An estimated 9.7 million children under the age of five die every year worldwide, approximately 41% of them in sub-Saharan Africa (SSA). Access to adequate health care is among the factors suggested to be associated with child mortality; improved access holds great potential for a significant reduction in under-five death in developing countries. Theory and corresponding frameworks indicate a wide range of factors affecting access to health care, such as traditionally measured variables (distance to a health provider and cost of obtaining health care) and additional variables (social support, time availability and caregiver autonomy). Few analytical studies of traditional variables have been conducted in SSA, and they have significant limitations and inconclusive results. The importance of additional factors has been suggested by qualitative and recent quantitative studies. We propose that access to health care is multidimensional; factors other than distance and cost need to be considered by those planning health care provision if child mortality rates are to be reduced through improved access. Analytical studies that comprehensively evaluate both traditional and additional variables in developing countries are required.

Objective To assess whether traditional measures of access to health care (distance and travel time to a facility) and non-traditional measures (social and financial support indicators) are associated with mortality among children under 5 years of age in the Gambia. Methods We conducted a case-control study in a population under demographic surveillance. Cases (n = 140) were children under 5 years of age who died between 31 December 2003 and 30 April 2006. Each case was matched in age and sex to five controls (n = 700). Information was gathered by interviewing primary caregivers. The data were analysed using conditional logistic regression. Findings Of traditional measures of access, only rural versus urban/periurban residence was important: children from rural areas were more likely to die (OR: 4.9; 95% confidence interval, CI: 1.2-20.2). For non-traditional measures, children were more likely to die if their primary caregivers lacked help with meal preparation (OR: 2.3; 95% CI: 1.2-4.1), had no one to relax with (OR: 1.8; 95% CI: 1.1-2.9), had no one who could offer good advice (OR: 23.1; 95% CI: 4.3-123.4), had little say over how earned money was spent (OR: 12.7; 95% CI: 1.3-127.6), were unable to cut spending for health care (OR: 2.5; 95% CI: 1.5-4.2) or had to carry out odd jobs to pay for the care (OR: 3.4; 95% CI: 2.1-5.5). A protective effect was observed when the caregiver had other children to care for (OR: 0.2; 95% CI: 0.1-0.5). Conclusion Improving access to health-care for children in the Gambia and similar settings is not simply a matter of reducing travel time and distance to a health facility, but requires improvements in caregivers' support networks and their access to the financial resources they need.Une traduction en français de ce résumé figure à la fin de l'article. Al final del artículo se facilita una traducción al español.

Young children living with a tuberculosis patient are at high risk of Mycobacterium tuberculosis infection and disease. WHO guidelines promote active screening and isoniazid (INH) preventive therapy (PT) for such children under 5 years, yet this well-established intervention is seldom used in endemic countries. We review the literature regarding barriers to implementation of PT and find that they are multifactorial, including difficulties in screening, poor adherence, fear of increasing INH resistance and poor acceptability among primary caregivers and healthcare workers. These barriers are largely resolvable, and proposed solutions such as the adoption of symptom-based screening and shorter drug regimens are discussed. Integrated multicomponent and site-specific solutions need to be developed and evaluated within a public health framework to overcome the policy-practice gap and provide functional PT programmes for children in endemic settings.

BackgroundIt is recommended that young child contacts of sputum smear positive tuberculosis cases receive isoniazid preventive therapy (IPT) but reported adherence is low and risk factors for poor adherence in children are largely unknown.MethodsWe prospectively determined rates of IPT adherence in children < 5 yrs in an Indonesian lung clinic. Possible risk factors for poor adherence, defined as ≤3 months prescription collection, were calculated using logistic regression. To further investigate adherence barriers in-depth interviews were conducted with caregivers of children with good and poor adherence.ResultsEighty-two children eligible for IPT were included, 61 (74.4%) of which had poor adherence. High transport costs (OR 3.3, 95% CI 1.1-10.2) and medication costs (OR 20.0, 95% CI 2.7-414.5) were significantly associated with poor adherence in univariate analysis. Access, medication barriers, disease and health service experience and caregiver TB and IPT knowledge and beliefs were found to be important determinants of adherence in qualitative analysis.ConclusionAdherence to IPT in this setting in Indonesia is extremely low and may result from a combination of financial, knowledge, health service and medication related barriers. Successful reduction of childhood TB urgently requires evidence-based interventions that address poor adherence to IPT.

Philip Campbell Hill and colleagues propose using a health needs assessment framework, research tools, and a strategy for clinical evaluation to help better manage child contacts of adult TB cases.

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M. tuberculosis infection according to either test was high, supporting screening and preventive treatment. Children of smear-positive TB cases who accompany their parents to the clinic should be prioritised for immediate screening.

Background. Screening of children who are household contacts of tuberculosis (TB) cases is universally recommended but rarely implemented in TB endemic setting. This paper aims to summarise published data of the prevalence of TB infection and disease among child contacts in South East Asia. Methods. Search strategies were developed to identify all published studies from South East Asia of household contact investigation that included children (0–15 years). Results. Eleven studies were eligible for review. There was heterogeneity across the studies. TB infection was common among child contacts under 15 years of age (24.4–69.2%) and was higher than the prevalence of TB disease, which varied from 3.3% to 5.5%. Conclusion. TB infection is common among children that are household contacts of TB cases in South East Asia. Novel approaches to child contact screening and management that improve implementation in South East Asia need to be further evaluated.