Association of anthropometric status and residential locality factors with cognitive scores of 4-6-year-old children in Kwazulu-Natal, South Africa.

Background: The Asenze study has the long-term goal of promoting better physical, cognitive and psychosocial functioning of children in a rural area in KwaZulu-Natal, 50 km from Durban with a view to planning interventions to promote growth and development for very young children. The specific objective in this paper was to provide information for the Child Health and Development project of the Valley Trust to assist with intervention planning. The broader goal was to assess developmental delays in communities ravaged by the HIV epidemic.The Asenze study was designed in two phases from 2008 and 2012. The current paper reports on 1581 4-6years old children in the baseline phase (2008-2010) in the five adjacent tribal areas in the study area. Method: The participants included all the 4 - 6 year olds whose parents had consented to inclusion in the project and their caregivers. Data were derived from a brief questionnaire administered in the homes of participants, and subsequently from medical and psychological assessments of the children and their caregivers at the Asenze clinic. The association between child factors and other factors (geographic area, socioeconomic status (SES), parental level of education, the child's pre-school education) on the one hand and, the child's cognitive performance (as measured by the Grover Counter and subtests of the KABC-11) were analysed. Linear regression models were employed to determine which predictor variables of interest in a model were associated with the children's cognitive scores as the dependent variables. Results: Based on the data, the principal factors associated with children's cognitive outcomes were height-for-age z-score (HAZ), preschool education and the area of residence, Generally children who had low cognitive scores were more often stunted (as defined by the WHO anthropometric tables), had not had pre-school education, and came from areas less favourable in terms of local infrastructure and access to employment opportunities and arable land. Conclusion: The finding from this cross-sectional analysis of baseline data showed that in addition to height for age and pre-school education, which are commonly thought to impact on cognition, the local authority area where the children lived was associated with their scores on cognitive tests. This has implications for intervention planning. The functioning of local government in promoting the type of community development which will protect the rights of children should be taken into account.

Community management of intellectual disabilities in Pakistan: a mixed methods study.

BACKGROUND: Pakistan has one of the highest reported rates of childhood intellectual disabilities (ID) in the world. Prevalence estimates vary from 19.1/1000 for serious ID to 65/1000 for mild ID. METHODS: We surveyed carers of persons with ID (n = 100) using quantitative and qualitative instruments. We conducted in-depth interviews of carers (n = 16) and key primary health providers (n = 10). We also carried out focus groups (n = 7). Data were triangulated and interpreted in light of peer reviewed literature. RESULTS: There was a delay of 2.92 (95% CI 1.9 to 3.94) to 4.17 (95% CI 2.34 to 6.01) years between detection and seeking of care. Parental stress associated with caring for these children was high (mean Self-Reporting Questionnaire score 8.4; 95% CI 6.80 to 9.91). Home management consisted mainly of physical containment. Stigma associated with ID contributed to decreased opportunity for these children and families to participate in community activities. There was a lack of knowledge about causation and effective interventions for ID. CONCLUSIONS: Our findings suggest that there is significant delay in detection of ID especially in rural setting where more than 70% of population of Pakistan resides. This missed opportunity for rehabilitation in early formative years is a cause of significant distress for the caregivers who rarely receive valid information about course, prognosis and what remedial action to take. There is a need to develop feasible, cost-effective, community level interventions, which can be integrated into existing healthcare systems.

A qualitative study of the experience of treatment for infertility among women who successfully became pregnant.

BACKGROUND: In a study in which 18,503 women who had recently given birth were interviewed, 460 women who had received treatment for infertility (2.6%) were asked to participate in a postal study. The aim was to investigate the experience of women who had undergone treatment for infertility and given birth as a consequence, focusing on perceptions of treatment and care. METHODS: The study relies on responses to open-ended questions about the impact of treatment, how treatment could be improved and advice to policy makers. The text responses to these questions were analysed qualitatively. RESULTS: A total of 230 women responded (50%). Emergent themes related to the treatment process, pain and distress, lack of choice and control, timing, emotional and financial costs, fairness and contrasts in care. CONCLUSIONS: Women wished to be treated with respect and dignity and given appropriate information and support. They wanted their distress recognized, to feel cared for and to have confidence in health professionals in situations where outcomes are uncertain. Women acknowledged receiving care from motivated and skilled health professionals and value the children they have enormously. For many, there is now a sense of being complete, though for some this has been at great emotional and financial cost.

Agreement between hospital records and maternal recall of mode of delivery: evidence from 12 391 deliveries in the UK Millennium Cohort Study.

OBJECTIVE: The objective of this study was to measure the agreement between hospital records and maternal reporting of mode of delivery in a representative UK sample. DESIGN: Population-based survey (Millennium Cohort Study). SETTING: UK. POPULATION: A total of 12,391 singleton infants born in 2000-2002. METHODS: Mothers were interviewed when infants were approximately 9 months old. Information was collected by interview on many obstetric and perinatal factors including mode of delivery. Record linkage to the mother's delivery hospital records was undertaken in those who gave consent (90%). A matching record was found for 83%. Maternal report and hospital records were compared using mode of delivery classified into three (normal, assisted and caesarean) and six groups. Factors associated with disagreement between the two data sources were identified. MAIN OUTCOME MEASURE: Proportion of records in which there was agreement between the two data sources. RESULTS: Agreement between maternal report and hospital records was at least 94% using six mode of delivery groups and 98% using three groups. Much of the disagreement (57-63%, depending on country) was between forceps and ventouse, and between planned and emergency caesarean. Disagreement was more common in women whose babies were first born and in women not born in the UK. CONCLUSION: Our study confirms that maternal reporting of mode of delivery is highly reliable. This is important for clinical staff caring for women and those conducting epidemiological studies. Additional data sources may be necessary to gather reliable data from ethnic minority women, particularly those born outside the UK, or to distinguish forceps from ventouse, or planned from emergency caesarean section.

Social and ethnic inequalities in the offer and uptake of prenatal screening and diagnosis in the UK: a systematic review.

OBJECTIVE: To review studies addressing the question of whether there are social inequalities in either the offer or the uptake of prenatal testing in the UK. METHOD: Systematic review of studies assessing the offer or uptake of prenatal screening or diagnosis according to social class or ethnic origin. Electronic databases were searched using a strategy developed for a review of inequalities in access to maternity care supplemented with terms specific to prenatal testing. Further papers were identified from reference lists, citation searches and key organizations. RESULTS: From over 600 identified papers, 41 were potentially relevant. Twenty met the inclusion criteria. The studies included covered screening and/or diagnosis for Down's syndrome, neural tube defects, haemoglobin disorders and HIV. Many studies were limited by small numbers or poor reporting of data and analysis. Six studies reported data on prenatal testing according to women's social class or educational level. None found any significant social inequalities in testing. Some studies suggested that women of South Asian origin might be up to 70% less likely to receive prenatal testing for haemoglobin disorders and Down's syndrome than White women. A small number of studies suggested that South Asian women might be less likely to be offered testing. CONCLUSIONS: This review provides some evidence of ethnic inequalities in access to prenatal testing. Further research is required to improve our understanding of why testing may not be offered, the reasons for failure to take up testing when offered, and to identify whether there are other social inequalities in access to prenatal testing.

Suboptimal care and perinatal mortality in ten European regions: methodology and evaluation of an international audit.

BACKGROUND: A European concerted action (the EuroNatal study) investigated differences in perinatal mortality between countries of Europe. This report describes the methods used in the EuroNatal international audit and discusses the validity of the results. METHODS: Perinatal deaths between 1993 and 1998 in regions of ten European countries were identified. The categories of death chosen for the study were singleton fetal deaths at 28 or more weeks of gestational age, all intrapartum deaths at 28 or more weeks of gestational age and neonatal deaths at 34 or more weeks of gestational age. Deaths with major congenital anomalies were excluded. An international audit panel used explicit criteria to review all cases, which were blinded for region. Subjective interpretation was used in cases of events or interventions where explicit criteria did not exist. Suboptimal factors were identified in the antenatal, intrapartum and neonatal periods, and classified as 'maternal/social', due to 'infrastructure/service organization', or due to 'professional care delivery'. The contribution of each suboptimal factor to the fatal outcome was listed and consensus was reached on a final grade using a procedure that included correspondence and plenary meetings. RESULTS: In all regions combined, 90% of all known or estimated cases in the selected categories were included in the audit. In total, 1619 cases of perinatal death were audited. Consensus was reached in 1543 (95%) cases. In 75% of all cases, the grade was based on explicit criteria. In the remaining cases, consensus was reached within subpanels without reference to predefined criteria. There was reasonable to good agreement between and within subpanels, and within panel members. CONCLUSIONS: The international audit procedure proved feasible and led to consistent results. The results that relate to suboptimal care will need to be studied in depth in order to reach conclusions about their implications for assessing the quality of perinatal care in the individual regions.

Economic implications of assisted reproductive techniques: a systematic review.

BACKGROUND: Approximately one in six couples experiences problems with their fertility at some point in their reproductive lives. The economic implications of the use of assisted reproductive techniques require consideration. Herein, the health economics research in this area are critically appraised. METHODS: Multiple strategies were used to identify relevant studies. Each title and abstract was independently reviewed by two members of the study team and categorized according to perceived relevance. The selected papers were then assessed for quality and data were extracted, converted to UK pounds sterling at 1999/2000 prices, tabulated and critically appraised. RESULTS: A total of 2547 papers was identified through the searches; this resulted in 30 economic evaluations, 22 cost studies and five economic benefit studies that met the selection criteria. The quality of these studies was mixed; many failed to disaggregate costs, discount future costs or conduct sensitivity analyses. Consistent findings included the following: initiating treatment with intrauterine insemination appeared to be more cost-effective than IVF; vasectomy reversal appeared to be more cost-effective than ICSI; factors associated with poor prognosis decreased the cost-effectiveness of interventions. CONCLUSIONS: The cost-effectiveness of different interventions should be considered when making decisions about treatment. Future economic appraisals of assisted reproductive techniques would benefit from more robust methodology than is evident in much of the published literature to date.

Admissions for critically ill children: where and why?

INTRODUCTION: Planning services for critically ill children requires identification of overall critical care activity as well as an assessment of population needs. METHOD AND OBJECTIVES: This prospective needs assessment took a census approach to estimating population-based admission rates for paediatric critical care irrespective of where care was provided. A survey form was completed for every child in the study population for all of their admissions. CRITERIA: The need for tracheal intubation was used as a proxy for defining need for intensive care in this study. Critical illness was defined by clinical criteria adapted from the Advanced Paediatric Life Support Guidelines. STUDY POPULATION: All children under 17 years resident in south-east England (Thames regions) who required care for a critical illness in any inpatient setting between 1 December 1996 and 30 November 1997. Critical illness was the presence of acute body-system or multi-system failure. RESULTS: A wide variation in the rates of critical care admission to different types of care settings was reported ranging from 1.2 admissions per 1000 resident children per year for PIC units (general and cardiothoracic units) to 0.02 admissions per 1000 children per year for children admitted from the community to neonatal units. The age of children and their rates of admission were directly related to the type of ward or unit where children received care. Tracheal intubation occurred in all care settings. The proportion of intubated children transferred to paediatric intensive care units (PICUs) or paediatric cardiothoracic intensive care units (PCICUs) varied according to the type of referring unit. The proportion of episodes involving tracheal intubation where the child was not transferred to a PICU or PCICU was 52% for children in stand-alone neurosurgical units, 41% for those in adult intensive care units (AICUs), and 4% for those in children's wards. CONCLUSIONS: This baseline study shows a significant number of critically ill children who are never cared for in PIC units. With national changes in UK policy to regionalise care for these children, monitoring care in all locations by cause of admission remains important. While the data were collected in 1997, the findings from this study remain relevant and provide the basis for planning regional critical care services for children. Results are also relevant to other geographical areas in that measuring the use of services for critically ill children must go beyond documenting admission to ICUs for children and adults. All settings for critical care must be identified, the activity documented, and the use of services measured against existing resources. Clear clinical criteria are needed to identify children who can be cared for appropriately on high dependency units.

Addressing domestic violence through maternity services: policy and practice.

OBJECTIVE: to explore current policies and practices in maternity units that aim to identify, assess and support women experiencing domestic violence. DESIGN AND SETTING: a postal survey, conducted between June and October 1999, of all NHS Trusts in England and Wales that provided maternity services. PARTICIPANTS: Heads of Midwifery or the midwife with expertise or interest in domestic violence in each Trust. MAIN OUTCOME MEASURES: use of written policies and agreed practices for identifying and referring women experiencing domestic violence, such as availability of information, routine questioning of all women and offering women an appointment without their partner. RESULTS: 87% (183) of the 211 NHS Trusts providing maternity care participated in the survey. Twelve per cent of units had written policies for identifying women experiencing domestic violence, and a further 30% had some form of agreed practice. Less than half of maternity units routinely offered women an appointment without their partner, and just over half displayed material about domestic violence in places where women receive maternity care. Only three units had undertaken audit on their domestic violence practices. CONCLUSIONS: there is considerable variability around England and Wales in policies and practices related to domestic violence. It is evident that clear guidelines for identification and referral, training, audit and the integration of domestic violence policies with child protection and other policies are necessary to fully address the issues.

Does poor communication contribute to stillbirths and infant deaths? A review.

BACKGROUND: Assessors from the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) have cited poor communication as a contributory factor in a proportion of such deaths. This review assesses what research evidence exists to support or explain this. METHODS: A structured review was carried out, including all studies of sub-optimal care in stillbirth or infant death and studies of litigation in perinatal care. The following databases were searched: MEDLINE, PsycLIT, The Cochrane Library, BIDS Science and Social Science Citation Indexes, Cinahl and Embase. For included studies, information was extracted on the type of study, the selection criteria and number of cases studied, other methods used and results relevant to the question. RESULTS: One hundred and four studies of potential relevance to the review were identified. Of these, 52 did not meet the inclusion criteria and were excluded. Of the remaining 52 studies, 11 considered communication failure explicitly as a factor in sub-optimal care leading to stillbirth or infant death. In three out of the four studies that presented their findings in terms of numbers of cases, communication failure was noted in between 24 and 29 per cent of cases. There was some consistency across different types of study in the types of communication problems noted. CONCLUSION: Poor communication may contribute to a proportion of stillbirths and infant deaths. However, given the small number of papers that looked explicitly at poor communication as a factor in sub-optimal care and the lack of comparative information on communication in cases that do not end in poor outcome, caution is needed in drawing conclusions based on the findings of these papers.

Training programs for healthcare professionals in domestic violence.

Although women who experience domestic violence seek healthcare services frequently, screening and counseling rates remain low, and healthcare professionals report feeling inadequately trained to care for abused women. The English language literature from 1989 to 1999 was searched to identify and evaluate published assessments of the education of healthcare providers in domestic violence toward women. Major deficiencies in program evaluation were found. They included the use of a historical comparison group, lack of an experimental design, selection of nonstandardized outcomes without clinical performance measures, short-term follow-up, limited documentation of course content and theory, and lack of focus on the impact of programs on abused women. Educational programs generally consisted of a single session of limited duration (1-3 hours). Based on published reports, it appears that few rigorously designed evaluations have been conducted of training programs for healthcare providers in the detection and treatment of women affected by domestic violence.

Prenatal and postnatal risk factors for mental retardation among children in Bangladesh.

This study evaluated the contribution of prenatal, perinatal, neonatal, and postnatal factors to the prevalence of cognitive disabilities among children aged 2-9 years in Bangladesh. A two-phase survey was implemented in 1987-1988 in which 10,299 children were screened for disability. In multivariate analyses, significant independent predictors of serious mental retardation in rural and urban areas included maternal goiter (rural odds ratio (OR) = 5.14, 95% confidence interval (CI): 1.23, 21.57; urban OR = 4.82, 95% CI: 2.73, 8.50) and postnatal brain infections (rural OR = 29.24, 95% CI: 7.17, 119.18; urban OR = 13.65, 95% CI: 4.69, 39.76). In rural areas, consanguinity (OR = 15.13, 95% CI: 3.08, 74.30) and landless agriculture (OR = 6.02, 95% CI: 1.16, 31.19) were also independently associated with the prevalence of serious mental retardation. In both rural and urban areas, independent risk factors for mild cognitive disabilities included maternal illiteracy (OR = 2.48, 95% CI: 0.86, 7.12), landlessness (OR = 4.27, 95% CI: 1.77, 10.29), maternal history of pregnancy loss (OR = 2.61, 95% CI: 0.95, 7.12), and small for gestational age at birth (OR = 3.86, 95% CI: 1.56, 9.55). Interventions likely to have the greatest impact on preventing cognitive disabilities among children in Bangladesh include expansion of existing iodine supplementation, maternal literacy, and poverty alleviation programs as well as prevention of intracranial infections and their consequences. Further population-based studies are needed to confirm and understand the association between consanguinity and serious cognitive disability.

Economic issues in the follow-up of neonates.

Children with conditions requiring neonatal intensive care impose a financial burden on health services, on families and carers, and on society generally. A systematic review of the literature identified 81 studies that conducted primary research on the cost of services as a result of conditions requiring neonatal intensive care. The majority of studies estimated costs incurred during the initial hospital stay. Relatively few studies considered health service costs following discharge from the neonatal intensive care unit, costs to other sectors of the economy or costs to families and carers. It is important that these costs are considered more fully.

Evaluating child disability programmes: the role of commissioners.

The paper briefly reviews the role of a health care commissioner in planning and evaluating children's disability services, an area with a strong statutory framework but a paucity of guidance. It also explores how different aspects of evaluation apply to commissioning.

Rates of, and the factors affecting, cycle helmet use among secondary schoolchildren in East Sussex and Kent.

OBJECTIVES: To assess the level of cycle helmet wearing among young people in two counties in the South East of England in 1994, and to identify the factors associated with helmet wearing. DESIGN: Cross sectional survey in a convenience sample. SETTING: Secondary schools in East Sussex and Kent. SUBJECTS: Students in year 7 (aged 10-12 years) and year 11 (aged 14-16 years). Main outcome measures--Self reported "always wears a helmet". RESULTS: Among those who ride a bicycle, 32% of boys and 29% of girls aged 10-12 years, and 14% of boys and 10% of girls aged 14-16, reported that they always wear helmets. The variables that were most consistently associated with helmet wearing (that is significantly associated with helmet wearing in at least five of the six age, sex, and county subgroups) were: "parental encouragement to wear a helmet" "closest friend wears a helmet", "belief that laws that make children wear helmets are good", and "sometimes rides off-road". CONCLUSIONS: The self reported rates of always wearing a cycle helmet in East Sussex and Kent are consistent with overseas findings for populations who had not been exposed to intensive helmet promotion. The evidence suggests that parental encouragement has a favourable effect on rates of cycle helmet use among secondary schoolchildren, which is separate from and additional to peer influences. When designing a helmet promotion programme, therefore, it will have added impact if both parents and children are addressed.

Epidemiology and prevention of severe assault and gun injuries to children in an urban community.

OBJECTIVES: To describe the epidemiology of severe assault and gun injuries to children in an urban population and consider the impact of a comprehensive injury prevention program. MATERIALS AND METHODS: Pediatric injury deaths and hospital admissions for Northern Manhattan (1983-1992) were linked to census counts to compute incidence. Poisson regression was used to compare trends in incidence of assault and gun injuries before and during a community-wide pediatric injury prevention program in Central Harlem. MAIN RESULTS: The incidence of severe nonfatal assault injury was 60.94/100,000/year, 10 times the fatality rate. The incidence of all gun injuries was 31.13. In adolescence, guns were the leading cause of both fatal and severe nonfatal assault injury, and were the most lethal method of assault (case-fatality = 18.5% for gun vs. 1.2% for all non-gun assault injury). Rates of assault and gun injuries declined by nearly 50% in the intervention community, while they increased in a neighboring community. CONCLUSIONS: Comprehensive interventions may be effective in curbing the incidence of severe assault injuries to urban youth. Further controlled evaluations are needed to confirm the effectiveness of programs such as this and to better understand the prevention of violent injuries.

Evaluating a ten questions screen for childhood disability: reliability and internal structure in different cultures.

This paper uses five strategies to evaluate the reliability and other measurement qualities of the Ten Questions screen for childhood disability. The screen was administered for 22,125 children, aged 2-9 years, in Bangladesh, Jamaica and Pakistan. The test-retest approach involving small sub-samples was useful for assessing reliability of overall screening results, but not of individual items with low prevalence. Alternative strategies focus on the internal consistency and structure of the screen as well as item analyses. They provide evidence of similar and comparable qualities of measurement in the three culturally divergent populations, indicating that the screen is likely to produce comparable data across cultures. One of the questions, however, correlates with the other questions differently in Jamaica, where it appears to "over-identify" children as seriously disabled. The methods and findings reported here have general applications for the design and evaluation of questionnaires for epidemiologic research, particularly when the goal is to gather comparable data in geographically and culturally diverse settings.

Use of Poisson regression and time series analysis for detecting changes over time in rates of child injury following a prevention program.

The use of two statistical methods to quantify time trends (Poisson regression and time series analysis) is illustrated in analyses of changes in child injury incidence after implementation of a community-based injury prevention program in Central Harlem, New York City. The two analytical methods are used to quantify changes in the rate of injury following the program, while taking into account the underlying annual and seasonal trends. Rates of severe injury during the period from 1983 to 1991 among children under the age of 17 years living in Central Harlem and in the neighboring community of Washington Heights are analyzed. The two methods provide similar point estimates of the effect of the intervention and have a good fit to the data. Although time series analysis has been promoted as the method of choice in analysis of sequential observations over long periods of time, this illustration suggests that Poisson regression is an attractive and viable alternative. Poisson regression provides a versatile analytical method for quantifying the time trends of relatively rare discrete outcomes, such as severe injuries, and provides a useful tool for epidemiologists involved with program evaluation.