Submitted by Luciana Ferreira (lucgeral@gmail.com) on 2017-10-31T12:09:45Z No. of bitstreams: 2 Dissertação - Juliana Carneiro de Souza - 2016.pdf: 2367691 bytes, checksum: 6ce0c60952965b5278ac890e5f16f9eb (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2017-10-31T12:11:25Z (GMT) No. of bitstreams: 2 Dissertação - Juliana Carneiro de Souza - 2016.pdf: 2367691 bytes, checksum: 6ce0c60952965b5278ac890e5f16f9eb (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Made available in DSpace on 2017-10-31T12:11:25Z (GMT). No. of bitstreams: 2 Dissertação - Juliana Carneiro de Souza - 2016.pdf: 2367691 bytes, checksum: 6ce0c60952965b5278ac890e5f16f9eb (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2016-02-11 / The human right to adequate food (DHAA) is enshrined in article 25 of the Universal Declaration of Human Rights, 1948. In Brazil, only in 2010, this right was inserted as a social right in the article 6 of the Constitution of the Federal Republic. The study discuss the guarantees of access to adequate food for infants and children with special dietary needs transitional or permanent, that due to metabolic changes, physiological or pathological conditions require exclusive diet. Among the changes, it is possible to cite illnesses affecting the gastrointestinal tract (vomiting, diarrhea), food hypersensitivities (allergies), malnutrition and inborn errors of metabolism. The lack or failure to provide special dietary formulas may damage the human growth and development and even consequence the death. Diarrhoea is a major cause of child mortality, killing more children than AIDS, malaria and measles combined. Considering the impact of child deaths from diarrhea in 2006, Brazilian managers of the Unified Health System (SUS) signed the Pact for Life, which aimed to reduce neonatal mortality by 5% and 50% infant deaths from diarrheal disease. The inductive qualitative method used to analyze the data collected in the Mortality Information System (SIM) - DATASUS demonstrated that there was a decrease in the deaths of infants and children up to 01 years of age in the Brazilian regions in the 2006-2013. / O Direito Humano à Alimentação Adequada (DHAA) está consagrado no Artigo 25 da Declaração Universal dos Direitos Humanos de 1948. No Brasil, somente em 2010, este direito foi inserido como direito social no dispositivo 6o da Constituição da República Federativa. O estudo busca debater as garantias do acesso à alimentação adequada de lactentes e crianças com necessidades alimentares especiais transitórias ou definitivas, que em função de alterações metabólicas, fisiológicas ou patologias necessitam de dieta alimentar exclusiva. Dentre as alterações, é possível citar doenças que hipersensibilidades afetam alimentares o trato gastrointestinal (alergias), desnutrição (vômitos, e erros diarreias), inatos do metabolismo. A falta ou falha no fornecimento de fórmulas dietéticas especiais pode prejudicar o crescimento e desenvolvimento humano e, até mesmo, levar o indivíduo a morte. A diarreia é uma das principais causas da mortalidade infantil, matando mais crianças do que a AIDS, a malária e o sarampo juntos 1 . Considerando o impacto das mortes infantis por diarreia, em 2006, os gestores brasileiros do Sistema Único de Saúde (SUS) firmaram o Pacto pela Vida, que tinha por objetivo reduzir a mortalidade neonatal em 5% e em 50% os óbitos infantis por doença diarréica. O método qualitativo indutivo utilizado para análise dos dados coletados no Sistema de Informações sobre Mortalidade (SIM) - DATASUS comprovou que houve um decréscimo nas mortes de lactentes e crianças até 01 ano de idade nas regiões brasileiras no período de 2006 a 2013.

Sub-Saharan Africa is the region in the world with the highest population growth and child mortality. By measuring to what extent the parents "replace" a child in the case of death, we estimate the direct child replacement effect in Niger between 1976 and 2011. Our novel empirical strategy is a modified 2SPS instrumental variable approach, which exploits the exogeneity of precipitation and outdoor temperature in connection with the mother's pregnancy and the child's first five years. We find an estimate of 0.9. The estimate found close to unity implicates a relatively small trade-off between reducing child mortality and population growth, both being large problems in Niger. Our approach is a contribution to the literature on quasi-experimental methods in that we consider properties of respondents on an individual level in the first stage model, and redefine the outcome to a household level in the second stage. The redefinition is thereby a way of drawing conclusions on a group level.

Background: South Africa accounts for more than a seventh of the global population living with HIV/AIDS and TB, and ranks highest in HIV/TB co-infection worldwide. Consequent high child mortality is exacerbated by child malnutrition, which is an important indicator of health status and is associated with morbidity as well as mortality. Rural areas usually present with the greatest burden of morbidity and mortality, yet the extent of geographical disparities in child mortality, malnutrition and HIV/TB has hardly been explored. This is a reservoir of information useful for effective public health interventions. In this thesis we investigated the factors associated with childhood HIV/TB mortality and malnutrition, how they interrelate and their spatial distribution in the rural Agincourt sub-district located in north-east South Africa close to the border with Mozambique. Rationale: Africa at large lacks data that are routinely and reliably collected then validated, to guide policy and intervention programmes. Causes of deaths and even death counts are often misclassified and underestimated respectively, especially for children. To bridge this gap, a health and socio-demographic surveillance systems located in the rural Agincourt sub-district hosts which annually collects and collates data on vital events including fertility, mortality and migration. These data have been collected since 1992 to-date and now cover 80,000 people living in more than 16,000 households situated in 27 villages; all households are fully geo-coded. These hierarchical data allow us to address several epidemiological questions on how person, place (spatial) and time (temporality) have impacted on mortality and malnutrition patterns in children living in the rural Agincourt sub-district. Objectives: The aims of this thesis were both methodological and applied: Methodological (1) To investigate the presence of spatial autocorrelation in the Agincourt sub-district and model this using geographical and geo-statistical procedures (2) To model large spatial random effects accurately and efficiently (3) To model hierarchical data with zero inflated outcomes Applied (1) To investigate childhood HIV/TB mortality determinants and their geographical distribution using retrospective and cross-sectional data (2) To determine factors associated with malnutrition outcomes adjusting for their multivariate spatial random effects and selection bias for children under five years (3) To model how the associated factors were interrelated as either underlying or proximate factors of child mortality or malnutrition using pathway analysis. Methods: We conducted a secondary data analysis based on retrospective and cross-sectional data collected from 1992 to 2010 from the Agincourt sub-district in rural northeast South Africa. During the period of our study 71,057 children aged 0 to 9 years from 15,703 households were observed. All the data in the thesis were for children aged 1 to under 5 except for the chapter 6 (last paper) who were aged from 0 to 9 years of age. Child HIV/TB death and malnutrition were the outcome measures; mortality was derived from physicianbased verbal autopsy. We investigated presence of spatial autocorrelation using Moran’s and Geary’s coefficients, semi-variograms and estimated the spatial parameters using Bayesianbased univariate and multivariate procedures. Regression modelling that adjusted for spatial random effects was done using linear regression and zero inflated variants for logistic, Poisson and Negative Binomial regression models. Structural equation models were used in modelling the complex relationships between multiple exposures and child HIV/TB mortality and malnutrition portrayed by conceptual frameworks. Risk maps were drawn based on spatial residuals (posteriors) with prediction (kriging) procedures used to estimate for households where no data were observed. Statistical inference on parameter estimation was done using both the frequentist; maximum likelihood estimation and Bayesian; Markov Chain Monte Carlo (MCMC) directly and sometimes aided with Metropolis Hastings or Integrated Nested Laplace Approximations (INLA). Results: The levels of child under-nutrition in this area were: 6.6% wasted, 17.3% stunted and 9.9% underweight. Moran’s (I) and Geary’s (c) coefficients indicated that there was global and local clustering respectively. Estimated severity of spatial variation using the partial-sill-to-sill ratio yielded 12.1%, 4.7% and 16.5%, for weight-for-age, height-for-age and weight-for-height Z-scores measures respectively. Maternal death had the greatest negative impact on child HIV/TB mortality. Other determinants included being a male child and belonging to a household that had experienced multiple deaths. A protective effect was found in households with better socio-economic status and where older children were present. Pathway analyses of these factors showed that HIV had a significant mediator effect and the greatest worsening effect on malnutrition after controlling for low birth-weight selection bias Several spatial hot spots of mortality and malnutrition were observed, with these regions consistently emerging as areas of greater risk, which reinforces geographical differentials in these public health indicators. Conclusion: Modelling that adjusts for spatial random effects, is a potentially useful technique to disclose hidden patterns. These geographical differences are often ignored in epidemiological regression modelling resulting in reporting of biased estimates. Proximate and underlying determinants, notably socioeconomic status and maternal deaths, impacteddirectly and indirectly on child mortality and malnutrition. These factors are highly relevant locally and should be used to formulate interventions to reduce child mortality. Spatial prediction maps can guide policy on where to best target interventions. Child interventions can be more effective if there is a dual focus: treatment and care for those already HIV/TB infected, coupled with prevention in those geographical areas of greatest risk. Public health population-level interventions aimed at reducing child malnutrition are pivotal in lowering morbidity and mortality in remote areas. Keywords: HIV/TB, Child mortality, Child malnutrition, Conceptual framework, Spatial analysis, MCMC, Path analysis, South Africa

Even if child mortality has decreased significantly since 1990, it is still a substantial issue that is prevalent all over the world. Regional differences are significant, and Sub-Saharan Africa is the most affected area. Traditionally, researchers have turned to the medical field for health-related issues. However, social, and structural factors, among them gender inequality, are also crucial in determining health and life conditions. The purpose of this thesis was to investigate how intrahousehold gender inequality affects child mortality in Sierra Leone. The study was made through a cross-sectional study using data from the Sierra Leone Demographic Health Survey. A quantitative method was used, and analysis was conducted using OLS regression. In contrast to previous research, the results do not show a significant covariation between maternal education and child mortality. Likewise, paternal education and the difference in education between men and women showed no significant covariation with child mortality. However, polygyny, the number of wives and the first event of intimate partner violence were positively associated with child mortality. More studies about gender inequality in relation to child mortality should be conducted to strengthen the results and increase the knowledge and understanding of this subject.

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Life in the eighteenth-century Tidewater was set against the grim specter of death. Children were especially vulnerable, perishing with disheartening frequency throughout the century. Yet despite the high rates of child mortality, Tidewater culture underwent a revolution in regard to the eighteenth-century family. Children became the emotional focus of the family, becoming cherished for their youthful capering and playful nature. However, child death was no less common. The way in which parents coped with the death of a child changed throughout the century, reflecting the emotionalized understanding of children and childhood. The rituals surrounding the death of a child—from preparations for burial, the funeral, and lasting commemorations—evolved over the course of the eighteenth century, reflecting the new place of the child within the eighteenth-century family and the emotional trauma felt by the family after the death of a child. / Master of Arts

Master of Agribusiness / Department of Agricultural Economics / John A. Fox / Child mortality is defined as the death of children under five years old. Worldwide, child mortality was about 8.1 million in 2009, of which over fifty percent is related to diarrhea, pneumonia and malaria. Food and water borne pathogens are an important cause of deaths related to diarrhea and pneumonia. Illiterate or semi-literate populations are often slow to adopt food and water safety standards. Practices such as washing of food in sewage water, which would repulse most westerners might be considered normal in some parts of the world. Understanding some of the basic science underlying food safety standards is important for the farm worker in California, the villager in Africa and the child in Afghanistan. Ultimately, food safety practices in production can affect the consumer of agricultural products no matter where they are in the world, and inadequate food safety standards can affect the producer as a result of diminished consumer confidence in their product, or lack of access to export markets. In the instance of food contamination, young children and the elderly are typically most at risk. Perhaps the most sobering consequence of inadequate food safety standards is child mortality. This thesis uses a regression model to investigate determinants of the level of child mortality. We find that income distribution and levels of tertiary education, particularly for females, are significantly correlated with child mortality rates. Estimates suggest that a one percent increase in tertiary education in the female workforce is associated with a reduction of almost seven percent in the child mortality rate in countries where the rate of female tertiary education is below fifteen percent.

Esta dissertação de mestrado tem por objetivo principal estabelecer os perfis de ocorrência de estresse e mortalidade de dois diferentes grupos pré-históricos de São Paulo - os construtores do sambaqui fluvial Moraes e do sambaqui litorâneo Piaçaguera - relacionando-os com o estilo de vida e subsistência de cada um desses grupos. O período foco de interesse foi o infantil mesmo que os indivíduos adultos estivessem sendo analisados. Foram considerados para tanto 88 indivíduos de Piaçaguera e 55 de Moraes, todos eles analisados para o estabelecimento do perfil de mortalidade. Já para a análise de hipoplasias foram considerados, respectivamente 28 e 21 indivíduos, que cumpriram os critérios de inclusão definidos para a análise. Como resultado observou-se uma alta mortalidade na infância em ambas as séries, no entanto com diferenças entre os períodos mais afetados. A série de Piaçaguera apresentou maior risco de morrer em períodos mais tardios da infância enquanto que Moraes apresentou maior risco ainda no período neonatal. Já ao se considerar as hipoplasias lineares de esmalte, há uma sinalização no sentido da ocorrência de estresse relativamente contínuo durante toda a fase intermediária da infância em Moraes, que não apresentou picos de ocorrência de defeitos hipoplásicos. Já para Piaçaguera, os dados sugerem a ocorrência de um período de maior ocorrência/susceptibilidade ao estresse, o qual corresponde a um pico de prevalência de defeitos hipoplásicos entre 3 e 4 anos. / This dissertation has as main objective to establish the profiles of occurrence of stress and mortality on two different prehistoric groups from São Paulo State, Brazil - the builders of the riverine shellmound Moraes and the builders of the coastal shellmound Piaçaguera - relating them to the lifestyle and subsistency of each of these groups. The period focus of interest was the childhood, even if the adults were being analyzed. In order to establish the mortality profile were analized 88 individuals from Piaçaguera and 55 individuals from Moraes. For the analysis of hypoplasias were considered, respectively, 28 and 21 individuals which met the inclusion criteria defined for the analysis. There is possible to stabilish that if the child mortality is very high in both series, there are strong differences between the ages periods more affecteds. The Piaçaguera\'s skeletal serie showed a higher risk of dying in later periods of childhood while Moraes had a higher risk in the neonatal period. Considering the data obteined for linear enamel hypoplasia, there is a signal towards the occurrence of stress relatively continuous throughout the intermediate phase of childhood in Moraes. For this sample there are no peaks of occurrence of hypoplastic defects. In contrast, the data produced for Piaçaguera\'s sample suggest the occurrence of a period of higher incidence / susceptibility to stress, which corresponds to a peak prevalence of hypoplastic defects between 3 and 4 years old .

As taxas de infecção hospitalar (IH) entre centros neonatais variam consideravelmente, sugerindo que fatores de risco possam ser modificados pela qualidade da assistência, as características do recém-nascido (RN) e o controle das infecções. O objetivo deste estudo foi analisar a epidemiologia da infecção e da mortalidade hospitalar na Unidade de Terapia Intensiva Neonatal do Hospital Geral de Itapecerica da Serra SECONCI SP OSS de 1º de janeiro de 2002 a 31 de dezembro de 2003. O estudo foi desenvolvido em modelo de coorte e a análise dos dados referentes às IH precoces e tardias foi retrospectiva, mas eles foram coletados prospectivamente, seguindo os métodos do NNIS (National Nosocomial Infection Surveillance System). Os RN foram classificados pelo Neonatal Therapeutic Intervention Scoring System (NTISS) para avaliar sua gravidade, dentro das primeiras 24 horas após a admissão. Foram incluídos no estudo 486 RN: 426 de origem interna (87,7%) e 60 de origem externa (12,3%). A incidência acumulada de IH foi de 30,6% e a densidade de 25,1 por 1.000 pacientes-dia (7,9 para infecção precoce e 17,2 para a tardia). A sepse foi o tipo de infecção mais freqüente (54,0%) seguida pela pneumonia (20,0%). Dos agentes microbianos isolados, 54,3% foram gram-positivos, sendo o mais encontrado o Staphylococcus coagulase negativo. A maioria dos RN teve um escore de gravidade menor ou igual a 19 (88,1%), sendo a pontuação máxima encontrada de 39, e os RN externos obtiveram uma pontuação significantemente maior. A aquisição de IH, tanto precoce como tardia, mostrou-se associada com a gravidade do RN à admissão. A taxa de mortalidade hospitalar foi de 8,6% e mostrou-se mais elevada entre os RN de origem externa. As IH foram a causa ou contribuíram para o óbito em 26 (61,9%) dos RN que faleceram. Não houve associação estatística entre o local de nascimento e a ocorrência de infecção hospitalar precoce e tardia. A análise univariada mostrou os seguintes fatores de risco para infecção tardia: prematuridade, baixo peso, pequeno para a idade gestacional, número de consultas de prénatal, reanimação na sala de parto, uso de respirador, cateter central, nutrição parenteral, tempo de permanência e escore de gravidade à admissão. Na análise múltipla, o modelo final incluiu as variáveis: peso de nascimento, escore terapêutico nas primeiras 24 horas após a admissão e uso de nutrição parenteral. A epidemiologia da infecção hospitalar da UTIN do HGIS está de acordo com o observado na literatura médica. Ela está sujeita às características dos RN assistidos, às práticas assistenciais e de controle de infecção hospitalar implementadas pelo serviço de terapia intensiva neonatal, independente do local de nascimento do RN admitido na UTIN. / Nosocomial infections rates varies widely among Neonatal Centers suggesting that risk factors can be modify by assistance quality, newborn characteristics and infection control practices. The aim of this study was to analyze nosocomial infections epidemiology and mortality rate among neonates admitted to a Neonatal Intensive Care Unit of Hospital Geral de Itapecerica da Serra SECONCI SP OSS from January 1, 2002 to December 31, 2003. The study was carried out in a cohort model, with data analyze retrospectively but collected by active surveillance following the NNIS (National Nosocomial Infection Surveillance System) methodology. Neonates were classified according to Neonatal Therapeutic Intervention Scoring System (NTISS) to assess illness severity within the first 24 hours of admission. 486 newborn infants were included in the study: 426 (87.7%) inborn infants and 60 (12.3%) out born infants. Nosocomial infection incidence rate was 30.6% and the incidence density was 25.1 per 1000 patients-day (7.9 for early infections and 17.2 for late infections). Sepsis was the most frequent infection (54.0%), followed by pneumonia (20.0%). Among microbial agents isolated 54.3% were Gram-positive organisms, and coagulase-negative staphylococci were the most frequent. Most neonates have shown a severity score lower or equal to 19 (88.1%), and the maximum score was 39. Outborn neonates have shown a significant higher severity score. Nosocomial infections were associated with newborn severity index at admission. Nosocomial mortality rate was 8.6% and higher among out born neonates. Hospital infections were classified as cause or contributed for death in 26 (61.9%) neonates. No statistic association was seen between the neonate birth place and nosocomial infections. Univariate analyzes showed the following risk factors for late infections: prematurity, low birth weigh, low weight for gestational age, prenatal visits number, resuscitation following birth, respirator, central catheter and parenteral nutrition use, length of stay and severity score at admission. Multivariate logistic regression model included the following variables: birth weigh, therapeutic score within 24 hours of admission and parenteral nutrition use. Nosocomial infection epidemiology at HGIS´s UTIN is similar with what was observed in medical literature. It is dependent of newborn characteristics, assistance and infection control practices within the neonatal intensive care therapy, and is independent of newborn place of birth