Tag Archives: Children

Vertical Health Care Programmes or Health System Strengthening: A False Dichotomy

Health care development is sometimes classified as vertical or horizontal. Vertical programmes target specific diseases or disease clusters. For example tuberculosis, HIV and malaria, are targeted by the Global Fund. Horizontal programmes, by contrast, seek to strengthen the system within which health care is embedded. Such programmes are concerned with human resources, financing, education, and supply chains, among many other functions.

There has been a strong push to move from vertical to horizontal programmes from many corners, including from this News Blog. Supporters of such a change in emphasis cannot but acknowledge the massive successes that vertical programmes have notched up, especially in the fields of infant health, maternal health, and infectious diseases.

However, the limitations of a purely diseased-based approach have become increasingly evident. Logically, it is not even possible to instigate a vertical approach in a complete system vacuum. For example, it would be difficult, if not impossible, to instigate a programme to improve HIV care, if the supply chain could not make drugs available and if the health system could not support basic diagnostic services. That said, vertical surfaces should not be able to siphon off more than their fair share of the health services infrastructure.

A recent Lancet paper on health services in Ethiopia made a further important point,[1] that vertical systems can make a very good platform to extend and deepen generic health systems. In fact, that is precisely what has happened in that country, with full support from the Global Fund and GAVI, the Vaccine Alliance. They refer to this combination of vertical and generic development as a “diagonal” investment approach. We would prefer to describe the relationship as one of symbiosis in which vertical and horizontal programmes are designed to reinforce each other.

The Ethiopian initiative involved strengthening the system at multiple levels, from health service financing, human resources policies, education, investment in primary care, and community outreach activities, along with support for community action and self-help (including the “IKEA model” previously described in this news blog).[2] Certainly, Ethiopia, along with other countries such as Bangladesh, Thailand and Rwanda, stand out for having achieved remarkable improvements over many dimensions of health. In Ethiopia the reduction in mortality for children under the age of five years was 67% from the 1990 baseline, while there was a 71% decline in the maternal mortality ratio and deaths from malaria, tuberculosis and HIV were halved. This took place against a financial backdrop of declining international aid but increasing domestic expenditure. The combination of vertical programmes and health system strengthening seems to have ensured that the money was not wasted.

— Richard Lilford, CLAHRC WM Director

References:

  1. Assefa Y, Tesfaye D, Van Damme W, Hill PS. Effectiveness and sustainability of a diagonal investment approach to strengthen the primary health-care system in Ethiopia. Lancet. 2018; 392: 1473-81.
  2. Lilford RJ. Pre-payment Systems for Access to Healthcare. NIHR CLAHRC West Midlands News Blog. 18 May 2018.
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Childhood IQ and Mortality

Many studies have shown an association between childhood intelligence and mortality. However, most studies have been conducted with male participants, and potential mechanisms for the putative association are poorly understood. A recent paper looked at a large sample of Swedish people in an attempt to clarify these issues.[1]

The authors looked at IQ data from 19,919 Swedes who were 13 years old at the time (9,817 women), along with socioeconomic data from their childhood and middle age over the following 53 years. The analysis found an association between lower IQ and increased all-cause mortality. A one standard deviation decrease in IQ was associated with increased risk of all-cause mortality in both men (hazard ratio 1.31, 95% CI 1.23-1.39) and women (HR 1.16, 95% CI 1.08-1.25). Most causes of death were associated with lower IQ in men, while in women a lower IQ was associated with an increased risk of death from cancer and cardiovascular disease. When the authors adjusted for childhood socioeconomic factors the associations were slightly attenuated; but were further attenuated when adjusting for adulthood factors – considerably in men (overall mortality HR=1.17, 95% CI 1.08-1.26), and almost completely in women (HR 1.02, 95% CI 0.93-1.12). These results suggest that it is the social and socioeconomic circumstances in adulthood that contribute to the association between IQ and mortality, particularly in women, though the authors state that more research is needed to clarify the pathways linking childhood IQ and mortality across genders.

— Peter Chilton, Research Fellow

Reference:

  1. Wallin AS, Allebeck P, Gustafsson J-E, Hemmingsson T. Childhood IQ and mortality during 53 years’ follow-up of Swedish men and women. J Epidemiol Community Health. 2018; 72(10): 926-32.

Impact of Childcare on Children

Leaving your child crying at the nursery door is a difficult experience that can leave a working parent questioning whether they have the right priorities. When I first experienced this a few years ago, a good friend working at Cancer Research sent me a summary of research showing an inverse association between institutional childcare and childhood cancer (probably mediated by early childhood infections). “Don’t worry, going to nursery is doing at least some good for your child!” she said.

A new study using data from the EDEN mother-child cohort (based in France) gives additional reasons to alleviate working parent guilt.[1] This study examined childcare arrangements in the first three years of life for 1,428 children, categorising this as: with a childminder, centre-based (i.e. nursery or crèche staffed with professionals), or informal (primarily parents, complemented with grandparents or other non-professionals). Emotional and behavioural development of the child were assessed at age 3, 5.5 and 8 years. Confounders, including child factors (such as birthweight, duration of breastfeeding), parental sociodemographic factors (such as marital status, mother’s perception of partner support), and parents’ mental health, were considered in analyses through propensity scores and inverse probability weights.

Formal childcare was found to predict lower levels of emotional symptoms and peer-relationship problems, and promote high levels of prosocial behaviour even at age 8. Children who were in centre-based childcare had the lowest levels of emotional symptoms and peer relationship problems.

Surprisingly (to me), subgroup analyses showed that girls, children whose mother had high education, and those whose mother was not depressed may benefit the most from formal childcare. The authors state that the result for girls is likely to be because childcare mainly reduces internalising problems which are more prevalent in girls. The fact that the other ‘low-risk’ children fare better when exposed to formal childcare is suggested to be because the universal curriculum is most appropriate for those who do not have more severe emotional and social development issues.

Clearly there are many things to consider when deciding whether to work while also a parent to a small child, even if a rule generally applies, only the person making the decision knows the context of their own family and what suits them best. Also worth noting that this observational study cannot prove a causal relationship. But for those of us who do choose to leave a child in centre-based care- this paper offers some solace in those moments of ambivalence.

— Oyinlola Oyebode, Associate Professor

Reference:

  1. Gomajee R, El-Khoury F, Côté S, van der Waerden J, Pryor L, Melchior M; EDEN mother-child Cohorts Study Group. Early childcare type predicts children’s emotional and behavioural trajectories into middle childhood. Data from the EDEN mother-child cohort study. Journal of epidemiology and community health. J Epidemiol Community Health. 2018;72(11):1033-1043.

Long-term Psychological Effects of Exposure to War in Young People

In last fortnight’s news blog we examined the effect of exposure to war on subsequent mortality among children and found an eight-percent overall increased risk of child death during a year of conflict, and a 25% increase in children under the age of one in large conflicts.[1] I have now come across a further study that examines psychological outcomes after six years in a cohort of war exposed children (in effect child soldiers) from Northern Uganda.[2] Depression and anxiety are common sequelae of exposure to war and this study replicates this finding, but the cohort is large (n=539), so the study was able to explore the effects of different types of violence exposure. Threats to loved ones and witnessing violence were particularly toxic, as was sexual abuse in young girls. Duration of exposure was also very important. I was uncertain how war violence compares with other factors leading to depression and anxiety and whether the children had received any form of psychological intervention. It was difficult as a non-psychiatrist/psychologist to perceive what the associations meant in terms of severity, but the abuse of child soldiers was extreme and the results could possibly be interpreted as showing a degree of resilience. In any event this study adds to the previously cited article on the terrible human cost of war, beyond the direct effects.

— Richard Lilford, CLAHRC WM Director

References:

  1. Lilford RJ. Health Effects of Armed Conflict. NIHR CLAHRC West Midlands News Blog. 19 Oct 2018.
  2. Amone-P’Olak K, Otim BN, Opio G, Ovuga E, Meiser-Stedman R. War experiences and psychotic symptoms among former child soldiers in Northern Uganda: the mediating role of post-war hardships – the WAYS Study. Soc Psychiatry Psychiatr Epidemiol. 2014; 49(11): 1783-92.

Health Effects of Armed Conflict: A Truly Fascinating Study

The phenomenon that more people die from the indirect effects of warfare than are killed directly is widely recognised. Wagner and colleagues studied the effect of armed conflict on child mortality in Africa.[1] They used a geospatial approach, linking georeferenced data on armed conflict to georeferenced data from the Demographic and Health Surveys. Their study covered two decades (1995-2015) and 35 African countries. The outcome variable was child survival to the age of one year. Overall, there was nearly an eight-percent increased risk of child death during a year of conflict. However, many of the conflicts were small, and the increased risk of death before the age of one year was over 25% for armed conflicts with more than 1,000 direct fatalities. The cumulative effect over eight years was up to four times higher than the contemporaneous increase, and the effect is greatly increased for long-lasting conflicts. There were significantly stronger effects in rural than in urban areas. The authors also examined child growth and found an increased risk of stunting in relation to conflict.

Sadly, there was no shortage of armed conflicts in the 35 African countries studied – 15,441 armed conflicts were recorded in the Uppsala Conflict Data Program over the two decades. The results reported here represent a massive burden of disease on a scale with malnutrition.

Avoiding conflict is a tricky subject, which lies outside the health domain, and which is discussed in Paul Collier’s book ‘The Bottom Billion’.[2] Conflict is also very strongly associated with national poverty, and generally the avoidance of conflict is, arguably, the biggest threat confronting humankind, as we will discuss in the future.

— Richard Lilford, CLAHRC WM Director

References:

  1. Wagner Z, Heft-Neal S, Bhutta ZA, Black RE, Burke M, Bendavid E. Armed conflict and child mortality in Africa: a geospatial analysis. Lancet. 2018; 392: 857-65.
  2. Collier P. The Bottom Billion: Why the Poorest Countries are Failing and What Can Be Done About It. Oxford: Oxford University Press; 2007.

Food Allergies and Childbirth

In a previous News Blog we looked at the practice of swabbing babies delivered via Caesarean section with vaginal fluid in an attempt to reduce the incidence of allergies in the child.[1] Another study has now been reported that could potentially strengthen this argument.[2] This was a nationwide cohort study conducted in Sweden that looked at over 1 million children, their route of delivery and the incidence of food allergies. Overall 2.5% of children were diagnosed with a food allergy, and this was positively associated with those who were delivered via C-section (hazard ratio 1.21, 95% CI 1.18-1.25) – both elective and emergency. Analysis of the data suggests that an extra 5 in 1,000 children delivered via C-section would develop a food allergy (compared to the reference group).

Interestingly there was also a negative association with those who were born prematurely (earlier than 32 weeks) (HR 0.74, 95% CI 0.56-0.98). The authors suggest this may be due to the postnatal care preterm infants receive, or is due to an immature gastrointestinal tract.

— Peter Chilton, Research Fellow

References:

  1. Lilford RJ. Exposure of the Baby to a Rich Mixture of Coliform Organisms from the Birth Canal. NIHR CLAHRC West Midlands News Blog. 22 April 2016.
  2. Mitselou N, Hallberg J, Stephansson O, Almqvist C, Melén E, Ludvigsson JF. Cesarean delivery, preterm birth, and risk of food allergy: Nationwide Swedish cohort study of more than 1 million children. J Allerg Clin Immunol. 2018.

Widespread Use of Antibiotics to Reduce Child Mortality

As discussed in our previous News Blog,[1] the rise in antibiotic resistance is a worrying situation, and it is widely recommended to limit the prescription of antibiotics to patients who are confirmed to have a treatable bacterial infection. However, a recent trial in three sub-Saharan African countries did the exact opposite with a mass distribution of azithromycin, a broad-spectrum antibiotic, to children under five with the aim of reducing child mortality.[2] This was a cluster-randomised trial of around 190,000 children in 1,533 communities of Malawi, Niger and Tanzania who were assigned to receive four biannual doses of antibiotic or a placebo. Overall, the mortality rate was 14.6 deaths per 1,000 person-years in areas that received the antibiotic, compared to 16.5 deaths in communities that received the placebo, while mortality was also 13.5% lower (95% confidence interval, 6.7-19.8) (p<0.001). The effect was greatest in the youngest sub-group of children, those aged between one and five months, with the authors estimating that one in four expected deaths were prevented due to administration of the antibiotic. There were no differences in serious adverse events within a week of administration. If this strategy was to be more widely rolled out, one approach to combat resistance developing would be to limit it to the populations most in need and only for a short time.[3]

— Peter Chilton, Research Fellow

References:

  1. Chilton PJ. Non-Antibiotic Medicines May Increase Antibiotic Resistance. NIHR CLAHRC West Midlands News Blog. 18 May 2018.
  2. Keenan JD, Bailey RL, West SK, Arzika AM, for the MORDOR Study Group. Azithromycin to Reduce Childhood Mortality in Sub-Saharan Africa. New Engl J Med. 2018; 378: 1583-92.
  3. Maxmen A. Giving at-risk children pre-emptive antibiotics reduces deaths. Nature. 25 April 2018.

Another Spectacular Study Based on Demographic and Health Surveys

Under five mortality has dropped sharply around the world in the last few decades.[1] For example, in sub-Saharan Africa mortality for children aged 1-5 dropped from 42.7 per thousand in 2002-08 to 22.0 per thousand in 2009-14. The situation in twins was recently investigated using data from 90 Demographic and Health surveys across no less than 30 countries.[2] The decline in mortality was much less steep among twins than among singleton live births.

Twins are very vulnerable and have benefited less than singletons from the reduction in child mortality. Clearly, this group of vulnerable people needs special attention.

— Richard Lilford, CLAHRC WM Director

Reference:

  1. UNICEF. Under-Five Mortality. 2018.
  2. Monden CWS, Smits J. Mortality among twins and singletons in sub-Saharan Africa between 1995 and 2014: a pooled analysis of data from 90 Demographic and Health Surveys in 30 countries. Lancet Glob Health. 2017; 5: e673-9.

What Do You Think When You Hear ‘Scientist’?

If you have spent much time in universities you may have seen various stickers or leaflets raising awareness of campaigns that support women in STEM fields (science, technology, engineering and mathematics). There has been a push in recent years to get more girls and women into STEM subjects. Fifty-two percent of those who graduated in STEM disciplines in 2014 were female.[1] This varies widely between disciplines though, with females making up around 80% of graduates in subjects allied to medicine or veterinary sciences, but only around 15% in computer science or engineering and technology. While the gender balance of all STEM graduates are roughly equal, this is not reflected in employment however, with figures suggesting around 23% of employees in UK STEM industries are female,[1] while data from the UNESCO Institute for Statistics less than 30% of scientific researchers worldwide are female.[2]

Does the future hold more promise? A meta-analysis by Miller and colleagues looked at fifty years worth of studies where school children were asked to draw a scientist and examined the genders depicted.[3] They found that over time the percentage showing female scientists has increased – from 0.6% in data collected in 1966-77 to around 40% in 2015. However, when looking at the age of children (in studies since the 1980s) they found that while there was roughly equal representation of male and female scientists among 5 and 6 year olds, by the age of 7-8 years significantly more men were drawn. In the drawings made by girls only, the switch from predominantly female to male depictions happened around 10-11 years. Perhaps with an increase in female representation in STEM roles, especially in public, then young girls might be more likely to see themselves in such a field and thus increase the proportion in the workplace. Equally more needs to be done to emphasise gender equality at these key developmental milestones.

— Peter Chilton, Research Fellow

References:

  1. WISE Campaign for Gender Balance in Science, Technology & Engineering. Women in STEM workforce 2017. 24 October 2017.
  2. UNESCO Institute for Statistics. Women in Science. Fact Sheet No. 43. March 2017.
  3. Miller DI, Nolla KM, Eagly AH, Uttal DH. The Development of Children’s Gender-Science Stereotypes: A Meta-analysis of 5 Decades of U.S. Draw-A-Scientist Studies. Child Development. 2018.

Immunisation Against Rotavirus: At What Age Should it be Given?

A three way RCT [1] from Thailand shows that rotavirus vaccine is effective in reducing the incidence of diarrhoea in children (which we know), and that a neonatal schedule is no less effective and probably more effective than an infant schedule. Giving the vaccine early may reduce the risk of intussusception – apparently a risk with the infant schedule.

— Richard Lilford, CLAHRC WM Director

Reference:

  1. Bines JE, At Thobari J, Satria CD, et al. Human Neonatal Rotavirus Vaccine (RV3-BB) to Target Rotavirus from Birth. New Engl J Med. 2018; 378(8): 719-30.