Health trends in Canada 1990-2019: An analysis for the Global Burden of Disease Study

OBJECTIVE

Monitoring trends in key population health indicators is important for informing health policies. The aim of this study was to examine population health trends in Canada over the past 30 years in relation to other countries.

METHODS

We used data on disability-adjusted life years (DALYs), years of life lost (YLL), years lived with disability, life expectancy (LE), and child mortality for Canada and other countries between 1990 and 2019 provided by the Global Burden of Disease Study.

RESULTS

Life expectancy, age-standardized YLL, and age-standardized DALYs all improved in Canada between 1990 and 2019, although the rate of improvement has leveled off since 2011. The top five causes of all-age DALYs in Canada in 2019 were neoplasms, cardiovascular diseases, musculoskeletal disorders, neurological disorders, and mental disorders. The greatest increases in all-age DALYs since 1990 were observed for substance use, diabetes and chronic kidney disease, and sense organ disorders. Age-standardized DALYs declined for most conditions, except for substance use, diabetes and chronic kidney disease, and musculoskeletal disorders, which increased by 94.6%, 14.6%, and 7.3% respectively since 1990. Canada's world ranking for age-standardized DALYs declined from 9th place in 1990 to 24th in 2019.

CONCLUSION

Canadians are healthier today than in 1990, but progress has slowed in Canada in recent years in comparison with other high-income countries. The growing burden of substance abuse, diabetes/chronic kidney disease, and musculoskeletal diseases will require continued action to improve population health.

Female genital mutilation/cutting among girls aged 0-14: evidence from the 2018 Mali Demographic and Health Survey data

BACKGROUND

Female genital mutilation/cutting (FGM/C) is considered a social norm in many African societies, with varying prevalence among countries. Mali is one of the eight countries with very high prevalence of FGM/C in Africa. This study assessed the individual and contextual factors associated with female FGM/C among girls aged 0-14 years in Mali.

METHODS

We obtained data from the 2018 Mali Demographic and Health Survey. The prevalence of FGM/C in girls was presented using percentages while a multilevel binary logistic regression analysis was conducted to assess the predictors of FGM/C and the results were presented using adjusted odds ratios with associated 95% confidence intervals (CIs).

RESULTS

The results indicate that more than half (72.7%, 95% CI = 70.4-74.8) of women in Mali with daughters had at least one daughter who has gone through circumcision. The likelihood of circumcision of girls increased with age, with women aged 45-49 having the highest odds compared to those aged 15-19 (aOR = 17.68, CI = 7.91-31.79). A higher likelihood of FGM/C in daughters was observed among women who never read newspaper/magazine (aOR = 2.22, 95% CI = 1.27-3.89), compared to those who read newspaper/magazine at least once a week. Compared to women who are not circumcised, those who had been circumcised were more likely to have their daughters circumcised (aOR = 53.98, 95% CI = 24.91-117.00).

CONCLUSION

The study revealed the age of mothers, frequency of reading newspaper/magazine, and circumcision status of mothers, as factors associated with circumcision of girls aged 0-14 in Mali. It is, therefore, imperative for existing interventions and new ones to focus on these factors in order to reduce FGM/C in Mali. This will help Mali to contribute to the global efforts of eliminating all harmful practices, such as child, early and forced marriage and female genital mutilation by 2030.

Influence of type of violence on women's help-seeking behaviour: Evidence from 10 countries in sub-Saharan Africa

BACKGROUND

Intimate partner violence (IPV) is a major public health concern that mostly impacts women's health and social well-being. This study explored how the various types of IPV (physical, sexual, and emotional) including women's experience of childhood violence influence their help-seeking behavior in sub-Saharan Africa (SSA).

METHODS

We analyzed data from the most recent Demographic and Health Surveys (DHS), carried out between 2018 and 2021. The outcome variable was help-seeking behavior. Descriptive and inferential analyses were carried out. The descriptive analysis looked at the bivariate analysis between the country and outcome variables. Using a binary logistic regression model, a multivariate analysis was utilized to determine the association between the outcome variable and the explanatory variables. Binary logistic regression modelling was used based on the dichotomous nature of the outcome variable. The results were sample-weighted to account for any under- or over-sampling in the sample.

RESULTS

The proportion of women who sought help for intimate partner violence was 36.1 percent. This ranged from 19.2 percent in Mali to 49.6 percent in Rwanda. Women who experienced violence in childhood (OR = 0.75, CI = 0.69, 0.82) have a lower likelihood of seeking help compared to those who did not experience violence in their childhood. Women who had experienced emotional violence (OR = 1.94, CI = 1.80, 2.08), and physical violence (OR = 1.37, CI = 1.26, 1.48) have a higher likelihood of seeking help compared to those who have not. Women with secondary educational levels (aOR = 1.13, CI = = 1.02, 1.24) have a higher likelihood of seeking help compared to those with no education. Cohabiting women have a higher likelihood (aOR = 1.22, CI = 1.10, 1.35) of seeking help compared to married women.

CONCLUSION

The study highlights the importance of early identification of IPV and fit-for-purpose interventions to demystify IPV normalization to enhance women's willingness to seek help. The study's findings suggest that education is crucial for increasing women's awareness of the legalities surrounding IPV and available structures and institutions for seeking help.

Utilisation of mobile phone interventions to improve the delivery of maternal health services in sub-Saharan Africa: A scoping review protocol

INTRODUCTION

There has been significant progress in maternal health outcomes in the sub-Saharan African region since the early 1990s, in part due to digital and mobile health interventions. However, critical gaps and disparities remain. Mobile phones in particular have potential to reach underserved, hard-to-reach populations with underdeveloped infrastructure. In spite of the opportunities for mobile phones to address maternal mortality in the region, there is no extensive mapping of the available literature on mobile phone interventions that aim to improve access of maternal care in sub-Saharan Africa. The proposed scoping review aims to map literature on the nature and extent of mobile phones interventions designed to improve maternal care health services in the region.

METHODS

Conduct of this scoping review will be guided by the Joanna Briggs Institute approach. Literature searches will be conducted in multiple electronic databases, including MEDLINE, Embase, CINAHL, APA PsycInfo, Cochrane Central Register of Controlled Trials, Global Health, African Index Medicus, Web of Science, and Applied Social Sciences Index & Abstracts. Grey literature will also be identified. Keyword searches will be used to identify articles. Two reviewers will independently screen eligible titles, abstracts and full articles with a third reviewer to help resolve any disputes. We will extract data on general study characteristics, population characteristics, concept, context, intervention details, study results, gaps and recommendations.

DISCUSSION

Understanding use of mobile phones among underserved, hard-to-reach populations with underdeveloped infrastructure to address maternal mortality in developing countries is very critical to informing health systems on potential effective strategies. This review will complement the evidence base on utilisation of mobile phone interventions to improve the delivery of maternal health services in sub-Saharan Africa.

Does women's empowerment and socio-economic status predict adequacy of antenatal care in sub-Saharan Africa?

BACKGROUND

Quality and adequate antenatal care (ANC) are key strategies necessary to achieve Sustainable Development Goal 3.1. However, in sub-Saharan Africa (SSA), there is a paucity of evidence on the role women's empowerment and socio-economic status play in ANC attendance. This study aimed to examine whether women's empowerment and socio-economic status predict the adequacy of ANC in SSA.

METHODS

Data from the recent Demographic and Health Surveys (DHSs) of 10 countries in SSA were used for the study. We included countries with a survey dataset compiled between 2018 and 2020. We included 57 265 women with complete observations on variables of interest in the study. Frequencies and percentages were used to summarize the results of the coverage of adequate ANC services across the 10 countries. A multivariable binary multilevel regression analysis was employed to examine the association between women's empowerment and socio-economic status indicators and the adequacy of ANC. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were used to present the findings of the regression analysis.

RESULTS

The average prevalence of adequate ANC in SSA was 10.4%. This ranged from 0.2% in Rwanda to 24.5% in Liberia. Women with medium (aOR 1.24 [CI 1.10 to 1.40]) and high (aOR 1.24 [CI 1.07 to 1.43]) decision-making power had higher odds of adequate ANC compared to those with low decision-making power. Women with higher levels of education (aOR 1.63 [CI 1.36 to 1.95]) as well as partners with higher education levels (aOR 1.34 [CI 1.14 to 1.56]) had the highest odds of adequate ANC compared to those with no formal education. Additionally, those working (aOR 1.35 [95% CI 1.23 to 1.49]) and those in the richest wealth category (aOR 2.29 [CI 1.90 to 2.76]) had higher odds of adequate ANC compared to those who are not working and those in the poorest wealth category. Those with high justification of violence against women (aOR 0.84 [CI 0.73 to 0.97]) had lower odds of adequate ANC compared to those with low justification of violence against women.

CONCLUSIONS

Adequacy of ANC was low across all 10 countries we included in this study. It is evident from the study that women's empowerment and socio-economic status significantly predicted the adequacy of ANC. As such, promoting women's empowerment programs without intensive improvements in women's socio-economic status would yield ineffective results. However, when women's empowerment programs are combined with active improvements in socio-economic status, then women will be encouraged to seek adequate ANC.

Implementation of lockdown, quarantine, and isolation measures in the context of COVID-19 among internally displaced persons in Burkina Faso: a qualitative study

BACKGROUND

The triple political, security, and health crisis in Burkina Faso has impacted the lives of Burkinabè people, resulting in massive internal displacement. These internally displaced persons (IDPs) are very vulnerable to epidemic diseases, which was exacerbated by the recent COVID-19 pandemic., The implementation of public health measures to curb the spread of COVID-19 represented a major concern among IDPs. The objective of this study was to document knowledge, difficulties, adjustments, and challenges faced by IDPs and humanitarian authorities/actors during implementation of lockdown, quarantine, and isolation measures in response to COVID-19.

METHODS

The study was conducted in Burkina Faso, in the north-central region Kaya, a commune which hosts the largest number of IDPs in the country. Qualitative research using semi-structured interviews collected discursive data from 18 authorities and/or humanitarian actors and 29 IDPs in June 2021. The transcribed interviews were coded with N'vivo 11 software and analyzed thematically.

RESULTS

Although respondents had a good knowledge of lockdown, isolation, and quarantine measures, the difference between these three concepts was not easily understood by either authorities/humanitarian actors or IDPs. Communication was one of the biggest challenges for humanitarian actors. The difficulties encountered by IDPs were economic (lack of financial resources), infrastructural (limited housing), and socio-cultural in the application of lockdown, isolation, and quarantine measures. As for adjustment measures, the health authorities developed a strategy for isolation and quarantine for the management of positive and suspected cases. The IDPs mentioned their commitment to compliance and awareness of lockdown measures as the main adjustment.

CONCLUSION

Although there were no known cases of COVID-19 among the IDPs at the time of the study, tailored response plans were developed to facilitate the application of these measures in emergencies. The involvement of IDPs in the communication and sensitization process was necessary to facilitate their adherence to these different measures.

Where's the Disconnect? Exploring Pathways to Healthcare Coordinated for Youth Experiencing Homelessness in Toronto, Canada, Using Grounded Theory Methodology

About 900 youth experiencing homelessness (YEH) reside at an emergency youth shelter (EYS) in Toronto on any given night. Several EYSs offer access to healthcare based on youths' needs, including access to primary care, and mental health and addictions support. However, youth also require healthcare from the broader health system, which is often challenging to navigate and access. Currently, little is known about healthcare coordination efforts between the EYS and health systems for YEH. Using grounded theory methodology, we interviewed 24 stakeholders and concurrently analyzed and compared data to explore pathways to healthcare coordinated for youth who reside at an EYS in Toronto. We also investigated fundamental parts (i.e., norms, resources, regulations, and operations) within the EYS and health systems that influence these pathways to healthcare using thematic analysis. A significant healthcare coordination gap was found between these two systems, typically when youth experience crises, often resulting in a recurring loop of transition and discharge between EYSs and hospitals. Several parts within each system act interdependently in hindering adequate healthcare coordination between the EYS and health systems. Incorporating training for system staff on how to effectively coordinate healthcare and work with homeless populations who have complex health needs, and rethinking information-sharing policies within circles of care are examples of how system parts can be targeted to improve healthcare coordination for YEH. Establishing multidisciplinary healthcare teams specialized to serve the complex needs of YEH may also improve healthcare coordination between systems, and access and quality of healthcare for this population.

Association between sexual violence and multiple high-risk fertility behaviours among women of reproductive age in sub-Saharan Africa

BACKGROUND

Intimate partner violence has adverse outcomes on the sexual and reproductive health of women. In this study, we examined the association between sexual violence and multiple high-risk fertility behaviours (MHRFB) among women in sub-Saharan Africa (SSA).

METHODS

We conducted a cross-sectional analysis of data pooled from the most recent Demographic and Health Surveys of 20 countries in SSA. We included countries with most recent datasets conducted from 2015 to 2021 and had data on all variables included in the study. A weighted sample of 88,011 was included in the study. We used a multilevel binary logistic regression to examine the association between sexual violence and MHRFB, controlling for other covariates. The regression results were presented using adjusted odds ratio (aOR) with 95% confidence interval (CI). Statistical significance was set at p < 0.05.

RESULTS

The overall prevalence of MHRFB was 22.53% (95% CI: 22.26-22.81), which ranged from 9.94% in South Africa to 30.38% in Chad. For sexual violence, the pooled prevalence was 7.02% (95% CI: 6.86-7.19). Burundi (20.58%) and the Gambia (2.88%) reported the highest and lowest proportions, respectively. Women who experienced sexual violence were more likely to engage in MHRFB compared to those who did not experience sexual violence [aOR = 1.11, 95% CI: 1.02, 1.21].

CONCLUSION

There is a positive association between sexual violence and the risk of MHRFB. Our findings underscore a need for sub-Saharan African countries to strengthen their efforts to reduce the occurrence of sexual violence in intimate partner relationships. To augment efforts and accelerate social change, sub-Saharan African countries can introduce pro-poor policies and interventions to improve the wealth status of women. Also, empowering women through the encouragement of attaining higher education would be a useful step in lowering the risk of MHRFB in SSA.

COVID-19 vaccine uptake, conspiracy theories, and health literacy among Black individuals in Canada: Racial discrimination, confidence in health, and COVID-19 stress as mediators

Factors influencing vaccine uptake in Black individuals remain insufficiently documented. Understanding the role of COVID-19 related stress, conspiracy theories, health literacy, racial discrimination experiences, and confidence in health authorities can inform programs to increase vaccination coverage. We sought to analyze these factors and vaccine uptake among Black individuals in Canada. A representative sample of 2002 Black individuals from Ontario, Quebec, Alberta, Nova Scotia, New Brunswick, British Columbia, and Manitoba, aged 14 years or older completed questionnaires assessing vaccine uptake, health literacy, conspiracy theories, racial discrimination experiences, COVID-19-related stress, and confidence in health authorities. Mediation analyses were conducted to assess (1) the effect of health literacy on COVID-19 vaccination uptake through confidence and need, COVID-19 related traumatic stress, and racial discrimination, and (2) the effect of conspiracy beliefs on COVID-19 vaccination uptake through the same factors. Overall, 69.57% (95% confidence interval, 67.55%-71.59%) of the participants were vaccinated and 83.48% of them received two or more doses. Those aged 55 years and older were less likely to be vaccinated, as well as those residing in British Columbia and Manitoba. Mediation models showed that the association between health literacy and COVID-19 vaccine uptake was mediated by confidence in health authorities (B = 0.02, p < 0.001), COVID-19-related stress (B = -0.02, p < 0.001), and racial discrimination (B = -0.01, p = 0.032), but both direct and total effects were nonsignificant. Lastly, conspiracy beliefs were found to have a partial mediation effect through the same mediators (B = 0.02, p < 0.001, B = -0.02, p < 0.001, B = -0.01, p = 0.011, respectively). These findings highlight the need for targeted interventions to address vaccine hesitancy and inform approaches to improve access to vaccinations among Black communities.

Where are the links? Using a causal loop diagram to assess interactions in healthcare coordination for youth experiencing homelessness in Toronto, Canada

BACKGROUND

Youth experiencing homelessness (YEH) suffer from poorer physical and mental health outcomes than stably housed youth. Additionally, YEH are forced to navigate fragmented health and social service systems on their own, where they often get lost between systems when transitioning or post-discharge. Inevitably, YEH require support with health system navigation and healthcare coordination. The aim of this study is to understand interactions within and between the emergency youth shelter (EYS) and health systems that affect healthcare coordination for YEH in Toronto, Canada, and how these interactions can be targeted to improve healthcare coordination for YEH.

METHODS

This study is part of a larger qualitative case study informed by the framework for transformative systems change. To understand interactions in healthcare coordination for YEH within and between the EYS and health systems, we developed a causal loop diagram (CLD) using in-depth interview data from 24 key informants at various levels of both systems. Open and focused codes developed during analysis using Charmaz's constructivist grounded theory methodology were re-analysed to identify key variables, and links between them to create the CLD. The CLD was then validated by six stakeholders through a stakeholder forum.

RESULTS

The CLD illustrates six balancing and one reinforcing feedback loop in current healthcare coordination efforts within the EYS and health systems, respectively. Increasing EYS funding, building human resource capacity, strengthening inter and intra-systemic communication channels, and establishing strategic partnerships and formal referral pathways were identified among several other variables to be targeted to spiral positive change in healthcare coordination for YEH both within and between the EYS and health systems.

CONCLUSIONS

The CLD provides a conceptual overview of the independent and integrated systems through which decision-makers can prioritize and guide interventions to strengthen healthcare coordination within and between the EYS and health systems. Overall, our research findings suggest that key variables such as streamlining communication and improving staff-youth relationships be prioritized, as each of these acts interdependently and influences YEH's access, quality and coordination of healthcare.

Engaging Community Health Workers (CHWs) in Africa: Lessons from the Canadian Red Cross supported programs

Universal Health Coverage (UHC) will not be achieved if health care worker shortages, estimated to increase to 18 million by 2030, are not addressed rapidly. Community-based health systems, which pivot to effective engagement of community health workers (CHW), may have an essential role in linking communities with health care facilities and reducing unmet health services needs caused by these shortages. The Canadian Red Cross (CRC) has partnered with different National Red Cross/Red Crescent Societies and Ministries of Health in Africa in the implementation of programs where CHWs contributed to the provision of various health services. This study reports on key findings (i.e., beneficiaries reached, CHWs engaged, programs implemented, intervention outcomes) and lessons learned from CRC supported CHW programs in Africa over the last 15 years (2007-2022). Qualitative methodology was employed to conduct document analysis on 17 sets of reports from each CRC-supported community health worker project in Africa over the past 15 years. Focus was on identifying challenges, facilitators, and lessons learned. CRC supported projects have trained over 9000 CHWs, benefiting nearly 7.5 million people across Africa. Key success factors include adaptability and agility in programming and project management, and considering contextual factors (political, social, and cultural systems). Investing in essential training for CHWs, staff, and volunteers is crucial, alongside employing an evidence-based approach to inform all aspects of programming and implementation. Additionally, projects prioritizing protection, gender and inclusion (PGI) while leveraging existing community structures and partnerships important for successful implementation. Despite challenges (i.e., weak health systems, lack of political commitment, insufficient funding, inadequate training) CHWs are recognized as crucial in promoting community-based health, improving access to care, addressing disparities, and contributing to achieving (UHC). Their unique position within communities enables them to provide culturally appropriate and localized primary health care- particularly in remote, resource limited and poverty-stricken regions.

Prevalence and health consequences of nonmedical use of tramadol in Africa: A systematic scoping review

Tramadol is a widely prescribed painkiller around the world. As a synthetic opioid, it offers a valuable substitute for morphine and its derivatives in African countries. However, the adverse health effects of tramadol use resulting from illicit trafficking, like those caused by fentanyl and methadone in North America, have not been well-documented in Africa. This scoping review aims to shed light on the nature and scope of the nonmedical use (NMU) of tramadol in Africa and its associated health consequences. To carry out our scoping review, we used Arksey and O'Malley's (2005) five-step approach for exploratory analysis and followed Joanna Briggs Institute guidelines for scoping reviews to ensure systematic and replicable studies. We then searched six databases: Medline, Global Health (EBSCO), Scopus, Web of Science, the African Journals online database, and for grey literature via Google Scholar without any time restriction. The articles were imported into Covidence and reviewed by two independent researchers. Eighty-three studies on NMU of tramadol's prevalence or health consequences were selected from 532 titles/abstracts screened, including 60 cross-sectional and six qualitative studies from 10 African countries. Findings from the included studies highlighted five distinct groups significantly affected by the NMU of tramadol. These groups include: 1) young adults/active populations with varying degrees of prevalence ranging from 1.9% to 77.04%, 2) professionals, where drivers exhibit a relatively high prevalence of tramadol NMU, ranging from 7.2% to 35.1%, and commercial motorcyclists, with a prevalence of 76%, 3) patients, who have a high rate of tramadol NMUs, with prevalence rates ranging from 77.1% to 92%, 4) academics, with a considerable rate of tramadol misuse among substance-using undergraduates (74.2%) and substance-using high school students (83.3%), and 5) other individuals impacted in various ways. The health consequences are classified into four distinct types: intoxication, dependence syndrome, withdrawal syndrome and other symptoms. Despite providing a comprehensive global overview of the phenomenon described in the African literature, this systematic scoping review's main limitations stem from the relatively limited exploration of various consequences of the NMU of tramadol, notably those of a social and economic nature. Our review shows that tramadol misuse affects diverse populations in Africa. The prevalence of misuse varies within sub-populations, indicating the complexity of the issue. Professional and academic groups have different rates of misuse across regions. This highlights the need for targeted interventions to address unique challenges contributing to tramadol misuse. Future studies should focus on the social and economic costs of abuse on households to better understand the impact on well-being. Systematic review registration: Open Science Framework: https://osf.io/ykt25/.

Socioeconomic inequalities in uptake of HIV testing during antenatal care: evidence from Sub-Saharan Africa

BACKGROUND

Measuring socioeconomic inequalities in healthcare usage represents a critical step towards promoting health equity, in alignment with the principles of universal health coverage and the United Nations' Sustainable Development Goals. In this study, we assessed the socioeconomic inequalities in HIV testing during antenatal care (ANC) in sub-Saharan Africa.

METHODS

Sub-Saharan Africa was the focus of this study. Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Mauritania, Mozambique, Rwanda, Sierra Leone, Uganda, Zambia, and Zimbabwe were the countries included in the study. This study used current Demographic and Health Surveys data spanning from 2015 to 2022. A total of 70,028 women who tested for HIV as part of antenatal contacts formed the sample for analysis. We utilized the standard concentration index and curve to understand the socioeconomic inequalities in HIV testing during antenatal care among women. Additionally, a decomposition analysis of the concentration index was ran to ascertain the contributions of each factor to the inequality.

RESULTS

Overall, 73.9% of women in sub-Saharan Africa tested for HIV during ANC. The countries with the highest proportions were Malawi, Rwanda, Zambia, and Zimbabwe. Mali Benin, Guinea, Mali, and Mauritania were the countries with the lowest proportions of HIV testing. Being among the richer [AOR 1.10, 95% CI: 1.02,1.18] and richest [AOR 1.41, 95% CI:1.30, 1.54] wealth quintiles increased the odds of HIV testing during ANC. The concentration value of 0.03 and the curve show that HIV testing is more concentrated among women in the highest wealth quintile. Hence, wealthy women are advantaged in terms of HIV testing. As the model's residual value is negative (-0.057), the model overestimates the level of inequality in the outcome variable (HIV during ANC), which means that the model's explanatory factors can account for higher concentration than is the case.

CONCLUSION

We found that there is substantial wealth index-related inequalities in HIV testing, with women of the poorest wealth index disadvantaged in relation to the HIV testing. This emphasizes the necessity for sub-Saharan Africa public health programs to think about concentrating their limited resources on focused initiatives to grasp women from these socioeconomic circumstances. To increase women's access to HIV testing, maternal and child health programs in sub-Saharan Africa should attempt to minimize female illiteracy and poverty. Consequently, health education may be required to provide women with comprehensive HIV knowledge and decrease the number of lost opportunities for women to get tested for HIV. Given the link between knowledge of HIV and HIV testing, it is important to focus on community education and sensitization about HIV and the need to know one's status.

Mother-child dyads of overnutrition and undernutrition in sub-Saharan Africa

BACKGROUND

Malnutrition remains one of the major public health concerns globally. To achieve the Sustainable Development Goal 2 which seeks to ensure that hunger and malnutrition are reduced by 2030, it is imperative to ascertain the factors influencing their occurrence. This study examined the prevalence and factors associated with mother-child dyads of overnutrition and undernutrition in sub-Saharan Africa.

METHODS

Demographic and Health Survey data from 25 sub-Saharan African countries were used for the study. The sample was made up of 125,280 mother-child dyads. Descriptive analysis was performed to determine the prevalence of overweight or obese mother (OWOBM) with a stunted child (OWOBM-SC), OWOBM with an underweight child (OWOBM-UC), OWOBM with a wasted child (OWOBM-WC), and OWOBM with any form of child's undernutrition indicators (OWOBM-SUWC). Multilevel regression models were developed to examine the factors associated with these indicators. The results were presented using an adjusted odds ratio (AOR) with their respective 95% confidence interval (CI).

RESULTS

Higher likelihood of OWOBM-SUWC was found among women aged 45-49 [AOR 2.20, 95% CI 1.70, 2.85], those with primary [AOR 1.32, 95% CI 1.21, 1.44] or secondary education [AOR 1.21, 95% CI 1.09, 1.35], and divorced women [AOR 1.32, 95% CI 1.02, 1.73]. However, lower odds of OWOBM-SUWC were observed among women who were working [AOR 0.82, 95% CI 0.76, 0.89] and those breastfeeding [AOR 0.75, 95% CI 0.70, 0.82]. The odds of OWOBM-SUWC was lower among females compared to male children [AOR 0.85, 95% CI 0.80, 0.90]. Compared to children aged <1 year, children of all other age groups were more likely to have OWOBM-SUWC. Other child characteristics significantly associated with OWOBM-SUWC were low birth weight [AOR 1.50, 95% CI 1.32, 1.71], having diarrhea [AOR 1.13, 95% CI 1.04, 1.24], and higher birth order [AOR 1.37, 95% CI 1.13, 1.66]. Children whose mothers used unimproved toilet facilities [AOR 0.90, 95% CI 0.83, 0.98], those who lived in rural areas [AOR 0.79, 95% CI 0.71, 0.87], and children from the Central [AOR 0.55, 95% CI 0.46, 0.65], Eastern [AOR 0.44, 95% CI 0.38, 0.52] and Western [AOR 0.76, 95% CI 0.65, 0.89] sub-Saharan Africa were less likely to have OWOBM-SUWC.

CONCLUSION

Combination of child, maternal, and contextual factors could explain mother-child dyads of overnutrition and undernutrition in sub-Saharan Africa. Addressing this situation requires multidimensional policies and interventions that empower women through education and economic engagement. The observed sub-regional differences in policies and commitments related to addressing malnutrition suggest the need for comprehensive and coordinated efforts to implement and strengthen multisectoral comprehensive nutrition plans across sub-Saharan Africa. Sharing best practices and lessons learned can help improve the effectiveness and comprehensiveness of nutrition interventions and contribute to reducing the prevalence of malnutrition.

Prevalence and predictors of infant and young child feeding practices in sub-Saharan Africa

BACKGROUND

This study assessed the prevalence and predictors of minimum dietary diversity (MDD), minimum meal frequency (MMF), and minimum acceptable diet (MAD) in sub-Saharan Africa (SSA).

METHODS

A sample of 87 672 mother-child pairs from the 2010-2020 Demographic and Health Surveys of 32 countries in SSA was used. Multilevel binary logistic regression analysis was carried out to examine the predictors of MDD, MMF, and MAD. Percentages and adjusted odds ratios (aORs) with a 95% confidence interval (CI) were used to present the findings.

RESULTS

The prevalence of MDD, MMF, and MAD in SSA were 25.3% (95% CI 21.7 to 28.9), 41.2% (95% CI 38.8 to 43.6), and 13.3% (95% CI 11.6 to 15.0), respectively. Children aged 18-23 months were more likely to have MDD and MAD but less likely to have MMF. Children of mothers with higher education levels were more likely to have MDD, MMF, and MAD. Children who were delivered in a health facility were more likely to have MDD and MAD but less likely to have MMF.

CONCLUSIONS

Following the poor state of complementary feeding practices for infants and young children, the study recommends that regional and national policies on food and nutrition security and maternal and child nutrition and health should follow the internationally recommended guidelines in promoting, protecting, and supporting age-appropriate complementary foods and feeding practices for infants and young children.

Is intimate partner violence vertically transmitted among women in sub-Saharan Africa? Evidence from demographic health surveys between 2010 and 2019

BACKGROUND

Violence against women is a major human rights violation, and the continuous occurrence of this can have many implications for women's social and health outcomes. The experience of violence from an intimate partner could be more intriguing, especially if such women experienced their mother's intimate partner violence (IPV) issues. Thus, this study examined the vertical transmission of IPV among women in sub-Saharan Africa (SSA).

METHODS

A total of 97,542 eligible women were drawn from 27 countries in SSA using a retrospective secondary dataset from Demographic Health Surveys conducted between 2010 and 2019. Multivariable analysis was employed to determine the association between the vertical transmission of IPV from mother to daughter and the covariates associated with IPV in SSA at p < 0.05.

RESULTS

The results showed that 40% of the respondents had experienced lifetime IPV, whilst 25% of those women reported that their mothers experienced it in childhood in SSA. Country-specific variations showed the highest prevalence of IPV experienced in Sierra Leone (60%) and the lowest in Comoros (9%). Results from model 1 showed that women who reported that their mothers experienced IPV were found to be significantly more than two times more likely to have experienced any form of IPV compared to those whose mothers did not (aOR = 2.66; 95% CI: 2.59-2.74), after adjusting for cofounders in Model 2, the result still showed that women who reported that their mothers experienced IPV were found to be significantly more than two times more likely to have experienced any form of IPV compared to those whose mothers did not (aOR = 2.56; 95% CI: 2.48-2.63). On the other hand, women with higher-educated partners, women in rural areas, and those from female-headed households were less likely to experience IPV.

CONCLUSION

This study concluded that women whose mothers experienced IPV were more likely to have experienced IPV. Our study also identified that education, rural areas, and female-headed households were protective factors against experiencing IPV. To address the groups of women at higher risk for experiencing IPV, we recommend ensuring that girls complete their education to promote greater wealth and resources.

"if we don't regroup, hunger will kill us…": a qualitative study on measures of physical distancing during covid-19 among internally displaced persons in Burkina Faso

This study contributes to the body of knowledge on IDPs in the context of security crisis related to terrorism. Very little research has been done on covid-19 amongst IDPs in Africa and this is one of the first studies in Burkina Faso. Our diversified sample allowed us to consider the discourses of humanitarian actors working with IDPs, but also the discourses of IDPs in a context of aggravated health and security crisis. The challenges encountered by IDPs in implementing physical distancing and the coping strategies have been documented. It showed some possible solutions that decision-makers could use in order to facilitate the appropriation of this measure by IDPs. This is a contribution to the field of applied human and social science research They will help to anticipate solutions in the event of a resurgence of covid-19 cases. In the current context, where the spread of the disease seems to be under control, concerted action should now be taken in the event of the detection of a case of covid-19 in the various IDP sites.

High risk fertility behaviour and health facility delivery in West Africa

BACKGROUND

Evidence suggests that women who give birth in a health facility have lower odds of experiencing pregnancy complications and significantly reduced risk of death from pregnancy-related causes compared to women who deliver at home. Establishing the association between high-risk fertility behaviour (HRFB) and health facility delivery is imperative to inform intervention to help reduce maternal mortality. This study examined the association between HRFB and health facility delivery in West Africa.

METHODS

Data for the study were extracted from the most recent Demographic and Health Surveys of twelve countries in West Africa conducted from 2010 to 2020. A total of 69,479 women of reproductive age (15-49 years) were included in the study. Place of delivery was the outcome variable in this study. Three parameters were used as indicators of HRFB based on previous studies. These were age at first birth, short birth interval, and high parity. Multivariable binary logistic regression analysis was performed to examine the association between HRFB and place of delivery and the results were presented using crude odds ratio (cOR) and adjusted odds ratio (aOR), with their respective 95% confidence interval (CI).

RESULTS

More than half (67.64%) of the women delivered in a health facility. Women who had their first birth after 34 years (aOR = 0.52; 95% CI = 0.46-0.59), those with short birth interval (aOR = 0.91; 95% CI = 0.87-0.96), and those with high parity (aOR = 0.58; 95% CI = 0.55-0.60) were less likely to deliver in a health compared to those whose age at first delivery was 18-34 years, those without short birth interval, and those with no history of high parity, respectively. The odds of health facility delivery was higher among women whose first birth occurred at an age less than 18 years compared to those whose age at first birth was 18-34 years (aOR = 1.17; 95% CI = 1.07-1.28).

CONCLUSION

HRFB significantly predicts women's likelihood of delivering in a health facility in West Africa. Older age at first birth, shorter birth interval, and high parity lowered women's likelihood of delivering in a health facility. To promote health facility delivery among women in West Africa, it is imperative for policies and interventions on health facility delivery to target at risk sub-populations (i.e., multiparous women, those with shorter birth intervals and women whose first birth occurs at older maternal age). Contraceptive use and awareness creation on the importance of birth spacing should be encouraged among women of reproductive age in West Africa.

Barriers and facilitators for interventions to improve ART adherence in Sub-Saharan African countries: A systematic review and meta-analysis

BACKGROUND

The HIV/AIDS pandemic remains a significant public health issue, with sub-Saharan Africa (SSA) at its epicentre. Although antiretroviral therapy (ART) has been introduced to decrease new infections and deaths, SSA reports the highest incidence of HIV/AIDS, constituting two-thirds of the global new infections. This review aimed to elucidate the predominant barriers and facilitators influencing ART adherence and to identify effective strategies to enhance ART adherence across SSA.

METHODS

A comprehensive review was conducted on studies examining barriers to ART adherence and interventions to boost adherence among HIV-positive adults aged 15 and above in SSA, published from January 2010 onwards. The research utilized databases like Medline Ovid, CINAHL, Embase, and Scopus. Included were experimental and quasi-experimental studies, randomized and non-randomized controlled trials, comparative before and after studies, and observational studies such as cross-sectional, cohort, prospective and retrospective studies. Two independent reviewers screened the articles, extracted pertinent data, and evaluated the studies' methodological integrity using Joanna Briggs Institute's standardized appraisal tools. The compiled data underwent both meta-analysis and narrative synthesis.

RESULTS

From an initial pool of 12,538 papers, 45 were selected (30 for narrative synthesis and 15 for meta-analysis). The identified barriers and facilitators to ART adherence were categorized into seven principal factors: patient-related, health system-related, medication-related, stigma, poor mental health, socioeconomic and socio-cultural-related factors. Noteworthy interventions enhancing ART adherence encompassed counselling, incentives, mobile phone short message service (SMS), peer delivered behavioural intervention, community ART delivery intervention, electronic adherence service monitoring device, lay health worker lead group intervention and food assistance. The meta-analysis revealed a statistically significant difference in ART adherence between the intervention and control groups (pooled OR = 1.56, 95%CI:1.35-1.80, p = <0.01), with evidence of low none statistically significant heterogeneity between studies (I2 = 0%, p = 0.49).

CONCLUSION

ART adherence in SSA is influenced by seven key factors. Multiple interventions, either standalone or combined, have shown effectiveness in enhancing ART adherence. To optimize ART's impact and mitigate HIV's prevalence in SSA, stakeholders must consider these barriers, facilitators, and interventions when formulating policies or treatment modalities. For sustained positive ART outcomes, future research should target specific underrepresented groups like HIV-infected children, adolescents, and pregnant women in SSA to further delve into the barriers, facilitators and interventions promoting ART adherence.

Examining the disparities: A cross-sectional study of socio-economic factors and food insecurity in Togo

BACKGROUND

Despite many interventions, Togo continues to have one of the highest rates of poverty and food insecurity in the sub-Saharan African region. Currently there is no systematic analysis of the factors associated with household food-insecurity in this country. This study aimed at exploring the factors associated with food insecurity in Togo.

METHODS

This was a cross-sectional study that used data from five waves (2014 to 2018) of the Gallup World Poll (GWP) for Togo. Sample size included 4754 participants, aged 15 and above. Food insecurity was measured using the Food Insecurity Experience Scale (FIES) questionnaire as per the Food and Agricultural Organization (FAO) guidelines. Our outcome variable was food insecurity, categorized as: 1) food secure (FIES score = 0-3), moderately food insecure (FIES score = 4-6), and severely food insecure (FIES score = 7-8). We did descriptive and multinomial regressions to analyze data using Stata version 16.

RESULTS

Between 2014 and 2018, the percentage of severe food insecurity fluctuated-42.81% in 2014, 37.79% in 2015, 38.98% in 2016, 45.41% in 2017, and 33.84% in 2018. Whereas that of moderate food insecurity increased from 23.55% to 27.33% except for 2016 and 2017 where the percentage increased to 32.33% and 27.46% respectively. In the logistic regression analysis, we found that respondents with lower than elementary education had a higher relative risk ratio of moderate (RRR = 1.45,95%CI = 1.22-1.72) and severe (RRR = 1.72, 95%CI = 1.46-2.02) food insecurity compared to those with secondary and higher education. Rural respondents had higher RRR of severe food insecurity (RRR = 1.37, 95%CI = 1.16-1.62) compared to those who lived in the urban areas. Compared with those in the richest wealth quintile, respondents in the poorest wealth quintile had 2.21 times higher RRR of moderate (RRR = 2.21, 95%CI = 1.69-2.87) and 3.58 times higher RRR of severe (RRR = 3.58, 95%CI = 2.81-4.55) food insecurity.

CONCLUSION

About two-thirds of participants experienced some level of food insecurity in 2018. Lower levels of education, rural residency and poorer household wealth index areas were associated with a higher risk of food insecurity. National food security programs should focus on promoting education and improving socioeconomic condition of people especially in rural areas.

Gender transformative approaches in mHealth for maternal healthcare in sub-Saharan Africa: a systematic review

Background

This review focuses on studies about digital health interventions in sub-Saharan Africa. Digital health interventions in sub-Saharan Africa are increasingly adopting gender-transformative approaches to address factors that derail women's access to maternal healthcare services. However, there remains a paucity of synthesized evidence on gender-transformative digital health programs for maternal healthcare and the corresponding research, program and policy implications. Therefore, this systematic review aims to synthesize evidence of approaches to transformative gender integration in digital health programs (specifically mHealth) for maternal health in sub-Saharan Africa.

Method

The following key terms "mobile health", "gender", "maternal health", "sub-Saharan Africa" were used to conduct electronic searches in the following databases: PsycInfo, EMBASE, Medline (OVID), CINAHL, and Global Health databases. The method and results are reported as consistent with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Data synthesis followed a convergent approach for mixed-method systematic review recommended by the JBI (Joanna Briggs Institute).

Results

Of the 394 studies retrieved from the databases, 11 were included in the review. Out of these, six studies were qualitative in nature, three were randomized control trials, and two were mixed-method studies. Findings show that gender transformative programs addressed one or more of the following categories: (1) gender norms/roles/relations, (2) women's specific needs, (3) causes of gender-based health inequities, (4) ways to transform harmful gender norms, (5) promoting gender equality, (6) progressive changes in power relationships between women and men. The most common mHealth delivery system was text messages via short message service on mobile phones. The majority of mHealth programs for maternal healthcare were focused on reducing unintended pregnancies through the promotion of contraceptive use. The most employed gender transformative approach was a focus on women's specific needs.

Conclusion

Findings from gender transformative mHealth programs indicate positive results overall. Those reporting negative results indicated the need for a more explicit focus on gender in mHealth programs. Highlighting gender transformative approaches adds to discussions on how best to promote mHealth for maternal health through a gender transformative lens and provides evidence relevant to policy and research.

Systematic review registration

PROSPERO CRD42023346631.

Health insurance coverage and access to child and maternal health services in West Africa: a systematic scoping review

BACKGROUND

According to the United Nations, the third Sustainable Development Goal, 'Ensure Healthy Lives and Promote Well-Being at All Ages', set numerous targets on child and maternal health. Universal health insurance is broadly seen as a solution to fulfil these targets. West Africa is known to have the most severe maternal mortality and under-five mortality rates in the world. This review seeks to understand whether health insurance provides increased access to services for mothers and children in this region.

METHODS

The protocol for this review is registered in the International Prospective Register of Systematic Reviews database (CRD42020203859). A search was conducted in the MEDLINE Complete, Embase, CINAHL Complete and Global Health databases. Eligible studies were from West African countries. The population of interest was mothers and children and the outcome of interest was the impact of health insurance on access to services. Data were extracted using a standardized form. The primary outcome was the impact of health insurance on the rate of utilization and access to services. The Joanna Briggs Institute Critical Appraisal Tool was used for methodological assessment.

RESULTS

Following screening, we retained 49 studies representing 51 study settings. In most study settings, health insurance increased access to child and maternal health services. Other determinants of access were socio-economic factors such as wealth and education.

CONCLUSIONS

Our findings suggest that health insurance may be a viable long-term strategy to alleviate West Africa's burden of high maternal and child mortality rates. An equity lens must guide future policy developments and significant research is needed to determine how to provide access reliably and sustainably to services for mothers and children in the near and long term.

Hygienic Disposal of Children's Stools Practices Among Women of Children With Diarrhoea in Sub-Saharan Africa

Background

Diarrhoea stools contain infectious agents and pose a public health threat to children and members of the entire family when exposed to them. Therefore, their hygienic disposal is essential. Empirical data are needed to stir the needed public health interventions to encourage or enforce proper disposal practices to curb associated clinical issues. This study assessed the prevalence and correlates of hygienic stool disposal practices by mothers of children with diarrhoea in sub-Saharan Africa (SSA).

Methods

The Demographic and Health Surveys (DHS) data of 16 sub-Saharan African countries from 2015 to 2021 involving 22 590 mother-child pairs were analysed. Multilevel binary logistic analysis was conducted to assess the individual- and household-level factors associated with the hygienic disposal of stool practices by mothers of children with diarrhoea. The results were presented using adjusted odds ratios (AOR) and 95% confidence intervals (CI) at a statistical significance of P < .05.

Results

The overall prevalence of hygienic disposal of children's stools among women of children with diarrhoea was 49.01% (95% CI: 48.40-49.62) and ranged from 15.70% in Liberia to 86.6% in Rwanda. The practice of hygienic disposal of stools of children with diarrhoea was likely to increase among mothers who are working (AOR: 1.19; 95% CI: 1.09-1.30), those with partners with primary level of education (AOR: 1.18; 95% CI: 1.06-1.31), Muslims (AOR: 1.69; 95% CI: 1.49-1.91) and widowed/divorced (AOR: 8.94, 95% CI: 3.55-22.53). Again, mothers in the richer (AOR: 1.23; 95% CI: 1.08-1.39) wealth index had increased odds of disposing of stools hygienically compared to those in the poorest wealth index. Women who were 20 years and above, to who belonged to Traditional Religions (AOR: 0.57; 95% CI: 0.43-0.74), and those with unimproved sources of water (AOR: 0.89; 95% CI: 0.82-0.98) and toilet facilities (AOR: 0.63; 95% CI: 0.58-0.69) were less likely to dispose of child's diarrhoea stool hygienically than their counterparts.

Conclusion

The study reveals that the unhygienic disposal of the stool of children with diarrhoea is prevalent in SSA and requires a concerted effort to curb it. Sanitation practices such as educating mothers about hygienic disposal of children's stool and improving water and sanitation facilities are crucial in lowering the high prevalence of unhygienic disposal of the diarrhoeic stool of children. Additional country-level research is needed to assess children's defecation behaviours and the disposal of diarrhoeic stools using different methodologies.

Occupational stressors and coping mechanisms among obstetrical nursing staff during the COVID-19 pandemic: a qualitative study

BACKGROUND

Due to heightened occupational stress throughout the COVID-19 pandemic, hospital nurses have experienced high rates of depression, anxiety, and burnout. Nurses in obstetrical departments faced unique challenges, such as the management of COVID-19 infection in pregnancy with limited evidence-based protocols and the unknown risks of the virus on pregnancy and fetal development. Despite evidence that obstetrical nurses have experienced high levels of job stress and a decrease in job satisfaction during the COVID-19 pandemic, there is less known about the working conditions resulting in these changes. Using the Job Demands-Resources (JD-R) model, this study aims to offer insight into the COVID-19 working environment of obstetrical nurses and shed light on their COVID-19 working experiences.

METHODS

The study was conducted using a qualitative approach, with data collection occurring through semi-structured interviews from December 2021 to June 2022. A total of 20 obstetrical nurses recruited from the obstetrical departments of a tertiary hospital located in Ontario, Canada, participated in the study. Interviews were audio-recorded, transcribed verbatim, and coded using NVivo. Data was analyzed using a theoretical thematic approach based on the JD-R model.

RESULTS

Four themes were identified: (1) Job stressors, (2) Consequences of working during COVID-19, (3) Personal resources, and (4) Constructive feedback surrounding job resources. The findings show that obstetrical nurses faced several unique job stressors during the COVID-19 pandemic but were often left feeling inadequately supported and undervalued by hospital upper management. However, participants offered several suggestions on how they believe support could have been improved and shared insight on resources they personally used to cope with job stress during the pandemic. A model was created to demonstrate the clear linkage between the four main themes.

CONCLUSIONS

This qualitative study can help inform hospital management and public policy on how to better support and meet the needs of nurses working in obstetrical care during pandemics. Moreover, applying the JD-R model offers both a novel and comprehensive look at how the COVID-19 hospital work environment has influenced obstetrical nurses' well-being and performance.

Rural-urban differentials in the association between sex preference for children and marital dissolution in sub-Saharan Africa

BACKGROUND

Marital dissolution, which refers to being divorced or separated, is considered one of the most dramatic demographic events that significantly disrupt families. Unearthing the factors predicting marital dissolution would support actions to reduce the incidence of this phenomenon. The present study sought to examine the association between sex preference for children and marital dissolution segregated by place of residence.

METHODS

Data for the study were extracted from the most recent Demographic and Health Surveys (DHS) of 25 countries in sub-Saharan Africa. Percentages were used to summarise the proportion of marital dissolution among women in sub-Saharan Africa. Binary logistic regression models were fitted to examine the association between sex preference for children and marital dissolution per place of residence. Results of the regression analysis were presented using adjusted odds ratios (aOR) with their respective 95% confidence interval (CI).

RESULTS

The overall prevalence of marital dissolution was 5.92% (95% CI: 5.83-6.00), and this ranged from 1.63% (95% CI: 1.41-1.85) in Burkina Faso to 15.62% (95% CI: 14.70-16.54) in Mozambique. In urban sub-Saharan Africa, the overall prevalence of marital dissolution was 8.88% (95% CI:8.78-8.99), with the lowest prevalence in Mali (3.30%; 95% CI: 2.91-3.69) and the highest in Uganda (18.60%; 95% CI: 17.95-19.25). For rural sub-Saharan Africa, the pooled prevalence was 4.11% (95% CI: 4.03-4.18), with the lowest (0.80%; 95% CI: 0.65-0.95) and highest (14.40%; 95% CI: 13.51-15.29) prevalences in Burkina Faso and Mozambique, respectively. Compared to women with no sex preference, the preference for boys was less likely to result in marital dissolution (aOR = 0.87; 95%CI = 0.83-0.90) in both urban and rural areas, whereas the preference for girls was more likely to result in marital dissolution (aOR = 1.06; 95%CI = 1.02-1.10). When the results were disaggregated by place of residence, in both urban (aOR = 0.87; 95%CI = 0.80-0.95) and rural areas (aOR = 0.87; 95%CI = 0.82-0.92), women who preferred boys were less likely to experience marital dissolution compared to those who had no preference. However, the preference for girls showed no statistically significant association with marital dissolution.

CONCLUSION

Our study has shown that sex preference for children has a significant association with marital dissolution in both rural and urban areas in sub-Saharan Africa. Whereas the preference for male children serves as a protective factor against marital dissolution, the preferences for females was found to increase the likelihood of marital dissolution. Thus, underscoring a need for anti-marital dissolution campaigns and initiatives to prioritise the sensitisation of society about the value of female children. Religious groups and leaders can leverage their platform to quell sex preferences and dissuade marital dissolution. Policies and programmes aimed at reducing the risk of marital dissolution in sub-Saharan Africa must also focus on enlightening the population on intimate partner violence prevention.

Multiple high-risk fertility behaviours and children under five mortality survivors among ever-married women of reproductive age in Nigeria

BACKGROUND

Multiple high-risk fertility behaviours (MHRFBs), including maternal age < 18 or > 34 years old, a birth order 4+, and birth spacing < 24 months, can directly or indirectly affect survival outcomes among under-five children. There is a dearth of available information and data about these two phenomena in Nigeria. Thus, this study evaluates the prevalence of MHRFBs and examines the association between MHRFBs and under-five mortality survival (U5M) outcomes among ever-married women of reproductive age in Nigeria.

METHODS

This study used the recent secondary datasets from the Nigerian Demographic Health Surveys conducted in 2018, with a total sample size of 10,304 women of reproductive age. The outcome variable was MHRFBs. Multivariable logistic regression analysis was employed to examine the association between U5M and MHRFBs. Odds ratios with a p-value of less than 0.05 were considered significant.

RESULTS

It was found that among women who had MHRFBs, U5M was prevalent, particularly in young maternal age (< 18 years) and within short birth intervals (< 24 months). The adjusted odds ratio of the association between MHRFBs and U5M shows the experience of MHRFBs, in addition to other factors such as household wealth index, type of marriage, and sex of child, to be significant predictors for U5M. The odds were higher for U5M to occur among women who had experienced MHRFBs compared to those who have not had an experience of MHRFBs [aOR = 1.48; 95%CI: 1.02-2.17 ]. Similarly, the odds of U5M occurrence among women in polygamous marriages are higher compared to those in monogamous unions [aOR = 1.35; 95% CI: 1.10-1.65]. While under-five children born in the richest households (wealth quintiles) are less likely to die compared to those born in the poorest households [aOR = 0.64; 95% CI: 0.41-1.01].

CONCLUSION

This study concludes that women in Nigeria who engaged in MHRFBs, particularly maternal ages < 18 years and short birth intervals (< 24 months), were more likely to experience U5M. Furthermore, children born to women who received post-natal care after delivery were more likely to survive U5M, as were children born to women with educated partners. We recommend strengthening educational opportunities and creating adaptive reproductive health education programs for ever-married women of reproductive age in Nigeria.

Unpacking the challenges of fragmentation in community-based maternal newborn and child health and health system in rural Ethiopia: A qualitative study

INTRODUCTION

In Ethiopia, country-wide community-based primary health programs have been in effect for about two decades. Despite the program's significant contribution to advancing Maternal Newborn and Child Health (MNCH), Ethiopia's maternal and child mortality is still one of the highest in the world. The aim of this manuscript is to critically examine the multifaceted fragmentation challenges of Ethiopia's Community Health Workers (CHWs) program to deliver optimum MNCH and build a resilient community health system.

METHODS

We conducted a qualitative case study in West Shewa Zone, rural Ethiopia. A purposive sampling technique was used to recruit participants. Data sources were two focus group discussions with sixteen CHWs, twelve key informant interviews with multilevel public health policy actors, and a policy document review related to the CHW program to triangulate the findings. Thematic analysis of the qualitative data was conducted. The World Health Organization's health systems framework and socio-ecological model guided the data collection, analysis, and interpretation.

RESULTS

The CHWs program has been an extended arm of Ethiopia's primary health system and has contributed to improved health outcomes. However, the program has been facing unique systemic challenges that stem from the fragmentation of health finance; medical and equipment supply; working and living infrastructures; CHWs empowerment and motivation, monitoring, supervision, and information; coordination and governance; and community and stakeholder engagement. The ongoing COVID-19 and volatile political and security issues are exacerbating these fragmentation challenges.

CONCLUSION

This study emphasized the gap between the macro (national) level policy and the challenge during implementation at the micro (district)level. Fragmentation is a blind spot for the community-based health system in rural Ethiopia. We argue that the fragmentation challenges of the community health program are exacerbating the fragility of the health system and fragmentation of MNCH health outcomes. This is a threat to sustain the MNCH outcome gains, the realization of national health goals, and the resilience of the primary health system in rural Ethiopia. We recommend that beyond the current business-as-usual approach, it is important to emphasize an evidence-based and systemic fragmentation monitoring and responsive approach and to better understand the complexity of the community-based health system fragmentation challenges to sustain and achieve better health outcomes. The challenges can be addressed through the adoption of transformative and innovative approaches including capitalizing on multi-stakeholder engagement and health in all policies in the framework of co-production.

Women's autonomy in refusing risky sex in sub-Saharan Africa: Evidence from 30 countries

Understanding the factors associated with women's autonomy to refuse risky sex is imperative to inform the development of policies and interventions to reduce the risk of unintended pregnancies, sexually transmitted infections, unsafe abortion, and maternal mortality. This study sought to examine the prevalence and factors associated with women's autonomy to refuse risky sex in sub-Saharan Africa (SSA). Data for the study were extracted from the most recent Demographic and Health Surveys (DHS) of thirty countries in SSA conducted from 2010 to 2020. We included a weighted sample of 260,025 women who were married or cohabiting in the final analysis. Percentages were used to present the results of the prevalence of women's ability to refuse risky sex. We used a multilevel logistic regression analysis to examine the factors associated with women's ability to refuse risky sex. Stata software version 16.0 was used for the analysis. We found that 61.69% (95% confidence interval [CI]: 56.22-67.15) of the women were autonomous to refuse sex if their partners have other women, and this was highest in Namibia (91.44% [95% CI: 90.77-92.18]) and lowest in Mali (22.25% [95% CI: 21.24-23.26]). The odds of autonomy in refusing risky sex was higher among women with higher education (adjusted odds ratio [aOR] = 1.88; 95% CI = 1.78-1.46) compared to those with no formal education. Employment status was also a significant predictor, with working women having higher odds of sex refusal compared to non-working women (aOR = 1.16; 95% CI = 1.13-1.18). Advocacy to improve women's autonomy to refuse risky sex must leverage the mass media as it emerged as a significant factor. Policies and intervention to enhance women's autonomy must also target high-risk sub-populations which constitutes adolescent girls, those with no formal education, and those without employment.

Barriers and facilitators to ART adherence among ART non-adherence people living with HIV in Cameroon: A qualitative phenomenological study

BACKGROUND

Antiretroviral therapy (ART) needs to be taken for life with near perfect levels of adherence for it to be effective. Nonetheless, ART non-adherence is still observed in sub-Saharan African (SSA) countries such as Cameroon. The objective of this study was to assess the factors influencing non-adherence and or adherence among people living with HIV (PLWH) who have experienced non-adherence to ART in Cameroon.

METHODS

A descriptive qualitative study of PLWH who have experienced non-adherence with ART in Cameroon was conducted. Data were collected using in-depth interviews. Collected data were analyzed using the NVIVO 12 software.

RESULTS

In total, 43 participants participated in this study. The Southwest and Littoral regions each contributed 15 (34.88%) of participants, participants' mean age was 37.1 years (SD: 9.81) and majority 34 (82.93%) were females. ART adherence barriers include those related to patient (forgetfulness, business with other things, unwillingness to swallow drugs daily), medication (side effects), health service (arrogance of caregivers, occasional drug shortages at treatment centre, poor counseling of patient), stigma (fear of status disclosure), use of alternative treatment (traditional medicine, prayers and deliverance), resource limitation (limited food, limited finances), environmental/social (limited or no home support), and political instability (disruption of free circulation by ghost towns, roadblocks and gunshots in some regions). ART adherence facilitators include social support (family and peer support), aligning treatment with patient's daily routines (align ART with schedule of family members), use of reminders (phone alarm, sound of church bell), health sector/caregiver support (messages to patient, financial support, proper counseling), and patient's awareness of HIV status/ART knowledge (awareness of HIV positive status, Knowledge of ART benefits).

CONCLUSION

ART adherence barriers in Cameroon include those related to patient, medication, health service, stigma, use of alternative treatment, resource limitation, environmental/social, and political instability. ART adherence facilitators include social support, aligning treatment with patient's daily routines, use of reminders, health sector/caregiver support, and patient's awareness of HIV status/ART knowledge. Given these barriers and facilitators, continuous information provision and consistent support both from patients' families and caregivers are needed to improve adherence among patients. Further studies including many regions and larger samples using both in-depth and focused group discussions as well as quantitative approaches are required to uncover the burden related to ART non-adherence.

HIV testing among women of reproductive age in 28 sub-Saharan African countries: a multilevel modelling

BACKGROUND

Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) remains one of the most significant public health challenges globally, particularly in sub-Saharan Africa (SSA). Although HIV testing is a vital step for both prevention and treatment, its uptake is still low in SSA. We therefore examined HIV testing in SSA and its individual/household and community factors among women of reproductive age groups (15-49 y).

METHODS

Demographic and Health Survey data collected between 2010 and 2020 from 28 SSA countries were used for this analysis. We analysed the coverage of HIV testing and individual/household and community factors on 384 416 women in the reproductive age groups (15-49 y). Bivariate and multivariable multilevel binary logistic regression analysis were conducted to select candidate variables and to identify significant explanatory variables associated with HIV testing and the results were presented using adjusted odd ratios (AORs) at 95% confidence intervals (CIs).

RESULTS

The pooled prevalence of HIV testing among women of reproductive age in SSA was 56.1% (95% CI 53.7 to 58.4), with the highest coverage found in Zambia (86.9%) and the lowest in Chad (6.1%). Age (45-49 y; AOR 0.30 [95% CI 0.15 to 0.62]), women's education level (secondary; AOR 1.97 [95% CI 1.36 to 2.84]) and economic status (richest; AOR 2.78 [95% CI 1.40 to 5.51]) were some of the individual/household factors associated with HIV testing. Similarly, religion (no religion; AOR 0.58 [95% CI 0.34 to 0.97]), marital status (married; AOR 0.69 [95% CI 0.50 to 0.95]) and comprehensive knowledge of HIV (yes; AOR 2.01 [95% CI 1.53 to 2.64]) were significantly associated individual/household factors for HIV testing. Meanwhile, place of residence (rural; AOR 0.65 [95% CI 0.45 to 0.94]) was found to be a significant community-level factor.

CONCLUSION

More than half of married women in SSA have been tested for HIV, with between-country variations. Both individual/household factors were associated with HIV testing. Stakeholders should therefore consider all above-mentioned factors to plan an integrated approach to enhancing HIV testing through health education, sensitization, counselling and empowering older and married women, those with no formal education, those who do not have comprehensive HIV/AIDS knowledge and those in rural areas.

Exploring health insurance and knowledge of the ovulatory cycle: evidence from Demographic and Health Surveys of 29 countries in Sub-Saharan Africa

BACKGROUND

Unplanned pregnancy continues to be a major public health concern in Sub-Saharan Africa (SSA). Understanding the ovulatory cycle can help women avoid unplanned pregnancy. Though a wide range of factors for ovulatory cycle knowledge in SSA countries has not been well assessed, the influence of health insurance on ovulatory cycle knowledge is largely unknown. As a result, we set out to investigate the relationship between health insurance enrollment and knowledge of the ovulatory cycle among women of childbearing age. This study aims to investigate the relationship between health insurance enrollment and knowledge of the ovulatory cycle among women of childbearing age in sub-Saharan Africa (SSA).

METHODS

Demographic and Health Surveys (DHSs) data from 29 SSA countries were analyzed. The association between health insurance and ovulatory cycle knowledge was investigated using bivariate and multivariate multilevel logistic regression models among 372,692 women of reproductive age (15-49). The findings were presented as adjusted odds ratios (AOR) with 95% confidence intervals (CI). A p-value of 0.05 was considered statistically significant.

RESULTS

The pooled result shows that the prevalence of knowledge of ovulatory cycle in the studied 29 SSA countries was 25.5% (95% CI; 24.4%-26.6%). Findings suggest higher odds of ovulatory cycle knowledge among women covered by health insurance (AOR = 1.27, 95% CI; 1.02-1.57), with higher education (higher-AOR = 2.83, 95% CI; 1.95-4.09), from the richest wealth quintile (richest-AOR = 1.39, 95% CI; 1.04-1.87), and from female headed households (AOR = 1.16, 95% CI; 1.01-1.33) compared to women who had no formal education, were from the poorest wealth quintile and belonged to male headed households, respectively. We found lower odds of ovulatory cycle knowledge among women who had 2-4 parity history (AOR = 0.80, 95% CI; 0.65-0.99) compared to those with history of one parity.

CONCLUSIONS

The findings indicate that the knowledge of the ovulatory cycle is lacking in SSA. Improving health insurance enrollment should be considered to increase ovulatory cycle knowledge as an approach to reduce the region's unplanned pregnancy rate. Strategies for improving opportunities that contribute to women's empowerment and autonomy as well as sexual and reproductive health approaches targeting women who are in poorest quintiles, not formally educated, belonging to male headed households, and having high parity should be considered.

Gender differences in the acceptance of wife-beating: evidence from 30 countries in Sub-Saharan Africa

BACKGROUND

The World Health Organization (WHO) has cited domestic violence as an urgent global maternal and child health priority. Gender differences in the acceptance of wife-beating have not been explored at the multi-country level in sub-Saharan Africa (SSA) where the occurrence of wife-beating (36%) is greater than the global average (30%). It is against this backdrop that we examine the gender differences in the acceptance of wife beating in SSA.

METHODS

We used Demographic and Health Survey data from 30 SSA countries. Acceptance of wife beating among women and men was the principal outcome variable of interest. We employed Multiple correspondence analysis and logistic regression model as the primary estimation methods for this study. The descriptive statistics show that women had a higher acceptance rate (44%) of wife beating than men (25%). For the women sample, Mali, Democratic Republic of Congo, Chad, and Guinea had higher rates of acceptance of the wife beating (80.6%, 78.4%, 77.1% and 70.3% respectively) For the men, only Guinea had an acceptance rate above 50 percent.

RESULTS

We found that all else equal, women's acceptance of wife beating is higher for male-headed households than for female-headed households. Women without formal education were 3.1 times more likely to accept wife beating than those with higher education. Men with no formal education were 2.3 times more likely to accept wife beating than men with higher education. We found that polygamous women were comparable to polygamous men. Polygamous women were 1.2 times more likely to accept wife beating than those in monogamous marriages. Women were 1.2 times more likely to accept wives beating if they had extramarital relationships. Contrarily, men who engaged in extramarital affairs were 1.5 times more likely to justify wife beating. We also found that women's acceptance of wife beating decreases as they age. Men who decide on major household purchases and spending decisions on their earnings are more likely to accept wife beating. Corollary, women with similar gender and employment roles also accept wife beating. Finally, exposure to mass media is significantly associated with lower acceptance of wife beating for women and men.

CONCLUSION

We conclude that women have a higher acceptance rate of wife beating than men in SSA. Acceptance of wife beating differs significantly by country. Given the same level of education, women are more likely to accept wife beating than men. If women and men have similar levels of employment and gender roles, acceptance of wife beating is higher when men make major household purchasing decisions and and it is still higher even when the woman makes these decisions. Acceptance of wife beating is higher among young women and men, the uneducated, those in polygamous marriages, women, and men who engage in extra marital affairs, poor households and in rural areas. The findings indicate the need for policies and programs by SSA countries to truncate the high acceptance rate of wife beating, especially among women.

Socioeconomic inequalities in modern contraceptive use among women in Benin: a decomposition analysis

BACKGROUND

Contraceptive use is crucial to achieving Sustainable Development Goal 3. Evidence of socioeconomic inequality in the use of modern contraceptives is essential to address the developing inequality in its utilisation given the low prevalence of contraceptive use among women in Benin. This study examined the socioeconomic inequalities in modern contraceptive use among women in Benin.

METHODS

We performed a cross-sectional analysis of the 2017-18 Benin Demographic and Health Survey data. A weighted sample of 7,360 sexually active women of reproductive age was included in the study. We used a concentration curve to plot the cumulative proportion of women using modern contraception. Decomposition analysis was conducted to determine factors accounting for the socioeconomic disparities in modern contraceptive use.

RESULTS

We noted that the richest women had higher odds of modern contraceptive use (adjusted odds ratio [aOR] = 1.67, CI = 1.22-2.30) compared to the poorest women. Other factors that showed significant associations with modern contraception use were age, marital status, religious affiliation, employment status, parity, women's educational level, and ethnicity. We found that modern contraceptive use is highly concentrated among the rich, with rich women having a higher propensity of using modern contraception relative to the poor. Also, the disadvantaged to modern contraceptive use included the poor, those aged 45-49, married women, those working, those with four or more live births, rural residents, and women of Bariba and related ethnicity. Conversely, favourable concentration in modern contraceptive use was found among the rich, women aged 20-24, the divorced, women with two live births, the highly educated, those with media exposure, and women of Yoruba and related ethnicity.

CONCLUSION

The study has shown that wealthy women are more likely to utilize contraceptives than the poor. This is because wealthy women could afford both the service itself and the travel costs to the health facility, hence overcoming any economic barriers to using modern contraception. Other factors such as age, marital status, religion, employment status, parity, mother's educational level, and ethnicity were associated with contraceptive use in Benin. The Benin government and other stakeholders should develop family planning intercession techniques that address both the supply and demand sides of the equation, with a focus on reaching the illiterate and under-resourced population without admittance to modern contraception.

Community participation for reproductive, maternal, newborn and child health: insights from the design and implementation of the BornFyne-prenatal management system digital platform in Cameroon

Introduction

Across communities in low-middle income countries, digital health is currently revolutionizing the delivery of health services, particularly in the field of reproductive, maternal, newborn, and child health (RMNCH) services. While studies have shown the effectiveness of mHealth in delivering RMNCH services, there is little information about factors that enhance mHealth services utilization in low-cost settings including stakeholders' level of influence on the implementation of digital health intervention in sub-Saharan Africa. This paper seeks to describe important lessons on the levels of stakeholders' direct or indirect influence on the design and implementation of the BornFyne-PNMS digital health platform to support RMNCH services.

Methods

A participatory research (PR) design approach was employed to explore stakeholders' perspectives of a new initiative, through direct engagement of local priorities and perspectives. The process of introducing the digital application called the BornFyne-PNMS for district health delivery system and the community, and integrating it within the district health delivery system was guided by research-to-action, consistent with the PR approach. To explore stakeholders' perspectives through a PR approach, we conducted a series of stakeholder meetings fashioned after focus group discussions.

Results

Issues around male involvement in the program, sensitization and equity concerns arose. Emergent challenges and proposed strategies for implementation from diverse stakeholders evidently enriched the design and implementation process of the project intervention. Stakeholder meetings informed the addition of variables on the mobile application that were otherwise initially omitted, which will further enhance the RMNCH electronic data collection for health information systems strengthening in Cameroon.

Discussion

This study charts a direction that is critical in digital health delivery of RMNCH in a rural and low-income community and describes the important iterative stakeholder input throughout the study. The strategy of stakeholders' involvement in the BornFyne PNMS implementation charts a direction for ownership and sustainability in the strengthening of Cameroon's health information system.

Early Sexual Debut and Its Associated Factors Among Young Women Aged 15-24 in Mali: A Multilevel Analysis

Early sexual debut is associated with increased risk of several sexual and reproductive health problems, including unwanted pregnancies and sexually transmitted infections. Hence, determining factors that promote early sexual initiation is significant to guide policy and inform interventions aimed to promote the health of young people through to adulthood. This study examined the prevalence of early sexual debut and its associated factors among young women in Mali. Using cross-sectional nationally representative data from the 2018 Mali Demographic and Health Survey, a total of 4063 young women aged 15-24 were included in the study. Multilevel binary logistic regression analysis was done to determine the factors associated with early sexual debut. The results were presented using adjusted odds ratios (aOR) and 95% confidence intervals (CIs). The prevalence of early sexual debut in Mali was 17.8% (95% CI; 16-19.7%). Young women who attended higher school had lower odds of early sexual debut (aOR = 0.10, 95% CI; 0.01-0.82) compared to young women who had no formal education. Young women from richest households had lower odds of early sexual debut compared to those from the poorest households (aOR = 0.48, 95% CI; 0.27-0.82). Young women from households with large family size also had lower odds of experiencing early sexual debut compared to those in small family size (aOR = 0.81, 95% CI; 0.66-0.99). Furthermore, the odds of early sexual debut were lower among young women in Koulikoro (aOR = 0.59, 95% CI; 0.39-0.90), Sikasso (aOR = 0.35, 95% CI; 0.21-0.56), Segou (aOR = 0.40, 95% CI; 0.25-0.64), and Mopti (aOR = 0.44, 95% CI; 0.23-0.82) regions compared to young women in Kayes region. Higher odds of early sexual debut were found among currently employed compared to not currently employed young women (aOR = 1.74, 95% CI; 1.42-2.12) and currently married compared to not currently married young women (aOR = 4.64, 95% CI; 3.64-5.92). Young women from the Peulh ethnic groups compared to those from the Bambara ethnic groups were at a higher odds of early sexual debut (aOR = 1.43, 95% CI; 1.03-1.99). The findings suggest the need for interventions aimed at addressing early sexual debut among young women. These can include emphasizing the promotion and importance of female education, addressing the cultural practices that promote negative sexual norms/practices such as child marriages, and ensuring social change through efforts such as creating employment or economic opportunities for families.

An in-depth qualitative study of health care providers' experiences of performance-based financing program as a nation-wide adopted policy in Cameroon: A principal-agent perspective

OBJECTIVES

The study applies the principal-agent approach to explore providers' experiences before and after the introduction of performance-based financing (PBF) in Cameroon, challenges and facilitators in the implementation process, and mechanisms in place to ensure sustainability.

METHODS

The study was an in-depth qualitative study whose goal was to provide multiple descriptions of experiences and insights from a principal-agent analysis perspective. Purposive sampling was used to identify the key characteristics of the participants relevant to the study. A snowballing technique was used to further identify eligible participants. Only healthcare providers who were exposed to the previous system and could reflect on and provide meaningful data that captured the everyday experiences before and after the implementation of PBF were included. Data were collected from three districts in the Southwest region of Cameroon from May 2021 to August 2021. Data were transcribed and analyzed using MaxQDA.

RESULTS

A total of 17 interviews and 3 focus group discussions (24 participants) were conducted with healthcare providers and key stakeholders involved in PBF. The respondents described a range of changes that they had experienced since the introduction of PBF. Each of these changes was categorized as either positive or negative. Positive changes were framed into 14 dominant categories: motivation, negotiations, innovation, resource allocation, autonomy, decentralization, transparency, improved quality of care, separation of function, performance, equity considerations, opportunity to recruit, participation in decision-making, and improved access to and utilization of maternal health services. The main challenges (negative experiences) reported were framed into nine categories: management of change, retention issues, conflict of interest, poor understanding of the PBF concept, resistance to change, verification challenges, delays in payment of PBF incentives, data entry and documentation, and challenges in meeting the equity considerations of the poor and vulnerable. Despite the challenges, providers preferred the decentralized approach to the centralized system.

CONCLUSION

PBF is a national strategy for achieving universal health coverage in Cameroon, and the experiences of providers provide a vital guide to refine national policy. The introduction of PBF has provided positive changes to providers' quality of care when compared to the previous system. Addressing the delays in PBF payments will help to overcome the challenges to implementation and provide opportunities for health facilities to be more efficient and improve their performance. Despite the limitations of delay in payment, PBF helps to align the incentives of the health workers (agent) with those of the Ministry of Health (principal).

Socio-economic and cultural factors associated with the utilization of maternal healthcare services in Togo: a cross-sectional study

BACKGROUND

Proper utilization of maternal healthcare services plays a major role on pregnancy and birth outcomes. In sub-Saharan Africa, maternal and child mortality remains a major public health concern, especially in least developed countries such as Togo. In this study, we aimed to analyze factors associated with use of maternal health services among Togolese women aged 15-49 years.

METHODS

This study used data from third round of nationally representative Demographic and Health Survey conducted in Togo in 2013. Analysis included 4,631 women aged 15-49 years. Outcome variables were timely first antenatal care (ANC) visits, adequate ANC4 + visits, and health facility delivery. Data were analyzed using Stata version 16.

RESULTS

Overall, proportion of maternal healthcare utilization was 27.53% for timely first ANC visits, 59.99% for adequate ANC visits, and 75.66% for health facility delivery. Our multivariable analysis showed significant differences among women in highest wealth quintile, especially in rural areas with increasing odds of timely first ANC visits (Odds ratio (OR) = 3.46, 95% CI = 2.32,5.16), attending adequate ANC visits (OR = 2.19, 95% CI = 1.48,3.24), and delivering in health facilities (OR = 8.53, 95% CI = 4.06, 17.92) compared to those in the poorest quintile. Also, women with higher education had increased odds of timely first ANC visits (OR = 1.37, 95% CI = 1.11,1.69), and attending adequate ANC visits (OR = 1.73, 95% CI = 1.42,2.12) compared to those with no formal education. However, having higher parity and indigenous beliefs especially in rural areas decreased odds of using healthcare services.

CONCLUSIONS

Findings from this study showed that socio-economic inequality and socio-cultural barriers influenced the use of maternal healthcare services in Togo. There is therefore a need to improve accessibility and the utilization of maternal healthcare services through women's economic empowerment and education to reduce the barriers.

Contraceptive use pattern based on the number and composition of children among married women in sub-Saharan Africa: a multilevel analysis

BACKGROUND

The relationship between composition of children and contraception use has received limited scholarly attention in sub-Saharan Africa. In this study, we examined the relationship between contraceptive methods, the number and composition of children in SSA.

METHODS

Data on 21 countries in sub-Saharan Africa (SSA) countries that had a Demographic and Health Survey on or before 2015 were analysed. We applied a multilevel multinomial logistic regression model to assess the influence of family composition on contraceptive use. Adjusted relative risk ratio (aRRR) and 95% CI were estimated. The significant level was set at p < 0.05. All the analyses were conducted using weighted data.

RESULTS

Women who had one son and two daughters (aRRR = 0.85, CI = 0.75, 0.95), two sons and one daughter (aRRR = 0.81 CI = 0.72, 0.92), one son and three daughters (aRRR = 0.66, CI = 0.54, 0.80), two sons and two daughters (aRRR = 0.59, CI = 0.50, 0.69), and three or more sons (aRRR = 0.75, CI = 0.63, 0.91) were less likely to use temporary modern contraceptive methods. Those with two sons and two daughters were less likely to use traditional methods (aRRR = 0.52, CI = 0.35, 0.78). Women in the older age group (35-49 years) were less likely to use temporary modern methods (aRRR = 0.60; 95%CI; 0.57, 0.63). However, this group of women were more likely to use permanent (sterilization) (aRRR = 1.71; 95%CI; 1.50, 1.91) and traditional methods (aRRR = 1.28; 95%CI; 1.14, 1.43).

CONCLUSION

These findings suggest that contraception needs of women vary based on the composition of their children, hence a common approach or intervention will not fit. As a result, contraception interventions ought to be streamlined to meet the needs of different categories of women. The findings can inform policymakers and public health professionals in developing effective strategies to improve contraceptive use in SSA.

Determinants of birth registration in sub-Saharan Africa: evidence from demographic and health surveys

Background

Birth registration is a crucial aspect of ensuring that children have access to their rights and benefits, including health care, education, and citizenship. In sub-Saharan Africa (SSA), birth registration rates remain low, with millions of children going unregistered each year. Understanding the predictors of birth registration among children in this sub-region is important for developing targeted interventions to improve registration rates. The study examines the predictors of birth registration among children in SSA.

Methods

We performed a cross-sectional analysis of secondary data pooled from the Demographic and Health Survey of 17 countries conducted from 2015 to 2021. A weighted sample of 162,500 children was included in the final analysis. We summarized the proportion of birth registration among children in SSA using a forest plot. We utilized a multilevel binary logistic regression analysis to examine the predictors of birth registration. The results were presented using adjusted odds ratios (aOR) with 95% confidence intervals (CIs).

Results

We found that 48.32% [48.15-48.49] of births in SSA were registered. The lowest and highest prevalence of birth registration were found in Ethiopia (2.70 [2.38-3.02]) and Sierra Leone (92.93 [92.36-93.50]), respectively. Increasing child's age was found to be significantly associated with a higher likelihood of birth registrations, with those aged 4 years [aOR = 1.55; CI = 1.49, 1.62] having the highest odds of birth registration compared to those aged below 1 year. Children born to mothers with primary [aOR = 1.17; CI = 1.11, 1.24], secondary [aOR = 1.44; CI = 1.34, 1.54], and higher education [aOR = 1.71; CI = 1.48, 1.99] were more likely to be registered than those born to mothers who had no formal education. Also, children born in health facilities were more likely to be registered [aOR = 1.60; CI = 1.48, 1.74] than those born at home. The odds of birth registration were significantly higher among children whose mothers received assistance during delivery [aOR = 1.88; CI = 1.72, 2.04], those in the richest wealth index [aOR = 3.91; CI = 3.54, 4.33], and those in rural areas [aOR = 1.92; CI = 1.76, 2.10].

Conclusion

There is low childbirth registration coverage in SSA. The predictors of this phenomenon are the child's age, maternal level of education, wealth index, place of residence, sub-region, maternal age, place of delivery, assistance during delivery, marital status, and sex of household head. Interventions and policies developed to improve childbirth registration coverage in SSA should prioritize mothers with no formal education, those who deliver at home, those with low socioeconomic status, those living in female headed household, and adolescent mothers.

An assessment of Individual, community and state-level factors associated with inadequate iodised salt consumption among pregnant and lactating women in Nigeria

BACKGROUND

Iodine deficiency is the most common cause of thyroid disease, and in its severe form can result in cretinism; the impairment of the brain development of a child. Pregnant and breastfeeding women's daily iodine requirement is elevated due to physiological changes in iodine metabolism, requiring up to double the iodine intake of other women. Although Nigeria was the first African country to be declared iodine sufficient in 2007, recent evidence has shown that only about seven in ten households consume salt with adequate iodine content (≥ 15 ppm), with variation across states. The study aimed to assess the Individual- and household-, community- and state-level factors associated with inadequate iodised salt consumption among pregnant women and breastfeeding mothers in Nigeria.

METHODS

This study utilised the Multiple Indicator Cluster Survey to assess factors associated with inadequate iodised salt consumption among 4911 pregnant women and breastfeeding mothers in Nigeria. The descriptive analysis was presented using frequencies and percentages. The prevalence of adequate and inadequate iodised salt consumption with their 95% confidence interval were computed. Several multi-level mixed effect log-binomial logistic regressions were used to explore the factors associated with inadequate iodised salt consumption. The Loglikelihood, Akaike Information Criterion and Bayesian Information Criterion were used to assess the goodness of fit of the models. All analyses were adjusted for the complex survey design and analysed using Stata 15.0 at p < 0.05.

RESULTS

The prevalence of inadequate iodised salt consumption among pregnant and breastfeeding mothers was 35.2% (95% CI: 33.1-37.5). Inadequate consumption of iodised salt was highest among pregnant and breastfeeding women aged 45-49 years (48.2%; 95%CI: 37.8-58.8), as well as those with non-formal education (52.7%; 95%CI: 47.7-57.6) and no education (34.6%; 95%CI: 31.3-38.1). Our findings revealed that pregnant and breastfeeding women living in the poorer, middle, richer and richest quintiles were 32%, 47%, 35% and 62% less likely to consume salt with inadequate iodine compared to those in the poorest households. Those with non-formal education were 1.8 times (95%CI: 1.36-2.42) more likely to consume salt with deficient iodine than those without education. Pregnant and breastfeeding mothers residing in moderately and most deprived communities were 3.5 (95%CI: 2.57-4.73) and 4.7 times (95%CI: 3.38-6.55) more likely to consume salt with inadequate iodine than those from least deprived communities. Women in the Northwestern region and those from the Southwestern region were 4.0 and 3.5 times, respectively, more likely to consume salt with inadequate iodine compared to pregnant and breastfeeding women residing in the North-Central region.

CONCLUSIONS

The study has shown that inadequate consumption of iodised salt dominates among older pregnant and breastfeeding women. Also, women with non-formal education have higher prospects of consuming salt with lesser iodine. There is a need to enhance women's economic opportunities and empowerment as well as sensitisation on their nutritional requirements during pregnancy and breastfeeding. Both formal and non-formal educational initiatives on nutrition are extremely important and should be prioritised by the Nigerian government in its efforts to encourage the consumption of iodised salt among pregnant and lactating mothers. Additionally, health promotion interventions that seek to advocate iodised salt intake must be prioritised by the actors in the health sector.

Seeking maternal health care in rural Nigeria: through the lens of negofeminism

BACKGROUND

Feminist scholarship is acutely aware that health is not dependent on behavioural choices alone but on interlocking social determinants that affect people's capacity to lead healthy lives. Women are situated within social structures that impact their health. but there is limited engagement with interpretive tools such as feminist theories that centre the realities of African women, particularly in the context of maternal health. It is imperative that women's control over their reproductive health and autonomy in seeking care, particularly skilled maternal healthcare are understood within this context. This study seeks to examine pregnant women's socio-cultural realities in a Nigerian context and in congruence with articulations of African feminism. Feminist scholarship acknowledges that women are situated within social structures that impact their health. Therefore, this paper seeks to examine pregnant women's socio-cultural realities in a Nigerian context and in congruence with articulations of African feminism.

METHOD

This is a cross-sectional qualitative study of a total of 64 participants: 39 women and 25 men in Ewato and Okpekpe communities, two Local Government Areas of Edo State in southern Nigeria. The study presents findings from eight sex-and-age desegregated focus group discussions. This study reports on emergent data related to women's decision-making in accessing skilled maternal care. Data were transcribed and translated to English. Using the NVivo 1.6 software, data were coded and analyzed using a conventional approach to content analysis.

RESULTS

Findings describe ways in which women negotiate authority by ascribing the role of decision-maker to their men spouses while maintaining influence over their pregnancy healthcare decisions and actions. Negofeminism's concepts of alliance, community and connectedness were highlighted through men's constructive involvement in maternal health. Furthermore, women were shown to maneuver patriarchal norms to gain control of their healthcare decisions.

CONCLUSION

This study offers a different narrative from the dominant view of non-Western women, specifically African women, as oppressed passive victims who are ineffectual in taking charge of their health. From the perspective of negofeminism, women navigate patriarchal environments to yield the best possible maternal health outcomes. The current study can be useful in informing policy and programming that acknowledges women's social embeddedness.

Barriers and facilitators associated with the use of mental health services among immigrant students in high-income countries: A systematic scoping review

BACKGROUND

Immigrant students face various challenges in high-income countries that can contribute to the decline of their mental well-being upon arrival in their host country. Despite the growing population of these students in several high-income countries, there is inadequate attention given to their mental health needs and their access to mental health services. Thus, this systematic scoping review aimed to identify gaps in existing research relating to the barriers and facilitators associated with access to and use of mental health services in high-income countries.

METHODS

Following the PRISMA-ScR checklist as guidance we systematically searched Ovid Medline, APA PsycInfo, Education Source, CINAHL, Web of Science databases for peer reviewed articles related to barriers and facilitators of mental health service use among immigrant students. We conducted a narrative evidence synthesis to highlight barriers and facilitators to the use of mental health services.

RESULTS

Out of the 2407 articles initially found, 47 studies met the inclusion criteria and were considered for this review. The increasing attention towards the mental health concerns of immigrant students and their access to mental health services is evident. However, various barriers like stigma, insufficient knowledge, or adherence to traditional gender roles (such as masculinity) hinder their utilization of these services. On the other hand, factors such as being a woman, having a strong sense of cultural adaptation, or possessing adequate mental health literacy serve as facilitators for accessing mental health services.

CONCLUSION

These students have unique experiences, and their needs are often unmet. To improve their mental health and use of mental health services, it is important to consider the barriers they face and their unique experience in their specific life context and to develop tailored prevention and intervention programs.

Physical violence during pregnancy in sub-Saharan Africa: why it matters and who are most susceptible?

OBJECTIVE

The study assessed the prevalence of physical violence against pregnant women and its associated factors in sub-Saharan Africa (SSA).

DESIGN

We analysed cross-sectional data of 108971 women in sexual unions from the most recent Demographic and Health Surveys of 26 countries in SSA. The predictors of physical violence were examined using a multilevel binary logistic regression. All the results were presented as adjusted odds ratios (aORs) with their corresponding 95% confidence intervals (CIs).

SETTING

Twenty-six countries in SSA.

PARTICIPANTS

108 971 women who had ever been pregnant.

OUTCOME MEASURE

Physical violence during pregnancy.

RESULTS

Physical violence was identified in 6.0% of pregnant women in SSA. The highest prevalence (14.0%) was reported in South Africa, while Burkina Faso recorded the lowest (2.1%). Women who had primary (aOR=1.26, 95% CI=1.15, 1.38) and secondary education (aOR=1.15, 95% CI=1.01,1.32); those who were cohabiting (aOR=1.21, 95% CI=1.11, 1.32); those who were working (aOR=1.17, 95% CI=1.08, 1.28); and those whose partners had primary (aOR=1.15, 95% CI=1.04, 1.28) and secondary education (aOR=1.14, 95% CI=1.01, 1.28) were more likely to experience physical violence during pregnancy compared with those who had no formal education; those who were married; those who were not working, and those whose partners had no formal education, respectively. Moreover, women whose partners consumed alcohol (aOR=2.37, 95% CI=2.20, 2.56); those who had parity of four or more (aOR=2.06, 95% CI=1.57, 2.72); and those who perceived intimate partner violence (IPV) as a culturally accepted norm (aOR=1.55, 95% CI=1.44, 1.67) had higher odds of experiencing physical violence during pregnancy compared to those whose partners did not consume alcohol, those with parity zero, and those who did not perceive IPV as culturally accepted, respectively. On the contrary, women who were aged 35-39, those who were of the richest wealth index, and those in rural areas had reduced odds of experiencing physical violence during pregnancy.

CONCLUSION

Based on the findings, community leaders are encouraged to liaise with law enforcement agencies to strictly enforce laws on gender-based violence by prosecuting perpetrators of IPV against pregnant women as a deterrent. Also, intensifying education on what constitutes IPV and the potential consequences on the health of pregnant women, their children, and their families will be laudable. Improving the socioeconomic status of women may also help to eliminate IPV perpetration against women at their pregnancy stage.

Relationship between history of hormonal contraceptive use and anaemia status among women in sub-Saharan Africa: A large population-based study

BACKGROUND

Anaemia among women has been reported to be a significant contributor to hemorrhage, exacerbated risk of stillbirths, miscarriages, and maternal mortalities. Hence, understanding the factors associated with anaemia is imperative to develop preventive strategies. We examined the association between history of hormonal contraceptive use and risk of anaemia among women in sub-Saharan Africa.

METHODS

We analyzed data from the recent Demographic and Health Surveys (DHS) of sixteen countries in sub-Saharan Africa. Countries with recent DHSs conducted from 2015 to 2020 were included in the study. A total of 88,474 women of reproductive age were included. We used percentages to summarize the prevalence of hormonal contraceptives and anaemia among women of reproductive age. We used multilevel binary logistic regression analysis to examine the association between hormonal contraceptives and anaemia. We presented the results using crude odds ratio (cOR) and adjusted odds ratios (aOR), with their respective 95 percent confidence intervals (95% CIs).

RESULTS

On the average, 16.2% of women are using hormonal contraceptives and this ranged from 7.2% in Burundi to 37.7% in Zimbabwe. The pooled prevalence of anaemia was 41%, ranging from 13.5% in Rwanda to 58.0% in Benin. Women who used hormonal contraceptives were less likely to be anaemic compared to those who were not using hormonal contraceptives (aOR = 0.56; 95%CI = 0.53, 0.59). At the country-level, hormonal contraceptive use was associated with a reduced likelihood of anaemia in 14 countries, except for Cameroon and Guinea.

CONCLUSION

The study underscores the importance of promoting the use of hormonal contraceptives in communities and regions that have a high burden of anaemia among women. Specifically, health promotion interventions aimed at promoting the use of hormonal contraceptives among women must be tailored to meet the needs of adolescents, multiparous women, those in the poorest wealth index, and women in union as these sub-populations were at significantly higher risk of anaemia in sub-Saharan Africa.

Prevalence, indications, and complications of caesarean section in health facilities across Nigeria: a systematic review and meta-analysis

BACKGROUND

Over 80,000 pregnant women died in Nigeria due to pregnancy-related complications in 2020. Evidence shows that if appropriately conducted, caesarean section (CS) reduces the odds of maternal death. In 2015, the World Health Organization (WHO), in a statement, proposed an optimal national prevalence of CS and recommended the use of Robson classification for classifying and determining intra-facility CS rates. We conducted this systematic review and meta-analysis to synthesise evidence on prevalence, indications, and complications of intra-facility CS in Nigeria.

METHODS

Four databases (African Journals Online, Directory of Open Access Journals, EBSCOhost, and PubMed) were systematically searched for relevant articles published from 2000 to 2022. Articles were screened following the PRISMA guidelines, and those meeting the study's inclusion criteria were retained for review. Quality assessment of included studies was conducted using a modified Joanna Briggs Institute's Critical Appraisal Checklist. Narrative synthesis of CS prevalence, indications, and complications as well as a meta-analysis of CS prevalence using R were conducted.

RESULTS

We retrieved 45 articles, with most (33 (64.4%)) being assessed as high quality. The overall prevalence of CS in facilities across Nigeria was 17.6%. We identified a higher prevalence of emergency CS (75.9%) compared to elective CS (24.3%). We also identified a significantly higher CS prevalence in facilities in the south (25.5%) compared to the north (10.6%). Furthermore, we observed a 10.7% increase in intra-facility CS prevalence following the implementation of the WHO statement. However, none of the studies adopted the Robson classification of CS to determine intra-facility CS rates. In addition, neither hierarchy of care (tertiary or secondary) nor type of facility (public or private) significantly influenced intra-facility CS prevalence. The commonest indications for a CS were previous scar/CS (3.5-33.5%) and pregnancy-related hypertensive disorders (5.5-30.0%), while anaemia (6.4-57.1%) was the most reported complication.

CONCLUSION

There are disparities in the prevalence, indications, and complications of CS in facilities across the geopolitical zones of Nigeria, suggestive of concurrent overuse and underuse. There is a need for comprehensive solutions to optimise CS provision tailor-made for zones in Nigeria. Furthermore, future research needs to adopt current guidelines to improve comparison of CS rates.

Identity and COVID-19 in Canada: Gender, ethnicity, and minority status

BACKGROUND

During the COVID-19 pandemic, growing evidence from the United States, the United Kingdom, and China has demonstrated the unequal social and economic burden of this health crisis. Yet, in Canada, studies assessing the socioeconomic and demographic determinants of COVID-19, and how these determinants vary by gender and ethnic minority status, remain scarce. As new strains of COVID-19 emerge, it is important to understand the disparities to be able to initiate policies and interventions that target and prioritise the most at-risk sub-populations.

AIM

The objective of this study is to assess the socioeconomic and demographic factors associated with COVID-19-related symptoms in Canada, and how these determinants vary by identity factors including gender and visible minority status.

METHODS

We implemented an online survey and collected a nationally representative sample of 2,829 individual responses. The original data collected via the SurveyMonkey platform were analysed using a cross-sectional study. The outcome variables were COVID-19-related symptoms among respondents and their household members. The exposure variables were socioeconomic and demographic factors including gender and ethnicity as well as age, province, minority status, level of education, total annual income in 2019, and number of household members. Descriptive statistics, chi-square tests, and multivariable logistic regression analyses were performed to test the associations. The results were presented as adjusted odds ratios (aORs) at p < 0.05 and a 95% confidence interval.

RESULTS

We found that the odds of having COVID-19-related symptoms were higher among respondents who belong to mixed race [aOR = 2.77; CI = 1.18-6.48] and among those who lived in provinces other than Ontario and Quebec [aOR = 1.88; CI = 1.08-3.28]. There were no significant differences in COVID-19 symptoms between males and females, however, we did find a significant association between the province, ethnicity, and reported COVID-19 symptoms for female respondents but not for males. The likelihood of having COVID-19-related symptoms was also lower among respondents whose total income was $100,000 or more in 2019 [aOR = 0.18; CI = 0.07-0.45], and among those aged 45-64 [aOR = 0.63; CI = 0.41-0.98] and 65-84 [aOR = 0.42; CI = 0.28-0.64]. These latter associations were stronger among non-visible minorities. Among visible minorities, being black or of the mixed race and living in Alberta were associated with higher odds of COVID-19-related symptoms.

CONCLUSION

We conclude that ethnicity, age, total income in 2019, and province were significantly associated with experiencing COVID-19 symptoms in Canada. The significance of these determinants varied by gender and minority status. Considering our findings, it will be prudent to have COVID-19 mitigation strategies including screening, testing, and other prevention policies targeted toward the vulnerable populations. These strategies should also be designed to be specific to each gender category and ethnic group, and to account for minority status.

Health and economic implications of the ongoing coronavirus disease (COVID-19) pandemic on women and children in Africa

The coronavirus disease (COVID-19) pandemic continues to pose major health and economic challenges for many countries worldwide. Particularly for countries in the African region, the existing precarious health status resulting from weak health systems have made the impact of the pandemic direr. Although the number of the COVID-19 infections in Africa cannot be compared to that of Europe and other parts of the world, the economic and health ramifications cannot be overstated. Significant impacts of the lockdowns during the onset of the pandemic caused disruptions in the food supply chain, and significant declines in income which decreased the affordability and consumption of healthy diets among the poor and most vulnerable. Access and utilization of essential healthcare services by women and children were also limited because of diversion of resources at the onset of the pandemic, limited healthcare capacity, fear of infection and financial constraint. The rate of domestic violence against children and women also increased, which further deepened the inequalities among these groups. While all African countries are out of lockdown, the pandemic and its consequent impacts on the health and socio-economic well-being of women and children persist. This commentary discusses the health and economic impact of the ongoing pandemic on women and children in Africa, to understand the intersectional gendered implications within socio-economic and health systems and to highlight the need for a more gender-based approach in response to the consequences of the pandemic in the Africa region.

A systematic review of the effect of performance-based financing interventions on out-of-pocket expenses to improve access to, and the utilization of, maternal health services across health sectors in sub-Saharan Africa

Background

Performance-based financing (PBF) assumes that subsidizing user fees for maternal health services to reduce out-of-pocket expenses will expand coverage and reduce inequities in access to maternal health services. It is usually associated with process changes, and the idea that increasing a facility's resources from PBF interventions can improve the availability of equipment, drugs, and medical supplies at the facility, has an indirect effect on out-of-pocket expenses. Assessment of complex interventions such as PBF requires consideration of specific underlying assumption or theories of change. Such assessment will allow a better and broader understanding of the system's strengths and weaknesses, where the gaps lie, whether the theory of change is sound, and will inform policy design and implementation.

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) checklist, we performed a systematic review and a critical appraisal of selected studies using the risk-of-bias criteria developed by the Cochrane Effective Practice and Organisation of Care. We used the Grading of Recommendation and Evaluation, Development and Assessment framework for assessing the overall strength of the evidence.

Results

After the abstract screening (n = 9873), we deemed 302 as relevant for full-text screening and assessed 85 studies for review eligibility. Finally, we included 17 studies in the review. We could not conduct a meta-analysis, so we report a narrative synthesis. As an add-on to an existing payment mechanism, PBF may facilitate the removal of operational barriers to enhance utilization of certain maternal health services in some contexts, especially in public facilities.

Conclusions

PBF strategies may potentially decrease out-of-pocket expenses for specific maternal health services, especially in settings that have already instituted some form of user fee exemption policies on maternal health services. The implementation of PBF can be considered a potential access instrument in reducing out-of-pocket expenses to stimulate demand for maternal services. However, the implementation approaches employed will determine utilization, taking into consideration existing equitable and inequitable access characteristics which vary by context.

Registration

PROSPERO CRD42020222893.

Health facility delivery and early initiation of breastfeeding: Cross-sectional survey of 11 sub-Saharan African countries

Background and Aims

Early initiation of breastfeeding (EIB) remains one of the promising interventions for preventing neonatal and child deaths. EIB is positively associated with healthcare delivery or childbirth. Meanwhile, no study in sub-Saharan Africa (SSA) appears to have investigated the relationship between health facility delivery and EIB; thus, we assessed the correlation between health facility delivery and EIB.

Methods

We used data from the Demographic and Health Survey (DHS) of 64,506 women from 11 SSA countries. The outcome variable was whether the respondent had early breastfeeding or not. Two logistic regression models were used in the inferential analysis. With a 95% confidence interval (CI), the adjusted odds ratios (aORs) for each variable were calculated. The data set was stored, managed, and analyzed using Stata version 13.

Results

The overall percentage of women who initiated early breastfeeding was 59.22%. Rwanda recorded the highest percentage of early initiation of breastfeeding (86.34%), while Gambia recorded the lowest (39.44%). The adjusted model revealed a significant association between health facility delivery and EIB (aOR = 1.80, CI = 1.73-1.87). Compared with urban women, rural women had higher likelihood of initiating early breastfeeding (aOR = 1.22, CI = 1.16-1.27). Women with a primary education (aOR = 1.26, CI = 1.20-1.32), secondary education (aOR = 1.12, CI = 1.06-1.17), and higher (aOR = 1.13, CI = 1.02-1.25), all had higher odds of initiating early breastfeeding. Women with the richest wealth status had the highest odds of initiating early breastfeeding as compared to the poorest women (aOR = 1.33, CI = 1.23-1.43).

Conclusion

Based on our findings, we strongly advocate for the integration of EIB policies and initiatives with healthcare delivery advocacy. Integration of these efforts can result in drastic reduction in infant and child mortality. Essentially, Gambia and other countries with a lower proclivity for EIB must reconsider their current breastfeeding interventions and conduct the necessary reviews and modifications that can lead to an increase in EIB.