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This study examined the spatial distribution and social inequalities in COVID-19 vaccine coverage among children aged 5-11 in Brazil. First and second dose vaccine coverage was calculated for all Brazilian municipalities and analyzed by geographic region and deciles based on human development index (HDI-M) and expected years of schooling at 18 years of age. Multilevel models were used to determine the variance partition coefficient, and bivariate local Moran's I statistic was used to assess spatial association. Results showed significant differences in vaccine coverage rates among Brazilian municipalities, with lower coverage in the North and Midwest regions. Municipalities with lower HDI and expected years of schooling had consistently lower vaccine coverage rates. Bivariate clustering analysis identified extensive concentrations of municipalities in the Northern and Northeastern regions with low vaccine coverage and low human development, while some clusters of municipalities in the Southeast and South regions with low coverage were located in areas with high HDI-M. These findings highlight the persistent municipal-level inequalities in vaccine coverage among children in Brazil and the need for targeted interventions to improve vaccine access and coverage in underserved areas.
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COVID-19 Vaccines , COVID-19 , Socioeconomic Factors , Vaccination Coverage , Humans , Brazil , Child , COVID-19 Vaccines/administration & dosage , Child, Preschool , Vaccination Coverage/statistics & numerical data , COVID-19/prevention & control , COVID-19/epidemiology , Cluster Analysis , Healthcare Disparities/statistics & numerical data , Spatial AnalysisABSTRACT
BACKGROUND: The health of India's children has improved over the past thirty years. Rates of morbidity and anthropometric failure have decreased. What remains unknown, however, is how those patterns have changed when examined by socioeconomic status. We examine changes in 11 indicators of child health by household wealth and maternal education between 1993 and 2021 to fill this critical gap in knowledge. Doing so could lead to policies that better target the most vulnerable children. METHODS: We used data from five rounds of India's National Family Health Survey conducted in 1993, 1999, 2006, 2016, and 2021 for this repeated cross-sectional analysis. We studied mother-reported cases of acute respiratory illness and diarrhea, hemoglobin measurements for anemia, and height and weight measurements for anthropometric failure. We examined how the prevalence rates of each outcome changed between 1993 and 2021 by household wealth and maternal education. We repeated this analysis for urban and rural communities. RESULTS: The socioeconomic gradient in 11 indicators of child health flattened between 1993 and 2021. This was in large part due to large reductions in the prevalence among children in the lowest socioeconomic groups. For most outcomes, the largest reductions occurred before 2016. Yet as of 2021, except for mild anemia, outcome prevalence remained the highest among children in the lowest socioeconomic groups. Furthermore, we show that increases in the prevalence of stunting and wasting between 2016 and 2021 are largely driven by increases in the severe forms of these outcomes among children in the highest socioeconomic groups. This finding underscores the importance of examining child health outcomes by severity. CONCLUSIONS: Despite substantial reductions in the socioeconomic gradient in 11 indicators of child health between 1993 and 2021, outcome prevalence remained the highest among children in the lowest socioeconomic groups in most cases. Thus, our findings emphasize the need for a continued focus on India's most vulnerable children.
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Child Health , Socioeconomic Factors , Humans , India/epidemiology , Female , Cross-Sectional Studies , Child, Preschool , Child Health/trends , Child Health/statistics & numerical data , Male , Infant , Child , Anemia/epidemiology , Health Status Disparities , Social Class , Prevalence , Health Surveys , Educational Status , Rural Population/statistics & numerical dataABSTRACT
OBJECTIVE: Social network-based reproductive decisions are critical. This study compares the effect of an older peer contraceptionuse on her younger peer's use, as they share the closest social network within the household, and tend to influence one another for reproductive decisions. In this study we considered peers as two sister-in-law living in the same household. METHODS: We used data from the fifth round of National Family Health Survey which was conducted between the year 2019 and 2021. We deployed multinomial multivariable logistic regression to find the association between older women contraception use on her younger peer. Also, an attempt has been made to determine contraceptive clustering within households in India and select states. RESULTS: The multinomial analysis found that all the women in the household used the similar method, but still relied only on the female sterilization as the sole method for their family planning. The multinomial multivariable method found that younger peers were 3.42 time odds more likely to use permanent method if her older peer had used it previously. Also, it was found 11% increase in any modern contraception use of younger peer if all her older peer will use any modern contraceptives in India. For all the states, the contraception clustering within household ranged from 5% to 14%, with highest in Himachal (14%). CONCLUSION: Empowering older women as peer educators in contraception workshops can foster informed discussions, dispel myths, and promote the use of modern contraceptive methods among younger peers. Integrating such initiatives into government existing policies like Mission Parivar Vikas is crucial for improving contraceptive uptake, with ASHA workers and community health volunteers playing a pivotal role in delivering targeted education within households.
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This cohort study examines ambulatory care revisits and same-day topical antibiotic prescription in insured patients with acute infectious conjunctivitis.
Subject(s)
Anti-Bacterial Agents , Conjunctivitis, Bacterial , Humans , Anti-Bacterial Agents/therapeutic use , Child , Adolescent , Male , Conjunctivitis, Bacterial/drug therapy , Conjunctivitis, Bacterial/microbiology , Female , Child, Preschool , Eye Infections, Bacterial/drug therapy , Eye Infections, Bacterial/microbiology , Infant , Conjunctivitis/drug therapyABSTRACT
INTRODUCTION: Early mid-life is marked by accumulating risks for cardiometabolic illness linked to health-risk behaviors like nicotine use. Identifying polygenic indices (PGI) has enriched scientific understanding of the cumulative genetic contributions to behavioral and cardiometabolic health, though few studies have assessed these associations alongside socioeconomic (SES) and lifestyle factors. METHODS: Drawing on data from 2,337 individuals from the United States participating in the National Longitudinal Study of Adolescent to Adult Health, the current study assesses the fraction of variance in five related outcomes - use of conventional and electronic cigarettes, body mass index (BMI), waist circumference, and glycosylated hemoglobin (A1c) - explained by PGI, SES, and lifestyle. RESULTS: Regression models on African ancestry (AA) and European ancestry (EA) subsamples reveal that the fraction of variance explained by PGI ranges across outcomes. While adjusting for sex and age, PGI explained 3.5%, 2.2%, and 0% in the AA subsample of variability in BMI, waist circumference, and A1c, respectively (in the EA subsample these figures were 7.7%, 9.4%, and 1.3%). The proportion of variance explained by PGI in nicotine-use outcomes is also variable. Results further indicate that PGI and SES are generally complementary, accounting for more variance in the outcomes when modeled together versus separately. CONCLUSIONS: PGI are gaining attention in population health surveillance, but polygenic variability might not align clearly with health differences in populations or surpass SES as a fundamental cause of health disparities. We discuss future steps in integrating PGI and SES to refine population health prediction rules. IMPLICATIONS: Study findings point to the complementary relationship of polygenic indices (PGI) and socioeconomic indicators in explaining population variance in nicotine outcomes and cardiometabolic wellness. Population health surveillance and prediction rules would benefit from the combination of information from both polygenic and socioeconomic risks. Additionally, the risk for electronic cigarette use among users of conventional cigarettes may have a genetic component tied to the cumulative genetic propensity for heavy smoking. Further research on PGI for vaping is needed.
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[This corrects the article DOI: 10.1371/journal.pgph.0002493.].
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Intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) has been welcomed as a new gold standard for quantitative evaluation of intersectional inequalities, and it is being rapidly adopted across the health and social sciences. In their commentary "What does the MAIHDA method explain?", Wilkes and Karimi (2024) raise methodological concerns with this approach, leading them to advocate for the continued use of conventional single-level linear regression models with fixed-effects interaction parameters for quantitative intersectional analysis. In this response, we systematically address these concerns, and ultimately find them to be unfounded, arising from a series of subtle but important misunderstandings of the MAIHDA approach and literature. Since readers new to MAIHDA may share confusion on these points, we take this opportunity to provide clarifications. Our response is organized around four important clarifications: (1) At what level are the additive main effect variables defined in intersectional MAIHDA models? (2) Do MAIHDA models have problems with collinearity? (3) Why does the Variance Partitioning Coefficient (VPC) tend to be small, and the Proportional Change in Variance (PCV) tend to be large in MAIHDA? and (4) What are the goals of MAIHDA analysis?
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Multilevel Analysis , Humans , Socioeconomic Factors , Health Status DisparitiesABSTRACT
Importance: The global success of the child survival agenda depends on how rapidly mortality at early ages after birth declines in India, and changes need to be monitored to evaluate the status. Objective: To understand the disaggregated patterns of decrease in early-life mortality across states and union territories (UTs) of India. Design, Setting, and Participants: Repeated cross-sectional data from the 5 rounds of the National Family Health Survey conducted in 1992-1993, 1998-1999, 2005-2006, 2015-2016, and 2019-2021 were used in a representative population-based study. The study was based on data of children born in the past 5 years with complete information on date of birth and age at death. The analysis was conducted in February 2024. Exposure: Time and geographic units. Main Outcomes and Measures: Mortality rates were computed for 4 early-life periods: early-neonatal (first 7 days), late-neonatal (8-28 days), postneonatal (29 days to 11 months), and child (12-59 months). For early and late neonatal periods, the rates are expressed as deaths per 1000 live births, for postneonatal, as deaths per 1000 children aged at least 29 days and for child, deaths per 1000 children aged at least 1 year. These are collectively mentioned as deaths per 1000 for all mortalities. The relative burden of each of the age-specific mortalities to total mortality in children younger than 5 years was also computed. Results: The final analytical sample included 33â¯667 (1993), 29â¯549 (1999), 23â¯020 (2006), 82â¯294 (2016), and 64â¯242 (2021) children who died before their fifth birthday in the past 5 years of each survey. Mortality rates were lowest for the late-neonatal and child periods; early-neonatal was the highest in 2021. Child mortality experienced the most substantial decrease between 1993 and 2021, from 33.5 to 6.9 deaths per 1000, accompanied by a substantial reduction in interstate inequalities. While early-neonatal (from 33.5 to 20.3 deaths per 1000), late-neonatal (from 14.1 to 4.1 deaths per 1000), and postneonatal (from 31.0 to 10.8 deaths per 1000) mortality also decreased, interstate inequalities remained notable. The mortality burden shifted over time and is now concentrated during the early-neonatal (48.3% of total deaths in children younger than 5 years) and postneonatal (25.6%) periods. A stagnation or worsening for certain states and UTs was observed from 2016 to 2021 for early-neonatal, late-neonatal, and postneonatal mortality. If this pattern continues, these states and UTs will not meet the United Nations Sustainable Development Goal targets related to child survival. Conclusions and Relevance: In this repeated cross-sectional study of 5 time periods, the decrease in mortality during early-neonatal and postneonatal phases of mortality was relatively slower, with notable variations across states and UTs. The findings suggest that policies pertaining to early-neonatal and postneonatal mortalities need to be prioritized and targeting of policies and interventions needs to be context-specific.
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Child Mortality , Infant Mortality , Humans , India/epidemiology , Child Mortality/trends , Infant , Infant, Newborn , Infant Mortality/trends , Cross-Sectional Studies , Child, Preschool , Female , Male , Health SurveysABSTRACT
Background: Postnatal care (PNC) utilisation within 24 hours of delivery is a critical component of health care services for mothers and newborns. While substantial geographic variations in various health outcomes have been documented in India, there remains a lack of understanding regarding PNC utilisation and underlying factors accounting for these geographic variations. In this study, we aimed to partition and explain the variation in PNC utilisation across multiple geographic levels in India. Methods: Using India's 5th National Family Health Survey (2019-21), we conducted four-level logistic regression analyses to partition the total geographic variation in PNC utilisation by state, district, and cluster levels, and to quantify how much of theses variations are explained by a set of 12 demographic, socioeconomic, and pregnancy-related factors. We also conducted analyses stratified by selected states/union territories. Results: Among 149 622 mother-newborn pairs, 82.29% of mothers and 84.92% of newborns were reported to have received PNC within 24 hours of delivery. In the null model, more than half (56.64%) of the total geographic variation in mother's PNC utilisation was attributed to clusters, followed by 26.06% to states/union territories, and 17.30% to districts. Almost 30% of the between-state variation in mother's PNC utilisation was explained by the demographic, socioeconomic, and pregnancy-related factors (i.e. state level variance reduced from 0.486 (95% confidence interval (CI) = 0.238, 0.735) to 0.320 (95% CI = 0.152, 0.488)). We observed consistent results for newborn's PNC utilisation. State-specific analyses showed substantial geographic variation attributed to clusters across all selected states/union territories. Conclusions: Our findings highlight the consistently large cluster variation in PNC utilisation that remains unexplained by compositional effects. Future studies should explore contextual drivers of cluster variation in PNC utilisation to inform and design interventions aimed to improve maternal and child health.
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Multilevel Analysis , Patient Acceptance of Health Care , Postnatal Care , Humans , India , Female , Postnatal Care/statistics & numerical data , Infant, Newborn , Adult , Pregnancy , Young Adult , Patient Acceptance of Health Care/statistics & numerical data , Adolescent , Mothers/statistics & numerical data , Socioeconomic FactorsABSTRACT
BACKGROUND: The problem of overweight/obesity often coexists with the burden of undernutrition in most low- and middle-income countries. BMI change in India incorporating the most recent trends has been under-researched. METHODS: This repeated cross-sectional study of 1,477,885 adults in India analyzed the prevalence of different categories of BMI among adults (age 20-54) in 4 rounds of National Family Health Surveys (1998-1999, 2005-2006, 2015-2016, and 2019-2021) for 36 states/UTs. State differences across time were harmonized for accurate analysis. The categories were Severely/Moderately Thin (BMI < 17.0), Mildly Thin (17.0-18.4), Normal (18.5-24.9), Overweight (25.0-29.9), and Obese (≥ 30.0). We also estimated change in Standardized Absolute Change (SAC), ranking of states, and headcount burden to quantify the trend of BMI distribution across time periods for all-India, urban/rural residence, and by states/UTs. RESULTS: The prevalence of thinness declined from 31.7% in 1999 to 14.2% in 2021 for women, and from 23.4% in 2006 to 10.0% in 2021 for men. Obesity prevalence increased from 2.9% (1999) to 6.3% (2021) for women, and from 2.0% (2006) to 4.2% (2021) for men. In 2021, the states with the highest obesity prevalence were Puducherry, Chandigarh, and Delhi. These states also had a high prevalence of overweight. Dadra and Nagar Haveli and Diu, Gujarat, Jharkhand, and Bihar had the highest prevalence of severe/moderately thin. Prevalence of extreme categories (severely/moderately thin and obese) was larger in the case of women than men. While States/UTs with a higher prevalence of thin populations tend to have a larger absolute burden of severe or moderate thinness, the relationship between headcount burden and prevalence for overweight and obese is unclear. CONCLUSIONS: We found persistent interstate inequalities of undernutrition. Tailored efforts at state levels are required to further strengthen existing policies and develop new interventions to target both forms of malnutrition.
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Body Mass Index , Obesity , Overweight , Humans , India/epidemiology , Adult , Male , Female , Cross-Sectional Studies , Prevalence , Middle Aged , Obesity/epidemiology , Young Adult , Overweight/epidemiology , Thinness/epidemiology , Health SurveysABSTRACT
Despite the well-known importance of high-quality care before and after delivery, not every mother and newborn in India receive appropriate antenatal and postnatal care (ANC/PNC). Using India's National Family Health Surveys (2015-2016 and 2019-2021), we quantified the socioeconomic and geographic inequalities in the utilization of ANC/PNC among women aged 15-49 years and their newborns (N = 161,225 in 2016; N = 150,611 in 2021). For each of the eighteen ANC/PNC components, we assessed absolute and relative inequalities by household wealth (poorest vs. richest), maternal education (no education vs. higher than secondary), and type of place of residence (rural vs. urban) and evaluated state-level heterogeneity. In 2021, the national prevalence of ANC/PNC components ranged from 19.8% for 8 + ANC visits to 91.6% for maternal weight measurement. Absolute inequalities were greatest for ultrasound test (33.3%-points by wealth, 30.3%-points by education) and 8 + ANC visits (13.2%-points by residence). Relative inequalities were greatest for 8 + ANC visits (1.8 ~ 4.4 times). All inequalities declined over time. State-specific estimates were overall consistent with national results. Socioeconomic and geographic inequalities in ANC/PNC varied significantly across components and by states. To optimize maternal and newborn health in India, future interventions should aim to achieve universal coverage of all ANC/PNC components.
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Healthcare Disparities , Postnatal Care , Prenatal Care , Socioeconomic Factors , Humans , India , Female , Adult , Prenatal Care/statistics & numerical data , Postnatal Care/statistics & numerical data , Adolescent , Middle Aged , Pregnancy , Young Adult , Infant, Newborn , Rural PopulationABSTRACT
Intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (I-MAIHDA) is an innovative approach for investigating inequalities, including intersectional inequalities in health, disease, psychosocial, socioeconomic, and other outcomes. I-MAIHDA and related MAIHDA approaches have conceptual and methodological advantages over conventional single-level regression analysis. By enabling the study of inequalities produced by numerous interlocking systems of marginalization and oppression, and by addressing many of the limitations of studying interactions in conventional analyses, intersectional MAIHDA provides a valuable analytical tool in social epidemiology, health psychology, precision medicine and public health, environmental justice, and beyond. The approach allows for estimation of average differences between intersectional strata (stratum inequalities), in-depth exploration of interaction effects, as well as decomposition of the total individual variation (heterogeneity) in individual outcomes within and between strata. Specific advice for conducting and interpreting MAIHDA models has been scattered across a burgeoning literature. We consolidate this knowledge into an accessible conceptual and applied tutorial for studying both continuous and binary individual outcomes. We emphasize I-MAIHDA in our illustration, however this tutorial is also informative for understanding related approaches, such as multicategorical MAIHDA, which has been proposed for use in clinical research and beyond. The tutorial will support readers who wish to perform their own analyses and those interested in expanding their understanding of the approach. To demonstrate the methodology, we provide step-by-step analytical advice and present an illustrative health application using simulated data. We provide the data and syntax to replicate all our analyses.
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BACKGROUND: Redlining began in the 1930s with the Home Owners' Loan Corporation (HOLC); this discriminatory practice limited mortgage availability and reinforced concentrated poverty that still exists today. It is important to understand the potential health implications of this federally sanctioned segregation. OBJECTIVE: To examine the relationship between historical redlining policies and present-day nonsuicide firearm fatalities. DESIGN: Maps from the HOLC were overlaid with incidence of nonsuicide firearm fatalities from 2014 to 2022. A multilevel negative binomial regression model tested the association between modern-day firearm fatalities and HOLC historical grading (A ["best"] to D ["hazardous"]), controlling for year, HOLC area-level demographics, and state-level factors as fixed effects and a random intercept for city. Incidence rates (IRs) per 100 000 persons, incidence rate ratios (IRRs), and adjusted IRRs (aIRRs) for each HOLC grade were estimated using A-rated areas as the reference. SETTING: 202 cities with areas graded by the HOLC in the 1930s. PARTICIPANTS: Population of the 8597 areas assessed by the HOLC. MEASUREMENTS: Nonsuicide firearm fatalities. RESULTS: From 2014 to 2022, a total of 41 428 nonsuicide firearm fatalities occurred in HOLC-graded areas. The firearm fatality rate increased as the HOLC grade progressed from A to D. In A-graded areas, the IR was 3.78 (95% CI, 3.52 to 4.05) per 100 000 persons per year. In B-graded areas, the IR, IRR, and aIRR relative to A areas were 7.43 (CI, 7.24 to 7.62) per 100 000 persons per year, 2.12 (CI, 1.94 to 2.32), and 1.42 (CI, 1.30 to 1.54), respectively. In C-graded areas, these values were 11.24 (CI, 11.08 to 11.40) per 100 000 persons per year, 3.78 (CI, 3.47 to 4.12), and 1.90 (CI, 1.75 to 2.07), respectively. In D-graded areas, these values were 16.26 (CI, 16.01 to 16.52) per 100 000 persons per year, 5.51 (CI, 5.05 to 6.02), and 2.07 (CI, 1.90 to 2.25), respectively. LIMITATION: The Gun Violence Archive relies on media coverage and police reports. CONCLUSION: Discriminatory redlining policies from 80 years ago are associated with nonsuicide firearm fatalities today. PRIMARY FUNDING SOURCE: Fred Lovejoy Housestaff Research and Education Fund.
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Firearms , Wounds, Gunshot , Humans , Firearms/legislation & jurisprudence , Wounds, Gunshot/mortality , United States/epidemiology , IncidenceABSTRACT
BACKGROUND: Eliminating unmet need for family planning by 2030 is a global priority for ensuring healthy lives and promoting well-being for all at all ages. We estimate the sub-national trends in prevalence of unmet need for family planning over 30 years in India and study differences based on socio-economic and demographic factors. METHODS: We used data from five National Family Health Surveys (NFHS) conducted between 1993 to 2021 for the 36 states/Union Territories (UTs) of India. The study population included women of ages 15-49 years who were married or in a union at the time of the survey. The outcome was unmet need for family planning which captures the prevalence of fecund and sexually active women not using contraception, who want to delay or limit childbearing. We calculated the standardized absolute change to estimate the change in prevalence on an annual basis across all states/UTs. We examined the patterning of prevalence of across demographic and socioeconomic characteristics and estimated the headcount of women with unmet need in 2021. RESULTS: The prevalence of unmet need in India decreased from 20·6% (95% CI: 20·1- 21·2%) in 1993, to 9·4% (95% CI: 9·3-9·6%) in 2021. Median unmet need prevalence across states/UTs decreased from 17·80% in 1993 to 8·95% in 2021. The north-eastern states of Meghalaya (26·9%, 95% CI: 25·3-28·6%) and Mizoram (18·9%, 95% CI: 17·2-20·6%), followed by the northern states of Bihar (13·6%, 95% CI: 13·1-14·1%) and Uttar Pradesh (12·9%, 95% CI: 12·5-13·2%), had the highest unmet need prevalence in 2021. As of 2021, the estimated number of women with an unmet need for family planning was 24,194,428. Uttar Pradesh, Bihar, Maharashtra, and West Bengal accounted for half of this headcount. Women of ages 15-19 and those belonging the poorest wealth quintile had a relatively high prevalence of unmet need in 2021. CONCLUSIONS: The existing initiatives under the National Family Planning Programme should be strengthened, and new policies should be developed with a focus on states/UTs with high prevalence, to ensure unmet need for family planning is eliminated by 2030.
This study looked at the trends in unmet need for family planning in India, which is defined as the percentage of women of reproductive age who want to delay or limit childbearing but are not using any contraceptive method. A public dataset was used to analyze national and sub-national trends from 1993 to 2021. It was determined that although the percentage prevalence of unmet need decreased in the last 30 years, there were still a substantial number of women with unmet need in 2021. More than half of these women were in Uttar Pradesh, Bihar, Maharashtra, and West Bengal. Furthermore, it was found that percentage prevalence of unmet need was relatively higher amongst younger women and those belonging to poorer households in 2021. Initiatives and policies aimed at reducing unmet need for family planning should be implemented while considering geographic, socioeconomic, and demographic differences.
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Contraception , Family Planning Services , Female , Humans , Prevalence , India/epidemiology , Fertility , Contraception BehaviorABSTRACT
BACKGROUND: Access to health care remains suboptimal in low- and middle-income countries (LMICs) and continues to hinder survival in early childhood. We systematically assessed the association between problems accessing health care (PAHC) and under-five mortality (U5M). METHODS: Child mortality data on 724 335 livebirths came from the latest Demographic and Health Surveys of 50 LMICs (2013-2021). Reasons for PAHC were classified into three domains: 'money needed for treatment' (economic), 'distance to health facility' (physical), 'getting permission' or 'not wanting to go alone' (socio-cultural). Multivariable logistic regression was used to estimate the association between PAHC (any and by each type) and U5M. RESULTS: In our pooled sample, 47.3 children per 1000 livebirths died before age of 5, and 57.1% reported having experienced PAHC (ranging from 45.3% in Europe & Central Asia to 72.7% in Latin America & Caribbean). Children with any PAHC had higher odds of U5M (OR: 1.05, 95% CI: 1.02, 1.09), and this association was especially significant in sub-Saharan Africa. Of different domains of PAHC, socio-cultural PAHC was found to be most significant. CONCLUSIONS: Access to health care in LMICs needs to be improved by expanding health care coverage, building health facilities, and focusing more on context-specific socio-cultural barriers.
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Background: Child undernutrition remains a major global health issue, particularly in sub-Saharan Africa (SSA). Given the important role mothers play in early childhood health and development, we examined how individual-level women's empowerment and country-level Gender Inequality Index (GII) are jointly related with child undernutrition in SSA. Methods: We pooled recent Demographic and Health Surveys from 28 SSA countries. For 137,699 children <5 years old, undernutrition was defined using anthropometric failures (stunting, underweight, wasting). Women's empowerment was assessed using three domains of Survey-based Women's EmPowERment (SWPER) index: attitude to violence, social independence, and decision-making; and country-level gender inequality was measured using GII from United Nations Development Programme. Three-level logistic regression was conducted to examine the joint associations of SWPER and GII as well as their interactions with child anthropometric failures, after adjusting for sociodemographic covariates. Results: Overall, 32.85% of children were stunted, 17.63% were underweight, and 6.68% had wasting. Children of mothers with low-level of empowerment for all domains of SWPER had higher odds of stunting (attitude to violence: OR=1.15; 95% CI, 1.11-1.19; social independence: OR=1.21; 95% CI, 1.17-1.25; decision-making: OR=1.16; 95% CI, 1.12-1.20), and consistent results were found for underweight and wasting. Independent of women's empowerment, country-level GII increased the probability of underweight (ranging ORs=1.46; 95% CI, 1.15-1.85 to 1.50; 95% CI, 1.18-1.90) and wasting (ranging ORs=1.56; 95% CI, 1.24-1.97 to 1.61; 95% CI, 1.27-2.03). Significant interaction was found between women's empowerment and country-level GII for stunting and underweight (p<0.05). Conclusions: In SSA countries with greater gender inequality, improving women's social independence and decision-making power in particular can reduce their children's risk of anthropometric failures. Policies and interventions targeted at strengthening women's empowerment should consider the degree of gender inequality in each country.
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Importance: The introduction of solid or semisolid foods alongside breast milk plays a vital role in meeting nutritional requirements during early childhood, which is crucial for child growth and development. Understanding the prevalence of zero-food children (defined for research purposes as children aged 6 to 23 months who did not consume animal milk, formula, or solid or semisolid food during the last 24 hours) is essential for targeted interventions to improve feeding practices. Objective: To estimate the percentage of zero-food children in 92 low- and middle-income countries. Design, Setting, and Participants: This cross-sectional study analyzed nationally representative cross-sectional household data of children aged 6 to 23 months from the Demographic and Health Surveys and the Multiple Indicator Cluster Surveys conducted between May 20, 2010, and January 27, 2022. Data were obtained from 92 low- and middle-income countries. Standardized procedures were followed to ensure data comparability and reliability. Both percentage and number of zero-food children were estimated. Main Outcomes and Measures: The outcome studied was defined as a binary variable indicating children aged 6 to 23 months who had not been fed any animal milk, formula, or solid or semisolid foods during the 24 hours before each survey, as reported by the mother or caretaker. Results: A sample of 276â¯379 children aged 6 to 23 months (mean age, 14.2 months [95% CI, 14.15-14.26 months]) in 92 low- and middle-income countries was obtained, of whom 51.4% (95% CI, 51.1%-51.8%) were boys. The estimated percentage of zero-food children was 10.4% (95% CI, 10.1%-10.7%) in the pooled sample, ranging from 0.1% (95% CI, 0%-0.6%) in Costa Rica to 21.8% (95% CI, 19.3%-24.4%) in Guinea. The prevalence of zero-food children was particularly high in West and Central Africa, where the overall prevalence was 10.5% (95% CI, 10.1%-11.0%), and in India, where the prevalence was 19.3% (95% CI, 18.9%-19.8%). India accounted for almost half of zero-food children in this study. Conclusions and Relevance: In this cross-sectional study of 276â¯379 children aged 6 to 23 months, substantial disparities in the estimates of food consumption across 92 low- and middle-income countries were found. The prevalence of zero-food children underscores the need for targeted interventions to improve infant and young child feeding practices and ensure optimal nutrition during this critical period of development. The issue is particularly urgent in West and Central Africa and India.
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Developing Countries , Milk , Infant , Male , Female , Animals , Child , Humans , Child, Preschool , Cross-Sectional Studies , Prevalence , Reproducibility of ResultsABSTRACT
Background: Prolonged exclusive breastfeeding (PEB) for children older than six months old is a threat to appropriate complementary feeding practices. This study aims to examine the trend of PEB among children aged 6-23 months in India. Methods: We adopted five waves of National Family Health Survey (NFHS) data between 1992-93 and 2019-21. PEB was defined as children aged six months and above currently consuming breastmilk as the only source of energy, protein and micronutrients. We generated descriptive statistics and a series of multivariable logistic regressions to estimate the prevalence and trend in the PEB rate. Moreover, we assessed how child age and socioeconomic factors (i.e. child gender and age, place of residence, household wealth, and maternal education) were related with PEB using mutually and single-adjusted model. Results: There were 184 891 Indian children aged 6-23 months old included in this study with 48.0% being female. We found that the proportion of PEB increased from 4.3% in 1992 to 7.7% in 2021, of which the rate for children aged six-eight months rose from 14.0 to 20.1%. Our results showed that children who were from poorer households or with lower-educated mothers were more likely to experience prolonged exclusive breastfed. Take the year of 2019-21 as an example, compared to the households of the richest quintile, children from households of the poorer quintile were significantly more likely to experience PEB, with odds ratio (OR) of 1.33 (95% confidence interval (CI) = 1.09-1.61). Moreover, children with illiterate mothers had 21% higher odds of having prolonged exclusively breastfeeding (OR = 1.21; 95% CI = 1.01-1.44) compared with children with mothers who have college and above education. Conclusions: PEB among children over six months old is prevalent in India, particularly among children from disadvantaged households. Poverty reduction and maternal education are of great potential importance for policymakers to promote appropriate complementary feeding practice.
Subject(s)
Breast Feeding , Mothers , Child , Humans , Female , Infant , Child, Preschool , Male , Cross-Sectional Studies , Prevalence , Mothers/education , India/epidemiologyABSTRACT
[This corrects the article DOI: 10.1016/j.eclinm.2023.102313.].