United Nations Children's Fund Kosovo

The World Summit for Children Plan of Action which seeks to reduce maternal mortality by half between 1990 and 2000 directs each country to establish appropriate mechanisms for the regular collection analysis and dissemination of data on program indicators. The conventional approach to monitoring progress uses repeated measurements of maternal mortality rates and ratios to assess trends over time. This manual outlines an alternative approach more applicable to developing countries where no comprehensive vital registration system is available. This approach is based on monitoring the processes or interventions aimed at reducing maternal mortality. Use of process indicators can help program managers identify priority issues and interventions and alert managers of areas that require strengthening. This manual outlines a series of process indicators that assess the availability use and quality of obstetric services and provides guidance on data collection and interpretation. An overall goal of this approach is to strengthen national capacity for data-led decision-making.

Adolescent sexual and reproductive health (ASRH) continues to be a major public health challenge in sub-Saharan Africa where child marriage, adolescent childbearing, HIV transmission and low coverage of modern contraceptives are common in many countries. The evidence is still limited on inequalities in ASRH by gender, education, urban-rural residence and household wealth for many critical areas of sexual initiation, fertility, marriage, HIV, condom use and use of modern contraceptives for family planning. We conducted a review of published literature, a synthesis of national representative Demographic and Health Surveys data for 33 countries in sub-Saharan Africa, and analyses of recent trends of 10 countries with surveys in around 2004, 2010 and 2015. Our analysis demonstrates major inequalities and uneven progress in many key ASRH indicators within sub-Saharan Africa. Gender gaps are large with little evidence of change in gaps in age at sexual debut and first marriage, resulting in adolescent girls remaining particularly vulnerable to poor sexual health outcomes. There are also major and persistent inequalities in ASRH indicators by education, urban-rural residence and economic status of the household which need to be addressed to make progress towards the goal of equity as part of the sustainable development goals and universal health coverage. These persistent inequalities suggest the need for multisectoral approaches, which address the structural issues underlying poor ASRH, such as education, poverty, gender-based violence and lack of economic opportunity.

Multisectoral action is key to addressing many pressing global health challenges and critical for achieving the Sustainable Development Goals, but to-date, understanding about how best to promote and support multisectoral action for health is relatively limited. The challenges to multisectoral action may be more acute in low-income and middle-income countries (LMICs) where institutions are frequently weak, and fragmentation, even within the health sector, can undermine coordination. We apply the lens of governance to understand challenges to multisectoral action. This paper (1) provides a high level overview of possible disciplines, frameworks and theories that could be applied to enrich analyses in this field; (2) summarises the literature that has sought to describe governance of multisectoral action for health in LMICs using a simple political economy framework that identifies interests, institutions and ideas and (3) introduces the papers in the supplement. Our review highlights the diverse, but often political nature of factors influencing the success of multisectoral action. Key factors include the importance of high level political commitment; the incentives for competition versus collaboration between bureaucratic agencies and the extent to which there is common understanding across actors about the problem. The supplement papers seek to promote debate and understanding about research and practice approaches to the governance of multisectoral action and illustrate salient issues through case studies. The papers here are unable to cover all aspects of this topic, but in the final two papers, we seek to develop an agenda for future action. This paper introduces a supplement on the governance of multisectoral action for health. While many case studies exist in this domain, we identify a need for greater theory-based conceptualisation of multisectoral action and more sophisticated empirical investigation of such collaborations.

Following the World Health Organization (WHO) declaration of a Public Health Emergency of International Concern regarding the Ebola outbreak in West Africa in July 2014, UNICEF was asked to co-lead, in coordination with WHO and the ministries of health of affected countries, the communication and social mobilization component-which UNICEF refers to as communication for development (C4D)-of the Ebola response. For the first time in an emergency setting, C4D was formally incorporated into each country's national response, alongside more typical components such as supplies and logistics, surveillance, and clinical care. This article describes the lessons learned about social mobilization and community engagement in the emergency response to the Ebola outbreak, with a particular focus on UNICEF's C4D work in Guinea, Liberia, and Sierra Leone. The lessons emerged through an assessment conducted by UNICEF using 4 methods: a literature review of key documents, meeting reports, and other articles; structured discussions conducted in June 2015 and October 2015 with UNICEF and civil society experts; an electronic survey, launched in October and November 2015, with staff from government, the UN, or any partner organization who worked on Ebola (N = 53); and key informant interviews (N = 5). After triangulating the findings from all data sources, we distilled lessons under 7 major domains: (1) strategy and decentralization: develop a comprehensive C4D strategy with communities at the center and decentralized programming to facilitate flexibility and adaptation to the local context; (2) coordination: establish C4D leadership with the necessary authority to coordinate between partners and enforce use of standard operating procedures as a central coordination and quality assurance tool; (3) entering and engaging communities: invest in key communication channels (such as radio) and trusted local community members; (4) messaging: adapt messages and strategies continually as patterns of the epidemic change over time; (5) partnerships: invest in strategic partnerships with community, religious leaders, journalists, radio stations, and partner organizations; (6) capacity building: support a network of local and international professionals with capacity for C4D who can be deployed rapidly; (7) data and performance monitoring: establish clear C4D process and impact indicators and strive for real-time data analysis and rapid feedback to communities and authorities to inform decision making. Ultimately, communication, community engagement, and social mobilization need to be formally placed within the global humanitarian response architecture with proper funding to effectively support future public health emergencies, which are as much a social as a health phenomenon.

The prior literature has highlighted a variety of workplace problems, such as racial and gender bias and lack of influence over work activities, as influences on police stress. Additional explanations for police stress include community conditions, for example, high crime rates and size of the community, token status within the police organization, and lack of family and coworker support for work-related activities. In a large-sample, exploratory study, this research examined the workplace problems that were hypothesized to predict stress. It also determined whether community conditions, token status, and lack of social support explained additional variance in officers’ stress levels. Lack of influence over work activities and bias against one’s racial, gender, or ethnic group stood out as important predictors of stress after controls were introduced for demographic variables. Interventions to redesign jobs to afford greater influence and to reduce within-department bias are approaches that could reduce police officers’ stress.

From 1985 to 2016, the prevalence of underweight decreased, and that of obesity and severe obesity increased, in most regions, with significant variation in the magnitude of these changes across regions. We investigated how much change in mean body mass index (BMI) explains changes in the prevalence of underweight, obesity, and severe obesity in different regions using data from 2896 population-based studies with 187 million participants. Changes in the prevalence of underweight and total obesity, and to a lesser extent severe obesity, are largely driven by shifts in the distribution of BMI, with smaller contributions from changes in the shape of the distribution. In East and Southeast Asia and sub-Saharan Africa, the underweight tail of the BMI distribution was left behind as the distribution shifted. There is a need for policies that address all forms of malnutrition by making healthy foods accessible and affordable, while restricting unhealthy foods through fiscal and regulatory restrictions.

The climate crisis is a child rights crisis presents the Children’s Climate Risk Index (CCRI), which uses data to generate new global evidence on how many children are currently exposed to climate and environmental hazards, shocks and stresses. A composite index, the CCRI brings together geographical data by analyzing 1.) exposure to climate and environmental hazards, shocks and stresses; and 2.) child vulnerability. The CCRI helps to understand and measure the likelihood of climate and environmental shocks or stresses leading to the erosion of development progress, the deepening of deprivation and/or humanitarian situations affecting children or vulnerable households and groups.

Over recent years, tuberculosis (TB) and disease caused by human immunodeficiency virus (HIV) have merged in a synergistic pandemic. The number of new cases of TB is stabilizing and declining, except in countries with a high prevalence of HIV infection. In these countries, where HIV is driving an increase in the TB burden, the capacity of the current tools and strategies to reduce the burden has been exceeded. This paper summarizes the current status of TB management and describes recent thinking and strategy adjustments required for the control of TB in settings of high HIV prevalence. We review the information on anti-TB drugs that is available in the public domain and highlight the need for continued and concerted efforts (including financial, human and infrastructural investments) for the development of new strategies and anti-TB agents.

BACKGROUND: Over the last decade, coverage of maternal and newborn health indicators used for global monitoring and reporting have increased substantially but reductions in maternal and neonatal mortality have remained slow. This has led to an increased recognition and concern that these standard globally agreed upon measures of antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC) only capture the level of contacts with the health system and provide little indication of actual content of services received by mothers and their newborns. Over this period, large household surveys have captured measures of maternal and newborn care mainly through questions assessing contacts during the antenatal, delivery and postnatal periods along with some measures of content of care. This study aims to describe the gap between contact and content -as a proxy for quality- of maternal and newborn health services by assessing level of co-coverage of ANC and PNC interventions. METHODS: We used Demographic and Health Surveys (DHS) data from 20 countries between 2010 and 2015. We analysed the proportion of women with at least 1 and 4+ antenatal care visit, who received 8 interventions. We also assessed the percentage of newborns delivered with a skilled birth attendant who received 7 interventions. We ran random effect logistic regression to assess factors associated with receiving all interventions during the antenatal and postnatal period. RESULTS: While on average 51% of women in the analysis received four ANC visits with at least one visit from a skilled health provider, only 5% of them received all 8 ANC interventions. Similarly, during the postnatal period though two-thirds (65%) of births were attended by a skilled birth attendant, only 3% of newborns received all 7 PNC interventions. The odds of receiving all ANC and PNC interventions were higher for women with higher education and higher wealth status. CONCLUSION: The gap between coverage and content as a proxy of quality of antenatal and postnatal care is excessively large in all countries. In order to accelerate maternal and newborn survival and achieve Sustainable Development Goals, increased efforts are needed to improve both the coverage and quality of maternal and newborn health interventions.

The Multiple Indicator Cluster Survey was used to provide information on feeding practices, caregiving, discipline and violence, and the home environment for young children across 28 countries. The findings from the series of studies in this Special Section are the first of their kind because they provide information on the most proximal context for development of the youngest children in the majority world using one of the only data sets to study these contexts across countries. Using the framework of the Convention on the Rights of the Child, in particular the Rights to Survival, Development and Protection, findings are explained with implications for international and national-level social policies. Implications are also discussed, with respect to policy makers and the larger international community, who have the obligation to uphold these rights.

This book review examines 'The rational animal: how evolution made us smarter than we think' by Douglas T. Kenrick and Vladas Griskevicius. A valuable contribution to the library of decision making and rationality, 'The rational animal' uses a solid scientific framework to address two issues of human behaviour: our apparent irrationality and our inconsistency. The book presents an alternative view of human nature that sees behaviour driven by occasions and circumstances, rather than by consistent traits. 'The rational animal' is not a to-do book, but it does offer helpful ideas for decision making and makes the reader reflect upon the fact that our desire for certain products or experiences is driven by deep evolutionary needs

In September 2016, the member states of the United Nations completed the process of adopting and defi ning indicators for the Sustainable Development Goals (SDGs; United Nations, 2015). Developed through a three-year, worldwide participatory process, these 17 goals and 169 targets represent a global consensus on the part of U.N. member nations towards an inclusive, sustainable world, centered around ensuring equity in all countries at a time of great environmental and humanitarian crises. This Social Policy Report describes the central role of supporting child and youth development in achieving the vision behind the U.N. Sustainable Development Agenda. The report then addresses the importance of developmental science in achieving the aims of the Sustainable Development Agenda through generating knowledge of child and youth development in diverse contexts, monitoring and measurement to reveal patterns of success and inequity, and building capacity for developmental science in all countries. We emphasize the goal that most clearly encompasses development from birth to young adulthood (SDG 4) and also describe the relevance of developmental science to the other goals.

INTRODUCTION: Neonatal mortality rate (NMR) has been declining in sub-Saharan African (SSA) countries, where historically rural areas had higher NMR compared with urban. The 2015-2016 Demographic and Health Survey (DHS) in Tanzania showed an exacerbation of an existing pattern with significantly higher NMR in urban areas. The objective of this study is to understand this disparity in SSA countries and examine the specific factors potentially underlying this association in Tanzania. METHODS: We assessed urban-rural NMR disparities among 21 SSA countries with four or more DHS, at least one of which was before 2000, using the DHS StatCompiler. For Tanzania DHS 2015-2016, descriptive statistics were carried out disaggregated by urban and rural areas, followed by bivariate and multivariable logistic regression modelling the association between urban/rural residence and neonatal mortality, adjusting for other risk factors. RESULTS: Among 21 countries analysed, Tanzania was the only SSA country where urban NMR (38 per 1000 live births) was significantly higher than rural (20 per 1,000), with largest difference during first week of life. We analysed NMR on the 2015-2016 Tanzania DHS, including live births to 9736 women aged between 15 and 49 years. Several factors were significantly associated with higher NMR, including multiplicity of pregnancy, being the first child, higher maternal education, and male child sex. However, their inclusion did not attenuate the effect of urban-rural differences in NMR. In multivariable models, urban residence remained associated with double the odds of neonatal mortality compared with rural. CONCLUSION: There is an urgent need to understand the role of quality of facility-based care, including role of infections, and health-seeking behaviour in case of neonatal illness at home. However, additional factors might also be implicated and higher NMR within urban areas of Tanzania may signal a shift in the pattern of neonatal mortality across several other SSA countries.

A recycling society must switch from linear solutions to circular approaches, protecting ecosystems and harmonising with natural systems. Ecological sanitation, an alternative to conventional approaches, considers excreta a resource. Excreta are rendered safe at the source prior to reuse. The ecosystem approach helps restore soil fertility, and ultimately enhances food security. It is a system requiring little or no water; thus it conserves and protects fresh and marine water sources, enhances biodiversity, and it may confer multiple benefits in urban settings. It can generate jobs, be financially more affordable than conventional approaches, improve local ecology, create decentralised economies, and contribute toward improved health and nutrition of people. Ecological sanitation closes water and nutrient loops, reducing reliance on external inputs and reducing output of wastes from the system.

There is still a substantial knowledge gap on how gender mediates child health in general, and child immunisation outcomes in particular. Similarly, implementation of interventions to mitigate gender inequities that hinder children from being vaccinated requires additional perspectives and research. We adopt an intersectional approach to gender and delve into the social ecology of implementation, to show how gender inequities and their connection with immunisation are grounded in the interplay between individual, household, community and system factors. We show how an ecological model can be used as an overarching framework to support more precise identification of the mechanisms causing gender inequity and their structural complexity, to identify suitable change agents and interventions that target the underlying causes of marginalisation, and to ensure outcomes are relevant within specific population groups.

INTRODUCTION: Healthcare-associated infections (HCAIs) are the most frequent adverse event compromising patient safety globally. Patients in healthcare facilities (HCFs) in low-income and middle-income countries (LMICs) are most at risk. Although water, sanitation and hygiene (WASH) interventions are likely important for the prevention of HCAIs, there have been no systematic reviews to date. METHODS: As per our prepublished protocol, we systematically searched academic databases, trial registers, WHO databases, grey literature resources and conference abstracts to identify studies assessing the impact of HCF WASH services and practices on HCAIs in LMICs. In parallel, we undertook a supplementary scoping review including less rigorous study designs to develop a conceptual framework for how WASH can impact HCAIs and to identify key literature gaps. RESULTS: Only three studies were included in the systematic review. All assessed hygiene interventions and included: a cluster-randomised controlled trial, a cohort study, and a matched case-control study. All reported a reduction in HCAIs, but all were considered at medium-high risk of bias. The additional 27 before-after studies included in our scoping review all focused on hygiene interventions, none assessed improvements to water quantity, quality or sanitation facilities. 26 of the studies reported a reduction in at least one HCAI. Our scoping review identified multiple mechanisms by which WASH can influence HCAI and highlighted a number of important research gaps. CONCLUSIONS: Although there is a dearth of evidence for the effect of WASH in HCFs, the studies of hygiene interventions were consistently protective against HCAIs in LMICs. Additional and higher quality research is urgently needed to fill this gap to understand how WASH services in HCFs can support broader efforts to reduce HCAIs in LMICs. PROSPERO REGISTRATION NUMBER: CRD42017080943.

Subnational inequalities have received limited attention in the monitoring of progress towards national and global health targets during the past two decades. Yet, such data are often a critical basis for health planning and monitoring in countries, in support of efforts to reach all with essential interventions. Household surveys provide a rich basis for interventions coverage indicators on reproductive, maternal, newborn and child health (RMNCH) at the country first administrative level (regions or provinces). In this paper, we show the large subnational inequalities that exist in RMNCH coverage within 39 countries in sub-Saharan Africa, using a composite coverage index which has been used extensively by Countdown to 2030 for Women's, Children's and Adolescent's Health. The analyses show the wide range of subnational inequality patterns such as low overall national coverage with very large top inequality involving the capital city, intermediate national coverage with bottom inequality in disadvantaged regions, and high coverage in all regions with little inequality. Even though nearly half of the 34 countries with surveys around 2004 and again around 2015 appear to have been successful in reducing subnational inequalities in RMNCH coverage, the general picture shows persistence of large inequalities between subnational units within many countries. Poor governance and conflict settings were identified as potential contributing factors. Major efforts to reduce within-country inequalities are required to reach all women and children with essential interventions.

<h3>Key Messages</h3> As part of the greater movement to decolonize global health, leadership in implementation science needs to diversify to increase the influence of researchers and practitioners from low- and middle-income countries (LMICs) and to accelerate the development of implementation research suited to LMICs. Addressing this need will require the engagement of policy makers in LMICs to fund and shape the local research agenda, the creation of global networks to adapt or develop implementation science frameworks aligned with LMIC settings, the advancement of peer-to-peer learning and LMIC-based mentorship, and the prioritization of equity in implementation research. Achieving these aspirations will require cooperation across regions and continents to diversify global leadership in the field.

Occupational noise-induced hearing loss is the second most self-reported occupational illness or injury in the United States. Among coal miners, more than 90% of the population reports a hearing deficit by age 55. In this formative evaluation, focus groups were conducted with coal miners in Appalachia to ascertain whether miners perceive hearing loss as a major health risk and if so, what would motivate the consistent wearing of hearing protection devices (HPDs). The theoretical framework of the Extended Parallel Process Model was used to identify the miners' knowledge, attitudes, beliefs, and current behaviors regarding hearing protection. Focus group participants had strong perceived severity and varying levels of perceived susceptibility to hearing loss. Various barriers significantly reduced the self-efficacy and the response efficacy of using hearing protection.

This article examines the role that implementation science can play in evidence-based parenting programs. Although parenting programs can support parents in their caregiving roles, adapting and taking an evidence-based approach from one place to another without attending to implementation factors may contribute to poor impact in a new setting. Implementation science enables researchers to move beyond monitoring and evaluation of outcomes of a parenting program to understanding the process of putting the program into practice. Factors such as whether the program meets the needs of families and communities, how to secure buy-in from key stakeholders, what training and supervision are needed for the workforce, and ways that parenting programs can be integrated in existing infrastructure are all critical to successful implementation. Quality improvement can be built into the implementation process through feedback loops that inform rapid changes and testing cycles over time as a program is implemented. If researchers lead initial implementation of parenting programs, they must determine how the program can continue to work when using community workers and local systems rather than researchers. Open access components are especially important for the implementation of parenting programs in low- and middle-income countries to avoid prohibitive costs of proprietary programs and to benefit from flexibility in adapting components to meet the needs of particular local populations. Parenting programs benefit when policy makers, program leaders, and researchers attend not only to the what but also to the how of implementation.Objective.Design.Results.Conclusions.