Determinants of accessing healthcare in Sub-Saharan Africa: a mixed-effect analysis of recent Demographic and Health Surveys from 36 countries

Knowledge and factors associated with active management of the third stage of labor in sub-Saharan Africa: A systematic review and meta-analysis

BACKGROUND

Postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality in sub-Saharan Africa. Implementing active management in the third stage of labor has significantly reduced the incidence of PPH. Thus, understanding the level of healthcare providers' knowledge of active management in the third stage of labor can inform guidelines, policies, and practices for effectively preventing PPH.

OBJECTIVE

This review aimed to assess the level of healthcare providers' knowledge and associated factors of active management in the third stage of labor in sub-Saharan Africa.

SEARCH STRATEGY

We conducted a search using PubMed, Scopus, Web of Science, Google Scholar, Cochrane Library, and the African Journals online international databases.

SELECTION CRITERIA

The inclusion criteria were determined before the review of the articles and adhere to the criteria of population, intervention, comparison, and outcome.

DATA COLLECTION AND ANALYSIS

Statistical analysis was performed using STATA data analysis software version 14, while Microsoft Excel was utilized for data abstraction. We checked publication bias using a funnel plot and Egger and Begg regression tests. A P value less than 0.05 was considered statistically significant, suggesting the presence of presence publication bias. The I2 statistic was used to assess heterogeneity between studies. The study's overall effect was evaluated using the random effects model.

MAIN RESULT

The study included 20 studies to conduct a pooled prevalence analysis. The overall prevalence of healthcare providers' knowledge of active management of third-stage labor in sub-Saharan Africa was 47.975% (95% CI: 32.585, 63.365). Having pre- and in-service training (AOR: 2.25, 95% CI: 1.00, 5.08), having a higher degree (AOR: 1.98, 95% CI: 1.39, 2.82), and having good practices (AOR: 8.91, 95% CI: 4.58, 17.40) were significantly associated with healthcare provider's knowledge regarding active management third stage of labor.

CONCLUSIONS

The overall healthcare providers' knowledge of active management of the third stage of labor (AMTSL) was low in sub-Saharan Africa. Obstetric healthcare providers should undertake comprehensive training covering all AMTSL components through pre- and in-service diploma training programs.

Social determinants of health and hypertension screening among women in The Gambia: an evaluation of 2019-2020 demographic and health survey data

Hypertension is a leading modifiable risk factor for morbidity and mortality among women in Sub-Saharan Africa. Social determinants of health (SDH) are associated with sex-based differences in access to preventative screenings globally. Little research has assessed the influence of SDH on screening for hypertension among women in The Gambia. The aim of this study was to identify SDH associated with the utilization of hypertension screening among women in The Gambia. Data was examined from the 2019-2020 Gambia Demographic and Health Survey. Weighted multivariate logistic was used to identify whether SDH were associated with hypertension screening. Among 4116 women, over one-fifth (21.1%) had not been screened for hypertension in their lifetime. In fully adjusted models, older age, rural residence, higher than secondary educational attainment, employment, identification with specific ethnic groups, richer wealth status, parity (1 or more), and antenatal care visits increased the likelihood of lifetime hypertension screening. Women who indicated that others made their healthcare decisions for them (partners or someone else) were significantly less likely to have been screened for hypertension in their lifetime than women who made their healthcare decisions alone (adjusted odds ratio = 0.552, 95% confidence interval = (0.384-0.794)). SDH influence access to screening for hypertension among women in The Gambia. Initiatives may need to address the role of SDH to improve access and uptake of hypertension screening.

Reported healthcare-seeking of loiasis patients and estimation of the associated monetary burden in Gabon: Data from a cross-sectional survey

BACKGROUND

Loiasis is a disease of relevance in endemic populations and there has been advocacy for its inclusion on the World Health Organization's neglected tropical diseases list. As loiasis-related healthcare-seeking behaviors and related costs are unknown, we aimed to evaluate these aspects in a population residing in an endemic region in Gabon.

METHODS

Data were collected during a community-based, cross-sectional study assessing the disease burden due to loiasis. Diagnostics for microfilaremia were performed and a history of eyeworm was obtained. In addition, a standardized questionnaire about type of healthcare resources and frequency of use, as well as respective associated costs was administered to each participant. Loiasis related healthcare-seeking behaviors were evaluated, and the associated monetary burden was estimated as a secondary outcome of the study.

FINDINGS

Individuals diagnosed with loiasis more frequently reported any healthcare-seeking (OR 1.52 (95%CI: 1.21-1.91)), self-medicating (OR 1.62 (1.26-2.08)), inability to work (OR 1.86 (1.47-2.35)), and consulting with traditional healers (logOdds 1.03 (0.52-1.53)), compared to loiasis negative individuals. The most frequently reported treatment for the eyeworm was traditional herbs. The estimated healthcare associated costs, per positive individual, was US-$ 58 (95% CI: 21-101) per year, which would correspond to 3.5% of the reported mean household income. Extrapolation to the rural population of Gabon (n = 204,000), resulted in an annual monetary burden estimate of US-$ 3,206,000 (1,150,000-5,577,000).

INTERPRETATION

Loiasis patients have demonstrated healthcare needs, often consulted traditional healers, and used traditional treatments for disease specific symptoms. Further, loiasis seems to be associated with substantial direct and indirect costs for individuals and thus may cause a relevant economic burden for endemic populations and economies of affected countries.

Examining the Intrapersonal, Interpersonal and Community Level Correlates of Access to Medical Care Among Women Employed by Sex Work in Southern Uganda: A cross-sectional Analysis of the Kyaterekera Study

Women employed by sex work (WESW) experience significant gaps in accessing necessary healthcare services, leading to unmet health needs. Yet, there is a dearth of literature on the barriers to medical care access among WESW in Uganda. We used data from the Kyaterekera baseline to examine the correlates of access to medical care among WESW, defined as the ability of individuals to obtain the necessary healthcare services they require in a timely, affordable, and equitable manner. The Kyaterekera study recruited 542 WESW aged 18-58 years from Southern Uganda. We conducted a multilevel linear regression model to determine the intrapersonal (age, education level, marital status, HIV knowledge, and asset ownership), interpersonal (family cohesion and domestic violence attitudes), and community (community satisfaction, sex work stigma and distance to health facility) level correlates of access to medical care among WESW. Intrapersonal and interpersonal factors were associated with access to medical care among WESW. There was no significant association between community level factors and access to medical care. WESW with secondary education (β = 0.928, 95% CI = 0.007, 1.849) were associated with increased access to medical care. WESW with high asset ownership (β = -1.154, 95% CI= -1.903, -0.405), high family cohesion (β = -0.069, 95% CI= -0.106, -0.031), and high domestic violence attitudes (β = -0.253, 95% CI= -0.438, -0.068) were associated with decreased access to medical care. The findings emphasize the critical need for targeted family strengthening interventions to enhance family support for WESW and address domestic violence.

Children with disabilities lack access to nutrition, health and WASH services: A secondary data analysis

Malnutrition and disability are major global public health problems. Poor diets, inadequate access to nutrition/health services (NaHS), and poor water, sanitation and hygiene (WASH) all increase the risk of malnutrition and infection. This leads to poor health outcomes, including disability. To better understand the relationship between these factors, we explored access to NaHS and household WASH and dietary adequacy among households with and without children with disabilities in Uganda. We used cross-sectional secondary data from 2021. Adjusted logistic regression was used to explore associations between disabilities, access to NaHS, WASH and dietary adequacy. Of the 6924 households, 4019 (57.9%) reported having access to necessary NaHS, with deworming and vaccination reported as both the most important and most difficult to access services. Access to services was lower for households with children with disabilities compared to those without, after adjusting for likely confounding factors (Odds ratio = 0.70; 95% CI 0.55-0.89, p = 0.003). There is evidence of an interaction between disability and WASH adequacy, with improved WASH adequacy associated with improved access to services, including for children with disabilities (interaction odds ratio = 1.12, 95% CI: 1.02-1.22, p = 0.012). The proportion of malnourished children was higher among households with children with disabilities than households without it (6.3% vs. 2.4% p < 0.001). There are concerning gaps in access to NaHS services in Uganda, with households with children with disabilities reporting worse access, particularly for those with low WASH adequacy. Improved and inclusive access to NaHS and WASH needs to be urgently prioritized, especially for children with disabilities.

Characterizing models of adolescent and youth-friendly health services in sub-Saharan Africa: a scoping review

This scoping review provides an up-to-date overview of the evidence on adolescent and youth-friendly health services (AYFHS) in sub-Saharan African countries. We conducted a search of four databases and grey literature sources to identify English language publications from January 1, 2005, to December 14th, 2022. The review synthesized evidence on the models and characteristics of AYFHS, the application of World Health Organization (WHO) standards, and whether AYFHS have improved young people's health outcomes. In total, 77 sources were included in the review, representing 47 AYFHS initiatives spanning 19 countries, and three multi-country reports. Most commonly, AYFHS were delivered in public health facilities and focused on sexual and reproductive health, with limited application of WHO standards. Some evidence suggested that AYFHS increased young people's health service utilization and contraceptives uptake. There is a clear need to strengthen and develop innovative and multi-pronged approaches to delivering and evaluating AYFHS in this region.

Exploring the path to optimal diabetes care by unravelling the contextual factors affecting access, utilisation, and quality of primary health care in West Africa: A scoping review protocol

BACKGROUND

The prevalence of diabetes in West Africa is increasing, posing a major public health threat. An estimated 24 million Africans have diabetes, with rates in West Africa around 2-6% and projected to rise 129% by 2045 according to the WHO. Over 90% of cases are Type 2 diabetes (IDF, World Bank). As diabetes is ambulatory care sensitive, good primary care is crucial to reduce complications and mortality. However, research on factors influencing diabetes primary care access, utilisation and quality in West Africa remains limited despite growing disease burden. While research has emphasised diabetes prevalence and risk factors in West Africa, there remains limited evidence on contextual influences on primary care. This scoping review aims to address these evidence gaps.

METHODS AND ANALYSIS

Using the established methodology by Arksey and O'Malley, this scoping review will undergo six stages. The review will adopt the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Review (PRISMA-ScR) guidelines to ensure methodological rigour. We will search four electronic databases and search through grey literature sources to thoroughly explore the topic. The identified articles will undergo thorough screening. We will collect data using a standardised data extraction form that covers study characteristics, population demographics, and study methods. The study will identify key themes and sub-themes related to primary healthcare access, utilisation, and quality. We will then analyse and summarise the data using a narrative synthesis approach.

RESULTS

The findings and conclusive report will be finished and sent to a peer-reviewed publication within six months.

CONCLUSION

This review protocol aims to systematically examine and assess the factors that impact the access, utilisation, and standard of primary healthcare services for diabetes in West Africa.

Benign breast disease and breast cancer risk in African women: a case-control study

PURPOSE

To examine the association between benign breast disease (BBD) and breast cancer (BC) in a heterogeneous population of African women.

METHODS

BC cases and controls were enrolled in three sub-Saharan African countries, Nigeria, Cameroon, and Uganda, between 1998 and 2018. Multivariable logistic regression was used to test the association between BBD and BC. Risk factors dually associated with BBD and BC were selected. Using a parametric mediation analysis model, we assessed if selected BC risk factors were mediated by BBD.

RESULTS

Of 6,274 participants, 55.6% (3,478) were breast cancer cases. 360 (5.7%) self-reported BBD. Fibroadenoma (46.8%) was the most commonly reported BBD. Women with a self-reported history of BBD had greater odds of developing BC than those without (adjusted odds ratio [aOR] 1.47, 95% CI 1.13-1.91). Biopsy-confirmed BBD was associated with BC (aOR 2.25, 95% CI 1.26-4.02). BBD did not significantly mediate the effects of any of the selected BC risk factors.

CONCLUSIONS

In this study, BBD was associated with BC and did not significantly mediate the effects of selected BC risk factors.

Factors influencing fever care-seeking for children under five years of age in The Gambia: a secondary analysis of 2019-20 DHS data

BACKGROUND

Malaria contributes to excess child mortality in The Gambia. Children under five are at risk of severe malaria and death if not treated promptly and appropriately. It is crucial that a child with fever receive appropriate care from a trained provider. The aim was to identify influences on child fever care-seeking in The Gambia to inform malaria control strategies.

METHODS

This cross-sectional analysis of The Gambia 2019-20 Demographic and Health Survey used logistic regression analysis to identify associations between source of care for a child with fever (public or private healthcare provider, other, or no treatment) and mother, child, and household characteristics.

RESULTS

Only 52.0% of mothers sought care from a trained healthcare provider for a child with fever-45.1% from a public facility and 7.0% from the private sector. 35.2% of mothers did not seek treatment. Mothers in urban households were 2.67 times as likely (aOR, 95% CI 1.504-4.736) as mothers in rural households to seek care from an informal source (e.g., pharmacy) versus not seeking treatment, and 0.29 times as likely (aOR, 95% CI 0.165-0.515) as mothers in rural households to seek care from a public provider versus informal source. Mothers in wealthier households were 2.30 times as likely (aOR, 95% CI 1.274-4.164) as mothers in poorer households to seek care from an informal source versus no treatment and half as likely as mothers in poorer households to seek care from a public provider versus informal source (aOR 0.53, 95% CI 0.291-0.959).

CONCLUSIONS

Maintaining The Gambia's malaria control achievements will require the active engagement and oversight of private pharmacies along with continued integrated community case management to reach mothers who do not seek care for a child with fever, and remove challenges to seeking appropriate care from trained providers. Whether influenced by convenience, costs, perceived urgency, or other factors, given the likelihood of urban mothers and mothers in wealthier households to seek care from private pharmacies, it will be necessary to incorporate private pharmacies into malaria control strategies while building public sector capacity and workforce, and initiating more effective attitude and behavioural change among mothers and households.

Six in ten female youths in low-income East African countries had problems in accessing health care: a multilevel analysis of recent demographic and health surveys from 2016-2021

BACKGROUND

Access to health care services is a basic human right, and an individual's health and overall quality of life may suffer as a result of barriers to accessing health services. Access to comprehensive and quality health care is fundamental for promoting and maintaining health, preventing and treating diseases, and reducing premature deaths. However, only half of the African population has access to modern health services. Therefore, this study aimed to assess the health care access and associated factors among female youths in low-income East African countries.

METHODS

This study used secondary data from 2016 to 2021 demographic and health surveys of 7 low-income East African countries. A total weighted sample of 51,064 youths was included. A multilevel binary logistic regression was employed to identify the associated factors of access to health care since the data has a hierarchical structure. Adjusted Odds Ratio (AOR) with a 95% confidence interval (CI) at a p-value less than 0.05 was used to measure the association of variables whereas Intra-class correlation coefficient (ICC), Median Odds Ratio (MOR), and proportional change in variance (PCV) were used to measure random effects.

RESULT

The overall magnitude of access to healthcare among female youths in low-income East African countries was 38.84% (95% CI: 38.41, 39.26). Youth's educational level, rich wealth status, media exposure, and community level education were the positive while higher youth's age and rural residence were the negative predictors of access to healthcare among female youths. Besides, living in different countries compared to Burundi was also an associated factor for accessing healthcare in low-income East African countries.

CONCLUSION

About six in ten female youths were not accessing health care in low-income East African countries. Therefore, to increase healthcare access, health managers and policymakers needed to develop strategies to improve the poor household wealth index, and redistribution of health services for rural residents. The decision-makers and program planners should also work on increasing access to education and media exposure for youths. Further research including health system and quality of service-related factors for accessing healthcare should also be considered by researchers.

Access to quality contraceptive counselling among adolescent girls and young women in sub-Saharan Africa

BACKGROUND

Improving women's access to and use of modern contraceptives is a key global strategy for improving the sexual and reproductive health of women. However, the use of modern contraceptives among adolescent girls and young women in sub-Saharan Africa (SSA) remains relatively low, despite the numerous interventions to increase patronage. This study examined adolescent girls and young women's receipt of quality contraceptive counselling and its associated factors in SSA.

METHODS

Data for the study were extracted from the recent Demographic and Health Surveys of 20 countries in SSA, spanning from 2015 to 2021. A sample of 19,398 adolescent girls and young women aged 15 to 24 years was included in the study. We presented the proportion of adolescent girls and young women who received quality contraceptive counselling using a spatial map. Multilevel binary logistic regression analysis was carried out to examine the factors associated with the receipt of quality contraceptive counselling.

RESULTS

Overall, 33.2% of adolescent girls and young women had access to quality contraceptive counselling, ranging from 13.0% in Cameroon to 67.0% in Sierra Leone. The odds of receiving quality contraceptive counselling was higher among adolescent girls and young women aged 20-24 (AOR = 1.48, CI: 1.32-1.67), those with primary (AOR = 1.32, CI: 1.11-1.57) and secondary or higher education (AOR = 1.31, CI: 1.09-1.58), and those married (AOR = 1.32, CI: 1.15-1.52), cohabiting (AOR = 1.47, CI: 1.23-1.76), and previously married (AOR = 1.48, CI: 1.20-1.83) compared to their counterparts in the reference groups. Adolescent girls and young women who were currently working (AOR = 1.22, CI: 1.09-1.37), those who heard of family planning from radio in the last few months (AOR = 1.34, CI:1.21-1.50), those who visited the health facility in the last 12 months (AOR = 1.69, CI: 1.52-1.88), and those residing in the Southern (AOR = 5.01, CI: 3.86-6.51), Eastern (AOR = 2.54, CI: 1.96-3.30), and Western (AOR = 4.09, CI: 3.19-5.25) SSA were more likely to receive quality contraceptive counselling compared to their counterparts in the reference groups. Conversely, adolescent girls and young women who used the internet, those who had problem getting permission to seek medical help, those facing problem in seeking medical help for not wanting to go alone, those from the middle and richest wealth indices, and those from the rural areas were less likely to receive quality contraceptive counselling compared to their counterparts in the reference groups.

CONCLUSION

Receipt of quality contraceptive counselling among adolescent girls and young women was low. Considering the importance of quality contraceptive counselling on the uptake and continuation of contraception, policymakers need to institute measures that improve adolescent girls and young women's access to quality contraceptive counselling in SSA, especially in countries like Cameroon, Angola, Madagascar, Mauritania, and Guinea, taking into consideration the factors identified in the study. Increasing adolescent girls and young women's access to quality contraceptive counselling could greatly minimize the risk of unintended pregnancies and its associated maternal and child health burden in SSA and subsequently contribute to the attainment of the Sustainable Development Goal 3, target 3.7.

Factors associated with barriers to healthcare access among ever-married women of reproductive age in Bangladesh: Analysis from the 2017-2018 Bangladesh Demographic and Health Survey

BACKGROUND

Globally, women experience healthcare inequalities, which may contribute to excessive mortality rates at various stages of their lives. Though Bangladesh has achieved excellent progress in providing healthcare, the country still has some critical challenges that need immediate attention. The objective of this study is to examine the association between social determinants and barriers to accessing healthcare among ever-married women aged 15-49 in Bangladesh.

METHODS

The study was conducted among 20,127 women aged 15-49, using data from the 2017-2018 Bangladesh Demographic and Health Survey. Four barriers to healthcare were considered: whether women face problems with permission, obtaining money, distance, and companionship. The multivariable logistic regression analysis was used, with a broad array of independent variables (such as age, and educational level) to identify the determinants of barriers to healthcare access. The associations were expressed as adjusted odds ratios (AOR) with a 95% confidence interval (CI).

RESULTS

More than two-thirds (66.3%) of women reported having at least one perceived barrier to accessing healthcare. Women with a higher level of education (AOR = 0.49, 95% CI: 0.41-0.57), owning a mobile telephone (AOR = 0.78, 95% CI: 0.73-0.84), and those in the richest wealth quintile (AOR = 0.45, 95% CI: 0.38-0.52) had lower odds of having barriers to accessing healthcare. In addition, widowed (AOR = 1.53, 95% CI: 1.26-1.84), divorced (AOR = 1.91, 95% CI:1.47-2.48), or separated (AOR = 1.98, 95% CI: 1.46-2.69) women had higher odds of having a money barrier to accessing healthcare, than married women.

CONCLUSIONS

This study shows that individual-, household-, and community-level factors are associated with barriers to healthcare accessibility. To improve the state of women's health in Bangladesh, it is vital to consider these socio-economic factors and implement fundamental measures, such as supporting the national health policy, empowering women's socio-economic situation, and spreading the flexible way of healthcare access.

Epilepsy among the older population of sub-Saharan Africa: Analysis of the global burden of disease database

INTRODUCTION

Epilepsy is considered one of the most burdensome neurologic diseases by the World Health Organization due to the high risk of morbidity and mortality. Few studies have investigated the epidemiology of idiopathic epilepsy in Sub-Saharan Africa (SSA). This study aims to characterize the disease burden of epilepsy among the older population in SSA via a large international database.

METHODS

Descriptive epidemiological data from the Global Burden of Disease (GBD) database was collected for idiopathic epilepsy in all regions of SSA. The "older" population was defined as 55 years of age and above. The variables of interest included mortality, incidence, prevalence, and disability-adjusted life years (DALYs) rates per one hundred thousand populations.

RESULTS

The average mortality rate was highest in Western SSA (6.34 per 100,000), and all regions were significantly higher than the global average (p < 0.001). DALYs and incidence rates of idiopathic epilepsy in all regions of SSA were significantly higher than the global averages (p < 0.01). Globally, the older population had a significantly higher mortality rate than the younger population (2.78 vs 1.62, respectively; p < 0.01). The older population had a higher mortality rate than the younger population in each region of SSA (p < 0.01). Conversely, for DALYs, the younger population had a higher disease burden than the older population globally and in each region of SSA (p < 0.01).

CONCLUSION

This study is the first to examine the epidemiologic profile of idiopathic epilepsy in the older population in SSA. Our results indicate that, when compared with the global population, older adults in SSA suffer a greater disease burden and mortality. This study reports the immense need for increased resources and awareness regarding epilepsy in the elderly population of Africa.

Female genital schistosomiasis, human papilloma virus infection, and cervical cancer in rural Madagascar: a cross sectional study

BACKGROUND

Women's health in resource-limited settings can benefit from the integrated management of high-burden diseases, such as female genital schistosomiasis (FGS) and human papilloma virus (HPV)-related cervical cancer. In schistosomiasis-endemic countries such as Madagascar, data on FGS and HPV prevalence are lacking as well as preventive measures for both conditions. This study aims to estimate the prevalence of FGS and HPV in rural Madagascar, and to examine associated risk factors to identify opportunities for improving women's health.

METHODS

After initial community outreach activities, interested women aged 18-49 years were recruited consecutively in 2021 at three primary health care centers in the district of Marovoay. FGS was detected by colposcopy. Colposcopy images were double-blind reviewed by two independent specialists. A Luminex bead-based assay was performed on cervical vaginal lavage specimens for HPV typing. Crude (CPR) and adjusted prevalence ratios (APR) of associations between selected factors and FGS and HPV positivity were estimated using univariable and multivariable binary Poisson regression with 95% confidence intervals (CIs).

RESULTS

Among 500 women enrolled, 302 had complete information on FGS and HPV diagnosis, and were thus eligible for analysis. Within the sample, 189 (62.6%, 95% CI: 56.9-68.1) cases of FGS were detected. A total of 129 women (42.7%, 95% CI: 37.1-48.5) tested positive for HPV. In total, 80 women (26.5%, 95% CI: 21.6-31.8]) tested positive for both conditions. No association was observed between FGS and HPV positivity, while previous pregnancy (APR = 0.65, 95% CI: 0.43-0.78) and older age (APR = 0.59, 95% CI: 0.42-0.81) are showing a negative association with HPV infection compared to no previous pregnancy and younger age groups.

CONCLUSIONS

The results of the study show that FGS and HPV are highly prevalent in rural Madagascar. The concurrent prevalence of these two conditions requires urgent adaptations of public health strategies to improve women's health, such as integrated services at primary level of care.

Benign breast disease and breast cancer risk in African women: A case-control study

Purpose

To examine the association between benign breast disease (BBD) and breast cancer (BC) in a heterogeneous population of African women.

Methods

BC cases and matched controls were enrolled in three sub-Saharan African countries, Nigeria Cameroon, and Uganda, between 1998-2018. Multivariable logistic regression was used to test the association between BBD and BC. Risk factors dually associated with BBD and BC were selected. Using a parametric mediation analysis model, we assessed if selected BC risk factors were mediated by BBD.

Results

Of 6418 participants, 55.7% (3572) were breast cancer cases. 360 (5.7%) self-reported BBD. Fibroadenoma (46.8%) was the most reported BBD. Women with a self-reported history of BBD had greater odds of developing BC than those without (adjusted odds ratio [aOR] = 1.47, 95% CI: 1.13-1.91). Biopsy-confirmed BBD was associated with BC (aOR = 3.11, 95% CI: 1.78-5.44). BBD did not significantly mediate the effects of any of the selected BC risk factors.

Conclusions

In this study, BBD was associated with BC and did not significantly mediate the effects of selected BC risk factors.

Invisible illness: The consequences of limited health insurance in Africa

Background

Limited health insurance coverage in Africa poses a significant challenge, impeding access to quality healthcare for millions of individuals.

Methods

This paper synthesizes information from existing literature and research on the topic of limited health insurance coverage in Africa. The identified consequences and root causes are presented in a structured format.

Results

The consequences of limited health insurance coverage in Africa include increased financial burden on households, decreased access to health services, and inadequate coverage for essential health services. These consequences contribute to reduced utilization of healthcare services and negative health outcomes, including the deterioration of existing health conditions and the development of new health problems. The financial burden is particularly significant due to high poverty rates in Africa, forcing households to pay for healthcare services out of pocket and leading to considerable financial strain and even financial ruin. Additionally, limited health insurance coverage restricts access to necessary health services, resulting in delayed treatment, missed diagnoses, and poor health outcomes.

Conclusion

The root causes of limited health insurance coverage in Africa are multifaceted and include factors such as poverty, lack of government support, and limited private-sector involvement. These systemic issues contribute to the persistence of inadequate health insurance coverage and hinder efforts to improve access to quality healthcare for African populations.

Regional disparities in hospital utilisation in Indonesia: a cross-sectional analysis data from the 2018 Indonesian Basic Health Survey

OBJECTIVES

Policymakers must ensure that the entire population has equal access to health services, and efforts to minimise inequalities are needed. This study aimed to analyse the regional disparities in hospital utilisation in Indonesia.

DESIGN

A cross-sectional study analysing secondary data from the 2018 Indonesian Basic Health Survey.

SETTING

National-level survey data from Indonesia.

PARTICIPANTS

A total of 629 370 participants were included in the study.InterventionWe employed no interventionPrimary and secondary outcome measuresThe primary outcome was hospital utilisation. Aside from region, we utilise residence type, age, gender, marital status, educational level, occupation, wealth, insurance and travel time as control variables. We used binary logistic regression in the final analysis RESULTS: The respondents in Sumatra were 1.079 times (95% CI 1.073 to 1.085) more likely than those in Papua to use the hospital. Furthermore, compared with the respondents in Papua, those in the Java-Bali region (1.075 times, 95% CI 1.069 to 1.081), Nusa Tenggara (1.106 times, 95% CI 1.099 to 1.113), Sulawesi (1.008 times, 95% CI 1.002 to 1.014) and Kalimantan (1.212 times, 95% CI 1.205 to 1.219) were more likely to use the hospital. However, those in Maluku were less likely than those in Papua to use the hospital (0.827 times, 95% CI 0.820 to 0.835). Six demographic variables (age, gender, marital status, educational level, occupation and wealth) and three other control variables (residence type, insurance and travel time to the hospital) were found to be associated with hospital utilisation.

CONCLUSIONS

Our findings highlight the existence of regional disparities in hospital utilisation in Indonesia.

HIV Prevention Tools Across the Pregnancy Continuum: What Works, What Does Not, and What Can We Do Differently?

PURPOSE OF REVIEW

Multiple tools exist to support the primary prevention of HIV in pregnant and postpartum women; however, there are opportunities to enhance their use and impact. This review summarizes the current status of HIV prevention tools and existing gaps and opportunities to improve their use along the pregnancy care continuum.

RECENT FINDINGS

HIV screening efforts have steadily improved with close to universal screening of pregnant women in several East and Southern African countries. Strategies to implement partner testing through the distribution of HIV self-test kits are promising though linkage to care remains challenging. Syphilis screening rates are increasing though detection of other sexually transmitted infections could benefit from improved diagnostic capacity. Male and female condoms are rarely used and are often not the optimal tool of choice during pregnancy. Oral pre-exposure prophylaxis (PrEP) is a promising tool, although barriers such as the need for daily adherence, side effects, and stigma may limit its use. There is a growing pipeline of PrEP agents with alternative delivery platforms that might suit women's preferences better and supports the notion that choice is vital to improving HIV prevention coverage during the pregnancy-postpartum continuum. Clear guidance on which tools to use and how to use them, safety data supporting their use, and surveillance data documenting the scale and effectiveness of the tools will be imperative in establishing a path to more impactful prevention efforts among pregnant and postpartum women.

Women empowerment and health insurance utilisation in Rwanda: a nationwide cross-sectional survey

Background

Health insurance coverage is one of the several measures being implemented to reduce the inequity in access to quality health services among vulnerable groups. Although women’s empowerment has been viewed as a cost-effective strategy for the reduction of maternal and child morbidity and mortality, as it enables women to tackle the barriers to accessing healthcare, its association with health insurance usage has been barely investigated. Our study aims at examining the prevalence of health insurance utilisation and its association with women empowerment as well as other socio-demographic factors among Rwandan women.

Methods

We used Rwanda Demographic and Health Survey (RDHS) 2020 data of 14,634 women aged 15–49 years, who were selected using multistage sampling. Health insurance utilisation, the outcome variable was a binary response (yes/no), while women empowerment was assessed by four composite indicators; exposure to mass media, decision making, economic and sexual empowerment. We conducted multivariable logistic regression to explore its association with socio-demographic factors, using SPSS (version 25).

Results

Out of the 14,634 women, 12,095 (82.6%) (95% CI 82.0–83.2) had health insurance, and the majority (77.2%) were covered by mutual/community organization insurance. Women empowerment indicators had a negative association with health insurance utilisation; low (AOR = 0.85, 95% CI 0.73–0.98) and high (AOR = 0.66, 95% CI 0.52–0.85) exposure to mass media, high decision making (AOR = 0.78, 95% CI 0.68–0.91) and high economic empowerment (AOR = 0.63, 95% CI 0.51–0.78). Other socio-demographic factors found significant include; educational level, wealth index, and household size which had a negative association, but residence and region with a positive association.

Conclusions

A high proportion of Rwandan women had health insurance, but it was negatively associated with women’s empowerment. Therefore, tailoring mass-media material considering the specific knowledge gaps to addressing misinformation, as well as addressing regional imbalance by improving women’s access to health facilities/services are key in increasing coverage of health insurance among women in Rwanda.