Amira M. Khan, Zohra S. Lassi, and Zulfiqar A. Bhutta
Nearly 80% of the world’s population lives in low- and middle-income countries (LMICs) and these regions bear the greatest burden of maternal, neonatal, and child mortality, with most of the deaths occurring at home. Much of global maternal and child mortality is attributable to easily preventable and treatable conditions. However, the challenge lies in reaching the most vulnerable communities, especially the rural populations, making it imperative that maternal, newborn, and child health (MNCH) interventions focus on communities in tandem with facility-based strategies. There is widespread consensus that delivering effective primary health care (PHC) interventions through the continuum of care, starting from pregnancy to delivery and then to the newborn, infant, and the young child, is an integral component of health strategies in high-, middle- and low-income settings.
Despite gaps in research, several effective community-based PHC approaches have been proven to impact MNCH positively. Implementation of these strategies is needed at scale in LMICs and in partnership with all stakeholders including the public and private sector. Community-based PHC, operating on the principles of community engagement and community mobilization, is now more critical than ever. Further robust studies are needed to evaluate certain strategies of community-based PHC and their impact on maternal and child health outcomes, such as the use of mobile technology and social franchises. Recognition of community health workers (CHWs) as a formal cadre and the integration of community-based health services within PHC are vital in strengthening efforts to impact maternal, neonatal, and child health outcomes positively. However, despite the importance of community-based PHC for MNCH in LMICs, the existence of a strong health system and skilled workforce is central to achieving positive health outcomes in these regions.
Ralph J. DiClemente and Nihari Patel
At the end of 2016, there were approximately 36.7 million people living with HIV worldwide with 1.6 million people being newly infected. In the same year, 1 million people died from HIV-related causes globally. The vast prevalence of HIV calls for an urgent need to develop and implement prevention programs aimed at reducing risk behaviors. Bronfenbrenner’s socio-ecological model provides an organizing framework to discuss HIV prevention interventions implemented at the individual, relational, community, and societal level. Historically, many interventions in the field of public health have targeted the individual level. Individual-level interventions promote behavior change by enhancing HIV knowledge, attitudes, and beliefs and by motivating the adoption of preventative behaviors. Relational-level interventions focus on behavior change by using peers, partners, or family members to encourage HIV-preventative practices. At the community-level, prevention interventions aim to reduce HIV vulnerability by changing HIV-risk behaviors within schools, workplaces, or neighborhoods. Lastly, societal interventions attempt to change policies and laws to enable HIV-preventative practices.
While previous interventions implemented in each of these domains have proven to be effective, a multipronged approach to HIV prevention is needed such that it tackles the complex interplay between the individual and their social and physical environment. Ideally, a multipronged intervention strategy would consist of interventions at different levels that complement each other to synergistically reinforce risk reduction while simultaneously creating an environment that promotes behavior change. Multilevel interventions provide a promising avenue for researchers and program developers to consider all levels of influences on an individual’s behavior and design a comprehensive HIV risk-reduction program.
Marie Thoma, Carie Cox, Jasmine Fledderjohann, and Rudolph Kantum Adageba
This is an advance summary of a forthcoming article in the Oxford Research Encyclopedia of Global Public Health. Please check back later for the full article.
Infertility remains a neglected area in sexual and reproductive health, yet its consequences are staggering. Infertility is estimated to impact about 15% (estimates range from 48 million to 180 million) of couples of reproductive age worldwide. It is associated with adverse physical and mental health outcomes, financial distress, severe social stigma, increased risk of domestic abuse, and marital instability. While men and women are equally likely to be infertile, women often bear the societal burden of infertility, particularly in societies where a woman’s identity and social value is closely tied to her ability to bear children. Despite these consequences, disparities in access to infertility treatment between low- and high-income populations persist, given the high cost and limited geographic availability of diagnostic services and assisted reproductive technologies. In addition, a significant proportion of infertility arises from preventable factors, such as smoking, sexually transmitted infections, pregnancy-related infection or unsafe abortion, and environmental contaminants.
Accordingly, programs that address the equitable prevention and treatment of infertility are not only in keeping with a reproductive rights perspective, but can also improve public health. However, progress on infertility as a global concern in the field of sexual and reproductive health and rights is stymied by challenges in understanding the global epidemiology of infertility, including its causes and determinants, barriers to accessing quality infertility care, and a lack of political will and attention to this issue. Tracking and measurement of infertility is highly complex, resulting in considerable ambiguity about its prevalence and stratification of reproduction globally. A renewed global focus on infertility epidemiology, risk factors, and access to and receipt of quality of care will support individuals in trying to reach their desired number and spacing of children and improve overall health and well-being.
Malnutrition is caused by consuming a diet with either too little and/or too much of one or more nutrients, such that the body malfunctions. These nutrients can be the macronutrients, including proteins, carbohydrates, and fats that provide the body with its building blocks and energy, or the micronutrients including vitamins and minerals, that help the body to function. Infectious diseases, such as diarrhea, can also cause malnutrition through decreased nutrient absorption, decreased intake of food, increased metabolic requirements, and direct nutrient loss. A double burden of malnutrition (both overnutrition and undernutrition) often occurs across the life course of individuals and can also coexist in the same communities and even the same households. While about a quarter of the world’s children are stunted, due to both maternal and young child undernutrition, overweight and obesity affects about one in three adults and one in ten children. Anemia, most commonly due to iron deficiency, is also affecting about a third of women of reproductive age and almost half of preschool children. Around 90 % of nations have a serious burden of either two or three of these different forms of malnutrition.
Malnutrition is one of the principal and growing causes of global disease and mortality, affecting at least half of the world’s inhabitants. Programs for tackling maternal and child undernutrition have gained impetus in the last decade with a consensus developing around a package of effective interventions. The nutrition-specific interventions, mostly delivered through the health sector, are directed at immediate levels of causality, while nutrition-sensitive interventions, directed at the underlying and basic levels of causality are delivered through other sectors such as agriculture, education, social welfare, as well as water and sanitation.
Less consensus exists around the interventions needed to reduce overnutrition and the associated non-communicable diseases (NCDs), including diabetes, high blood pressure, and coronary heart disease. Prevention is certainly better than cure, however, and creating enabling environments for healthy food choices seems to be the most promising approach. Achieving “healthy diets for all,” by reducing consumption of meat and ultra-processed foods, as well as increasing consumption of fruit and vegetables, would help control rising rates of obesity and reduce NCD mortality. Adopting such healthy diets would also greatly contribute to reducing greenhouse gas emissions: the agriculture sector is responsible for producing a third of emissions, and a reduction on livestock farming would contribute to reducing global warming. Public health nutrition capacity to manage such nutrition programs is still widely lacking, however, and much still needs to be done to improve these programs and their governance.
Colin Binns and Mi Kyung Lee
Breastfeeding is one of the best public health “buys” available for countries at all levels of development. In the first year of life, appropriate infant nutrition (exclusive breastfeeding to around 6 months) reduces infant mortality and hospital admissions by 50% or more. Early life nutrition has important influences, including on childhood illnesses, obesity, cognitive development, hospitalizations, and later chronic disease. Breastfeeding is consistent with the historical cultural practices of all societies, and its benefits of breastfeeding last a lifetime. While the development of infant formula has been of benefit to some infants, its inappropriate promotion has resulted in a decline of breastfeeding, and, as a result, health gains in many countries have not been as great as they could have been. The health benefits of breastfeeding will provide some protection against the effects of climate change, which will cause a decline in potable water supplies and increases in the incidence of some infections. Infant formula production has very high environmental costs, while breastfeeding as well as being the best infant feeding intervention also has very low environmental impact. An important part of the sustainable development agenda must be to promote breastfeeding and its benefits and to reverse the inappropriate promotion and use of infant formula.