Predicting poverty. Data mining approaches to the health and demographic surveillance system in Cuatro Santos, Nicaragua.

BACKGROUND: In order to further identify the needed interventions for continued poverty reduction in our study area Cuatro Santos, northern Nicaragua, we aimed to elucidate what predicts poverty, measured by the Unsatisfied Basic Need index. This analysis was done by using decision tree methodology applied to the Cuatro Santos health and demographic surveillance databases. METHODS: Using variables derived from the health and demographic surveillance update 2014, transferring individual data to the household level we used the decision tree framework Conditional Inference trees to predict the outcome "poverty" defined as two to four unsatisfied basic needs using the Unsatisfied Basic Need Index. We further validated the trees by applying Conditional random forest analyses in order to assess and rank the importance of predictors about their ability to explain the variation of the outcome "poverty." The majority of the Cuatro Santos households provided information and the included variables measured housing conditions, assets, and demographic experiences since the last update (5 yrs), earlier participation in interventions and food security during the last 4 weeks. RESULTS: Poverty was rare in households that have some assets and someone in the household that has a higher education than primary school. For these households participating in the intervention that installed piped water with water meter was most important, but also when excluding this variable, the resulting tree showed the same results. When assets were not taken into consideration, the importance of education was pronounced as a predictor for welfare. The results were further strengthened by the validation using Conditional random forest modeling showing the same variables being important as predicting the outcome in the CI tree analysis. As assets can be a result, rather than a predictor of more affluence our results in summary point specifically to the importance of education and participation in the water installation intervention as predictors for more affluence. CONCLUSION: Predictors of poverty are useful for directing interventions and in the Cuatro Santos area education seems most important to prioritize. Hopefully, the lessons learned can continue to develop the Cuatro Santos communities as well as development in similar poor rural settings around the world.

Effect of a food supplementation and psychosocial stimulation trial for severely malnourished children on the level of maternal depressive symptoms in Bangladesh.

BACKGROUND: Maternal depression is associated with poor child development and growth in low-income countries. This paper evaluates the effect of a community-based trial providing psychosocial stimulation and food supplements to severely malnourished children on maternal depressive symptoms in Bangladesh. METHODS: Severely underweight (weight-for-age Z-score < -3) hospitalized children aged 6-24 months (n = 507), were randomly assigned to: psychosocial stimulation (PS), food supplementation (FS), PS+FS, clinic control (CC) and hospital control (CH) at discharge. PS included play sessions with children and parental counselling to mothers during fortnightly follow-up visit at community clinics, conducted by trained play leaders for 6 months. FS involved cereal-based supplements (150-300 kcal/day) for 3 months. All groups received medical care, micronutrient supplements and growth monitoring. We used Bayley scales, Home Observation for Measurement of Environment (HOME) inventory and a parenting questionnaire to assess child development, home stimulation and mothers' child-rearing practices, respectively. We assessed mothers' depressive symptoms using a modified version of Centre for Epidemiologic Studies Depression Scale at baseline and at 6 months post intervention. RESULTS: Maternal depressive symptoms were significantly lower in the CH group at baseline (P = 0.014). After 6 months of intervention there was no significant effect of intervention after adjusting for baseline scores and all possible confounders. Maternal depressive symptoms were higher among poorer (P = 0.06), older (P = 0.057) and less educated (P = 0.019) mothers, who were housewives (P = 0.053), and whose husbands had more unstable jobs (P = 0.058). At 6 months post intervention, children's cognitive (P = 0.045) and motor (P = 0.075) development, HOME (P = 0.012) and mother's parenting score (P = 0.057) were higher among mothers with lower depressive symptoms. CONCLUSION: The study did not show a significant effect of the intervention on the level of maternal depressive symptoms. Interventions with higher intensity and/or of longer duration focusing directly on maternal psychosocial functioning are probably needed to reduce maternal depressive symptoms.

Disproportionate early fetal growth predicts postnatal thymic size in humans.

Prenatal events can affect neonatal thymus size and adult immune function. The causal insults are unknown, although fetal nutrient restriction is suspected. We used ultrasound at three time points during pregnancy (14, 19 and 30 weeks) to measure the growth of six fetal dimensions in rural Bangladeshi women participating in the Maternal and Infant Nutrition Interventions, Matlab study. Postnatal ultrasound was used to calculate thymic index (TI) at birth, 2, 6 and 12 m. Of the 3267 women recruited, 2861 participated by providing data at least at one fetal biometry and one TI time point. Patterns of fetal growth were summarized using principal components calculated from fetal dimension z-scores. Random effects regression, controlling for infant size and season of measurement were used to relate these patterns to TI. We found that smaller leg length relative to head circumference, characteristic of head-sparing growth restriction, was predictive of lower TI. This association was significant at all time points but strongest in earlier pregnancy. Each standard deviation increase in leg-head proportion was associated with an increase in TI of ∼5%. We conclude that growth patterns typical of poor fetal nutrition are associated with poor thymic development. The greater strength of this association in the first trimester is consistent with a period of vulnerability during the early ontogeny of the thymus and suggests that preventative intervention would need to be given in early pregnancy.

Effects of a community-based approach of food and psychosocial stimulation on growth and development of severely malnourished children in Bangladesh: a randomised trial.

BACKGROUND/OBJECTIVE: Psychosocial stimulation (PS) and food supplementation (FS) improve development of malnourished children. This study evaluates the effects of a community-based approach of PS and FS on growth and development of severely malnourished children. SUBJECTS/METHODS: Severely underweight hospitalised children aged 6-24 months (n = 507) were randomly allocated on discharge to five groups: (i) PS, (ii) FS, (iii) PS+FS, (iv) clinic-control and (v) hospital-control. PS included play sessions and parental counselling on child development. This was done at each fortnightly follow-up visit, that is, every second week, for 6 months at community clinics. FS included distribution of cereal-based food packets (150-300 kcal/day) for 3 months. All groups received medical care, micronutrient supplementation, health-education and growth monitoring. Children's development was assessed using revised version of Bayley Scales of Infant Development at baseline and after 3 and 6 months of intervention. Anthropometry was measured using standard procedure. RESULTS: Comparing groups with any stimulation with those with no stimulation there was a significant effect of stimulation on children's mental development index (group*session interaction P = 0.037, effect size = 0.37 s.d.) and weight-for-age Z-score (group*session interaction P = 0.02, effect size=0.26 s.d.). Poor levels of development and nutritional status were sustained, however, due to their initial very severe malnutrition. There was no effect on motor development and linear growth. CONCLUSION: Children receiving any stimulation showed a significant benefit to mental development and growth in weight. More intensive intervention with longer duration is needed to correct their poor developmental levels and nutritional status.

Household food security is associated with early childhood language development: results from a longitudinal study in rural Bangladesh.

BACKGROUND: Although household food security (HHFS) has been linked to academic performance in school children, its association with early childhood development has received less attention, particularly in low-income countries. We investigated the association of HHFS with subsequent language development of children at 18 months of age in rural Bangladesh. METHODS: We followed 1439 infants born in 2002-2003 to the mothers in Maternal and Infant Nutrition Intervention in Matlab study, a large intervention trial conducted in rural Bangladesh. A HHFS scale was created from data collected from mothers during pregnancy. At 18 months, children's language (expression and comprehension) development was assessed using a Bengali adaptation of MacArthur's Communicative Development Inventory which was based on mothers' report of their children's ability to comprehend and express words in different categories. General linear regression models were used to examine the association between HHFS and language development at 18 months of age adjusting for potential confounders. RESULTS: Household food security was associated with language comprehension (B = 0.19, 95% CI = 0.09, 0.30, P < 0.001) and expression (B = 1.01, 95% CI = 1.00, 1.02, P < 0.01) at 18 months of age. Mean language comprehension and expression at 18 months of the children in higher quartiles of HHFS were higher (P < 0.05) than those of the children in lower quartiles. CONCLUSIONS: Household food security is positively associated with subsequent language development of rural Bangladeshi children. Early language development has been reported to predict later child development. Therefore, strategies to ensure HHFS status in Bangladesh and similar settings should be considered for optimum child development.

Survival of infants in the context of prevention of mother to child HIV transmission in South Africa.

AIM: We sought to study the survival of newborn children according to HIV status of the mother, that of the child and the timing of infection. METHODS: This is a prospective cohort study of 883 mothers (665 HIV-positive and 218 HIV-negative) and their infants. Data were collected using semi-structured questionnaires during home visits between the antenatal period and 36 weeks post-delivery. Infant HIV status was determined at 3, 24 and 36 weeks by HIV DNA PCR. RESULTS: The majority (81.3%) of infected infants who died were infected by 3 weeks of age. Of the HIV-exposed infants who died, 19 (28.4%) died before 6 weeks and 38 (56.7%) died by 12 weeks. The hazard ratio (HR) of mortality at 36 weeks of age in HIV-infected infants compared with exposed but negative infants was 8.9 (95% CI: 6.7-11.8). There was no significant difference in 36 week survival rates between HIV-non-exposed and HIV-exposed but negative infants (HR: 0.7; 95% CI: 0.3-1.5). The infant being HIV-positive at age 3 weeks (HR: 32 95% CI: 14.0-73.1) and rural site (HR: 4.4 95% CI: 1.2-23.4) were the two independent risk factors for infant death amongst HIV-exposed infants. CONCLUSION: The prognosis for infants with early HIV infection was very poor in this cohort. A greater focus on prevention of early infection, earlier screening for HIV infection and access to antiretrovirals for eligible infants is recommended.

Early-life nutritional and environmental determinants of thymic size in infants born in rural Bangladesh.

AIM: The aim was to assess the impact of nutritional status and environmental exposures on infant thymic development in the rural Matlab region of Bangladesh. METHODS: In a cohort of N(max) 2094 infants born during a randomized study of combined interventions to improve maternal and infant health, thymic volume (thymic index, TI) was assessed by ultrasonography at birth and at 8, 24 and 52 weeks of age. Data on birth weight, infant anthropometry and feeding status were also collected. RESULTS: At all ages, TI was positively associated with infant weight and strongly associated with the month of measurement. Longer duration of exclusive breastfeeding resulted in a larger TI at 52 weeks. TI at birth and at 8 weeks correlated positively with birth weight, but by 24 and 52 weeks and when adjusted for infant weight this effect was no longer present. Thymic size was not affected by pre-natal maternal supplementation or by socioeconomic status but was correlated to arsenic exposure during pregnancy. CONCLUSION: In this population of rural Bangladeshi infants, thymic development is influenced by both nutritional and environmental exposures early in life. The long-term functional implications of these findings warrant further investigation.

Violence against women and the risk of fetal and early childhood growth impairment: a cohort study in rural Bangladesh.

OBJECTIVE: To assess whether different forms of family violence against women were associated with impaired size at birth and early childhood growth. METHODS: A substudy embedded into a community-based food and micronutrient supplementation trial (MINIMat) of pregnant women in rural Bangladesh included a 2-year follow-up of the 3164 live-born children of participating women. Anthropometric data were collected from birth up to 24 months of age, and converted to WHO growth standard SD scores. Size at birth and early childhood growth were assessed in relation to women's exposure to physical, sexual and emotional violence and the level of controlling behaviour in the family. RESULTS: Fifty per cent of all women reported a lifetime experience of some form of family violence. The mean birth weight was 2701 g, 30% were low birth weight (<2500 g), mean birth length was 47.8 cm (17.5%,

Delivery care utilisation and care-seeking in the neonatal period: a population-based study in Vietnam.

BACKGROUND: If millions of neonatal deaths each year are to be prevented, one crucial component that must be improved is adequate care-seeking behaviour and effective use of existing health care systems. We have investigated these factors in relation to delivery and the neonatal period in a province in Northern Vietnam, a setting currently in socio-economic transition. METHODS: Information on births and neonatal deaths between January and December 2005 in Quang Ninh province was collected. Narratives of the neonatal deaths were gathered and information about care-seeking in relation to delivery and illness was extracted. This information was then compared with the time and place of delivery and death. RESULTS: We registered 17,519 births and 284 neonatal deaths occurring between January and December 2005. The neonatal mortality rate varied from 7.5/1000 to 38/1000, depending on the place of delivery. A quarter of the neonatal deaths had no contact with the health-care system at the time of death. Neonatal death within 24 hours of birth was more likely when the mother did not seek care at the time of delivery, or did so at the lowest level of the system (chi2=35.5, p<0.001). Mothers of ethnic minorities were more likely to exhibit this care-seeking behaviour at delivery. CONCLUSION: Further improvement in neonatal survival can be achieved by changes in health system utilisation that aim to secure safe delivery for pregnant women. More efforts at local level are needed to encourage adequate care-seeking.

Effects of weaning cereals with different phytate content on growth, development and morbidity: a randomized intervention trial in infants from 6 to 12 months of age.

BACKGROUND: Phytate decreases iron and zinc bioavailability and contributes to deficiencies of iron and zinc, potentially causing anaemia, poor psychomotor development, impaired growth and increased risk of diarrhoea and respiratory infections. AIM: To investigate whether a reduced dietary intake of phytate, either via extensively phytate-reduced infant cereals [milk cereal drinks (MCDs) and porridge] or a milk-based infant formula, would improve growth and development and reduce morbidity in infants. DESIGN: Infants (n = 300) were, in a double-blind design, randomized to three diet intervention groups from 6 to 12 mo of age-commercial MCD and porridge (CC group), phytate-reduced MCD and phytate-reduced porridge (PR group), or milkbased infant formula and porridge with regular phytate content (IF group)-then followed until 18 mo. Dietary intake, anthropometry, development (Bayley Scales of Infant Development) and episodes of infectious diseases were registered. RESULTS: There were no significant differences between study groups in growth, development or morbidity until 12 mo of age. The IF group had a 77% higher risk (95% CI: 1.05-2.97) of diarrhoea compared to the PR group during the 12-17-mo period. Infants with haemoglobin concentration (Hb) < 110 g/l at 12 mo had lower attained weight at 18 mo (11.14 kg vs 11.73 kg, p = 0.012). Infants with serum zinc (S-Zn) <10.7 pmol/l at 12 mo had higher risk of respiratory infections (RR = 1.74, 95% CI: 1.19-2.56) compared to controls. CONCLUSION: Phytate reduction had no effect on growth, development or incidence of diarrhoeal or respiratory infections. Infants with low Hb or low S-Zn may be at higher risk of poor growth and respiratory infections, even in this high-income population.

Children born in the summer have increased risk for coeliac disease.

STUDY OBJECTIVE: Coeliac disease, also called permanent gluten sensitive enteropathy, is being recognised as a widespread health problem. Defining the possible role of environmental factors in its aetiology might open doors to primary prevention. This study therefore analysed if the risk for coeliac disease varies with month of birth as a proxy for a seasonal pattern for possible causal environmental exposure(s). DESIGN: A population based incidence register of coeliac disease in children below 15 years of age covering the period from 1973 to 1997. Incidence rates were calculated by month of birth, stratified for age at diagnosis. Poisson regression analyses were used to estimate the relative risk for coeliac disease for children below 2 years of age by season of birth, also taking into account gender and time period of diagnosis. SETTING: Sweden. PARTICIPANTS: All 2151 children in the study base with verified coeliac disease. MAIN RESULTS: The risk for coeliac disease was significantly higher if born during the summer as compared with the winter (RR=1.4, 95% CI 1.2 to 1.7), but only in children below 2 years of age at diagnosis. This relative seasonal risk pattern prevailed during a 10 year epidemic of coeliac disease, although incidence rates varied threefold. The incidence was constantly higher among girls as compared with boys, but boys showed a more pronounced seasonal variation in risk than girls. CONCLUSIONS: An increased coeliac disease risk in children born in the summer compared with the winter reflects causal environmental exposure(s) with a seasonal pattern. Infections might be the exposure of importance, either by means of a direct causal role and/or through interaction with other exposures, for example, gluten intake. However, non-infectious exposures should also be explored as possible contributing causal factors.

Public health services use in a mountainous area, Vietnam: implications for health for policy.

AIMS: The aim of this study is to describe the use of public health services in different social and ethnic groups and to explore the implementation of user fee exemption in a mountainous area in Vietnam. METHODS: A cross-sectional household survey with a structured questionnaire and a four-week diary were used to collect information on illnesses, health seeking behaviour and socioeconomic factors. Three communes in a mountainous district in Northern Vietnam were selected and a random sample of 1,452 individuals in 300 households was drawn. RESULTS: Self-medication was most common (57%) while 30% used public health services when suffering from a health problem. Persons living far from health services attended public health services less frequently than the others (adjusted OR = 0.28; 95% CI 0.15-0.51). This was especially the case for ethnic minorities who were less likely to use public health services than the others were (adjusted OR = 0.47; 95% CI 0.25-0.87). Persons with mild conditions tended to use public health services less than those with more severe conditions (OR = 0.19; 95% CI 0.10-0.37). Health services use was similar among women and men, but the total expenditure per visit was higher for men. Almost no patients supposed to get free attendance had been exempted from user fees. CONCLUSIONS: It was found that there was a geographical inequity in use of public health services while there was relatively equal use of these services between social, gender, and ethnic groups. Long distance in combination with failure of the fee exemption may increase inequity in use of health services in remote and isolated areas. These observations contribute to the basis for implementation of the Vietnamese health policy, emphasizing efficiency and equity.

Screening for adult coeliac disease - which serological marker(s) to use?

OBJECTIVE: To determine which serological marker(s) to use when screening for coeliac disease. DESIGN: In a population-based cross-sectional study we compared the use of antigliadin antibodies (AGA) of isotypes IgA and IgG, antiendomysial antibodies (AEA) of isotype IgA and antitransglutaminase antibodies (ATGA) of isotype IgA for detecting coeliac disease amongst adults. SETTING: Northern Sweden. SUBJECTS: A total of 1850 of 2500 (74%) invited adults (aged 25-74 years) who were randomly selected from the population register after stratification for age and sex. MAIN OUTCOME MEASURES: The sensitivity, specificity and predictive values of the AGA, ATGA and AEA tests. RESULTS: Nine cases of biopsy proven, previously undiagnosed coeliac disease were detected by screening. The sensitivity of both ATGA and AEA was 100% whilst AGA IgA and IgG both had a sensitivity of 89%. The AEA test had a specificity of 100% whereas the specificities of the ATGA, AGA IgA and IgG tests were 97, 96 and 78%, respectively. The positive predictive value for the AEA test was 100%, whereas it was considerably lower for the other tests (ATGA > AGA IgA > AGA IgG), with further decreases for all tests when shifting from a clinical to a screening situation. CONCLUSIONS: When screening for coeliac disease we suggest a serial testing approach, i.e. an initial ATGA test and, when positive, followed by an AEA test, provided that IgA deficiency has been excluded. However, assessment of the small intestinal mucosal morphology is still required to ascertain the diagnosis.

Prevalence of iron deficiency in 12-mo-old infants from 11 European areas and influence of dietary factors on iron status (Euro-Growth study).

A prospective longitudinal cohort study was performed to assess the prevalence of iron deficiency in European infants at 12 mo of age, and to study the influence of socio-economic status, dietary factors, growth and morbidity on iron status. The cohort consisted of 488 normal term infants from primary healthcare centres in 11 European areas. Assessed were socio-economic variables, dietary intake, anthropometry and morbidity at regular intervals from birth to 12 mo, and haemoglobin, serum ferritin, mean corpuscular volume, transferrin saturation and serum transferrin receptor concentrations at age 12 mo. The prevalence of anaemia was 9.4%, of iron deficiency 7.2%, and of iron deficiency anaemia 2.3%. More than 40% of anaemia was associated with normal iron status and associated with an increased frequency of recent infections. Iron deficiency anaemia was significantly more frequent with low (5.1%) than high socio-economic status (0%). Dietary factors accounted for most of this variation in multiple regression analysis. Early introduction of cows' milk was the strongest negative determinant of iron status. Feeding of iron-fortified formula was the main factor positively influencing iron status. Other dietary factors, including breastfeeding, did not play a significant role as determinants of iron status at age 12 mo. Conclusion. Iron deficiency anaemia is present in 2.3% of 12-mo-old European infants. The prevalence of iron deficiency anaemia varies strongly with socio-economic status. Avoidance of cows' milk feeding during the first year of life is the key measure in the prevention of iron deficiency.

Stories of pre-war, war and exile: Bosnian refugee children in Sweden.

While standardized questionnaires produce counts of isolated events, a semi-structured interview derives a story, a complex narrative in time and place. Ninety Bosnian refugee children and adolescents (ages 1-20), resettled in Sweden, were assessed in a semi-structured clinical interview designed to identify and offer support to children at risk. A family-child account of traumatic exposure was analysed quantitatively and qualitatively. Type-stories or clusters of experience were identified for three distinct periods: prior to war, during war, and after war in exile. The extent of trauma-stress exposure during each of these periods proved unrelated. Pre-war experience presented as preponderantly good and safe. Differences in child exposure during war and exile could be understood in relation to identifiable socio-demographic factors; particularly ethnic background, social class, child age and family size. Further, the stories derived cast light on the equity of Swedish refugee reception, exposing both egalitarian and discriminatory tendencies.

Coeliac disease: effect of early feeding on the incidence of the disease.

Coeliac disease, also called permanent gluten sensitive enteropathy, has recently been recognised as constituting a widespread health problem. Effective treatment involves the strict exclusion of wheat, rye, barley and possibly also oats from the diet. Genetic susceptibility and the presence of gluten in the diet are prerequisites for developing the disease. Sweden has recently experienced an epidemic of coeliac disease in children below 2 years of age. Previously, considerable changes in incidence over time have also been reported from England, Scotland and Ireland. Such obvious changes in incidence over rather short time periods, in genetically stable populations, emphasise the importance of environmental factors in the aetiology. Thus, most likely, the aetiology of coeliac disease is multifactorial. However, further conclusive evidence is required to settle if environmental factors, beyond presence of gluten in the diet, really influence the immunological process resulting in the coeliac small intestinal lesion, or merely influence the clinical expression of the disease. The search for contributing exposures has thus far focused on early feeding, suggesting that breast-feeding duration and the amount of gluten consumed are of importance, and possibly also the age for introducing gluten into the diet of infants. The pattern of causation may vary over time and between countries, however, which may obscure the search for risk factors. Nevertheless, a challenging possibility that needs to be explored is if coeliac disease can be delayed, or possibly even prevented for an entire life span, by favourable dietary habits.

Does breast-feeding affect the risk for coeliac disease?

Coeliac disease, or permanent gluten sensitive enteropathy, has emerged as a widespread health problem. It is considered an immunological disease, possibly of autoimmune type, albeit strictly dependent on the presence in the diet of wheat gluten and similar proteins from rye and barley. There are reasons to believe that the aetiology of coeliac disease is multifactorial, i.e. that other environmental exposures than the mere presence in the diet of gluten affect the disease process. Our studies have shown that prolonged breast-feeding, or perhaps even more important, ongoing breast-feeding during the period when gluten-containing foods are introduced into the diet, reduce the risk for coeliac disease. The amount of gluten consumed is also of importance in as much as larger amounts of gluten-containing foods increase the risk for coeliac disease, while it still is uncertain if the age for introducing gluten into the diet of infants is important. Thus, a challenging possibility, that need to be further explored, is if the coeliac enteropathy can be postponed, or possibly even prevented for the entire life span, by favourable dietary habits early in life.