Validity of rapid estimates of household wealth and income for health surveys in rural Africa

STUDY OBJECTIVE—To test the validity of proxy measures of household wealth and income that can be readily implemented in health surveys in rural Africa.DESIGN—Data are drawn from four different integrated household surveys. The assumptions underlying the choice of wealth proxy are described, and correlations with the true value are assessed in two different settings. The expenditure proxy is developed and then tested for replicability in two independent datasets representing the same population.SETTING—Rural areas of Mali, Malawi, and Côte d''Ivoire (two national surveys).PARTICIPANTS—Random sample of rural households in each setting (n=275, 707, 910, and 856, respectively).MAIN RESULTS—In both Mali and Malawi, the wealth proxy correlated highly (r?0.74) with the more complex monetary value method. For rural areas of Côte d''Ivoire, it was possible to generate a list of just 10 expenditure items, the values of which when summed correlated highly with expenditures on all items combined (r=0.74, development dataset, r=0.72, validation dataset). Total household expenditure is an accepted alternative to household income in developing country settings.CONCLUSIONS—It is feasible to approximate both household wealth and expenditures in rural African settings without dramatically lengthening questionnaires that have a primary focus on health outcomes.     

Interdepartmental Committee on Nutrition for National Defense surveys in Asia and Africa

I suppose I should establish my bonafides for participation in this symposium. I did participate in 3 Interdepartmental Committee on Nutrition for National Defense (ICNND) surveys as far separated as one on the Blackfeet Indian Reservation (1) in Montana and 2 in Asia-Burma (2) and East Pakistan (3). In fact, the Blackfeet Reservation and Burma surveys were my training grounds for becoming the clinical chief for the East Pakistan survey and later the codirector. More importantly, in 1962, I followed Alan Forbes, who is much missed at this symposium, as the deputy to Arnie Schaefer at ICNND and NIH, and did have experience of an office in the Stone House on the NIH campus. There I participated in the transmutation of the ICNND to the Interdepartmental Committee on National Development and its alignment with the Office of International Research at the NIH and a repositioning within the Department of Health and Human Services. It was from this position that ICNND went on to organize some civilian surveys in the mid-1960s, including those in Central America and Panama (4), and it was from this position that the groundwork was laid for the application of ICNND techniques to the first U.S. domestic survey outside of an Indian reservation, culminating in the Ten State Nutrition Survey (5), which documented that there was hunger in America, as well as abroad.     

Prevalence and pattern of HIV-related malnutrition among women in sub-Saharan Africa: a meta-analysis of demographic health surveys

Background  

The world's highest HIV infection rates are found in Sub-Saharan Africa (SSA), where adult prevalence in most countries exceeds 25%. Food shortages and malnutrition have combined with HIV/AIDS to bring some countries to the brink of crisis. The aim of this study was to describe prevalence of malnutrition among HIV-infected women and variations across socioeconomic status using data from 11 countries in SSA.     

Risk factors for domestic physical violence: national cross-sectional household surveys in eight southern African countries

Background  

The baseline to assess impact of a mass education-entertainment programme offered an opportunity to identify risk factors for domestic physical violence.     

Household and community HIV/AIDS status and child malnutrition in sub-Saharan Africa: evidence from the demographic and health surveys

This paper examines the extent to which under five children in households or communities adversely affected by HIV/AIDS are disadvantaged, in comparison with other children in less affected households/communities. The study is based on secondary analysis of the Demographic and Health Survey (DHS) data collected during 2003-2008 from 18 countries in sub-Saharan Africa, where the DHS has included HIV test data for adults of reproductive age. We apply multilevel logistic regression models that take into account the effect of contextual community/country level HIV/AIDS factors on child malnutrition. The outcome variable of interest is child undernutrition: stunting, wasting and underweight. The results suggest that across countries in sub-Saharan Africa, children whose mothers are infected with HIV are significantly more likely to be stunted, wasted or underweight compared to their counterparts of similar demographic and socio-economic background whose mothers are not infected. However, the nutritional status of children who are paternal orphans or in households where other adults are HIV positive are not significantly different from non-orphaned children or those in households where no adult is infected with HIV. Other adult household members being HIV positive is, however, associated with higher malnutrition among younger children below the age of one. Further analysis reveals that the effect of mothers' HIV status on child nutritional status (underweight) varies significantly across communities within countries, the effect being lower in communities with generally higher levels of malnutrition. Overall, the findings have important implications for policy and programme efforts towards improved integration of HIV/AIDS and child nutrition services in affected communities and other sub-groups of the population made vulnerable by HIV/AIDS. In particular, children whose mothers are infected with HIV deserve special attention.     

Demographic levels and trends in sub-Saharan Africa

Census data, the findings of 9 World Fertility Surveys (WFSs), and the results of several demographic surveys were used to assess fertility and infant and child mortality trends in sub-Saharan Africa. Major determinants of these trends were also identifed. Fertility levels are still high in most sub-Saharan countries. Estimated crude birth rates ranged from 44-51 during the 1960s and from 45 (Burundi) to 53 (Kenya) in 1982. The estimated mean number of children ever born t married women aged 45-49 years of age ranged from 5.3 in Cameroon to 7.9 in Kenya. Total fertility rates, based on WFS data, declined from 7.8 to 7.2 in Senegal and from 7.3 to 6.5 in Ghana between the 1960s and mid-1970s; remained stable in Ivory Coast (7.5), Benin (7.0) and Lesotho (5.7) in recent years; declined slowly from 9.2 to 8.3 in Kenya between the 1950s and 1970s; and increased between the 1960s and 1970s from 6.5-7.2 and then declined slightly in the late 1970s in Mauritania. In contrast, the total fertility rate increased in cameroon from 5.3-6.4 between the 1960s and 1980 and, according to 1 demographic study, increased slightly in Zaire in recent years. The variations in the fertility rates were determined in large measure by nuptiality patterns, the level of contraceptive use, sterility levels, breastfeeding patterns, the degree to which postpartum abstinence was practiced, and the demand level for children. Marriage is almost universal and the remarriage rate is high. contraceptive use is low and ranges from 1.6% in Mauritania to 39.9% in Ghana. Breastfeeding is almost universal; however, breastfeeding is negatively associated with maternal education, urban residence, contraceptive use, and maternal employment outside the home. With continued modernizarion, breastfeeding may decline. Postpartum abstinence is also declining in a number of countries. Furture declines in fertility will, to a large extent, be a function of trends in these fertility determinants. Infecundity, as measured by the number of older women with no children, apparently declined in several countries in recent years. The mean number of children desired remains high and ranged from 5.5 in Lesotho to 7.3 in Cameroon. Almost all the countries experienced a decline in infant mortality since 1950 when the rate ranged from 120-235. In almost all countries the rate in recent years was less than 150 and substantially lower in Benin (102), Cameroon (95), Ivory Coast (101), and Kenya (83). WFS data indicates that the child mortality rate is still high and ranges from 135 in Kenya to 251 in Senegal; however, in all WFS countries, except Mauritania, it is considerably lower than in the 1960s. Further declines in mortality will depend on improvements in the nutritional status of women, infants and children, increased health service provision and utilization, improvements in agriculture and income distribution, and increased parental education.     

An overlooked priority: puberty in sub-Saharan Africa

Early adolescence remains an overlooked window of opportunity for public health intervention with girls and boys in sub-Saharan Africa. Minimal health data exist on pubescent girls and boys. Considerable morbidity and mortality related to HIV, sexually transmitted infections, and pregnancy emerge soon after puberty, suggesting the importance of targeting early adolescents. The fundamental goal of primary prevention would be better served if girls and boys between the ages of 10 and 14 years were targeted for effective and contextually relevant interventions. Such interventions should address healthy transitions to young adulthood to effectively advance the public health agenda with postpubescent (aged 15 to 24 years) young women and men. The global health community is overdue to build the empirical database for intervention with this age group.     

Public autonomous hospitals in sub-Saharan Africa: trends and issues

Since the late 1980s, many countries in Africa have been granting increased autonomy to their main teaching hospitals. This policy has significant international support but has been evaluated little from either theoretical or empirical perspectives. This paper attempts to fill this gap by assembling evidence from policy documents, theoretical debates and empirical evidence of related policy changes in other contexts such as the development of trust hospitals in the UK NHS. The paper attempts to locate the policy in the broader context of the package of health sector reform measures proposed at international level, and to identify the role it is intended to play in the achievement of the implicit objectives of that package. The objectives identified are improvements in allocative efficiency and equity, improvements in internal efficiency and improvements in responsiveness, accountability and choice. Each of these objectives presents difficulties which suggest that only modest short-term expectations of the policy can be justified. Given the lack of evidence from existing experience, a research agenda is suggested, which aims to provide information to guide further implementation of the policy.     

Different delivery models for antiretroviral therapy in sub-Saharan Africa in the context of 'universal access'

In 10 years, in line with the concept of universal access, 25 million HIV-infected patients in sub-Saharan Africa might be on antiretroviral therapy (ART). There are different models of ART delivery, from the individualised, medical approach to the simple, public health approach, both having distinct advantages and disadvantages. This mini-review highlights the essential components of both models and argues that, whatever the mix of different models in a country, both must be underpinned by similar core principles so that uninterrupted drug supplies, patient adherence to therapy and compliance with follow up are assured. Failure to do otherwise is to court disaster.     

Polygyny and women's health in sub-Saharan Africa

In this paper we review the literature on the association between polygyny and women's health in sub-Saharan Africa. We argue that polygyny is an example of "co-operative conflict" within households, with likely implications for the vulnerability of polygynous women to illness, and for their access to treatment. We begin with a review of polygyny and then examine vulnerability to sexually transmitted infections (STIs, including HIV) and differential reproductive outcomes. Polygyny is associated with an accelerated transmission of STIs, both because it permits a multiplication of sexual partners and because it correlates with low rates of condom use, poor communication between spouses, and age and power imbalances among other factors. Female fertility is affected by the interplay between marital rank, household status, and cultural norms in polygynous marriages. Finally, we present areas which have received only cursory attention: mental health and a premature, "social" menopause. Although data are scarce, polygyny seems to be associated with higher levels of anxiety and depression, particularly around stressful life events. It is our hope that the examples reviewed here will help build a framework for mixed method quality research, which in turn can inform decision makers on more appropriate, context-dependent health policies.     

Primary and secondary infertility in sub-Saharan Africa

BACKGROUND: No previous study has provided national estimates of the prevalence of primary and secondary infertility in sizeable areas of sub-Saharan Africa. METHODS: Primary infertility is measured by the proportion childless among women who entered their first marriage at least 7 years before date of censoring. Secondary infertility is measured by the 'subsequently infertile estimator' from parous ever-married women. Exposure begins at the age of the woman at the birth of her first child, and exposure ends when the woman is of an age, which is 5 years lower than her age at censoring. These last 5 years are used to determine her status as infertile or fertile at the last observation 5 years before censoring. A woman is considered infertile at last observation if she has had no livebirths during the last 5 years before censoring, otherwise she is considered fertile. A woman who has not given birth at age a or later is defined as being 'infertile subsequent to age a'. The index of the proportion subsequently infertile at age a is estimated as the number of women infertile subsequent to age a, divided by the total number of women observed at that age. Infertility is estimated for women age 20-44. RESULTS: Primary infertility is relatively low and it exceeds 3% in less than a third of the 28 African countries analysed. In contrast, elevated levels of secondary infertility prevail in most countries. Secondary infertility for women age 20-44 ranges from 5% in Togo to 23% in Central African Republic. CONCLUSIONS: It is feasible to gauge national levels of primary and secondary infertility from population based surveys including a birth history. The prevalence of infertility of pathological origin is so high in sub-Saharan Africa that infertility is not merely an individual concern, it is a public health problem.     

控烟条例实施1年对北京市15岁及以上人群烟草使用的影响

目的 评价“你戒烟 我支持 – 北京市出租车驾驶员健康关爱项目”的戒烟效果。 方法 2017年9 — 12月招募并入选103名北京市吸烟的出租车驾驶员。由北京某三甲医院戒烟门诊向参加者提供免费戒烟服务,包括戒烟药物（伐尼克兰）、心理行为干预与随访管理。同时组织单位给予该项目大力支持并进行多次媒体宣传。在戒烟门诊首诊时收集参加者的基线信息,并在首诊后第1、4、8、12周和第24周进行随访,收集参加者的吸烟行为变化、伐尼克兰服用情况及不良反应情况等信息。 结果 参加者在第4、8周和第12周的7天时点戒烟率分别为39.8 %、43.7 %和54.4 %,第5～8周和第9～12周的持续戒烟率分别为38.8 %和45.6 %。尼古丁依赖程度和持续用药时间是戒烟成功的影响因素。 结论 该项目实施的提供戒烟门诊专业戒烟服务联合单位支持和媒体宣传等综合措施,可有效促进出租车驾驶员戒烟,具有推广应用价值。     

Medical education in sub-Saharan Africa: a literature review

Medical Education 2011: 45 : 973–986 Objectives This review synthesises research published in the traditional and ‘grey’ literature to promote a broader understanding of the history and current status of medical education in sub‐Saharan Africa (SSA). Methods We performed an extensive review and analysis of existing literature on medical education in SSA. Relevant literature was identified through searches of five traditional medical databases and three non‐traditional or grey literature databases featuring many African journals not indexed by the traditional databases. We focused our inquiry upon three themes of importance to educators and policymakers: innovation; capacity building, and workforce retention. Results Despite the tremendous heterogeneity of languages and institutions in the region, the available literature is published predominantly in English in journals based in South Africa, the UK and the USA. In addition, first authors usually come from those countries. Several topics are thoroughly described in this literature: (i) human resources planning priorities; (ii) curricular innovations such as problem‐based and community‐based learning, and (iii) the ‘brain drain’ and internal drain. Other important topics are largely neglected, including: (i) solution implementation; (ii) programme outcomes, and (iii) the development of medical education as a specialised field of inquiry. Conclusions Medical education in SSA has undergone dramatic changes over the last 50 years, which are recorded within both the traditionally indexed literature and the non‐traditional, grey literature. Greater diversity in perspectives and experiences in medical education, as well as focused inquiry into neglected topics, is needed to advance medical education in the region. Lessons learned from this review may be relevant to other regions afflicted by doctor shortages and inequities in health care resulting from inadequate capacity in medical education; the findings from this study might be used to inform specific efforts to address these issues.     

Reproductive inequality in sub-Saharan Africa: differentials versus concentration

Within developing countries, our understanding of reproductive inequality-how fertility is distributed within a population-has been shaped largely by studies of fertility differentials, a practical but partial-information measure. In this study, we examine whether exclusive reliance on differentials biases this understanding. Findings based on recent data from sub-Saharan Africa show bias. We find that historical and especially cross-country comparisons can yield substantially different conclusions about the magnitude and even the direction of inequality patterns and trends, depending on whether differentials or fuller-information measures are used. For instance, the fertility differentials associated with education have remained relatively stable as national fertility has fallen, but inequality (as calculated by a fuller measure) has increased. Such results underscore the value of complementing existing studies of fertility differentials with analyses based on fuller-information measures. The analyses also show how change in differential fertility behavior and in the educational composition of national populations has shaped recent variations in reproductive inequality in the region.     

Cost-effectiveness of strategies to prevent road traffic injuries in eastern sub-Saharan Africa and Southeast Asia: new results from WHO-CHOICE

Background

Road safety has been receiving increased attention through the United Nations Decade of Action on Road Safety, and is also now specifically addressed in the sustainable development goals 3.6 and 11.2. In an effort to enhance the response to Road Traffic Injuries (RTIs), this paper aims to examine the cost effectiveness of proven preventive interventions and forms part of an update of the WHO-CHOICE programme.

Methods

Generalized cost-effectiveness analysis (GCEA) approach was used for our analysis. GCEA applies a null reference case, in which the effects of currently implemented interventions are subtracted from current rates of burden, in order to identify the most efficient package of interventions. A population model was used to arrive at estimates of intervention effectiveness. All heath system costs required to deliver the intervention, regardless of payer, were included. Interventions are considered to be implemented for 100 years. The analysis was undertaken for eastern sub-Saharan Africa and Southeast Asia.

Results

In Southeast Asia, among individual interventions, drink driving legislation and its enforcement via random breath testing of drivers at roadside checkpoints, at 80% coverage, was found to be the most cost-effective intervention. Moreover, the combination of “speed limits?+?random breath testing?+?motorcycle helmet use”, at 90% coverage, was found to be the most cost-effective package. In eastern sub-Saharan Africa, enforcement of speed limits via mobile/handheld cameras, at 80% coverage, was found to be the most cost-effective single intervention. The combination of “seatbelt use?+?motorcycle helmet use?+?speed limits?+?random breath testing” at 90% coverage was found to be the most cost-effective intervention package.

Conclusion

This study presents updated estimates on cost-effectiveness of practical, evidence-based strategies that countries can use to address the burden of RTIs. The combination of individual interventions that enforces simultaneously multiple road safety measures are proving to be the most cost-effective scenarios. It is important to note, however, that, in addition to enacting and enforcing legislation on the risk factors highlighted as part of this paper, countries need to have a coordinated, multi-faceted strategy to improve road safety.

     

Cause-specific mortality rates in sub-Saharan Africa and Bangladesh

OBJECTIVE: To provide internationally comparable data on the frequencies of different causes of death. METHODS: We analysed verbal autopsies obtained during 1999 -2002 from 12 demographic surveillance sites in sub-Saharan Africa and Bangladesh to find cause-specific and age-specific mortality rates. The cause-of-death codes used by the sites were harmonized to conform to the ICD-10 system, and summarized with the classification system of the Global Burden of Disease 2000 (Version 2). FINDINGS: Causes of death in the African sites differ strongly from those in Bangladesh, where there is some evidence of a health transition from communicable to noncommunicable diseases, and little malaria. HIV dominates in causes of mortality in the South African sites, which contrast with those in highly malaria endemic sites elsewhere in sub-Saharan Africa (even in neighbouring Mozambique). The contributions of measles and diarrhoeal diseases to mortality in sub-Saharan Africa are lower than has been previously suggested, while malaria is of relatively greater importance. CONCLUSION: The different patterns of mortality we identified may be a result of recent changes in the availability and effectiveness of health interventions against childhood cluster diseases.     

Nutrition and HIV/AIDS in sub-Saharan Africa: an overview

HIV/AIDS is most prevalent in Sub-Saharan Africa where, exacerbated by the presence of other common conditions such as malnutrition and opportunistic infections, it is wreaking devastation on families, communities, and nations. Just as epidemics vary by country, so do national responses to this complex emergency. This is illustrated by the cases of Botswana, South Africa, and Uganda. Nutritional and micronutrient deficiencies play an important additive role in immune degradation and impaired development in children. Careful implementation of antiretroviral drugs, complemented by simultaneous efforts to ensure proper nutrition among HIV-infected children and adults are essential components of an effective response to the HIV/AIDS pandemic in Africa and elsewhere.     

Early marriage and HIV risks in sub-Saharan Africa

This article examines the effects of girls' early marriage on their risk of acquiring HIV/AIDS. By comparing several underlying HIV risk factors, it explores the counterintuitive finding that married adolescent girls in urban centers in Kenya and Zambia have higher rates of HIV infection than do sexually active unmarried girls. In both countries, we find that early marriage increases coital frequency, decreases condom use, and virtually eliminates girls' ability to abstain from sex. Moreover, husbands of married girls are about three times more likely to be HIV-positive than are boyfriends of single girls. Although married girls are less likely than single girls to have multiple partners, this protective behavior may be outweighed by their greater exposure via unprotected sex with partners who have higher rates of infection. These results challenge commonly held assumptions about sex within marriage.