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CHOP Global Health Center: Advancing Child Health in Resource-limited Countries
By Nancy McCann
Leading the charge to improve the health and well-being of children and adolescents in low- and middle-income countries is Children's Hospital of Philadelphia Global Health Center.
Created in 2007, the Center advocates for children, seeking to optimize mutually beneficial partnerships between clinical and academic institutions in diverse settings. Its focus is to provide excellent clinical care and effective training, facilitate locally relevant high-quality research, and engage in evidence-based advocacy in over 18 countries around the world.
"CHOP has brilliant researchers in many different areas, and our partners have brilliant researchers too," said Andrew Steenhoff, MBBCh, DCH, the Global Health Center's Medical Director. "What we are seeking to do is to allow magic to happen where those partners and CHOP colleagues work together to advance child health in low- and middle-income countries."
The CHOP team looks to its partners in Botswana, the Dominican Republic, and Ghana for information on locally relevant research priorities for children and where they could use help from CHOP experts. This could include getting more clinical expertise on their teams, or a trainee interested in leading work in a certain area where the site has clinical questions of importance.
"CHOP has the critical mass that is allowing us to accelerate the pace at which we're able to support these important global health issues," said Elizabeth Lowenthal, MD, MSCE, who is the Research Director of the Center and lived full-time in Botswana for four years serving in a large clinic dedicated to the care and treatment of children with HIV infection. "We're trying to help children in resource-limited settings by leveraging what we can within the CHOP community for mutual benefit."
The partnerships' intention is always focused on capacity building.
"We must be careful about what our goal is and make sure that we have a plan from the beginning of a partnership to ensure our exit is intentional and doesn't leave a gap," she said.
Addressing Needs of Newborns and Adolescents
Concentrating on age groups of children who are at high risk for adverse outcomes in resource-limited countries, CHOP investigators are working to advance newborn and adolescent health globally.
"Newborns around the world, particularly in low- and middle-income countries (LMIC), are dying at a disproportionate rate as compared to other children," Dr. Steenhoff said. "And on the other end of the spectrum, adolescents are a neglected group in many low- and middle-income countries — often after the age of 13 years, teens just get moved to the adult world, and some fall through the cracks."
Working to advance newborn health in these countries are CHOP physicians and researchers Carolyn McGann, MD; Susan Coffin, MD, MPH; and Jonathan Strysko, MD, MSc, IBCLC, a CHOP pediatrician and infectious disease epidemiologist based in Botswana. Their research focuses on the prevention of healthcare-associated infections in neonates and young children in resource-limited countries.
Participating in a study on antibiotic use for sepsis in hospitalized neonates in Botswana, the researchers found there were factors associated with guideline-divergent prescribing. The majority of neonates (325/470, 69%) were prescribed one or more antibiotic, and 31 (10%) received a guideline-divergent antibiotic, with prematurity being a risk factor for divergent prescribing. Microorganisms published this high-impact neonatology paper.
"Studies are needed to both define the causes of this differential rate of guideline-divergence and then to address it," Dr. Coffin said.
Merrian Jacqueline Brooks, DO, an adolescent medicine specialist and pediatric global health expert, is CHOP's lead pediatrician based in Botswana. Her research focuses on improving access to evidence-based behavioral interventions for youth in LMIC.
In a study led by Dr. Brooks, the research team created a problem-solving-based counseling intervention in Botswana called Safe Haven, delivered by near-peer youth lay counselors for youth living with HIV. Safe Haven was seen as largely acceptable among the youth, a place where they had freedom of expression and could receive practical advice from well-trained and approachable counselors.
"Trained near-peer youth lay counselors show promise to meet the mental health needs of mild and moderately symptomatic youth, where mental health professionals are in short supply," Dr. Brooks said.
Providing Guidelines to Treat Infections
HIV, tuberculosis, pneumonia, and diarrhea are driving the highest child mortality and morbidity rates in LMIC. Take tuberculosis, for instance. It's a common infection, as a quarter of the world's population is infected with TB, according to Dr. Steenhoff, who studies the disease.
"Worldwide, TB is the second leading infectious killer after COVID-19," Dr. Steenhoff said. "Children are at high risk for TB infection and more severe TB disease, particularly in their first few years of life, because their immune systems have not matured yet."
Dr. Steenhoff and a group of pediatricians from around the world published in The Lancet a systematic review and consensus practice guidelines for clinicians to use when they see a mother with TB who has just delivered a baby. Even though TB is a common and important infection, this is the first paper to offer a clear clinical pathway to approach newborn babies when the mother has TB disease or when the mother has TB infection, which is usually asymptomatic.
"We are hopeful these guidelines will lift the standard of care in every situation where a newborn baby has been exposed to TB infection or disease," Dr. Steenhoff said. "It's helpful for doctors and nurses everywhere to have access to a global standard of care, and also to encourage further research in this neglected area."
Translating Implementation Science Frameworks
As research director for CHOP's Global Health Center, Dr. Lowenthal supports junior researchers, and senior researchers newly working in international settings, to develop projects addressing other health priorities for children in resource-limited countries. One project she is most proud of is the "Spanish Translation of the Expert Recommendations for Implementing Change (ERIC) compilation," published in July.
ERIC is one of many implementation science frameworks created to help scientists move things from development to implementation on a much faster timeline than normal evidence-based intervention, which traditionally can take 18 years. These frameworks are almost all developed and available only in English. Although English is the language of choice in some of CHOP's partner countries, Spanish is a commonly utilized language in resource-limited settings.
And so the Global Health Research Affinity Group, sponsored by the CHOP Research Institute, adapted two of the most commonly used frameworks into Spanish: ERIC and the Consolidated Framework for Implementation Research (CFIR). The CFIR translation is awaiting publication.
Multicultural, bilingual Spanish speakers worked with the research team to adapt these frameworks to use the terminology while being cognizant of the differences in medical systems, so that the Spanish version will translate across cultures.
The ERIC paper's authors describe the translation itself as well as the process, with the hope of more researchers replicating it for other languages and cultures. Dr. Lowenthal's former doctorate student Amy Van Pelt, PhD, is the lead author, and her co-authors are from Northwestern University, Columbia University, George Mason University, Washington University, and the University of Pennsylvania.
Editor's Note: Join the Global Health Center team at this year's 16th Annual CHOP Pediatric Global Health Conference, "Rising Up Together: Child Health in the Face of Climate Change." It will explore short- and long-term interventions to help mitigate the impact of climate change on child health. The event takes place Oct. 25 – 26. Registration is required.
"The impact of climate change on children is disproportionate to the impact on other populations," Dr. Lowenthal said. "Providing the evidence for what we already know is going to be important to the political conversations that are needed to make a difference in where this world is headed."