ObjectiveAnaemia affects the majority of children in sub-Saharan Africa (SSA). Previous studies of risk factors for anaemia have been limited by sample size, geography and the association of many risk factors with poverty. In order to measure the relative impact of individual, maternal and household risk factors for anaemia in young children, we analysed data from all SSA countries that performed haemoglobin (Hb) testing in the Demographic and Health Surveys.Design and settingThis cross-sectional study pooled household-level data from the most recent Demographic and Health Surveys conducted in 27 SSA between 2008 and 2014.Participants96 804 children age 6–59 months.ResultsThe prevalence of childhood anaemia (defined as Hb <11 g/dL) across the region was 59.9%, ranging from 23.7% in Rwanda to 87.9% in Burkina Faso. In multivariable regression models, older age, female sex, greater wealth, fewer household members, greater height-for-age, older maternal age, higher maternal body mass index, current maternal pregnancy and higher maternal Hb, and absence of recent fever were associated with higher Hb in tested children. Demographic, socioeconomic factors, family structure, water/sanitation, growth, maternal health and recent illnesses were significantly associated with the presence of childhood anaemia. These risk factor groups explain a significant fraction of anaemia (ranging from 1.0% to 16.7%) at the population level.ConclusionsThe findings from our analysis of risk factors for anaemia in SSA underscore the importance of family and socioeconomic context in childhood anaemia. These data highlight the need for integrated programmes that address the multifactorial nature of childhood anaemia.

CONTEXT: Birth asphyxia contributes substantially to neonatal mortality in low-and middleincome countries (LMICs). The effects of training birth attendants in neonatal resuscitation (NR) on mortality are limited by falloff of skills and knowledge over time and transference of learned skills into clinical practice.OBJECTIVE: This review examined acquisition and retention of NR knowledge and skills by birth attendants in LMICs and the effectiveness of interventions to improve them.DATA SOURCES: Medline, Cochrane, Embase, CINAHL, Bireme, and African Index Medicus databases were searched. We reviewed Web pages and reports from non-peer-reviewed (or "gray") literature sources addressing NR training in LMICs. STUDY SELECTION:Articles on acquisition and retention of NR knowledge and skills, and interventions to improve them, were limited to LMICs. RESULTS:The initial search identified 767 articles, of which 45 met all inclusion criteria. Of these, 31 articles analyzed acquisition of knowledge and skills, and 19 analyzed retention. Most studies found high acquisition rates, although birth attendants struggled to learn bag-mask ventilation. Although significant falloff of knowledge and skills occurred after training, refresher training seemed to improve retention. Results of the gray literature analysis suggest that formal, structured practice sessions improve retention. LIMITATIONS: This review did not analyze training's direct impact on mortality.CONCLUSIONS: Knowledge and skills falloff is a significant barrier to the success of NR training programs and possibly to reducing newborn mortality in LMICs. Refresher training and structured practice show significant promise. Additional research is needed to implement and assess retention improvement strategies in classroom and clinical settings.a Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; b Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts; c Harvard Medical School, Boston, Massachusetts; and d Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah Dr Reisman oversaw the literature reviews, interpreted the results, and drafted the initial manuscript; Ms Arlington assisted with the gray literature search and reviewed and revised the manuscript; Dr Jensen performed the initial gray literature analysis and reviewed and revised the manuscript; Mr Louis and Ms SuarezRebling conducted the initial literature review; and Dr Nelson conceptualized and designed the literature review and reviewed and revised the manuscript. All authors approved the fi nal manuscript as submitted.

OBJECTIVES: This first-ever country-level study assesses the implementation of the Helping Babies Breathe (HBB) program in 15 of Tanzania's mainland regions by measuring coverage, adoption and retention of provider skills, acceptability among providers, and barriers and challenges to at-scale implementation. METHODS:Longitudinal facility-level follow-up visits assessed provider resuscitation knowledge and skills in using objective structured clinical examinations and readiness of facilities to resuscitate newborns, in terms of birth attendants trained and essential equipment available and functional. Focus group discussions were held with providers to determine the acceptability, challenges, and barriers to implementation of the HBB program. RESULTS:Immediately after HBB training, 87.1% of providers passed the objective structured clinical examination. This number dropped to 79.4% at 4 to 6 weeks and 55.8% at 4 to 6 months (P < .001). Noting this fall-off in skills, the program implemented structured on-thejob training and supportive supervisory visits, which were associated with an improvement in skill retention. At long-term follow-up, >90% of facilities had bag-mask devices available to all beds in the labor and delivery ward, and 96% were functional. Overall, providers were highly satisfied with the HBB program but thought that the 1-day training used in Tanzania was too short, so they would welcome additional training and follow-up visits to reinforce skills. CONCLUSIONS:The HBB program in Tanzania has gained acceptability and shown success in equipping providers with neonatal resuscitation knowledge, skills, and supplies. However, assessing the program's impact on neonatal mortality has proven challenging.

Health systems are frequently among the casualties of conflict. Within these settings, increased knowledge is needed on how to rebuild and strengthen health infrastructure resilience, such as primary health care (PHC) systems, in context-specific ways that promote health equity. Therefore, this study aimed to explore perspectives of experts with experience working on frontlines of social crises to contribute to understandings of pathways toward equitable PHC in conflict-affected settings. Semistructured qualitative interviews with 18 expert participants were completed. Through engaging elements of grounded theory situational analysis, three themes emerged iteratively, including (a) Building Blocks, (b) Intermediating Factors, and (c) a Roadmap. These emergent themes contribute to conceptual frameworks explaining key contextually specific priorities, challenges, and facilitating factors for developing resilient health infrastructures under social crises. Findings inform policy and practical guidelines that address complexities of conflict conditions and underscore the importance of PHC development toward promoting health as a human right.

BackgroundHelping Babies Breathe (HBB) has become the gold standard globally for training birth-attendants in neonatal resuscitation in low-resource settings in efforts to reduce early newborn asphyxia and mortality. The purpose of this study was to do a first-ever activity-based cost-analysis of at-scale HBB program implementation and initial follow-up in a large region of Tanzania and evaluate costs of national scale-up as one component of a multi-method external evaluation of the implementation of HBB at scale in Tanzania.MethodsWe used activity-based costing to examine budget expense data during the two-month implementation and follow-up of HBB in one of the target regions. Activity-cost centers included administrative, initial training (including resuscitation equipment), and follow-up training expenses. Sensitivity analysis was utilized to project cost scenarios incurred to achieve countrywide expansion of the program across all mainland regions of Tanzania and to model costs of program maintenance over one and five years following initiation.ResultsTotal costs for the Mbeya Region were $202,240, with the highest proportion due to initial training and equipment (45.2%), followed by central program administration (37.2%), and follow-up visits (17.6%). Within Mbeya, 49 training sessions were undertaken, involving the training of 1,341 health providers from 336 health facilities in eight districts. To similarly expand the HBB program across the 25 regions of mainland Tanzania, the total economic cost is projected to be around $4,000,000 (around $600 per facility). Following sensitivity analyses, the estimated total for all Tanzania initial rollout lies between $2,934,793 to $4,309,595. In order to maintain the program nationally under the current model, it is estimated it would cost $2,019,115 for a further one year and $5,640,794 for a further five years of ongoing program support.ConclusionHBB implementation is a relatively low-cost intervention with potential for high impact on perinatal mortality in resource-poor settings. It is shown here that nationwide expansion of this program across the range of health provision levels and regions of Tanzania would be feasible. This study provides policymakers and investors with the relevant cost-estimation for national rollout of this potentially neonatal life-saving intervention.