Factors Affecting Anemia among Women of Reproductive Age in Mexico: A Mixed-Methods Country Case Study.

BACKGROUND: In Mexico, anemia prevalence among women of reproductive age (WRA) decreased from 16.4% in 2006 to 11.6% in 2012, only to increase to 18.3% in 2016. The factors associated with this fluctuation are uncertain. OBJECTIVE: We conducted a systematic in-depth assessment of the quantitative and qualitative determinants of anemia among WRA in Mexico between 2006 and 2018. METHODS: Using multivariate stepwise linear regression, we analyzed Mexico's Encuesta Nacional de Salud y Nutrición (ENSANUT) surveys from 2006, 2012, and 2018 to identify determinants of WRA anemia. We also conducted a review of anemia-relevant programs and policies, including financing documents, and conducted in-depth interviews and focus group discussions with key stakeholders in Mexico. RESULTS: Among non-pregnant women (NPW) 15-49 years, mean hemoglobin (Hb) increased from 13.8 g/dL in 2006 to 14.0 g/dL in 2012, decreasing to 13.2 g/dL in 2018 (p<0.001). Inequities by geographical region and household wealth persisted throughout this period, with household wealth, urban residence and gravidity emerging as significant predictors of Hb among NPW. Qualitative analyses generally supported these findings. The most discussed program was Progresa-Oportunidades-Prospera (POP), where most resources for health were invested and most participants acknowledged that its cancellation in 2019 would lead to worsening in health and nutrition among the poor. Financing analyses showed a drop of funding for nutrition-related programs between 2014 and 2018. Cultural norms around gender roles were still prevalent, along with increasing rates of teenage pregnancy. CONCLUSIONS: Anemia prevention efforts need to refocus on poverty alleviation, continuity of adequate coverage and financing of nutrition programs, especially with safety nets, and increase in uptake of family planning, especially among adolescent girls.

Drivers of Anemia Reduction among Women of Reproductive Age in the Philippines: A Country Case Study.

BACKGROUND: Anemia prevalence among women of reproductive age (WRA) in the Philippines was 25% in 2000, decreasing to 13% in 2018. To date, an in-depth assessment of the determinants associated with this decline has not been conducted. OBJECTIVE: To conduct a systematic in-depth assessment of the quantitative and qualitative determinants of anemia among WRA in the Philippines between 2008 and 2018. METHODS: Employing standard Exemplars methodology, we conducted quantitative analyses using the Philippines' National Nutrition Survey, the Expanded National Nutrition Survey, and the Philippines National Demographic and Health Surveys. Qualitative analyses included a comprehnsive literature review, program/policy analysis, and interviews with stakeholders to understand country-level enablers and barriers to WRA anemia decline in the Philippines. A final Oaxaca-Blinder decomposition analysis (OBDA) evaluated the relative contribution of direct and indirect factors. RESULTS: Among non-pregnant women (NPW), mean hemoglobin (Hb) increased from 12.7 g/dL in 2008 to 13.1 g/dL in 2018 (p<0.01), corresponding to an 11%-point decline in anemia prevalence (23% to 12%). Inequities by geographical region, household wealth, and women's educational attainment narrowed considerably during this time. Important direct and indirect nutrition programs were introduced during our study period, including universal healthcare and food fortification. Country experts interviewed credited programs focused on alleviating micronutrient deficiencies and poverty, and improvements in women's health and well-being, for the country's extraordinary success. OBDA explained ∼50% of the observed change in mean Hb among NPW, with family planning (35%), household socio-demographics (29%), and improvement in women's nutrition (23%) emerging as critical drivers of anemia decline, corroborating our qualitative and policy analyses. CONCLUSIONS: To protect these gains, WRA anemia prevention efforts in the Philippines should continue to focus on universal healthcare access, women's empowerment, and poverty alleviation.

Drivers of Anemia Reduction among Women of Reproductive Age in Senegal: A Country Case Study.

BACKGROUND: In Senegal, anemia prevalence among women of reproductive age (WRA) decreased from 59% in 2005 to 54% in 2017. However, determinants of reduction in disease burden under challenging public health conditions have not been studied. OBJECTIVE: To conduct a systematic in-depth assessment of the quantitative and qualitative determinants of anemia reduction among WRA in Senegal between 2005 and 2017. METHODS: Standard Exemplars in Global Health methodology was used for quantitative analyses using Senegal's Demographic and Health Surveys. Qualitative analyses included a systematic literature review, program/policy analysis, and interviews with key stakeholders. A final Oaxaca-Blinder decomposition analysis (OBDA) evaluated the relative contribution of direct and indirect factors. RESULTS: Among non-pregnant women (NPW), mean hemoglobin (Hb) increased from 11.4 g/dL in 2005 to 11.7 g/dL in 2017 (p<0.0001), corresponding to a 5%-point decline in anemia prevalence (58% to 53%). However, inequities by geographical region, household wealth, women's educational attainment, urban compared to rural residence, and antenatal care (ANC) during last pregnancy continue to persist. During this time period, several indirect nutrition programs were implemented, with stakeholders acknowledging the importance of these programs, but agreeing there needs to be more consistency, evaluation, and oversight for them to be effective. Our OBDA explained 59% of the observed change in mean Hb, with family planning (25%), malaria prevention programs (17%), use of iron and folic acid (IFA) during last pregnancy (17%), and improvement in women's empowerment (12%) emerging as drivers of anemia decline, corroborating our qualitative and policy analyses. CONCLUSIONS: Despite a reduction in anemia prevalence, anemia remains a severe public health problem in Senegal. To protect the gains achieved to date, as well as accelerate reduction in WRA anemia burden, focused efforts to reduce gender and social disparities, and improve coverage of health services, such as family planning, IFA, and antimalarial programs, are needed.

Prevalence of hearing loss in children living in low- and middle-income countries over the last 10 years: A systematic review.

AIM: To summarize the literature on the prevalence of pediatric hearing loss in low- and middle-income countries (LMICs). METHOD: A systematic review initially identified 2833 studies, of which 122 met the criteria for inclusion. Eighty-six of those studies included diagnoses and were included in a meta-analysis. RESULTS: The meta-analysis indicated a 1% (95% confidence interval = 0.8-2.0) prevalence of childhood hearing loss across LMICs. There was significant heterogeneity between studies and evidence of publication bias. The prevalence of mild and moderate cases of hearing loss was higher than more severe cases and there were fewer cases of mixed hearing loss compared to conductive or sensorineural hearing loss. No differences were identified between the prevalence of unilateral versus bilateral hearing loss or hearing loss according to sex. The quality of the studies, age of participants, and location of data collection may have influenced the results. High variability in the reporting of etiology made the causes of hearing loss unclear. INTERPRETATION: The literature indicates that 1% of children in LMICs have hearing losses. However, most studies missed children with acquired hearing loss, which may lead to under-reporting of global prevalence. This systematic review is an initial step toward developing and implementing population-appropriate treatment and prevention programs for childhood hearing loss in LMICs. WHAT THIS PAPER ADDS: The prevalence of childhood hearing loss in low- and middle-income countries is 1%. Reporting of hearing loss etiology was highly variable.

Comparison of 14 body size variables on adult skeletal age methods: how body mass, BMI, fat and muscle influence age estimations.

Background: Skeletal age estimations consistently under-age individuals with low body mass and over-age individuals with high body mass.Aim: To assess the directional biases of body size variables, including fat and muscle tissue, on skeletal age estimates.Subjects and methods: CT scans of 420 age- and size-selected cadavers were assessed using the fourth rib and pubic symphysis age estimation methods. MANCOVA was used to test the effects of stature, body mass, circumference, and fat and muscle tissue area on age estimation biases.Results: For both methods, there were biases based on body mass, BMI, circumference and fat tissue area. Individuals with the lowest measurements for these variables were under-aged while individuals with the highest measurements were over-aged. Age estimation biases were not affected by stature, muscle area, or skeletal measurements of bi-iliac breadth, femoral head diameter, or femoral length.Conclusion: Increased body mass, and specifically fat tissue, accelerates skeletal ageing. Increased muscle area generally did not show a protective effect on skeletal ageing. The accuracy of age estimations would be improved by factoring in body mass. However, femoral head diameter and bi-iliac breadth are not good proxies for body mass. Osteological markers of obesity offer a promising new approach.

Inaccuracy and bias in adult skeletal age estimation: Assessing the reliability of eight methods on individuals of varying body sizes.

Accurate age estimations are essential for identifying human skeletal remains and narrowing missing persons searches. This study examines how BMI, body mass, and stature influence inaccuracy and bias in adult skeletal age estimations obtained using eight methods. 746 skeletons from the Hamann-Todd and William Bass Collections were used. Underweight BMI, light body mass, and short-stature individuals have the most error associated with their age estimates and are consistently under-aged between 3 to 13years. Obese BMI, heavy body mass, and tall-stature individuals are consistently over-aged between 3 to 8.5years. The most reliable methods for smaller-bodied individuals are Kunos et al. (first rib) and Buckberry-Chamberlain (auricular surface); for individuals in the average range, Iscan et al. (fourth ribs) and Passalacqua (sacrum); and for larger-bodied individuals, Iscan et al., Passalacqua, and Rougé-Maillart et al. (auricular surface and acetabulum). Lovejoy et al. (auricular surface) and Suchey-Brooks (pubic symphysis) produce consistent inaccuracy and bias scores across all body size groups. The least reliable method for smaller-bodied individuals is Iscan et al.; for larger-bodied individuals, Buckberry-Chamberlain; and across all body size groups, DiGangi et al. (first rib).

The influence of body size on adult skeletal age estimation methods.

Accurate age estimations are essential to archaeological and forensic analyses. However, reliability for adult skeletal age estimations is poor, especially for individuals over the age of 40 years. This is the first study to show that body size influences skeletal age estimation. The Iscan et al., Lovejoy et al., Buckberry and Chamberlain, and Suchey-Brooks age methods were tested on 764 adult skeletons from the Hamann-Todd and William Bass Collections. Statures ranged from 1.30 to 1.93 m and body masses ranged from 24.0 to 99.8 kg. Transition analysis was used to evaluate the differences in the age estimations. For all four methods, the smallest individuals have the lowest ages at transition and the largest individuals have the highest ages at transition. Short and light individuals are consistently underaged, while tall and heavy individuals are consistently overaged. When femoral length and femoral head diameter are compared with the log-age model, results show the same trend as the known stature and body mass measurements. The skeletal remains of underweight individuals have fewer age markers while those of obese individuals have increased surface degeneration and osteophytic lipping. Tissue type and mechanical loading have been shown to affect bone turnover rates, and may explain the differing patterns of skeletal aging. From an archaeological perspective, the underaging of light, short individuals suggests the need to revisit the current research consensus on the young mortality rates of past populations. From a forensic perspective, understanding the influence of body size will impact efforts to identify victims of mass disasters, genocides, and homicides.

A test of Hartnett's revisions to the pubic symphysis and fourth rib methods on a modern sample.

Estimating age at death is one of the most important aspects of creating a biological profile. Most adult age estimation methods were developed on North American skeletal collections from the early to mid-20th century, and their applicability to modern populations has been questioned. In 2010, Hartnett used a modern skeletal collection from the Maricopia County Forensic Science Centre to revise the Suchey-Brooks pubic symphysis method and the Iscan et al. fourth rib methods. The current study tests Hartnett's revised methods as well as the original Suchey-Brooks and Iscan et al. methods on a modern sample from the William Bass Skeletal Collection (N = 313, mean age = 58.5, range 19-92). Results show that the Suchey-Brooks and Iscan et al. methods assign individuals to the correct phase 70.8% and 57.5% of the time compared with Hartnett's revised methods at 58.1% and 29.7%, respectively, with correctness scores based on one standard deviation of the mean rather than the entire age range. Accuracy and bias scores are significantly improved for Hartnett's revised pubic symphysis method and marginally better for Hartnett's revised fourth rib method, suggesting that the revised mean ages at death of Hartnett's phases better reflect this modern population. Overall, both Hartnett's revised methods are reliable age estimation methods. For the pubic symphysis, there are significant improvements in accuracy and bias scores, especially for older individuals; however, for the fourth rib, the results are comparable to the original Iscan et al. methods, with some improvement for older individuals.

Discernment of mortality risk associated with childbirth in archaeologically derived forager skeletons.

An obstetric dilemma may have been a persistent characteristic of human evolution, in which the bipedal female's pelvis is barely large enough to accommodate the birth of a large-brained neonate. Evidence in the archaeological record for mortality risk associated with childbirth is rare, especially among highly mobile, immediate return hunter-gatherer populations. This research explores the idea that if excess mortality is associated with first pregnancy, females will outnumber males among young adult skeletons. The sample is of 246 skeletons (119 males, 127 females) representing Later Stone Age (LSA) foragers of the South African Cape. Young adults are distinguished through incomplete maturation of the medial clavicle, iliac crest and vertebral bodies. With 26 women and 14 men in the young category, a higher mortality risk for women is suggested, particularly in the Southern Cape region. Body size does not distinguish mortality groups; there is evidence of a dietary protein difference between young and older women from the Southern Cape. Possible increased mortality associated with first parturition may have been linked to morphological or energetic challenges, or a combination of both. Exploration of the sex ratio among young adult skeletons provides a tool for exploring the antiquity of an important evolutionary factor.