Estimates and trends of zero vegetable or fruit consumption among children aged 6-23 months in 64 countries.

Children require a diverse diet, that includes vegetables and fruits, to support growth and development and prevent non-communicable diseases. The WHO-UNICEF established a new infant and young child feeding (IYCF) indicator: zero vegetable or fruit (ZVF) consumption among children aged 6-23 months. We estimated the prevalence, trends, and factors associated with ZVF consumption using nationally representative, cross-sectional data on child health and nutrition in low-and-middle-income countries. We examined 125 Demographic and Health Surveys in 64 countries conducted between 2006-2020 with data on whether a child ate vegetables or fruits the previous day. Prevalence of ZVF consumption was calculated by country, region, and globally. Country trends were estimated and tested for statistical significance (p<0.05). Logistic regression analysis was used to examine the relationship between ZVF and child, mother, household, and survey cluster characteristics by world region and globally. Using a pooled estimate of the most recent survey available in each country, we estimate the global prevalence of ZVF consumption as 45.7%, with the highest prevalence in West and Central Africa (56.1%) and the lowest in Latin America and the Caribbean (34.5%). Recent trends in ZVF consumption varied by country (16 decreasing, eight increasing, 14 no change). Country trends in ZVF consumption represented diverse patterns of food consumption over time and may be affected by the timing of surveys. Children from wealthier households and children of mothers who are employed, more educated, and have access to media were less likely to consume ZVF. We find the prevalence of children aged 6-23 months who do not consume any vegetables or fruits is high and is associated with wealth and characteristics of the mother. Areas for future research include generating evidence from low-and-middle-income countries on effective interventions and translating strategies from other contexts to improve vegetable and fruit consumption among young children.

Unrealized fertility among women in low and middle-income countries.

BACKGROUND: There has been little research on women who have fewer than their ideal number of children toward the end of their childbearing years in low and middle-income countries (LMICs). We examine the level and distribution of unrealized fertility in LMICs across three geographical regions. We also examine the role of sex preference and other factors associated with unrealized fertility. DATA AND METHODS: We used Demographic and Health Survey (DHS) data for women age 44-48 in 36 countries from the three geographical regions of Western and Central Africa, Eastern and Southern Africa, and South and Southeast Asia. We conducted descriptive analysis to examine the distribution of unwanted fertility and unrealized fertility, and fit adjusted logistic regressions of unrealized fertility. The main variables are number of living children (including by sex) and the sex composition of children. Other variables included education, marital status, age at first childbirth, wealth quintile, place of residence, exposure to family planning messages, contraceptive use, and country. RESULTS: Unrealized fertility was highest in Western and Central Africa, followed by Eastern and Southern Africa. In all regions, there was a decrease in unrealized fertility with an increasing number of children. Findings for sex preference varied with little sex preference in the African regions, and some limited evidence of preference for sons in South and Southeast Asia. In most regions, higher levels of education, higher wealth quintile, and use of contraceptive methods were associated with decreased unrealized fertility. CONCLUSION: Family planning programs and messages should consider regional and socioeconomic differences in unrealized fertility in order to give women and families the right to achieve the family size they desire regardless of their status.

The Demographic and Health Surveys Faculty Fellows Program: Successes, Challenges, and Lessons Learned.

Primarily funded by the United States Agency for International Development (USAID), the Demographic and Health Surveys (DHS) Faculty Fellows Program is designed to strengthen the institutional capacity of universities in low- and middle-income countries to use and analyze DHS data. This article provides an overview of the program's evolution and its current form; presents successes and impacts; and discusses challenges, lessons learned, and potential further directions.Initiated in 2008, the Fellows Program underwent several rounds of improvement. The current model involves a competitive team application process, 2 intensive in-person workshops, completion of a working paper of publishable quality, and the transfer of analysis skills learned during the fellowship to students and colleagues at home universities, all completed over 1 year. Since 2011, the Fellows Program has trained 152 researchers from 45 universities in 25 countries in Africa, Asia, and the Middle East. The program has not only strengthened individual skills in conducting research with data from large surveys but also substantially increased institutional capacity to analyze DHS data through fellows' capacity-building activities at their home universities. These successes have happened despite the many and continuing challenges related to fellows' diverse backgrounds, experience, skills, language barriers, logistical difficulties in organizing in-person workshops in fellows' countries, and sometimes fellows' varying levels of commitment.With continuous support from USAID, the program hopes to expand to more universities and countries, especially francophone countries. Overall, the DHS Faculty Fellows Program has proven to be highly successful and provides a model for other groups aiming to strengthen capacity for data use and research in low- and middle-income countries.

Stunting and Anemia in Children from Urban Poor Environments in 28 Low and Middle-income Countries: A Meta-analysis of Demographic and Health Survey Data.

Child malnutrition remains a global concern with implications not only for children's health and cognitive function, but also for countries' economic growth. Recent reports suggest that global nutrition targets will not be met by 2025. Large gaps are evident between and within countries. One of the largest disparities in child malnutrition within counties is between urban and rural children. Large disparities also exist in urban areas that have higher rates of child malnutrition in the urban poor areas or slums. This paper examines stunting and anemia related to an urban poverty measure in children under age 5 in 28 low and middle-income countries with Demographic and Health Survey data. We used the United Nations Human Settlements Programme (UN-HABITAT) definition to define urban poor areas as a proxy for slums. The results show that in several countries, children had a higher risk of stunting and anemia in urban poor areas compared to children in urban non-poor areas. In some countries, this risk was similar to the risk between the rural and urban non-poor. Tests of heterogeneity showed that these results were not homogeneous across countries. These results help to identify areas of greater disadvantage and the required interventions for stunting and anemia.

Using geographical analysis to identify child health inequality in sub-Saharan Africa.

One challenge to achieving Millennium Development Goals was inequitable access to quality health services. In order to achieve the Sustainable Development Goals, interventions need to reach underserved populations. Analyzing health indicators in small geographic units aids the identification of hotspots where coverage lags behind neighboring areas. The purpose of these analyses is to identify areas of low coverage or high need in order to inform effective resource allocation to reduce child health inequity between and within countries. Using data from The Demographic and Health Survey Program surveys conducted in 27 selected African countries between 2010 and 2014, we computed estimates for six child health indicators for subnational regions. We calculated Global Moran's I statistics and used Local Indicator of Spatial Association analysis to produce a spatial layer showing spatial associations. We created maps to visualize sub-national autocorrelation and spatial clusters. The Global Moran's I statistic was positive for each indicator (range: 0.41 to 0.68), and statistically significant (p <0.05), suggesting spatial autocorrelation across national borders, and highlighting the need to examine health indicators both across countries and within them. Patterns of substantial differences among contiguous subareas were apparent; the average intra-country difference for each indicator exceeded 20 percentage points. Clusters of cross-border associations were also apparent, facilitating the identification of hotspots and informing the allocation of resources to reduce child health inequity between and within countries. This study exposes differences in health indicators in contiguous geographic areas, indicating that specific regional and subnational, in addition to national, strategies to improve health and reduce health inequalities are warranted.

Counseling and Knowledge of Danger Signs of Pregnancy Complications in Haiti, Malawi, and Senegal.

Objectives Providing counseling on danger signs of pregnancy complications as part of visits for antenatal care (ANC) can raise expecting women's awareness so that if danger signs occur they can seek assistance in time. The study examines the level of agreement in counseling on danger signs between observation of the provider during the ANC visit and the client's report in the exit interview, and the association of this agreement with the client's level of knowledge on danger signs. Methods The analysis used data from service provision and assessment (SPA) surveys in Haiti, Malawi, and Senegal. Agreement between the observation and client's report was measured by Cohen's kappa and percent agreement. Regressions were performed on the number of danger signs the client knew, with the level of agreement on the counseling on danger signs as the main independent variable. Results The study found little agreement between the observation of counseling and the client's report that the counseling occurred, despite the fact that the exit interview with the client was performed immediately following the ANC visit with the provider. The level of positive agreement between observation and client's report was 17% in Haiti, 33% in Malawi, and 23% in Senegal. Clients' overall knowledge of danger signs was low; in all three countries the mean number of danger signs known was 1.5 or less. The regression analysis found that, in order to show a significant increase in knowledge of danger signs, it was important for the client to report that it took place. Conclusions Ideally, there should be 100% positive agreement that counseling occurred. To achieve this level requires raising both the level of counseling on danger signs of pregnancy complications and its quality. While challenges exist, providing counseling that is more client-centered and focuses on the client's needs could improve quality and thus could increase the client's knowledge of danger signs.

Quality of care in family planning services in Senegal and their outcomes.

BACKGROUND: High quality of care in family planning (FP) services has been found to be associated with increased and continued use of contraceptive methods. The interpersonal skills and technical competence of the provider is one of the main components of quality of care. To study the process component of quality of care, the distribution of the FP counseling topics was examined by client, provider and facility characteristics. To assess the outcomes of quality of care, client satisfaction and their knowledge of their method's protection from STIs were used. This study examined the factors associated with these outcomes with a focus on provider counseling and training. METHODS: Data from the 2012-2013 Senegal Service Provision Assessment survey was used for the analysis. The survey included a representative sample of the health facilities in Senegal and collects data by observing the clients' FP visits and conducting exit interviews. The main outcomes of interest were provider's counseling in FP, client's satisfaction with FP services and client's knowledge of their method's protection from STIs. Several covariates were used in the analysis which represent client, provider and facility characteristics. RESULTS: The level of counseling was inadequate-- very low proportions of providers that performed different types of counseling. Counseling was more likely to be provided to new than returning clients. Approximately 84% of the clients were very satisfied with services but only 58% had correct knowledge of their method's protection from STIs. Clients were significantly less likely to be very satisfied when their providers counseled on side effects and when to return, and counseling provided on method's protection from STIs did not significantly improve knowledge in this area. Clients seen by a provider with FP training had almost twice the odds of having correct knowledge about their method's protection from STIs compared with clients seen by a provider with no recent training. CONCLUSIONS: The percentage of providers offering FP counseling to their clients was relatively low and was ineffective on the client-focused outcomes. Interventions may be required for more effective counseling methods that are client-centered as well as providing more FP training to providers.

Analyzing disparity trends for health care insurance coverage among non-elderly adults in the US: evidence from the Behavioral Risk Factor Surveillance System, 1993-2009.

OBJECTIVE: To explore the changing disparities in access to health care insurance in the United States using time-varying coefficient models. DATA: Secondary data from the Behavioral Risk Factor Surveillance System (BRFSS) from 1993 to 2009 was used. STUDY DESIGN: A time-varying coefficient model was constructed using a binary outcome of no enrollment in health insurance plan versus enrolled. The independent variables included age, sex, education, income, work status, race, and number of health conditions. Smooth functions of odds ratios and time were used to produce odds ratio plots. RESULTS: Significant time-varying coefficients were found for all the independent variables with the odds ratio plots showing changing trends except for a constant line for the categories of male, student, and having three health conditions. Some categories showed decreasing disparities, such as the income categories. However, some categories had increasing disparities in health insurance enrollment such as the education and race categories. CONCLUSIONS: As the Affordable Care Act is being gradually implemented, studies are needed to provide baseline information about disparities in access to health insurance, in order to gauge any changes in health insurance access. The use of time-varying coefficient models with BRFSS data can be useful in accomplishing this task.

Application of the varying coefficient model to the behaviour risk factor surveillance data in Italy: a study of changing smoking prevalence among sub-populations.

BACKGROUND: Behaviour risk factor surveillance (BRFS) data can be an important source of information for studying changes in various health outcomes and risk factors. Results obtained from surveillance data analysis are vital for informing health policy interventions, particularly with regards to evolutionary aspects. The objective of this analysis was to recommend a method that can be used for analysing trends in the association among variables from large public health data sets. This was demonstrated by examining the changing effects of various covariates, representing different sub-populations, on smoking status over time. METHODS: In our work, we propose the use of varying coefficient models (VCM) with non-parametric techniques to catch the dynamics of the evolutionary processes under study. This is a useful method, which allows coefficients to vary with time using smooth functions. Italian BRFS data from 2008-2012 was used with a sample size of 185,619 observations. In the application, a time VCM is fit for a smoking status binary outcome variable using the P-spline estimation method. The model includes ten independent variables comprising socio-demographic, health risk and behaviour variables. RESULTS: The VCM fit for the data indicates that the coefficients for some of the categories for the age and the alcohol consumption variables varied with time. The main results show that Italians aged 18-29 and 40-49 had higher odds of being smokers compared to those aged 60-69; however, these odds significantly decreased in the period 2008-2012. In addition, those who do not drink had lower odds for being a smoker compared to high risk drinkers and these odds decreased further during the observation period. CONCLUSION: The application of the VCM to the BRFS data in Italy has shown that this method can be useful in detecting which sub-populations require interventions. Although the results have shown a decrease in the odds of being a smoker for certain age groups and non-drinkers, other sub-populations have not decreased their odds and health inequalities remain. This observation indicates that efforts and interventions are still required to target these non-changing sub-populations in order to modify their smoking behaviour.

Domestic violence against single, never-married women in the Occupied Palestinian Territory.

This study examines the association between decision-making power, with other background variables, and domestic violence against single, never-married women in the Occupied Palestinian Territory (OPT). Secondary analysis using data from a 2006 Palestinian Central Bureau of Statistics domestic violence survey revealed that decision-making power and age were significant predictors of physical and psychological abuse. Relation to household head, refugee status, education, employment, and locality were not significant; region was only significant for psychological abuse. Further studies are needed to understand what factors allow single, never-married women to exercise decision-making power in the household and its association with domestic violence.

Predictors of displacement behaviour during the 2006 Lebanon war.

The July 2006 war in Lebanon was one of the country's shortest wars. Yet perhaps it was also the worst interstate war in the history of Lebanon. Over the course of 33 days, the war resulted in over 1000 deaths, thousands of injuries, large-scale destruction of infrastructure and properties, as well as massive population displacements. Approximately a third of the Lebanese population was displaced during the war. Population-based survey data collected in early 2007 and logistic regression models were used to examine the effects of some demographic and socio-economic factors on displacement, stratified by war-affected and non-affected areas. The sample was restricted to adults who were at least 18 years old. We found that the intensity of the conflict as captured by the region of residence was understandably the most important variable in predicting displacement. The odds of displacement were higher for those who were younger in age, married or who had obtained a higher education. Females and those of Lebanese nationality had higher odds of displacement than their male and non-Lebanese counterparts, but only in war-damaged areas. Interestingly, household composition and size, economic standing and car ownership were not related to the odds of displacement. Findings from the present study may help policy-makers and humanitarian agencies in their planning efforts during emergencies, including wars.

Consanguinity and reproductive wastage in the Palestinian Territories.

Many studies have found that consanguinity poses a threat to child mortality and health and can also pose a threat to offspring survival before birth. However, there are conflicting findings with some studies having found no increased risk on offspring survival associated with consanguinity. Data from a population-based survey conducted in 2004 in the Palestinian Territories was used to assess the risk of consanguinity on offspring survival. The analysis was conducted on 4418 women aged 15-49 who were asked whether or not they had experienced a stillbirth or a spontaneous abortion. These two outcomes were combined together for the analysis of reproductive wastage. Multivariable negative binomial regression was conducted to calculate the incidence risk ratios (IRR) for each region in the Palestinian Territories separately. The strongest risk factors for reproductive wastage, after controlling for other variables, were found to be consanguinity, age and parity with age presenting the highest IRRs. Standard of living, locality type, education level, women's employment and past intrauterine device use were not found to be significant risk factors for reproductive wastage. In the West Bank only first cousin level of consanguinity was found to be significant and 'hamola' level (or from same family clan) lost its significance after adjusting for other variables. In the Gaza Strip both the first cousin and 'hamola' levels of consanguinity were significant and presented almost equal IRRs of 1.3. In conclusion, consanguinity was found to be a significant risk factor for reproductive wastage.

Consanguinity trends and correlates in the Palestinian Territories.

Secondary analysis of the trends and correlates of consanguinity in the Palestinian Territories was conducted using data from two separate surveys in 1995 and 2004. The analysis was conducted on ever-married women aged 15-54 who were asked about their relation to their husband in both surveys. A total of 16,197 women in 1995 and 4971 women in 2004 were successfully interviewed. Consanguinity was found to be widely practised in the Palestinian Territories with rates of total consanguinity reaching 45% of all marriages in 2004. Analysis was conducted with the data from the two surveys combined and this indicated that consanguinity was significantly decreasing with time after controlling for other variables. Age of the women, their age at marriage, region and locality type they lived in and their standard of living were all found to be significant predictors of consanguinity. The education level of the women was not found to be significant. After controlling for the survey year, women's labour force status was also found to be a non-significant predictor of consanguinity. Although consanguinity was found to be significantly decreasing slowly with time after controlling for other variables, the future trends of consanguinity are not known due to the unstable political situation in the territories, which could have a direct effect on marriage patterns.