Reduced incidence of respiratory, gastrointestinal and malaria infections among children during the COVID-19 pandemic in Western Kenya: An analysis of facility-based and weekly diaries data.

Background: Epidemics can cause significant disruptions of essential health care services. This was evident in West-Africa during the 2014-2016 Ebola outbreak, raising concerns that COVID-19 would have similar devastating consequences for the continent. Indeed, official facility-based records show a reduction in health care visits after the onset of COVID-19 in Kenya. Our question is whether this observed reduction was caused by lower access to health care or by reduced incidence of communicable diseases resulting from reduced mobility and social contacts. Methods: We analysed monthly facility-based data from 2018 to 2020, and weekly health diaries data digitally collected by trained fieldworkers between February and November 2020 from 342 households, including 1974 individuals, in Kisumu and Kakamega Counties, Kenya. Diaries data was collected as part of an ongoing longitudinal study of a digital health insurance scheme (Kakamega), and universal health coverage implementation (Kisumu). We assessed the weekly incidence of self-reported medical symptoms, formal and informal health-seeking behaviour, and foregone care in the diaries and compared it with facility-based records. Linear probability regressions with household fixed-effects were performed to compare the weekly incidence of health outcomes before and after COVID-19. Results: Facility-based data showed a decrease in health care utilization for respiratory infections, enteric illnesses, and malaria, after start of COVID-19 measures in Kenya in March 2020. The weekly diaries confirmed this decrease in respiratory and enteric symptoms, and malaria / fever, mainly in the paediatric population. In terms of health care seeking behaviour, our diaries data find a temporary shift in consultations from health care centres to pharmacists / chemists / medicine vendors for a few weeks during the pandemic, but no increase in foregone care. According to the diaries, for adults the incidence of communicable diseases/symptoms rebounded after COVID-19 mobility restrictions were lifted, while for children the effects persisted. Conclusions: COVID-19-related containment measures in Western Kenya were accompanied by a decline in respiratory infections, enteric illnesses, and malaria / fever mainly in children. Data from a population-based survey and facility-based records aligned regarding this finding despite the temporary shift to non-facility-based consultations and confirmed that the drop in utilization of health care services was not due to decreased accessibility, but rather to a lower incidence of these infections.

The impact of unconditional cash transfers on morbidity and health-seeking behaviour in Africa: evidence from Ghana, Malawi, Zambia and Zimbabwe.

Unconditional cash transfers have demonstrated widespread, positive impacts on consumption, food security, productive activities and schooling. However, the evidence to date on cash transfers and health-seeking behaviours and morbidity is not only mixed, but the evidence base is biased towards conditional programmes from Latin America and is more limited in the context of Africa. Given contextual and programmatic design differences between the regions, more evidence from Africa is warranted. We investigate the impact of unconditional cash transfers on morbidity and health-seeking behaviour using data from experimental and quasi-experimental study designs of five government cash transfer programs in Ghana, Malawi, Zambia and Zimbabwe. Programme impacts were estimated using difference-in-differences models with longitudinal data. The results indicate positive programme impacts on health seeking when ill and on health expenditures. Our findings suggest that while unconditional cash transfers can improve health seeking when ill, morbidity impacts were mixed. More research is needed on longer-term impacts, mechanisms of impact and moderating factors. Additionally, taken together with existing evidence, our findings suggest that when summarizing the impacts of cash transfers on health, findings from conditional and unconditional programmes should be disaggregated.

Determinants and drivers of young children's diets in Latin America and the Caribbean: Findings from a regional analysis.

The Latin America and Caribbean region exhibit some of the lowest undernutrition rates globally. Yet, disparities exist between and within countries and countries in the region increasingly face other pressing nutritional concerns, including overweight, micronutrient deficiencies and inadequate child feeding practices. This paper reports findings from a regional analysis to identify the determinants and drivers of children's diets, with a focus on the complementary feeding window between the age of 6-23 months. The analysis consists of a narrative review and descriptive data analysis, complemented with qualitative interviews with key informants in four countries: Guatemala, Paraguay, Peru and Uruguay. Findings indicate that poverty and inequality (disparities within countries by wealth and residence), unequal access to services, inadequate coverage of social programmes and lack of awareness on appropriate feeding practices are important drivers for inadequate diets. We conclude that countries in the region need to invest in policies to tackle overweight and micronutrient deficiencies in young children, considering inequalities between and within countries, enhance coverage of social protection programmes, improve coordination between sectors to improve children's diets and expand the coverage and intensity of awareness campaigns on feeding practices, using iterative programme designs.

The impact of i-PUSH on maternal and child health care utilization, health outcomes, and financial protection: study protocol for a cluster randomized controlled trial based on financial and health diaries data.

BACKGROUND: Universal Health Coverage ensures access to quality health services for all, with no financial hardship when accessing the needed services. Nevertheless, access to quality health services is marred by substantial resource shortages creating service delivery gaps in low-and middle-income countries, including Kenya. The Innovative Partnership for Universal Sustainable Healthcare (i-PUSH) program, developed by AMREF Health Africa and PharmAccess Foundation (PAF), aims to empower low-income women of reproductive age and their families through innovative digital tools. This study aims to evaluate the impact of i-PUSH on maternal and child health care utilization, women's health including their knowledge, behavior, and uptake of respective services, as well as women's empowerment and financial protection. It also aims to evaluate the impact of the LEAP training tool on empowering and enhancing community health volunteers' health literacy and to evaluate the impact of the M-TIBA health wallet on savings for health and health insurance uptake. METHODS: This is a study protocol for a cluster randomized controlled trial (RCT) study that uses a four-pronged approach-including year-long weekly financial and health diaries interviews, baseline and endline surveys, a qualitative study, and behavioral lab-in-the-field experiments-in Kakemega County, Kenya. In total, 240 households from 24 villages in Kakamega will be followed to capture their health, health knowledge, health-seeking behavior, health expenditures, and enrolment in health insurance over time. Half of the households live in villages randomly assigned to the treatment group where i-PUSH will be implemented after the baseline, while the other half of the households live in control village where i-PUSH will not be implemented until after the endline. The study protocol was reviewed and approved by the AMREF Ethical and Scientific Review Board. Research permits were obtained from the National Commission for Science, Technology and Innovation agency of Kenya. DISCUSSION: People in low-and middle-income countries often suffer from high out-of-pocket healthcare expenditures, which, in turn, impede access to quality health services. Saving for healthcare as well as enrolment in health insurance can improve access to healthcare by building capacities at all levels-individuals, families, and communities. Notably, i-PUSH fosters savings for health care through the mobile-phone based "health wallet," it enhances enrolment in subsidized health insurance through the mobile platform-M-TIBA-developed by PAF, and it seeks to improve health knowledge and behavior through community health volunteers (CHVs) who are trained using the LEAP tool-AMREF's mHealth platform. The findings will inform stakeholders to formulate better strategies to ensure access to Universal Health Coverage in general, and for a highly vulnerable segment of the population in particular, including low-income mothers and their children. TRIAL REGISTRATION: Registered with Protocol Registration and Results System (protocol ID: AfricanPHRC; trial ID: NCT04068571 : AEARCTR-0006089 ; date: 29 August 2019) and The American Economic Association's registry for randomized controlled trials (trial ID: AEARCTR-0006089; date: 26 June 2020).

Disability status and multi-dimensional personal well-being among adolescents in the Southern Highlands Region of Tanzania: results of a cross-sectional study.

OBJECTIVE: Examine how disability status among adolescents is associated with the following domains of personal well-being: schooling, livelihoods, health, violence and psychosocial well-being. It is hypothesised that adolescents with a disability will have greater deficits in these areas of well-being compared with their healthier counterparts. DESIGN: Cross-sectional data from 2018 were obtained from the second round of an on-going study of adolescents living in poor households in two regions of the Southern Highlands of Tanzania (Iringa and Mbeya). We use the Washington Group (WG) Short Set indicators to measure disability and undertook logistic and linear multivariate regressions to understand the association between disability and the outcomes of interest. PARTICIPANTS: The sample included 2274 participants aged 15-20 years living in households participating in a government social protection programme targeted to households living in extreme poverty. RESULTS: Overall, 310 participants (14%) were classified as having disabilities. Outcomes not associated with disability status included literacy, schooling, livelihoods and self-efficacy. Adolescents with disabilities were less likely to report good or very good health (adjusted OR (aOR)=0.39, 95% CI 0.29 to 0.52) and had increased odds of reporting depressive symptoms in (aOR=1.46, 95% CI 1.11 to 1.90), emotional violence (aOR=2.18, 95% CI 1.49 to 3.20) and physical violence (aOR=1.71, 95% CI 1.13 to 2.59), compared with those without disabilities. Reports of depression were higher among men, and violence was more prevalent among women. Patterns of association were generally similar between men and women, although the association of disability with markers of well-being reached statistical significance more often among men. CONCLUSION: This study highlights areas where adolescents with disabilities are falling behind their peers in terms of personal well-being. These findings suggest that interventions may be needed to mainstream disability in programmes and policies aiming to improve well-being, mental health and violence prevention among adolescents. TRIAL REGISTRATION NUMBER: Pan African Clinical Trial Registry (PACTR201804003008116).

Equality in financial access to healthcare in Cambodia from 2004 to 2014.

Since the end of its internal conflict in 1998, Cambodia has experienced tremendous developments in the social, economic and health sectors, with the government embarking on substantial reforms in health financing. Health equity funds that have improved access to public health services for poor people have gradually been extended to the entire country. Using the World Health Organization's methods for the analysis of healthcare expenditure and household survey data from the 2004, 2009 and 2014 Cambodian Socio-Economic Survey, we assessed trends in reported illness, utilization of healthcare services and associated financial burden on households. The impact of out-of-pocket expenditures for health on catastrophic health expenditures, poverty headcount and depth over the same 10-year period are presented, disaggregated by consumption quintile and place of residence (rural, urban and capital). At the aggregated national level, evolution of these indicators was very positive and correlates with a substantial increase in the capacity-to-pay of households, which reduced the average financial burden on households. However, over time inequalities grew between rural and urban areas. By 2014, the national incidence of catastrophic health expenditure was 4.9%, but four times more likely among rural households than their peers in the capital. For rural households with members seeking medical care, catastrophic health expenditure incidence was 12.3%. The impoverishment rate due to health spending among the lowest consumption quintile was 15.3%; the highest rate in this analysis. These findings suggest that economic and health sector developments have indeed benefited many Cambodian people. However, these gains mainly benefited urban residents; especially those in the capital city. We argue that more resources should be allocated to rural health services to address inequalities and healthcare-related financial hardship, which traps vulnerable people into poverty.

Child marriage and associated outcomes in northern Ghana: a cross-sectional study.

BACKGROUND: Child marriage is a human rights violation disproportionately affecting girls in lower- and middle-income countries and has serious public health implications. In Ghana, one in five girls marry before their 18th birthday and one in 20 girls is married before her 15th birthday. This paper uses a unique dataset from Northern Ghana to examine the association between child marriage and adverse outcomes for women among a uniquely vulnerable population. METHODS: Baseline data from on ongoing impact evaluation of a government-run cash transfer programme was used. The sample consisted of 1349 ever-married women aged 20-29 years from 2497 households in the Northern and Upper East regions of Ghana. We estimated a series of ordinary least squares (OLS) and logistic regression models to examine associations of child marriage with health, fertility, contraception, child mortality, social support, stress and agency outcomes among women, controlling for individual characteristics and household-level factors. RESULTS: Child marriage in this sample was associated with increased odds of poorer health, as measured by difficulties in daily activities (OR = 2.08; CI 1.28-3.38 among women 20-24 years and OR = 1.58; CI 1.19-2.12 among women 20-29 years), increased odds of child mortality among first-born children (OR = 2.03; CI 1.09-3.77 among women 20-24 years) and lower odds of believing that one's life is determined by their own actions (OR = 0.42; CI 0.25-0.72 among women 20-24 years and OR = 0.54; CI 0.39-0.75 among women 20-29 years). Conversely, child marriage was associated with lower levels of reported stress (regression coefficient = - 1.18; CI -1.84--0.51 among women 20-29 years). CONCLUSIONS: Child marriage is common in Northern Ghana and is associated with poor health, increased child mortality, and low agency among women in this sample of extremely poor households. While not much is known about effective measures to combat child marriage in the context of Ghana, programmes that address key drivers of early marriage such as economic insecurity and school enrolment at the secondary level, should be examined with respect to their effectiveness at reducing early marriage. TRIAL REGISTRATION: Registered in the Registry for International Development Impact Evaluations (RIDIE) on 01 July 2015, with number RIDIE-STUDY-ID- 55942496d53af .

Effect of multi-micronutrient-fortified rice on cognitive performance depends on premix composition and cognitive function tested: results of an effectiveness study in Cambodian schoolchildren.

OBJECTIVE: Even though current policy is strongly focused on the crucial first '1000 days', it might be still possible to enhance cognitive function during the pre-adolescent and adolescent years by improving micronutrient status. In Cambodia, nutritional status is poor. Provision of rice fortified with micronutrients through a school meal programme (SMP) could be a cost-effective strategy to help improve health and school performance. The present study aimed to evaluate the effect of three different micronutrient-fortified rice formulations on cognitive function in Cambodian children. SETTING: Sixteen Cambodian schools receiving SMP. DESIGN: The FORISCA-UltraRice®+NutriRice® study was a randomized, double-blind, placebo-controlled trial. Four groups of four schools were randomly allocated to receive normal rice, UltraRice®Original, UltraRice®New or NutriRice®. Within each school, 132 children were randomly selected. Data on cognitive performance (picture completion, block design and Raven's coloured progressive matrices (RCPM)), anthropometry, parasite infestation and micronutrient status were collected before the intervention and after 6 months. SUBJECTS: Cognitive data were available for 1796 children aged 6-16 years. RESULTS: All cognitive scores improved after 6 months (P<0·001). Block design score improvement was significantly higher in children consuming UltraRice®Original (P=0·03) compared with the other fortified rice groups and placebo. No difference among groups was found on RCPM or picture completion scores. Stunting, parasite infestation and inflammation negatively affected the impact of the intervention. CONCLUSIONS: Combined with other interventions, using SMP to distribute fortified rice to schoolchildren may be a cost-effective way to increase cognitive performance and thereby improve school performance and educational achievements.

Cash Transfers and Child Nutrition: Pathways and Impacts.

Childhood malnutrition remains a significant global problem, with an estimated 162 million children under the age of five suffering from stunted growth. This article examines the extent to which cash transfer programmes can improve child nutrition. It adopts a framework that captures and explains the pathways and determinants of child nutrition. The framework is then used to organize and discuss relevant evidence from the impact evaluation literature, focusing on impact pathways and new and emerging findings from sub-Saharan Africa to identify critical elements that determine child nutrition outcomes as well as knowledge gaps requiring further research, such as children's dietary diversity, caregiver behaviours and stress.

Financial access to health care for older people in Cambodia: 10-year trends (2004-14) and determinants of catastrophic health expenses.

BACKGROUND: Older people make up an increasing proportion of the population in low- and middle-income countries. This brings a number of challenges, as their health needs are greater than, and different from, those of younger people. In general, these health systems are not geared to address their needs, and traditional support systems tend to erode, potentially causing financial hardship when accessing health care. This paper provides an overview of older Cambodians' financial access to health care over time, using nationally representative data to enable the formulation of appropriate responses. METHODS: Using data from three nationally representative household surveys from 2004, 2009 and 2014, we assess key indicators of financial access to health care for households with older people (aged 60 years or older), and compare these with households without older members. For 2014 data, the determinants of catastrophic health expenses at the 10 and 40 % threshold were determined for older people. Data was stratified by age and place of residence (urban/rural), and analysed using Stata statistical software. Sample weights were calibrated to reflect accurate population composition at the time of the survey. Monetary values for 2004 and 2009 were transformed into 2014 values using annual inflation rate figures. RESULTS: Care-seeking when sick among older people increased considerably from 2004 to 2014, irrespective of gender or place of residence. There were positive trends in the incidence of catastrophic and impoverishing healthcare expenses over the studied time periods. This was also the case for indebtedness. Rural households with older people were considerable more likely to suffer financial hardship due to health-related expenses than their urban equivalents. In 2014, older people spent 50 % more per month on health care than younger people. Determinants of catastrophic health expenditures among households with older people were residing in a rural area, and having a household member with an illness, especially a non-communicable disease. CONCLUSION: In order to make health care more equitable for older people, efforts should be directed to rural areas. Interventions should include improving management of non-communicable diseases at the primary care level, together with a reconfiguration of social health protection schemes to increase the inclusion of older people.

Current MUAC Cut-Offs to Screen for Acute Malnutrition Need to Be Adapted to Gender and Age: The Example of Cambodia.

BACKGROUND: Early identification of children <5 yrs with acute malnutrition is a priority. Acute malnutrition is defined by the World Health Organization as a mid-upper-arm circumference (MUAC) <12.5 cm or a weight-for-height Z-score (WHZ) <-2. MUAC is a simple and low-cost indicator to screen for acute malnutrition in communities, but MUAC cut-offs currently recommended by WHO do not identify the majority of children with weight-for-height Z-score (<-2 (moderate malnourished) or r<-3 (severe malnourished). Also, no cut-offs for MUAC are established for children >5 yrs. Therefore, this study aimed at defining gender and age-specific cut-offs to improve sensitivity of MUAC as an indicator of acute malnutrition. METHODS: To establish new age and gender-specific MUAC cut-offs, pooled data was obtained for 14,173 children from 5 surveys in Cambodia (2011-2013). Sensitivity, false positive rates, and areas under receiver-operator characteristic curves (AUC) were calculated using wasting for children <5yrs and thinness for children ≥5yrs as gold standards. Among the highest values of AUC, the cut-off with the highest sensitivity and a false positive rate ≤33% was selected as the optimal cut-off. RESULTS: Optimal cut-off values increased with age. Boys had higher cut-offs than girls, except in the 8-10.9 yrs age range. In children <2yrs, the cut-off was lower for stunted children compared to non stunted children. Sensitivity of MUAC to identify WHZ<-2 and <-3 z-scores increased from 24.3% and 8.1% to >80% with the new cut-offs in comparison with the current WHO cut-offs. CONCLUSION: Gender and age specific MUAC cut-offs drastically increased sensitivity to identify children with WHZ-score <-2 z-scores. International reference of MUAC cut-offs by age group and gender should be established to screen for acute malnutrition at the community level.

Optimal screening of children with acute malnutrition requires a change in current WHO guidelines as MUAC and WHZ identify different patient groups.

BACKGROUND: Timely treatment of acute malnutrition in children <5 years of age could prevent >500,000 deaths annually. Screening at community level is essential to identify children with malnutrition. Current WHO guidelines for community screening for malnutrition recommend a Mid Upper Arm Circumference (MUAC) of <115 mm to identify severe acute malnutrition (SAM). However, it is currently unclear how MUAC relates to the other indicator used to define acute malnutrition: weight-for-height Z-score (WHZ). METHODS: Secondary data from >11,000 Cambodian children, obtained by different surveys between 2010 and 2012, was used to calculate sensitivity and ROC curves for MUAC and WHZ. FINDINGS: The secondary analysis showed that using the current WHO cut-off of 115 mm for screening for severe acute malnutrition over 90% of children with a weight-for-height z-score (WHZ) <-3 would have been missed. Reversely, WHZ<-3 missed 80% of the children with a MUAC<115 mm. CONCLUSIONS: The current WHO cut-off for screening for SAM should be changed upwards from the current 115 mm. In the Cambodian data-set, a cut-off of 133 mm would allow inclusion of >65% of children with a WHZ<-3. Importantly, MUAC and WHZ identified different sub-groups of children with acute malnutrition, therefore these 2 indicators should be regarded as independent from each other. We suggest a 2-step model with MUAC used a screening at community level, followed by MUAC and WHZ measured at a primary health care unit, with both indicators used independently to diagnose severe acute malnutrition. Current guidelines should be changed to reflect this, with treatment initiated when either MUAC <115 mm or WHZ<-3.