Antenatal care coverage and early childhood mortality in Zimbabwe: new interpretations from nationally representative household surveys.

Zimbabwe has implemented universal antenatal care (ANC) policies since 1980 that have significantly contributed to improvements in ANC access and early childhood mortality rates. However, Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), two of Zimbabwe's main sources of health data and evidence, often provide seemingly different estimates of ANC coverage and under-five mortality rates. This creates confusion that can result in disparate policies and practices, with potential negative impacts on mother and child health in Zimbabwe. We conducted a comparability analysis of multiple DHS and MICS datasets to enhance the understanding of point estimates, temporal changes, rural-urban differences and reliability of estimates of ANC coverage and neonatal, infant and under-five mortality rates (NMR, IMR and U5MR, separately) from 2009 to 2019 in Zimbabwe. Our two samples z-tests revealed that both DHS and MICS indicated significant increases in ANC coverage and declines in IMR and U5MR but only from 2009 to 2015. NMR neither increased nor declined from 2009 to 2019. Rural-urban differences were significant for ANC coverage (2009-15 only) but not for NMR, IMR and U5MR. We found that there is a need for more precise DHS and MICS estimates of urban ANC coverage and all estimates of NMR, IMR and U5MR, and that shorter recall periods provide more reliable estimates of ANC coverage in Zimbabwe. Our findings represent new interpretations and clearer insights into progress and gaps around ANC coverage and under-five mortality rates that can inform the development, implementation, monitoring and evaluation of policy and practice responses and further research in Zimbabwe.

"Youth as accessories": Stakeholder Perspectives on Youth Participation in Mental Health Policymaking [Part II].

PURPOSE: To elicit stakeholder perspectives on the findings from our scoping review on youth participation in mental health policymaking, we conducted a global consultation with young people and adults directly involved in mental health policymaking. METHOD: Forty-four stakeholders from 16 countries, including 15 young people, 9 policymakers and 20 facilitators of youth participation, took part in individual interviews and/or focus groups. They were asked about how the review findings contrasted with their own experiences in mental health policymaking. The transcribed data were thematically analyzed. RESULTS: All participants viewed lived experience as valuable in identifying policy gaps. Youth pointed out that children and youth with disabilities, diverse sexual orientations, and/or gender identities were often excluded, and spoke about feelings of being an "accessory", illustrating a lack of power-sharing in a tokenized policymaking process. Adult participants' accounts highlighted the challenges inherent in policymaking such as the need for political knowledge and institutional time constraints. A range of cultural, socio-economic, and political barriers to youth participation, that were often context-specific, were identified. CONCLUSIONS: The diverse perspectives of stakeholders extended the review results. Based on our findings, we recommend that adults and institutions: (1) recognize lived experience as expertise in shaping mental health policies; (2) include diverse groups; (3) reduce tokenistic relationships through the creation of safer spaces, adult feedback, co-production, and social accountability; and (4) adopt an intersectional approach to address cultural, socio-economic, and political barriers to participation. Methodologically, our work demonstrates why stakeholder consultations are an essential component of scoping reviews.

Participation of Children and Youth in Mental Health Policymaking: A Scoping Review [Part I].

Although youth participation is oft-acknowledged as underpinning mental health policy and service reform, little robust evidence exists about the participation of children and youth in mental health policymaking. A scoping review based on Arksey and O'Malley's framework was conducted to identify and synthesize available information on children and youth's participation in mental health policymaking. Published studies up to November 30, 2020 were searched in Medline (OVID), PsycINFO (OVID), Scopus, and Applied Social Sciences Index and Abstracts (PROQUEST). Further studies were identified through Google Scholar and a grey literature search was conducted using Google and targeted web searches from October to December, 2020. Three reviewers performed screening and data extraction relevant to the review objective, followed by an online consultation. From 2,981 records, 25 publications were included. A lack of diversity among the youth involved was found. Youth were often involved in situational analysis and policy design, but seldom in policy implementation and evaluation. Both the facilitators of and barriers to participation were multifaceted and interconnected. Despite a range of expected outcomes of participation for youth, adults, organizations, and communities, perceived and actual effects were neither substantially explored nor reported. Our recommendations for mental health policymaking highlight the inclusion of children and youth from diverse groups, and the creation of relational spaces that ensure safety, inclusiveness, and diversity. Identified future research directions are: the outcomes of youth participation in mental health policymaking, the role of adults, and more generally, how the mental health of children and youth shapes and is shaped by the policymaking process.

The Families First Program to Prevent Child Abuse: Results of a Cluster Randomized Controlled Trial in West Java, Indonesia.

The Families First parenting program is a 10-week paraprofessional-administered adaptation of the Positive Discipline in Everyday Parenting program for West Java, Indonesia. It has not been tested in a randomized controlled trial. The objective was to evaluate the effects of Families First on physical and emotional punishment. We conducted a cluster randomized controlled trial and randomly assigned 20 rural and urban villages in West Java, Indonesia, to intervention or waitlist. Caregivers of children aged 0-7 years in intervention villages received Families First. Between 2017 and 2018, measurements were taken before randomization, immediately post-intervention, and 6 months post-intervention. Primary outcome was presence versus absence of caregiver-reported physical or emotional punishment immediately post-intervention. Intention-to-treat regression models accounted for clustering within villages and were run to compare between groups. Participants and study personnel could not be blinded. There were 374 caregivers in the 10 intervention villages and 362 in the 10 waitlist villages included in the trial and in outcome analyses. The intervention did not result in a lower proportion of intervention families using punishment immediately post-intervention (odds ratio [OR] for physical or emotional punishment immediately post intervention = 1.20 (95% CI 0.79-1.82). There were no significant differences for positive and involved parenting, setting limits, and opinion on discipline, but caregivers in the intervention group had significantly lower odds of using positive discipline (OR = 0.65 (95% CI 0.53-0.80). Families First did not prevent punishment in a setting with low levels of reported punishment but should be tested in a setting with higher levels or among people selected for risk or presence.

Protecting only white children: the impact of child restraint legislation in Brazil.

BACKGROUND: In 2010, Brazil introduced child restraint legislation (CRL). We assessed the effectiveness of CRL in reducing child (aged 0-8 years) injuries and fatalities by race. We performed an evaluation study with an interrupted time-series design. METHODS: We measured the effect of CRL on two outcomes-number of child deaths and number of child injured in traffic collisions per child population, stratified by race, from 2008 to 2014. We controlled for time, unemployment rate and oil consumption (barrels/day in thousands). RESULTS: The CRL was associated with a 3% reduction in the rate of child injuries among whites (incidence rate ratio (IRR): 0.97; 95% CI: 0.96-0.99), but no reduction in child injuries among non-whites (IRR: 0.99; 95% CI: 0.99-1.00). In the first month after the implementation of Brazil's CRL we observed a 39% reduction in all child fatalities (IRR: 0.61; 95% CI: 0.44-0.84), including a 52% reduction among whites (IRR: 0.48; 95% CI: 0.33-0.68), but no reduction in non-white fatalities (IRR: 0.87; 95% CI: 0.55-1.37). CONCLUSIONS: Our results support the hypothesis that socially advantaged populations were more likely to consistently adopt and employ restraint devices following the reform. Countries should also consider complementary policies that facilitate an equitable distribution of safety devices that reach vulnerable populations.

Mental health among adolescents living with HIV in Namibia: the role of poverty, orphanhood and social support.

The mental health needs of children and adolescents living with HIV (ALHIV) in Namibia are poorly understood, despite the dramatic improvement in their survival. ALHIV in resource poor contexts face particular risk factors, such as poverty, orphanhood, and poor social support. This study examines the mental health of ALHIV in Namibia, and the factors that contribute to mental health problems. A case-control design assessed emotional and behavioural symptoms of distress, risk and protective factors among adolescents aged 12-18 years. Case participants were 99 HIV-positive adolescents. Case controls were 159 adolescents from the same community who were not known to be HIV seropositive at the time of the study. Control group participants were selected from schools using a stratified random sampling. A larger proportion of HIV-positive adolescents were orphaned (62.6% vs. 20.8%, p < .001); the groups showed no differences in poverty factors. HIV-positive adolescents scored lower than the control group on total perceived social support (p < .05) and caregiver support (p < .05), but no differences in perceived friend support and support from a self-selected person were present. HIV-positive adolescents reported significantly more total emotional and behavioural difficulties (p = .027) and conduct problems (p = .025), even after controlling for socio-demographic factors. However, after controlling for the effects of orphanhood, group differences in mental health outcomes were no longer significant. Furthermore, mediation analysis suggested that social support completely mediated the relationship between HIV status and mental health (standardised pathway coefficients = .05, p = .021). Policies and programmes that aim to strengthen social support and take orphanhood status into consideration may improve the mental health of adolescents living with HIV.

Predictors of mental health problems in adolescents living with HIV in Namibia.

BACKGROUND: Little research in sub-Saharan Africa has looked at factors that predict mental health problems in adolescents living with HIV (ALHIV). This study examines the psychological impact of HIV in adolescents in Namibia, including risk and protective factors associated with mental health. METHODS: Ninety-nine fully disclosed ALHIV between the ages of 12 and 18 were interviewed at a State Hospital in Windhoek. A structured questionnaire assessed mental health, using the SDQ (Goodman, 1997), sociodemographic factors, poverty, social support, adherence and stigma. RESULTS: Mean age was 14.3 years, 52.5% were female and most were healthy. Twelve percent scored in the clinical range for total mental health difficulties and 22% for emotional symptoms. Poverty was associated with more total mental health difficulties, t(96) = -2.63, p = .010, and more emotional symptoms, t(96) = -3.45, p = .001, whereas better social support was a protective factor, particularly caregiver support (r = -.337, p = .001). Adherence problems, HIV-related stigma and disclosing one's own HIV status to others were also associated with more total mental health difficulties. Poverty (ß = -.231, p = .023) and stigma (ß = .268, p = .009) were the best predictors for total mental health difficulties, whereas stigma (ß = .314, p = .002) predicted emotional symptoms. Social support had a protective effect on peer problems (p = .001, ß = -.349). CONCLUSIONS: Several contextual factors associated with poorer mental health in ALHIV are identified.

Maternal Education and Children Home Alone in 63 Low- and Middle-Income Countries.

Background. Maternal education may influence child supervision practices in low-and middle-income countries (LMIC). However, little is known about the maternal factors that can improve child supervision in LMIC with scarce childcare facilities. Objective. To investigate the prevalence of children under 5 years home alone and examine the association between mother's formal education and children home alone across 63 LMIC. Methods. The study used data from 50 Multiple Indicator Cluster Surveys and 13 Demographic and Health Surveys with a sample of 501 769 children. We estimated Prevalence Ratios (PRs) for the association between maternal education and children home alone using multivariable Poisson regression, adjusting for covariates such as child's age and sex, mother's age and marital status, number of adults inhabiting the households, and urbanicity. Results. Prevalence of children home alone across 63 LMIC ranged from 1.1% to 50.1%. A significant negative association between mothers with more years of formal education and children home alone was found across 16 LMIC. However, the opposite trend was observed in Nigeria, Senegal, and Côte d'Ivoire. Null association was found across 44 LMIC. Conclusions. The varied pattern of the associations observed across LMIC underscores the importance of regional and local factors when developing policies and interventions to ensure safety and adequate care for children aged under 5 years in LMIC.

Access to health care for undocumented migrant children and pregnant women: the paradox between values and attitudes of health care professionals.

Access to health care for undocumented migrant children and pregnant women confronts human rights and professional values with political and institutional regulations that limit services. In order to understand how health care professionals deal with these diverging mandates, we assessed their attitudes toward providing care to this population. Clinicians, administrators, and support staff (n = 1,048) in hospitals and primary care centers of a large multiethnic city responded to an online survey about attitudes toward access to health care services. Analysis examined the role of personal and institutional correlates of these attitudes. Foreign-born respondents and those in primary care centers were more likely to assess the present access to care as a serious problem, and to endorse broad or full access to services, primarily based on human rights reasons. Clinicians were more likely than support staff to endorse full or broad access to health care services. Respondents who approved of restricted or no access also endorsed health as a basic human right (61.1%) and child development as a priority (68.6%). A wide gap separates attitudes toward entitlement to health care and the endorsement of principles stemming from human rights and the best interest of the child. Case-based discussions with professionals facing value dilemmas and training on children's rights are needed to promote equitable practices and advocacy against regulations limiting services.