Children's Environmental Health Indicators for Low- and Middle-Income Countries in Asia.

BACKGROUND: Given that low- and middle-income countries (LMICs) in Asia still have high child mortality rates, improved monitoring using children's environmental health indicators (CEHI) may help reduce preventable deaths by creating healthy environments. OBJECTIVES: Thus, the aim of this study is to build a set of targeted CEHI that can be applied in LMICs in Asia through the CEHI initiative using a common conceptual framework. METHODS: A systematic review was conducted to identify the most frequently used framework for developing CEHI. Due to the limited number of eligible records, a hand search of the reference lists and an extended search of Google Scholar were also performed. Based on our findings, we designed a set of targeted CEHI to address the children's environmental health situation in LMICs in Asia. The Delphi method was then adopted to assess the relevance, appropriateness, and feasibility of the targeted CEHI. FINDINGS: The systematic review indicated that the Driving-Pressure-State-Exposure-Effect-Action framework and the Multiple-Exposures-Multiple-Effects model were the most common conceptual frameworks for developing CEHI. The Multiple-Exposures-Multiple-Effects model was adopted, given that its population of interest is children and its emphasis on the many-to-many relationship. Our review also showed that most of the previous studies covered upper-middle- or high-income countries. The Delphi results validated the targeted CEHI. The targeted CEHI were further specified by age group, gender, and place of residence (urban/rural) to enhance measurability. CONCLUSIONS: Improved monitoring systems of children's environmental health using the targeted CEHI may mitigate the data gap and enhance the quality of data in LMICs in Asia. Furthermore, critical information on the complex interaction between the environment and children's health using the CEHI will help establish a regional environmental children's health action plan, named "The Children's Environment and Health Action Plan for Asia."

Children's Environmental Health Indicators in Australia.

BACKGROUND: Adverse environmental exposures in early life increase the risk of chronic disease but do not attract the attention nor receive the public health priority warranted. A safe and healthy environment is essential for children's health and development, yet absent in many countries. A framework that aids in understanding the link between environmental exposures and adverse health outcomes are environmental health indicators-numerical estimates of hazards and outcomes that can be applied at a population level. The World Health Organization (WHO) has developed a set of children's environmental health indicators (CEHI) for physical injuries, insect-borne disease, diarrheal diseases, perinatal diseases, and respiratory diseases; however, uptake of steps necessary to apply these indicators across the WHO regions has been incomplete. A first indication of such uptake is the management of data required to measure CEHI. OBJECTIVES: The present study was undertaken to determine whether Australia has accurate up-to-date, publicly available, and readily accessible data on each CEHI for indigenous and nonindigenous Australian children. FINDINGS: Data were not readily accessible for many of the exposure indicators, and much of the available data were not child specific or were only available for Australia's indigenous population. Readily accessible data were available for all but one of the outcome indicators and generally for both indigenous and nonindigenous children. Although Australia regularly collects data on key national indicators of child health, development, and well-being in several domains mostly thought to be of more relevance to Australians and Australian policy makers, these differ substantially from the WHO CEHI. CONCLUSIONS: The present study suggests that the majority of these WHO exposure and outcome indicators are relevant and important for monitoring Australian children's environmental health and establishing public health interventions at a local and national level and collection of appropriate data would inform public health policy in Australia.

Monitoring the inputs required to extend and sustain hygiene promotion: findings from the GLAAS 2013/2014 survey.

OBJECTIVES: There are significant gaps in information about the inputs required to effectively extend and sustain hygiene promotion activities to improve people's health outcomes through water, sanitation and hygiene (WASH) interventions. We sought to analyse current country and global trends in the use of key inputs required for effective and sustainable implementation of hygiene promotion to help guide hygiene promotion policy and decision-making after 2015. METHODS: Data collected in response to the GLAAS 2013/2014 survey from 93 countries of 94 were included, and responses were analysed for 12 questions assessing the inputs and enabling environment for hygiene promotion under four thematic areas. Data were included and analysed from 20 External Support Agencies (ESA) of 23 collected through self-administered surveys. RESULTS: Firstly, the data showed a large variation in the way in which hygiene promotion is defined and what constitutes key activities in this area. Secondly, challenges to implement hygiene promotion are considerable: include poor implementation of policies and plans, weak coordination mechanisms, human resource limitations and a lack of available hygiene promotion budget data. CONCLUSION: Despite the proven benefits of hand washing with soap, a critical hygiene-related factor in minimising infection, GLAAS 2013/2014 survey data showed that hygiene promotion remains a neglected component of WASH. Additional research to identify the context-specific strategies and inputs required to enhance the effectiveness of hygiene promotion at scale are needed. Improved data collection methods are also necessary to advance the availability and reliability of hygiene-specific information.

Health of the world's adolescents: a synthesis of internationally comparable data.

Adolescence and young adulthood offer opportunities for health gains both through prevention and early clinical intervention. Yet development of health information systems to support this work has been weak and so far lagged behind those for early childhood and adulthood. With falls in the number of deaths in earlier childhood in many countries and a shifting emphasis to non-communicable disease risks, injuries, and mental health, there are good reasons to assess the present sources of health information for young people. We derive indicators from the conceptual framework for the Series on adolescent health and assess the available data to describe them. We selected indicators for their public health importance and their coverage of major health outcomes in young people, health risk behaviours and states, risk and protective factors, social role transitions relevant to health, and health service inputs. We then specify definitions that maximise international comparability. Even with this optimisation of data usage, only seven of the 25 indicators, covered at least 50% of the world's adolescents. The worst adolescent health profiles are in sub-Saharan Africa, with persisting high mortality from maternal and infectious causes. Risks for non-communicable diseases are spreading rapidly, with the highest rates of tobacco use and overweight, and lowest rates of physical activity, predominantly in adolescents living in low-income and middle-income countries. Even for present global health agendas, such as HIV infection and maternal mortality, data sources are incomplete for adolescents. We propose a series of steps that include better coordination and use of data collected across countries, greater harmonisation of school-based surveys, further development of strategies for socially marginalised youth, targeted research into the validity and use of these health indicators, advocating for adolescent-health information within new global health initiatives, and a recommendation that every country produce a regular report on the health of its adolescents.

Neonatal mortality levels for 193 countries in 2009 with trends since 1990: a systematic analysis of progress, projections, and priorities.

BACKGROUND: Historically, the main focus of studies of childhood mortality has been the infant and under-five mortality rates. Neonatal mortality (deaths <28 days of age) has received limited attention, although such deaths account for about 41% of all child deaths. To better assess progress, we developed annual estimates for neonatal mortality rates (NMRs) and neonatal deaths for 193 countries for the period 1990-2009 with forecasts into the future. METHODS AND FINDINGS: We compiled a database of mortality in neonates and children (<5 years) comprising 3,551 country-years of information. Reliable civil registration data from 1990 to 2009 were available for 38 countries. A statistical model was developed to estimate NMRs for the remaining 155 countries, 17 of which had no national data. Country consultation was undertaken to identify data inputs and review estimates. In 2009, an estimated 3.3 million babies died in the first month of life-compared with 4.6 million neonatal deaths in 1990-and more than half of all neonatal deaths occurred in five countries of the world (44% of global livebirths): India 27.8% (19.6% of global livebirths), Nigeria 7.2% (4.5%), Pakistan 6.9% (4.0%), China 6.4% (13.4%), and Democratic Republic of the Congo 4.6% (2.1%). Between 1990 and 2009, the global NMR declined by 28% from 33.2 deaths per 1,000 livebirths to 23.9. The proportion of child deaths that are in the neonatal period increased in all regions of the world, and globally is now 41%. While NMRs were halved in some regions of the world, Africa's NMR only dropped 17.6% (43.6 to 35.9). CONCLUSIONS: Neonatal mortality has declined in all world regions. Progress has been slowest in the regions with high NMRs. Global health programs need to address neonatal deaths more effectively if Millennium Development Goal 4 (two-thirds reduction in child mortality) is to be achieved.

Global burden of disease in young people aged 10-24 years: a systematic analysis.

BACKGROUND: Young people aged 10-24 years represent 27% of the world's population. Although important health problems and risk factors for disease in later life emerge in these years, the contribution to the global burden of disease is unknown. We describe the global burden of disease arising in young people and the contribution of risk factors to that burden. METHODS: We used data from WHO's 2004 Global Burden of Disease study. Cause-specific disability-adjusted life-years (DALYs) for young people aged 10-24 years were estimated by WHO region on the basis of available data for incidence, prevalence, severity, and mortality. WHO member states were classified into low-income, middle-income, and high-income countries, and into WHO regions. We estimated DALYs attributable to specific global health risk factors using the comparative risk assessment method. DALYs were divided into years of life lost because of premature mortality (YLLs) and years lost because of disability (YLDs), and are presented for regions by sex and by 5-year age groups. FINDINGS: The total number of incident DALYs in those aged 10-24 years was about 236 million, representing 15·5% of total DALYs for all age groups. Africa had the highest rate of DALYs for this age group, which was 2·5 times greater than in high-income countries (208 vs 82 DALYs per 1000 population). Across regions, DALY rates were 12% higher in girls than in boys between 15 and 19 years (137 vs 153). Worldwide, the three main causes of YLDs for 10-24-year-olds were neuropsychiatric disorders (45%), unintentional injuries (12%), and infectious and parasitic diseases (10%). The main risk factors for incident DALYs in 10-24-year-olds were alcohol (7% of DALYs), unsafe sex (4%), iron deficiency (3%), lack of contraception (2%), and illicit drug use (2%). INTERPRETATION: The health of young people has been largely neglected in global public health because this age group is perceived as healthy. However, opportunities for prevention of disease and injury in this age group are not fully exploited. The findings from this study suggest that adolescent health would benefit from increased public health attention. FUNDING: None.

Too much or too little? A review of the conundrum of selenium.

Chemical elements such as selenium, fluoride, iron, calcium and magnesium are essential to the human being, although some are toxic when absorbed in high doses. In this paper, the risks associated with insufficient and excessive intake of selenium in the diet are reviewed, focusing on drinking water. Two different approaches are used to derive recommended nutrient intakes (RNI) for adequate nutritional status and guideline values to prevent excessive exposure. The former is based on the daily intake which meets the nutrient requirements of 97.5% of the population. The latter is a value derivation based on an assumed daily per capita consumption at the individual level, a conservative approach used where there is any uncertainty and is related to a negligible risk to health at population level across life stages. There is an increasing need to develop a conceptual framework bringing together aspects of toxicity and essentiality especially for elements apparently exhibiting narrow or overlapping ranges between essentiality and toxicity and to provide guidance on the nature and severity of risks in order to better protect human. While there are a number of frameworks available, these generally only consider food. There is a need to include water, which can be a significant source in some circumstances.

Quantifying the burden of disease associated with inadequate provision of water and sanitation in selected sub-Saharan refugee camps.

A WHO methodology is used for the first time to estimate the burden of disease directly associated with incomplete water and sanitation provision in refugee camps in sub-Saharan African countries. In refugee camps of seven countries, containing just fewer than 1 million people in 2005, there were 132,000 cases of diarrhoea and over 280,000 reported cases of malaria attributable to incomplete water and sanitation provision. In the period from 2005 to 2007 1,400 deaths were estimated to be directly attributable to incomplete water and sanitation alone in refugee camps in Ethiopia, Kenya and Tanzania. A comparison with national morbidity estimates from WHO shows that although diarrhoea estimates in the camps are often higher, mortality estimates are generally much lower, which may reflect on more ready access to medical aid within refugee camps. Despite the many limitations, these estimates highlight the burden of disease connected to incomplete water and sanitation provision in refugee settings and can assist resource managers to identify camps requiring specific interventions. Additionally the results reinforce the importance of increasing dialogue between the water, sanitation and health sectors and underline the fact that efforts to reduce refugee morbidity would be greatly enhanced by strengthening water and sanitation provision.

Workgroup report: developing environmental health indicators for European children: World Health Organization Working Group.

A working group coordinated by the World Health Organization developed a set of indicators to protect children's health from environmental risks and to support current and future European policy needs. On the basis of identified policy needs, the group developed a core set of 29 indicators for implementation plus an extended set of eight additional indicators for future development, focusing on exposure, health effects, and action. As far as possible, the indicators were designed to use existing information and are flexible enough to be developed further to meet the needs of policy makers and changing health priorities. These indicators cover most of the priority topic areas specified in the Children's Environment and Health Action Plan for Europe (CEHAPE) as adopted in the Fourth Ministerial Conference on Health and Environment in 2004, and will be used to monitor the implementation of CEHAPE. This effort can be viewed as an integral part of the Global Initiative on Children's Environmental Health Indicators, launched at the World Summit on Sustainable Development in 2002.

Urban environmental health hazards and health equity.

This paper outlines briefly how the living environment can affect health. It explains the links between social and environmental determinants of health in urban settings. Interventions to improve health equity through the environment include actions and policies that deal with proximal risk factors in deprived urban areas, such as safe drinking water supply, reduced air pollution from household cooking and heating as well as from vehicles and industry, reduced traffic injury hazards and noise, improved working environment, and reduced heat stress because of global climate change. The urban environment involves health hazards with an inequitable distribution of exposures and vulnerabilities, but it also involves opportunities for implementing interventions for health equity. The high population density in many poor urban areas means that interventions at a small scale level can assist many people, and existing infrastructure can sometimes be upgraded to meet health demands. Interventions at higher policy levels that will create more sustainable and equitable living conditions and environments include improved city planning and policies that take health aspects into account in every sector. Health equity also implies policies and actions that improve the global living environment, for instance, limiting greenhouse gas emissions. In a global equity perspective, improving the living environment and health of the poor in developing country cities requires actions to be taken in the most affluent urban areas of the world. This includes making financial and technical resources available from high-income countries to be applied in low-income countries for urgent interventions for health equity. This is an abbreviated version of a paper on "Improving the living environment" prepared for the World Health Organization Commission on Social Determinants of Health, Knowledge Network on Urban Settings.