Complementary feeding practices: Current global and regional estimates.

Insufficient quantities and inadequate quality of complementary foods, together with poor feeding practices, pose a threat to children's health and nutrition. Interventions to improve complementary feeding are critical to reduce all forms of malnutrition, and access to data to ascertain the status of complementary feeding practices is essential for efforts to improve feeding behaviours. However, sufficient data to generate estimates for the core indicators covering the complementary feeding period only became available recently. The current situation of complementary feeding at the global and regional level is reported here using data contained within the UNICEF global database. Global rates of continued breastfeeding drop from 74.0% at 1 year of age to 46.3% at 2 years of age. Nearly a third of infants 4-5 months old are already fed solid foods, whereas nearly 20% of 10-11 months old had not consumed solid foods during the day prior to their survey. Of particular concern is the low rate (28.2%) of children 6-23 months receiving at least a minimally diverse diet. Although rates for all indicators vary by background characteristics, feeding behaviours are suboptimal even in richest households, suggesting that cultural factors and poor knowledge regarding an adequate diet for young children are important to address. In summary, far too few children are benefitting from minimum complementary feeding practices. Efforts are needed not only to improve children's diets for their survival, growth, and development but also for governments to report on progress against global infant and young child feeding indicators on a regular basis.

Diet quality and risk of stunting among infants and young children in low- and middle-income countries.

Age-appropriate complementary feeding practices are far from optimal among low- and middle-income countries with available data. The evidence on the association between feeding practices and linear growth is mixed. We sought to systematically examine the association between two indictors of dietary quality-dietary diversity and animal source food (ASF) consumption (WHO, 2008)-and stunting (length-for-age z-score) employing existing data from 39 Demographic and Health Surveys. Data on 74,548 children aged 6-23 months were pooled and multiple logistic regression models, adjusting for child, maternal, and household characteristics, employed to assess the association between dietary quality and stunting. Stratified models by child age and by World Bank country-income classifications (World Bank, 2015) were also applied. Children aged 6-23 months consuming zero food groups in the previous day had a 1.345 higher odds of being stunted when compared to the reference group (≥5 food groups); those who did not consume any ASF in the previous day had a 1.436 higher odds of being stunted compared to children consuming all three types of ASF (egg, meat, and dairy). We estimated that 2,629 cases of stunting would have been averted (12.6% of those stunted) among the population studied if all children had consumed five or more food groups. Outcomes by country-income groupings showed larger associations of diet diversity and ASF consumption for upper- and lower-middle income countries compared to low-income countries. In summary, dietary diversity and ASF consumption were associated with stunting, with associations varying by stratified groups.

Correction: Leppäniemi et al. Nutrition Profile for Countries of the Eastern Mediterranean Region with Different Income Levels: An Analytical Review. Children 2023, 10, 236.

In the original publication [...].

Nutrition Profile for Countries of the Eastern Mediterranean Region with Different Income Levels: An Analytical Review.

The World Health Organization's (WHO) Eastern Mediterranean Region (EMR) is suffering from a double burden of malnutrition in which undernutrition coexists with rising rates of overweight and obesity. Although the countries of the EMR vary greatly in terms of income level, living conditions and health challenges, the nutrition status is often discussed only by using either regional or country-specific estimates. This analytical review studies the nutrition situation of the EMR during the past 20 years by dividing the region into four groups based on their income level-the low-income group (Afghanistan, Somalia, Sudan, Syria, and Yemen), the lower-middle-income group (Djibouti, Egypt, Iran, Morocco, Pakistan, Palestine, and Tunisia), the upper-middle-income group (Iraq, Jordan, Lebanon, and Libya) and the high-income group (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates)-and by comparing and describing the estimates of the most important nutrition indicators, including stunting, wasting, overweight, obesity, anaemia, and early initiation and exclusive breastfeeding. The findings reveal that the trends of stunting and wasting were decreasing in all EMR income groups, while the percentages of overweight and obesity predominantly increased in all age groups across the income groups, with the only exception in the low-income group where a decreasing trend among children under five years existed. The income level was directly associated with the prevalence rates of overweight and obesity among other age groups except children under five, while an inverse association was observed regarding stunting and anaemia. Upper-middle-income country group showed the highest prevalence rate of overweight among children under five. Most countries of the EMR revealed below-desired rates of early initiation and exclusive breastfeeding. Changes in dietary patterns, nutrition transition, global and local crises, and nutrition policies are among the major explanatory factors for the findings. The scarcity of updated data remains a challenge in the region. Countries need support in filling the data gaps and implementing recommended policies and programmes to address the double burden of malnutrition.

Large and persistent subnational inequalities in reproductive, maternal, newborn and child health intervention coverage in sub-Saharan Africa.

Subnational inequalities have received limited attention in the monitoring of progress towards national and global health targets during the past two decades. Yet, such data are often a critical basis for health planning and monitoring in countries, in support of efforts to reach all with essential interventions. Household surveys provide a rich basis for interventions coverage indicators on reproductive, maternal, newborn and child health (RMNCH) at the country first administrative level (regions or provinces). In this paper, we show the large subnational inequalities that exist in RMNCH coverage within 39 countries in sub-Saharan Africa, using a composite coverage index which has been used extensively by Countdown to 2030 for Women's, Children's and Adolescent's Health. The analyses show the wide range of subnational inequality patterns such as low overall national coverage with very large top inequality involving the capital city, intermediate national coverage with bottom inequality in disadvantaged regions, and high coverage in all regions with little inequality. Even though nearly half of the 34 countries with surveys around 2004 and again around 2015 appear to have been successful in reducing subnational inequalities in RMNCH coverage, the general picture shows persistence of large inequalities between subnational units within many countries. Poor governance and conflict settings were identified as potential contributing factors. Major efforts to reduce within-country inequalities are required to reach all women and children with essential interventions.

Trends and inequalities in the nutritional status of adolescent girls and adult women in sub-Saharan Africa since 2000: a cross-sectional series study.

INTRODUCTION: Evidence on the rate at which the double burden of malnutrition unfolds is limited. We quantified trends and inequalities in the nutritional status of adolescent girls and adult women in sub-Saharan Africa. METHODS: We analysed 102 Demographic and Health Surveys between 1993 and 2017 from 35 countries. We assessed regional trends through cross-sectional series analyses and ran multilevel linear regression models to estimate the average annual rate of change (AARC) in the prevalence of underweight, anaemia, anaemia during pregnancy, overweight and obesity among women by their age, residence, wealth and education levels. We quantified current absolute inequalities in these indicators and wealth-inequality trends. RESULTS: There was a modest decline in underweight prevalence (AARC=-0.14 percentage points (pp), 95% CI -0.17 to -0.11). Anaemia declined fastest among adult women and the richest pregnant women with an AARC of -0.67 pp (95% CI -1.06 to -0.28) and -0.97 pp (95% CI -1.60 to -0.34), respectively, although it affects all women with no marked disparities. Overweight is increasing rapidly among adult women and women with no education. Capital city residents had a threefold more rapid rise in obesity (AARC=0.47 pp, 95% CI 0.39, 0.55), compared with their rural counterparts. Absolute inequalities suggest that Ethiopia and South Africa have the largest gap in underweight (15.4 pp) and obesity (28.5 pp) respectively, between adult and adolescent women. Regional wealth inequalities in obesity are widening by 0.34 pp annually. CONCLUSION: Underweight persists, while overweight and obesity are rising among adult women, the rich and capital city residents. Adolescent girls do not present adverse nutritional outcomes except anaemia, remaining high among all women. Multifaceted responses with an equity lens are needed to ensure no woman is left behind.

Enhancing immunization during second year of life by reducing missed opportunities for vaccinations in 46 countries.

BACKGROUND: Delivering vaccination services during the second year of life (2YL)1 provides countries with an opportunity to achieve greater coverage, to provide booster doses and vaccines missed during the first year of life, as well as contribute towards disease control and elimination goals. METHODS: Using data from demographic health surveys (DHSs) conducted during 2010 to 2016, this paper explores the proportion of missed opportunities for vaccinations generally provided during routine immunization among children in their 2YL. RESULTS: DHS data in 46 countries surveyed 478,737 children, from which 169,259 children were 12-23 months old and had vaccination/health cards viewed by surveyors. From this group, 69,489 children aged 12-23 months had contact with health services in their 2YL. Three scenarios for a missed opportunity for vaccinations were analysed: (1) a child received one vaccine in the immunization schedule and was eligible for another vaccine, but did not receive any further vaccination, (2) a child received a vitamin A supplementation (VAS) and was due for a vaccine, but did not receive vaccines that were due, and (3) a child was taken to a health facility for a sick visit and was due (and eligible) for a vaccine, but did not receive the vaccine. A total of 16,409 (24%) children had one or more missed opportunities for vaccinations. CONCLUSION: This analysis highlights the magnitude of the problem of missed opportunities in the 2YL. The global community needs to provide better streamlined guidance, policies and strategies to promote vaccination screenings at well-child and sick child visits in the 2YL. Where they do not exist, well-child visits in the 2YL should be established and strengthened.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 5. equity effects for neonates and children.

BACKGROUND: The degree to which investments in health programs improve the health of the most disadvantaged segments of the population-where utilization of health services and health status is often the worst-is a growing concern throughout the world. Therefore, questions about the degree to which community-based primary health care (CBPHC) can or actually does improve utilization of health services and the health status of the most disadvantaged children in a population is an important one. METHODS: Using a database containing information about the assessment of 548 interventions, projects or programs (referred to collectively as projects) that used CBPHC to improve child health, we extracted evidence related to equity from a sub-set of 42 projects, identified through a multi-step process, that included an equity analysis. We organized our findings conceptually around a logical framework matrix. RESULTS: Our analysis indicates that these CBPHC projects, all of which implemented child health interventions, achieved equitable effects. The vast majority (87%) of the 82 equity measurements carried out and reported for these 42 projects demonstrated "pro-equitable" or "equitable" effects, meaning that the project's equity indicator(s) improved to the same degree or more in the disadvantaged segments of the project population as in the more advantaged segments. Most (78%) of the all the measured equity effects were "pro-equitable," meaning that the equity criterion improved more in the most disadvantaged segment of the project population than in the other segments of the population. CONCLUSIONS: Based on the observation that CBPHC projects commonly provide services that are readily accessible to the entire project population and that even often reach down to all households, such projects are inherently likely to be more equitable than projects that strengthen services only at facilities, where utilization diminishes greatly with one's distance away. The decentralization of services and attention to and tracking of metrics across all phases of project implementation with attention to the underserved, as can be done in CBPHC projects, are important for reducing inequities in countries with a high burden of child mortality. Strengthening CBPHC is a necessary strategy for reducing inequities in child health and for achieving universal coverage of essential services for children.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 6. strategies used by effective projects.

BACKGROUND: As part of our review of the evidence of the effectiveness of community-based primary health care (CBPHC) in improving maternal, neonatal and child health (MNCH), we summarize here the common delivery strategies of projects, programs and field research studies (collectively referred to as projects) that have demonstrated effectiveness in improving child mortality. Other articles in this series address specifically the effects of CBPHC on improving MNCH, while this paper explores the specific strategies used. METHODS: We screened 12 166 published reports in PubMed of community-based approaches to improving maternal, neonatal and child health in high-mortality, resource-constrained settings from 1950-2015. A total of 700 assessments, including 148 reports from other publicly available sources (mostly unpublished evaluation reports and books) met the criteria for inclusion and were reviewed using a data extraction form. Here we identify and categorize key strategies used in project implementation. RESULTS: Six categories of strategies for program implementation were identified, all of which required working in partnership with communities and health systems: (a) program design and evaluation, (b) community collaboration, (c) education for community-level staff, volunteers, beneficiaries and community members, (d) health systems strengthening, (e) use of community-level workers, and (f) intervention delivery. Four specific strategies for intervention delivery were identified: (a) recognition, referral, and (when possible) treatment of serious childhood illness by mothers and/or trained community agents, (b) routine systematic visitation of all homes, (c) facilitator-led participatory women's groups, and (d) health service provision at outreach sites by mobile health teams. CONCLUSIONS: The strategies identified here provide useful starting points for program design in strengthening the effectiveness of CBPHC for improving MNCH.

The Role of Child Health Days in the Attainment of Global Deworming Coverage Targets among Preschool-Age Children.

BACKGROUND: Global deworming programs aim to reach 75% of at-risk preschool-age children (pre-SAC) by 2020. The 2013 global pre-SAC deworming coverage initially published by the World Health Organization (WHO) was 23.9%, but this estimate inadequately captured deworming delivered through Child Health Day (CHD) platforms. OBJECTIVE: To update global and regional coverage estimates of pre-SAC deworming in 2013 by supplementing data from the WHO Preventive Chemotherapy and Transmission Control (PCT) databank with national CHD data. METHODS: UNICEF country offices (n = 82) were mailed a questionnaire in July 2014 to report on official national biannual CHD deworming coverage as part of the global vitamin A supplementation coverage reporting mechanism. Coverage data obtained were validated and considered for inclusion in the PCT databank in a collaboration between UNICEF and WHO. Descriptive statistical analyses were conducted to update the number of pre-SAC reached and the number of treatments delivered. RESULTS: Of the 47 countries that responded to the UNICEF pre-SAC deworming questionnaire, 73 data points from 39 countries were considered for inclusion into the WHO PCT databank. Of these, 21 new data points were from 12 countries were newly integrated into the WHO database. With this integration, deworming coverage among pre-SAC increased to 49.1%, representing an increase in the number of children reached and treatments administered from 63.7 million to 130.7 million and 94.7 million to 234.8 million, respectively. The updated databank comprised 98 mass deworming activities conducted in 55 countries, in which 80.4% of the global pre-SAC population requiring deworming reside. In all, 57 countries requiring deworming were not yet represented in the database. CONCLUSIONS: With the inclusion of CHD data, global deworming programs are on track to achieving global pre-SAC coverage targets. However, further efforts are needed to improve pre-SAC coverage reporting as well as to sustain and expand deworming delivery through CHDs and other platforms.