011 (2.8 percent per annum) greatly lags behind the achievements in under-five and infant mortality, and varies across population groups. For the year 2011, stark absolute and relative inequalities in neonatal mortality exist in relation to wealth status (rd = 21.4, rr = 2.2); these are less pronounced for other measures of socio-economic status, child sex and urban-rural residence, ecological and development region. Among many efforts to promote child and maternal health, three established programs and two pilot programs emerged as particularly relevant to reducing neonatal mortality. While these were designed based on national and international evidence, information about coverage of different population groups and effectiveness is limited. CONCLUSION: Neonatal mortality varies greatly by socio-demographic variables. This study clearly shows that much remains to be achieved in terms of reducing neonatal mortality across different socio-economic, ethnic and geographical population groups in Nepal. In moving forward it will be important to scale up programs of proven effectiveness, conduct in-depth evaluation of promising new approaches, target unreached and hard-to-reach populations, and maximize use of financial and personnel resources through integration across programs.

Understanding child stunting in India: a comprehensive analysis of socio-economic, nutritional and environmental determinants using additive quantile regression.

BACKGROUND: Most attempts to address undernutrition, responsible for one third of global child deaths, have fallen behind expectations. This suggests that the assumptions underlying current modelling and intervention practices should be revisited. OBJECTIVE: We undertook a comprehensive analysis of the determinants of child stunting in India, and explored whether the established focus on linear effects of single risks is appropriate. DESIGN: Using cross-sectional data for children aged 0-24 months from the Indian National Family Health Survey for 2005/2006, we populated an evidence-based diagram of immediate, intermediate and underlying determinants of stunting. We modelled linear, non-linear, spatial and age-varying effects of these determinants using additive quantile regression for four quantiles of the Z-score of standardized height-for-age and logistic regression for stunting and severe stunting. RESULTS: At least one variable within each of eleven groups of determinants was significantly associated with height-for-age in the 35% Z-score quantile regression. The non-modifiable risk factors child age and sex, and the protective factors household wealth, maternal education and BMI showed the largest effects. Being a twin or multiple birth was associated with dramatically decreased height-for-age. Maternal age, maternal BMI, birth order and number of antenatal visits influenced child stunting in non-linear ways. Findings across the four quantile and two logistic regression models were largely comparable. CONCLUSIONS: Our analysis confirms the multifactorial nature of child stunting. It emphasizes the need to pursue a systems-based approach and to consider non-linear effects, and suggests that differential effects across the height-for-age distribution do not play a major role.