Comparison of physical, public and human assets as determinants of socioeconomic inequalities in contraceptive use in Colombia - moving beyond the household wealth index

How Poor Is Your Sample? A Simple Approach for Estimating the Relative Economic Status of Small and Nonrepresentative Samples

BACKGROUND

Asset-based indices of living standards, or wealth indices, are widely used proxies for economic status; however, such indices are not readily available for small and nonrepresentative samples.

METHODS

We describe a simple out-of-sample prediction approach that uses estimates from large and representative "reference" samples to calculate measures of relative economic status (e.g., wealth index scores) for small and/or nonrepresentative "target" samples. The method relies on the availability of common variables and assumptions about comparable associations between these variables and the underlying construct of interest (e.g., household wealth). We provide 2 sample applications that use Demographic and Health Surveys (DHS) from 5 countries as reference samples. Using ordinary least squares regression, we estimate associations between household characteristics and the DHS wealth index. We use parameter estimates to predict wealth index scores for small nonrepresentative target samples. Comparisons of wealth distributions in the reference and target samples highlight selection effects.

RESULTS

Applications of the approach to diverse populations, including populations at high risk of HIV infection and households with orphaned and separated children, demonstrate its usefulness for characterizing the economic status of small and nonrepresentative samples relative to existing reference samples. Women and men in northern Tanzania at high risk of HIV infection were concentrated in the upper half of the wealth distribution. By contrast, the relative distribution of household wealth among households with orphaned and separated children varied greatly across countries and rural versus urban settings.

CONCLUSIONS

Public health professionals who implement, manage, and evaluate programs in low- and middle-income countries may find this approach applicable because of the simplicity of the estimation methods, low marginal cost of primary data acquisition, and availability of established measures of relative economic status in many publicly available household surveys (e.g., those administered by the DHS Program, World Bank, International Labour Organization, and UNICEF).

Contraceptive use and its determinants among adolescent women in Tigray, Ethiopia: a multilevel modeling

Background Adolescent women are central for intergenerational health of human populations. Adolescent women are the most vulnerable to a range of reproductive health problems. One of the leading causes of death for adolescent women is complications from childbirth and pregnancy. Contraceptive prevents the occurrence of unwanted pregnancies and its complications, thus potentially lower the death rate for adolescent women. However, contraceptive use assumed to be affected by multilevel factors thus needs statistical modeling that account the effect of these factors. Understanding multilevel factors affecting contraceptive use among adolescent women is important for improving the access to and quality of health services. Objective The aim of this study was to assess the contraceptive use and its multilevel determinants among adolescent women in Tigray region. Methods A community based cross-sectional study was conducted. Women who were 15-19 years of age residing in the selected households at the time of data collection were included in the survey. Multi-stage cluster sampling was used to select study units. A multivariable two-level mixed effect binary logistic regression model was fitted to assess the effect of the explanatory variables on contraceptive use. Results A total of 1,755 adolescent women were participated. Of these 12.3% were contraceptive users. Pills (40%) and intrauterine device (30%) were commonly used contraceptive methods. Educational level, schooling, marital status, age, being informed about contraceptive, health facility visit, duration of stay at their residence, having partner and hearing of contraceptive use message through media were the most important determinants for use of contraceptive among adolescent women. Study participants who were not at school currently had more likely to use contraceptive methods compared to those who were at school (Adjusted odds ratio [AOR]=2.05; 95% confidence interval [CI]: 1.502, 4.183). Similarly, adolescent women who had no history of health facility visit had less likely to use contraceptive methods than those have history of health facility visit (AOR=0.057; 95% CI: 0.034, 0.096). Adolescent women who heard of contraceptive through median had two times (AOR=2.103; 95% CI: 1.207, 3.664) more likely to use contraceptive methods than those not heard contraceptive through media. Conclusion and recommendation The factors affecting use of contraceptive method among adolescent women were educational level, schooling, marital status, age, being informed about contraceptive, health facility visit, duration of stay at their residence, having partner and hearing of contraceptive use message through media. This study recommends that in order to increase use of contraceptive method among adolescent women, interventions should continue like the promotion of contraceptive methods through media.

Individual and community level associates of contraceptive use in Ethiopia: a multilevel mixed effects analysis

BACKGROUND

Family planning is one of the four pillars of safe motherhood initiative to reduce maternal death in developing countries. Despite progress in contraceptive use, unmet needs are wide open and fertility remains high. Ethiopia have a higher fertility rate which contributes to maternal and child health destitution, putting pressure on the already weak health system. This study examined individual and community-level factors associated with contraceptive use in Ethiopia.

METHODS

Data from Ethiopian Demographic and Health Survey 2016 were used to identify individual and community level associated factors among reproductive-age women. Non-pregnant, fecund and sexually active women aged 15-49 were included. Six hundred forty-two communities and 6854 women were involved from this two-stage cluster sampled data. The analysis was done using two-level mixed-effects logistic regression to determine fixed effects of individual and community-level factors and random intercept of between characteristics.

RESULTS

From the total eligible women for contraceptive use 2393 (34.9%) of them were users. Injectables were the commonest of all contraceptive methods. Various individual-level variables were associated with contraceptive use. Household wealth index, women's age, number of living children, husband's occupation, ever experience of a terminated pregnancy, current working status of the women, number of births in the last 3 years, and hearing of FP messages through different media were significantly associated individual-level variables after adjusting other factors. Community characteristics like region, place of residence, religion, and community-level wealth were the factors associated with contraceptive use.

CONCLUSION

Both individual and community-level characteristics were significant predictors of use of contraceptives in Ethiopian women. Besides the individual-level factors, interventions should also consider community-level associates.

Sanitation in Rural India: Exploring the Associations between Dwelling Space and Household Latrine Ownership

In 2017, the Joint Monitoring Programme estimated that 520 million people in India were defecating in the open every day. This is despite efforts made by the government, Non-Governmental Organizations (NGOs), and multilaterals to improve latrine coverage throughout India. We hypothesize that this might be because current interventions focus mostly on individual-level determinants, such as attitudes and beliefs, instead of considering all possible social determinants of latrine ownership. Given this, we ask two questions: what is the association between the amount of dwelling space owned by households in rural India and their likelihood of toilet ownership and what proportion of the variation in household latrine ownership is attributable to villages and states? We used multilevel modeling and found significant associations between the amount of household dwelling space and the likelihood of latrine ownership. Furthermore, considerable variation in latrine ownership is attributable to villages and states, suggesting that additional research is required to elucidate the contextual effects of villages and states on household latrine ownership. Thus, sanitation interventions should consider household dwelling space and village and state context as important social determinants of latrine ownership in rural India. Doing so could bolster progress towards Sustainable Development Goal (SDG) 6.

Housing index, urbanisation level and lifetime prevalence of depressive and anxiety disorders: a cross-sectional analysis of the Colombian national mental health survey

OBJECTIVES

To study socioeconomic inequalities in mental health in rural and urban Colombia, a country with a history of internal conflict and large socioeconomic inequalities. Recent survey data are available to study this understudied topic in a middle-income country.

METHODS

Using data from 9656 respondents from the 2015 Colombian Mental Health survey, we investigated the association between lifetime prevalence of depressive and anxiety disorders and quality of dwellings and access to public services housing score (HS). We calculated the relative index of inequality (RII) and slope index of inequality (SII) for HS in urban and rural areas, adjusting for potential confounders and mediating factors.

OUTCOMES

The lifetime prevalence of anxiety and depression (combined) was 9.6% in urban versus 6.9% in rural areas (p<0.001). HS was not associated with prevalence of anxiety and depression in urban settings, whereas a higher HS (poorer housing quality) was associated with fewer mental disorders in rural areas in both univariate and multivariate models (multivariate RII_urban0.96 (95% CI 0.51 to 1.81); RII_rural0.11 (95% CI 0.04 to 0.32)). In rural areas, the prevalence of mental health problems was 12% points lower in persons living in the poorest quality dwellings than in those living in high-quality dwellings (SII -0.12 (95% CI -0.18 to -0.06)). Interestingly, within rural areas, persons living in 'populated centres' (small towns, villages) had a higher lifetime prevalence of any mental health disorder (9.8% (95% CI 6.9 to 13.6)) compared with those living in more isolated, dispersed areas (6.0% (95% CI 4.6 to 7.7)).

INTERPRETATION

In rural Colombia, those living in the poorest houses and in dispersed areas had a lower prevalence of mental health problems. Further understanding of this phenomenon of a seemingly inverse association of prevalence of mental disorders with poverty and/or urbanisation in rural areas is needed. Particularly, considering the progressive urbanisation process in Colombia, it is important to monitor mental health in populations migrating to the cities.

Social patterning of cardiovascular and metabolic risk in Colombian adults

OBJECTIVES

To test for differences in cardiovascular and metabolic risk (CMR) by educational attainment and physical capital. To compare CMR among black, indigenous, and mixed populations, accounting for socioeconomic status (SES).

DESIGN

We conducted multivariate analyses using cross-sectional data from a national survey of Colombian adults (n = 10,814) to examine the social patterning of CMR. In sex/gender-stratified models, a CMR index was regressed on educational attainment, physical capital, ethnicity/race, and age.

RESULTS

Women with a primary education (OR = 1.64, 95% CI: 1.25, 2.15) had higher age- and ethnicity/race-adjusted odds of CMR than women with more than secondary education. Men with a primary education (OR = 0.67, 95% CI: 0.48, 0.92) had significantly lower adjusted odds of CMR than men with more than secondary education; these associations did not remain significant after adjustments for physical capital. Men in the first (OR = 0.45, 95% CI: 0.36, 0.57) and second (OR = 0.72, 95% CI: 0.57, 0.91) physical capital tertiles had significantly lower adjusted odds of CMR than those in the highest tertile. There was not a significant patterning of CMR by ethnicity/race for women or men, or by physical capital for women.

CONCLUSIONS

Findings suggest that for Colombian adults CMR is patterned by SES; these associations differ by sex/gender.

Use of modern contraceptives among married women in Vietnam: a multilevel analysis using the Multiple Indicator Cluster Survey (2011) and the Vietnam Population and Housing Census (2009)

Background

The prevalence of modern contraceptive use is an important indicator that reflects accessibility to reproductive health services. Satisfying unmet needs for family planning alone could reduce the number of maternal deaths by almost a third. This study uses multiple data sources to examine multilevel factors associated with the use of modern contraceptives among married women in Vietnam aged 15–49 years.

Design

Data from different national surveys (Vietnam Population and Housing Census, Vietnam Living Standard Survey, and Multiple Indicator Cluster Survey) were linked to create a dataset including individual and contextual (provincial) variables (N=8,341). Multilevel modeling was undertaken to examine the impact of both individual and provincial characteristics on modern contraceptive use. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported.

Results

Individual factors significantly associated with the use of modern contraceptives were age 30–34 years (reference 15–19 years) (OR=1.63); high socioeconomic status (SES) (OR=0.8); having two living children (OR=2.4); and having a son (OR=1.4). The provincial poverty rate mediated the association between the individual's SES and the likelihood of using modern contraceptives.

Conclusions

The proportion of women in Vietnam using modern contraceptive methods has remained relatively high in recent years with significant variation across Vietnam's 63 provinces. Women of lower SES are more likely to use modern contraceptive methods, especially in the poorer provinces. Achieving access to universal reproductive health is one of the Millennium Development Goals. Vietnam must continue to make progress in this area.

A decade of improvements in equity of access to reproductive and maternal health services in Cambodia, 2000-2010

INTRODUCTION

Despite encouraging reductions in global maternal mortality rates, Millennium Development Goal (MDG) 5 on reducing maternal mortality and achieving universal access to reproductive health remains the most off-track of all MDGs. Furthermore a preoccupation with aggregate coverage statistics masks extensive disparities in health improvements between societal groups. Recent national health indicators for Cambodia highlight impressive improvements, for example, in maternal, infant and child mortality, whilst substantial government commitments have been made since 2000 to address health inequities. It is therefore timely to explore the extent of equity in access to key reproductive and maternal health services in Cambodia and how this has changed over time.

METHODS

Analysis was conducted on three rounds of Demographic and Health Survey data from 2000, 2005 and 2010. Outcome variables comprised utilisation of six reproductive and maternal health services--antenatal care, skilled birth attendance, facility-based delivery, postnatal care, met need for family planning and abortion by skilled provider. Four equity measures were calculated--equity gaps, equity ratios, concentration curves and concentration indices. Household assets were used to create the social-stratification variable, using principal components analysis.

RESULTS

Coverage levels of all six services improved over the decade. Coverage improvements were greatest amongst wealthier quintiles of the population, although poorer quintiles also increased use of services. Critically, inequity in service use of all services dramatically reduced over time, except for postnatal care where inequity increased slightly. However, in 2010 inequity in service use remained favouring wealthier quintiles, greatest in use of skilled birth attendance and facility-based delivery, though the magnitude of inequity was substantially reduced compared to 2000. Met need for family planning was almost perfectly equitable in 2010.

CONCLUSIONS

Cambodia has made impressive improvements in overall coverage of reproductive and maternal health services over the last decade, and also in the distribution of their use across wealth quintiles. A range of pro-poor health financing and supply-side policies as well as non-health factors may have contributed to these achievements. Further research will explore specific schemes qualitatively and quantitatively to assess their impact on equity and service use.

The influence of socioeconomic status on women's preferences for modern contraceptive providers in Nigeria: a multilevel choice modeling

BACKGROUND

Contraceptives are one of the most cost effective public health interventions. An understanding of the factors influencing users' preferences for contraceptives sources, in addition to their preferred methods of contraception, is an important factor in increasing contraceptive uptake. This study investigates the effect of women's contextual and individual socioeconomic positions on their preference for contraceptive sources among current users in Nigeria.

METHODS

A multilevel modeling analysis was conducted using the most recent 2008 Nigerian Demographic and Health Surveys data of women aged between 15 and 49 years old. The analysis included 1,834 ever married women from 888 communities across the 36 states of the federation, including the Federal Capital Territory of Abuja. Three outcome variables, private, public, and informal provisions of contraceptive sources, were considered in the modeling.

RESULTS

There was variability in women's preferences for providers across communities. The result shows that change in variance accounted for about 31% and 19% in the odds of women's preferences for both private and public providers across communities. Younger age and being from the richest households are strongly associated with preference for both private and public providers. Living in rural areas and economically deprived neighborhoods were the community level determinants of women's preferences.

CONCLUSION

This study documents the independent association of contextual socioeconomic characteristics and individual level socioeconomic factors with women's preferences for contraceptive commodity providers in Nigeria. Initiatives that seek to improve modern contraceptive uptake should jointly consider users' preferences for sources of these commodities in addition to their preference for contraceptive type.

Individual and community level socioeconomic inequalities in contraceptive use in 10 Newly Independent States: a multilevel cross-sectional analysis

INTRODUCTION

Little is known regarding the association between socioeconomic factors and contraceptive use in the Newly Independent States (NIS), countries that have experienced profound changes in reproductive health services during the transition from socialism to a market economy.

METHODS

Using 2005-2006 data from Demographic Health Surveys (Armenia, Azerbaijan, and Moldova) and Multiple Indicator Cluster Surveys (Belarus, Georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Ukraine, and Uzbekistan), we examined associations between individual and community socioeconomic status with current modern contraceptive use (MCU) among N = 55,204 women aged 15-49 married or in a union. Individual socioeconomic status was measured using quintiles of wealth index and education level (higher than secondary school, secondary school or less). Community socioeconomic status was measured as the percentage of households in the poorest quintile of the nationals household wealth index (0%, 0-25%, or greater than 25%). We used multilevel logistic regression to estimate associations adjusted for age, number of children, urban/rural, and socioeconomic variables.

RESULTS

MCU varied by country from 14% (in Azerbaijan) to 62% (in Belarus). Overall, women living in the poorest communities were less likely than those in the richest to use modern contraceptives (adjusted odds ratio (aOR) = 0.82, 95% Confidence Interval = 0.76, 0.89). Similarly, there was an increasing odds of MCU with increasing individual-level wealth. Women with a lower level of education also had lower odds of MCU than those with a higher level of education (aOR = .75, 95%CI = 0.71, 0.79). In country-specific analyses, community-level socioeconomic inequalities were apparent in 4 of 10 countries; in contrast, inequalities by individual-level wealth were apparent in 7 countries and by education in 8 countries. All countries in which community-level socioeconomic status was associated with MCU were in Central Asia, whereas at the individual-level inequalities of the largest magnitude were found in the Caucasus. There were no distinct patterns found in Eastern European countries.

CONCLUSIONS

Community-level socioeconomic inequalities in MCU were most pronounced in Central Asian countries, whereas individual-level socioeconomic inequalities in MCU were most pronounced in the Caucasus. It is important to consider multilevel contextual determinants of modern contraceptive use in the development of reproductive health and family planning programs.

Comparison of two approaches for measuring household wealth via an asset-based index in rural and peri-urban settings of Hunan province, China

Background

There are growing concerns regarding inequities in health, with poverty being an important determinant of health as well as a product of health status. Within the People's Republic of China (P.R. China), disparities in socio-economic position are apparent, with the rural-urban gap of particular concern. Our aim was to compare direct and proxy methods of estimating household wealth in a rural and a peri-urban setting of Hunan province, P.R. China.

Methods

We collected data on ownership of household durable assets, housing characteristics, and utility and sanitation variables in two village-wide surveys in Hunan province. We employed principal components analysis (PCA) and principal axis factoring (PAF) to generate household asset-based proxy wealth indices. Households were grouped into quartiles, from 'most wealthy' to 'most poor'. We compared the estimated household wealth for each approach. Asset-based proxy wealth indices were compared to those based on self-reported average annual income and savings at the household level.

Results

Spearman's rank correlation analysis revealed that PCA and PAF yielded similar results, indicating that either approach may be used for estimating household wealth. In both settings investigated, the two indices were significantly associated with self-reported average annual income and combined income and savings, but not with savings alone. However, low correlation coefficients between the proxy and direct measures of wealth indicated that they are not complementary. We found wide disparities in ownership of household durable assets, and utility and sanitation variables, within and between settings.

Conclusion

PCA and PAF yielded almost identical results and generated robust proxy wealth indices and categories. Pooled data from the rural and peri-urban settings highlighted structural differences in wealth, most likely a result of localized urbanization and modernization. Further research is needed to improve measurements of wealth in low-income and transitional country contexts.