Substantial and sustained reduction in under-5 mortality, diarrhea, and pneumonia in Oshikhandass, Pakistan: evidence from two longitudinal cohort studies 15 years apart

Abstract

Background: Oshikhandass is a rural village in northern Pakistan where a 1989-1991 verbal autopsy study showed that diarrhea and pneumonia were the top causes of under-5 mortality. Intensive surveillance, active community health education and child health interventions were delivered in 1989-1996; here we assess improvements in under-5 mortality, diarrhea, and pneumonia over this period and 15 years later. Methods: Two prospective open-cohort studies in Oshikhandass from 1989 to 1996 (Study 1) and 2011-2014 (Study 2) enrolled all children under age 60 months. Study staff trained using WHO guidelines, conducted weekly household surveillance and promoted knowledge on causes and management of diarrhea and pneumonia. Information about household characteristics and socioeconomic status was collected. Hurdle models were constructed to examine putative risk factors for diarrhea and pneumonia. Results: Against a backdrop of considerable change in the socioeconomic status of the community, under-5 mortality, which declined over the course of Study 1 (from 114.3 to 79.5 deaths/1000 live births (LB) between 1989 and 1996), exceeded Sustainable Development Goal 3 by Study 2 (19.8 deaths/ 1000 LB). Reductions in diarrhea prevalence (20.3 to 2.2 days/ Child Year [CY]), incidence (2.1 to 0.5 episodes/ CY), and number of bloody diarrhea episodes (18.6 to 5.2%) seen during Study 1, were sustained in Study 2. Pneumonia incidence was 0.5 episodes /CY in Study 1 and 0.2/CY in Study 2; only 5% of episodes were categorized as severe or very severe in both studies. While no individual factors predicted a statistically significant difference in diarrhea or pneumonia episodes, the combined effect of water, toilet and housing materials was associated with a significant decrease in diarrhea; higher household income was the most protective factor for pneumonia in Study 1.

Examining the relationships between early childhood experiences and adolescent and young adult health status in a resource-limited population: A cohort study

“…Childhood mortality in Oshikhandass decreased significantly from 1989 to 1996 [ 9 ], allowing families to focus more on helping surviving children grow and thrive. During this time, educational opportunities significantly improved in Oshikhandass, from there being 1 government high school for boys and 1 middle school for girls to the current situation of 9 early childhood education centers, 11 schools, and 2 colleges (up to class 12).…”

“…From 1989 to 1996, all children under age 5 years in Oshikhandass were enrolled with parental consent in the prospective cohort of the Oshikhandass Diarrhea and Pneumonia Project. Local health workers visited families weekly until the child’s fifth birthday, out-migration, or death; data collection methods and variable definitions are described elsewhere [ 9 ]. These data were used to estimate the burden of child morbidity (number of diarrhea and pneumonia episodes divided by days of follow-up).…”

“…These data were used to estimate the burden of child morbidity (number of diarrhea and pneumonia episodes divided by days of follow-up). Pneumonia was not included in the main analyses because of a smaller sample size [ 9 ]. The mean length/height-for-age z score (HAZ) was calculated for each child from their available quarterly data, using 2006 WHO growth standards.…”

“…The mean length/height-for-age z score (HAZ) was calculated for each child from their available quarterly data, using 2006 WHO growth standards. At enrollment, a survey was conducted of household characteristics (e.g., house type based on construction materials, number of rooms and occupants, and type of water and sanitation) and parental educational attainment (illiterate/no formal education, primary to 10 years, or more), occupation, and income [ 9 ].…”

“…We report the findings of an observational longitudinal study of a cohort of children who were followed up 15–20 years later, when they were adolescents and young adults (hereafter referred to as adolescents) [ 4 ]. The childhood cohort came from Oshikhandass, an ethnically mixed, remote rural village with high morbidity and mortality [ 9 ], 20 km from the capital of G-B. This study examines individual-level associations between childhood health and family socioeconomic indicators of early life adversity and adolescent health and development.…”