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Asempah E, Wiktorowicz ME. Understanding HPV Vaccination Policymaking in Rwanda: A Case of Health Prioritization and Public-Private-Partnership in a Low-Resource Setting. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6998. [PMID: 37947556 PMCID: PMC10649882 DOI: 10.3390/ijerph20216998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/12/2023]
Abstract
Rwanda is the first African country to implement a national HPV vaccination program in 2011. This study sought to clarify the HPV vaccination policymaking process in Rwanda through the lens of Kingdon's multiple stream framework and Foucault's concept of governmentality. Perspectives of policymakers engaged in HPV vaccination policy were gathered from published sources, along with key informant interviews. Rwanda's track record of successful vaccination programs enabled by a culture of local accountability created public and private sector incentives. Effective stakeholder engagement, health priority setting, and resource mobilization garnered locally and through international development aid, reflect indicators of policy success. The national HPV policymaking process in Rwanda unfolded in a relatively cohesive and stable policy network. Although peripheral stakeholder resistance and a constrained national budget can present a threat to policy survival, the study shows that such factors as the engagement of policy entrepreneurs within a policy network, private sector incentives, and international aid were effective in ensuring policy resolution.
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Affiliation(s)
- Eric Asempah
- School of Health Policy & Management, Faculty of Health, York University, 4700 Keele Street, Toronto, ON M3J 1P3, Canada;
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2
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Rosenberg A, Wojick M, Asay B, Williams K, Wolfe L, Baghdassarian A, Umuhoza C, Ntaganda E, Kabagema I, Uwitonze JM, Dushime T, Jayaraman S. Developing Sustainable Prehospital Pediatric Care in Rwanda. Pediatr Emerg Care 2022; 38:224-227. [PMID: 35482495 DOI: 10.1097/pec.0000000000002699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Unintentional injury is the leading cause of death in children older than 1 year and disproportionately affects pediatric patients in low- and middle-income countries.Improved prehospital care capacity has demonstrated the ability to improve care and save lives. Our collaboration developed and implemented a sustainable prehospital emergency pediatrics care course (EPCC) for Service d'Aide Medicale Urgente, the public emergency medical service in Rwanda. METHODS A 1-day context-specific EPCC was developed based on international best practices and local feedback. Two cohorts were created to participate in the course. The first group, EPCC 1, was made of 22 Service d'Aide Medicale Urgente providers with preexisting knowledge on the topic who participated in the course and received training to lead future sessions. After completion of the EPCC1, this group led the second cohort, EPCC 2, which was composed of 26 healthcare providers from around Rwanda. Each group completed a 50 question assessment before and after the course. RESULTS Emergency pediatrics care course 1 mean scores were 58% vs 98% (pre vs post), EPCC 2 mean scores were 49% vs 98% (pre vs post), using matched-pair analysis of 22 and 32 participants, respectively. When comparing unequal variances across the groups with a 2-tailed paired t test, EPCC 1 and EPCC 2 had a statistically significant mean change in pretest and posttest assessment test scores of 40% compared with 46%, P < 0.0001, with 95% confidence interval. A 1-way analysis of variance mean square analysis for the change in scores showed that regardless of the baseline level of training for each participant, all trainees reached similar postassessment scores (F(1) = 1.45, P = 0.2357). CONCLUSIONS This study demonstrates effective implementation of a context-appropriate prehospital pediatric training program in Kigali, Rwanda. This program may be effective to support capacity development for prehospital care in Rwanda using a qualified local source of instructors.
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Affiliation(s)
- Ashley Rosenberg
- From the Division of Acute Care Surgery, Department of Surgery, Virginia Commonwealth University School of Medicine
| | - Megan Wojick
- Virginia Commonwealth University School of Medicine
| | | | - Kenneth Williams
- Center for Trauma and Critical Care Education, Department of Surgery, Virginia Commonwealth University
| | - Luke Wolfe
- From the Division of Acute Care Surgery, Department of Surgery, Virginia Commonwealth University School of Medicine
| | - Aline Baghdassarian
- Department of Pediatric Emergency Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA
| | | | - Edmond Ntaganda
- Department of Pediatrics, University Teaching Hospital of Kigali
| | - Ignace Kabagema
- Service d'Aide Medicale Urgente, Rwanda Ministry of Health, Kigali, Rwanda
| | | | - Theophile Dushime
- Service d'Aide Medicale Urgente, Rwanda Ministry of Health, Kigali, Rwanda
| | - Sudha Jayaraman
- From the Division of Acute Care Surgery, Department of Surgery, Virginia Commonwealth University School of Medicine
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3
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Karema C, Wen S, Sidibe A, Smith JL, Gosling R, Hakizimana E, Tanner M, Noor AM, Tatarsky A. History of malaria control in Rwanda: implications for future elimination in Rwanda and other malaria-endemic countries. Malar J 2020; 19:356. [PMID: 33028337 PMCID: PMC7539391 DOI: 10.1186/s12936-020-03407-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 09/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malaria was first reported in Rwanda in the early 1900s with significant heterogeneity and volatility in transmission over subsequent decades. Here, a comprehensive literature review of malaria transmission patterns and control strategies in Rwanda between 1900 and 2018 is presented to provide insight into successes and challenges in the country and to inform the future of malaria control in Rwanda. METHODS A systematic literature search of peer-reviewed publications (Web of Knowledge, PubMed, Google Scholar, and the World Health Organization Library (WHOLIS) and grey literature on malaria control in Rwanda between 1900 and 2019 was conducted with the following search terms: "malaria"", "Rwanda", "epidemiology", "control", "treatment", and/or "prevention." Reports and other relevant documents were also obtained from the Rwanda National Malaria Control Programme (NMCP). To inform this literature review and evidence synthesis, epidemiologic and intervention data were collated from NMCP and partner reports, the national routine surveillance system, and population surveys. RESULTS Two hundred sixty-eight peer-reviewed publications and 56 grey literature items were reviewed, and information was extracted. The history of malaria control in Rwanda is thematically described here according to five phases: 1900 to 1954 before the launch of the Global Malaria Eradication Programme (GMEP); (2) Implementation of the GMEP from 1955 to 1969; (3) Post- GMEP to 1994 Genocide; (4) the re-establishment of malaria control from 1995 to 2005, and (5) current malaria control efforts from 2006 to 2018. The review shows that Rwanda was an early adopter of tools and approaches in the early 2000s, putting the country ahead of the curve and health systems reforms created an enabling environment for an effective malaria control programme. The last two decades have seen unprecedented investments in malaria in Rwanda, resulting in significant declines in disease burden from 2000 to 2011. However, in recent years, these gains appear to have reversed with increasing cases since 2012 although the country is starting to make progress again. CONCLUSION The review shows the impact and fragility of gains against malaria, even in the context of sustained health system development. Also, as shown in Rwanda, country malaria control programmes should be dynamic and adaptive to respond and address changing settings.
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Affiliation(s)
- Corine Karema
- Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland. .,Quality and Equity Health Care, Kigali, Rwanda.
| | - Shawn Wen
- Malaria Elimination Initiative, Global Health Group, University of California, San Francisco, USA
| | - Abigail Sidibe
- Malaria Elimination Initiative, Global Health Group, University of California, San Francisco, USA
| | - Jennifer L Smith
- Malaria Elimination Initiative, Global Health Group, University of California, San Francisco, USA
| | - Roly Gosling
- Malaria Elimination Initiative, Global Health Group, University of California, San Francisco, USA
| | - Emmanuel Hakizimana
- Malaria and Other Parasitic Diseases Division, RBC-Ministry of Health, Kigali, Rwanda
| | - Marcel Tanner
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Abdisalan M Noor
- Strategic Information for Response, Global Malaria Programme, World Health Organization, Geneva, Switzerland
| | - Allison Tatarsky
- Malaria Elimination Initiative, Global Health Group, University of California, San Francisco, USA
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Agho KE, Ezeh OK, Ferdous AJ, Mbugua I, Kamara JK. Factors associated with under-5 mortality in three disadvantaged East African districts. Int Health 2020; 12:417-428. [PMID: 31925447 PMCID: PMC7443723 DOI: 10.1093/inthealth/ihz103] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 11/20/2019] [Accepted: 12/03/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The high rate of avoidable child mortality in disadvantaged communities in Africa is an important health problem. This article examines factors associated with mortality in children <5 y of age in three disadvantaged East African districts. METHODS Pooled cross-sectional data on 9270 live singleton births from rural districts in Rwanda (Gicumbi), Uganda (Kitgum) and Tanzania (Kilindi) were analysed using logistic regression generalized linear latent and mixed models to adjust for clustering and sampling weights. Mortality outcomes were neonatal (0-30 d), post-neonatal (1-11 months), infant (0-11 months), child (1-4 y) and under-5 y (0-4 y). RESULTS The odds of post-neonatal and infant mortality were lower among children delivered by a health professional (adjusted odds ratio [AOR] 0.62 [95% confidence interval {CI} 0.47-0.81] for post-neonatal; AOR 0.60 [95% CI 0.46-0.79] for infant), mothers who had four or more antenatal care (ANC) visits during pregnancy (AOR 0.66 [95% CI 0.51-0.85]) and mothers who initiated breastfeeding within 1 h after birth (AOR 0.60 [95% CI 0.47-0.78]). Neonates not exclusively breastfed had higher mortality (AOR 3.88 [95% CI 1.58-9.52]). Children who lived >6 h away from the nearest health centre (6-23 h: AOR 1.66 [95% CI 1.4-2.0] and ≥24 h: AOR 1.43 [95% CI 1.26-1.72]) reported higher mortality rates in children <5 y of age. CONCLUSIONS Interventions for reducing deaths in children ≤5 y of age in disadvantaged East African communities should be strengthened to target communities >6 h away from health centres and mothers who received inadequate ANC visits during pregnancy.
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Affiliation(s)
- Kingsley E Agho
- School of Sciences and Health, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751, Australia
| | - Osita K Ezeh
- School of Sciences and Health, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751, Australia
| | - Akhi J Ferdous
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Irene Mbugua
- World Vision International, Karen Road, Off Ngong Road, P Box 133 - 00502 Karen, Nairobi, Kenya
| | - Joseph K Kamara
- World Vision International, Southern Africa Regional Office, Mbabane H100, Swaziland
- School of Social Science and Psychology, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751, Australia
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Cha S, Jin Y. Have inequalities in all-cause and cause-specific child mortality between countries declined across the world? Int J Equity Health 2019; 19:1. [PMID: 31892330 PMCID: PMC6938619 DOI: 10.1186/s12939-019-1102-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 11/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Comparing the distribution of all cause or cause-specific child mortality in countries by income and its progress over time has not been rigorously monitored, and hence remains unknown. We therefore aimed to analyze child mortality disparities between countries with respect to income level and progression for the period 2000-2015, and further explored the convergence of unequal income levels across the globe. METHODS Four types of measures were used to assess the degree of inequality across countries: difference and ratio of child mortality rate, the concentration index, and the Erreygers index. To assess the longitudinal trend of unequal child mortality rate by wealth ranking, hierarchical mixed effect analysis was used to examine any significant changes in the slope of under-5 child mortality rate by GDP per capita between 2000 and 2015. RESULTS All four measures reveal significant inequalities across the countries by income level. Compared with children in the least deprived socioeconomic quintile, the mortality rate for children in the most deprived socioeconomic quintile was nearly 20.7 times higher (95% Confidence Interval: 20.5-20.8) in 2000, and 12.2 times (95% CI: 12.1-12.3) higher in 2015. Globally, the relative and absolute inequality of child mortality between the first and fifth quintiles have declined over time in all diseases, but was more pronounced for infectious diseases (pneumonia, diarrhea, measles, and meningitis). In 2000, post-neonatal children in the first quintile had 105.3 times (95% CI: 100.8-110.0) and 216.3 times (95% CI: 202.5-231.2) higher risks of pneumonia- and diarrhea-specific child mortality than children in the fifth quintile. In 2015, the corresponding rate ratios had decreased to 59.3 (95% CI: 56.5-62.1) and 101.9 (95% CI: 94.3-110.0) times. However, compared with non-communicable disease, infectious diseases still show a far more severe disparity between income quintile. Mixed effect analysis demonstrates the convergence of under-5 mortality in 194 countries across income levels. CONCLUSION Grand convergence in child mortality, particularly in post neonatal children, suggests that the global community has witnessed success to some extent in controlling infectious diseases. To our knowledge, this study is the first to assess worldwide inequalities in cause-specific child mortality and its time trend by wealth.
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Affiliation(s)
- Seungman Cha
- Department of Global Development and Entrepreneurship, Graduate School of Global Development and Entrepreneurship, Handong Global University, Pohang, 37554, South Korea.,Department of Disease Control, Faculty of Infectious and Tropical Disease, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Yan Jin
- Department of Microbiology, Dongguk University College of Medicine, Dongdaero 123, Gyeongju, Republic of Korea, 38066.
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Roder-DeWan S, Gupta N, Kagabo DM, Habumugisha L, Nahimana E, Mugeni C, Bucyana T, Hirschhorn LR. Four delays of child mortality in Rwanda: a mixed methods analysis of verbal social autopsies. BMJ Open 2019; 9:e027435. [PMID: 31133592 PMCID: PMC6549629 DOI: 10.1136/bmjopen-2018-027435] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES We sought to understand healthcare-seeking patterns and delays in obtaining effective treatment for rural Rwandan children aged 1-5 years by analysing verbal and social autopsies (VSA). Factors in the home, related to transport and to quality of care in the formal health sector (FHS) were thought to contribute to delays. DESIGN We collected quantitative and qualitative cross-sectional data using the validated 2012 WHO VSA tool. Descriptive statistics were performed. We inductively and deductively coded narratives using the three delays model, conducted thematic content analysis and used convergent mixed methods to synthesise findings. SETTING The study took place in the catchment areas of two rural district hospitals in Rwanda-Kirehe and Southern Kayonza. Participants were caregivers of children aged 1-5 years who died in our study area between March 2013 and February 2014. RESULTS We analysed 77 VSAs. Although 74% of children (n=57) had contact with the FHS before dying, most (59%, n=45) died at home. Many caregivers (44%, n=34) considered using traditional medicine and 23 (33%) actually did. Qualitative themes reflected difficulty recognising the need for care, the importance of traditional medicine, especially for 'poisoning' and poor perceived quality of care. We identified an additional delay-phase IV-which occurred after leaving formal healthcare facilities. These delays were associated with caregiver dissatisfaction or inability to adhere to care plans. CONCLUSION Delays in deciding to seek care (phase I) and receiving quality care in FHS (phase III) dominated these narratives; delays in reaching a facility (phase II) were rarely discussed. An unwillingness or inability toadhere to treatment plans after leaving facilities (phase IV) were an important additional delay. Improving quality of care, especially provider capacity to communicate danger signs/treatment plans and promote adherence in the presence of alternative explanatory models informed by traditional medicine, could help prevent childhood deaths.
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Affiliation(s)
- Sanam Roder-DeWan
- Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Ifakara Health Institute, Dar es Salaam, Dar es Salaam, United Republic of Tanzania
| | - Neil Gupta
- Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | | | | | | | - Catherine Mugeni
- Maternal Child and Community Health Rwanda Biomédical Center, Rwanda Ministry of Health, Kigali, Rwanda
| | - Tatien Bucyana
- Maternal Child and Community Health Rwanda Biomédical Center, Rwanda Ministry of Health, Kigali, Rwanda
| | - Lisa R Hirschhorn
- Ariadne Labs, Boston, Massachusetts, USA
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Mejía-Guevara I, Zuo W, Bendavid E, Li N, Tuljapurkar S. Age distribution, trends, and forecasts of under-5 mortality in 31 sub-Saharan African countries: A modeling study. PLoS Med 2019; 16:e1002757. [PMID: 30861006 PMCID: PMC6413894 DOI: 10.1371/journal.pmed.1002757] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 02/01/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Despite the sharp decline in global under-5 deaths since 1990, uneven progress has been achieved across and within countries. In sub-Saharan Africa (SSA), the Millennium Development Goals (MDGs) for child mortality were met only by a few countries. Valid concerns exist as to whether the region would meet new Sustainable Development Goals (SDGs) for under-5 mortality. We therefore examine further sources of variation by assessing age patterns, trends, and forecasts of mortality rates. METHODS AND FINDINGS Data came from 106 nationally representative Demographic and Health Surveys (DHSs) with full birth histories from 31 SSA countries from 1990 to 2017 (a total of 524 country-years of data). We assessed the distribution of age at death through the following new demographic analyses. First, we used a direct method and full birth histories to estimate under-5 mortality rates (U5MRs) on a monthly basis. Second, we smoothed raw estimates of death rates by age and time by using a two-dimensional P-Spline approach. Third, a variant of the Lee-Carter (LC) model, designed for populations with limited data, was used to fit and forecast age profiles of mortality. We used mortality estimates from the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) to adjust, validate, and minimize the risk of bias in survival, truncation, and recall in mortality estimation. Our mortality model revealed substantive declines of death rates at every age in most countries but with notable differences in the age patterns over time. U5MRs declined from 3.3% (annual rate of reduction [ARR] 0.1%) in Lesotho to 76.4% (ARR 5.2%) in Malawi, and the pace of decline was faster on average (ARR 3.2%) than that observed for infant (IMRs) (ARR 2.7%) and neonatal (NMRs) (ARR 2.0%) mortality rates. We predict that 5 countries (Kenya, Rwanda, Senegal, Tanzania, and Uganda) are on track to achieve the under-5 sustainable development target by 2030 (25 deaths per 1,000 live births), but only Rwanda and Tanzania would meet both the neonatal (12 deaths per 1,000 live births) and under-5 targets simultaneously. Our predicted NMRs and U5MRs were in line with those estimated by the UN IGME by 2030 and 2050 (they overlapped in 27/31 countries for NMRs and 22 for U5MRs) and by the Institute for Health Metrics and Evaluation (IHME) by 2030 (26/31 and 23/31, respectively). This study has a number of limitations, including poor data quality issues that reflected bias in the report of births and deaths, preventing reliable estimates and predictions from a few countries. CONCLUSIONS To our knowledge, this study is the first to combine full birth histories and mortality estimates from external reliable sources to model age patterns of under-5 mortality across time in SSA. We demonstrate that countries with a rapid pace of mortality reduction (ARR ≥ 3.2%) across ages would be more likely to achieve the SDG mortality targets. However, the lower pace of neonatal mortality reduction would prevent most countries from achieving those targets: 2 countries would reach them by 2030, 13 between 2030 and 2050, and 13 after 2050.
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Affiliation(s)
- Iván Mejía-Guevara
- Department of Biology, Stanford University, Stanford, California, United States of America
- Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, United States of America
| | - Wenyun Zuo
- Department of Biology, Stanford University, Stanford, California, United States of America
| | - Eran Bendavid
- Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, United States of America
- Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, United States of America
| | - Nan Li
- United Nations Population Division, New York, New York, United States of America
| | - Shripad Tuljapurkar
- Department of Biology, Stanford University, Stanford, California, United States of America
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Gupta N, Hirschhorn LR, Rwabukwisi FC, Drobac P, Sayinzoga F, Mugeni C, Nkikabahizi F, Bucyana T, Magge H, Kagabo DM, Nahimana E, Rouleau D, VanderZanden A, Murray M, Amoroso C. Causes of death and predictors of childhood mortality in Rwanda: a matched case-control study using verbal social autopsy. BMC Public Health 2018; 18:1378. [PMID: 30558586 PMCID: PMC6296058 DOI: 10.1186/s12889-018-6282-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 11/29/2018] [Indexed: 11/10/2022] Open
Abstract
Background Rwanda has dramatically reduced child mortality, but the causes and sociodemographic drivers for mortality are poorly understood. Methods We conducted a matched case-control study of all children who died before 5 years of age in eastern Rwanda between 1st March 2013 and 28th February 2014 to identify causes and risk factors for death. We identified deaths at the facility level and via a community health worker reporting system. We used verbal social autopsy to interview caregivers of deceased children and controls matched by area and age. We used InterVA4 to determine probable causes of death and cause-specific mortality fractions, and utilized conditional logistic regression to identify clinical, family, and household risk factors for death. Results We identified 618 deaths including 174 (28.2%) in neonates and 444 (71.8%) in non-neonates. The most commonly identified causes of death were pneumonia, birth asphyxia, and meningitis among neonates and malaria, acute respiratory infections, and HIV/AIDS-related death among non-neonates. Among neonates, 54 (31.0%) deaths occurred at home and for non-neonates 242 (54.5%) deaths occurred at home. Factors associated with neonatal death included home birth (aOR: 2.0; 95% CI: 1.4–2.8), multiple gestation (aOR: 2.1; 95% CI: 1.3–3.5), both parents deceased (aOR: 4.7; 95% CI: 1.5–15.3), mothers non-use of family planning (aOR: 0.8; 95% CI: 0.6–1.0), lack of accompanying person (aOR: 1.6; 95% CI: 1.1–2.1), and a caregiver who assessed the medical services they received as moderate to poor (aOR: 1.5; 95% CI: 1.2–1.9). Factors associated with non-neonatal deaths included multiple gestation (aOR: 2.8; 95% CI: 1.7–4.8), lack of adequate vaccinations (aOR: 1.7; 95% CI: 1.2–2.3), household size (aOR: 1.2; 95% CI: 1.0–1.4), maternal education levels (aOR: 1.9; 95% CI: 1.2–3.1), mothers non-use of family planning (aOR: 1.6; 95% CI: 1.4–1.8), and lack of household electricity (aOR: 1.4; 95% CI: 1.0–1.8). Conclusion In the context of rapidly declining childhood mortality in Rwanda and increased access to health care, we found a large proportion of remaining deaths occur at home, with home deliveries still representing a significant risk factor for neonatal death. The major causes of death at a population level remain largely avoidable communicable diseases. Household characteristics associated with death included well-established socioeconomic and care-seeking risk factors.
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Affiliation(s)
- Neil Gupta
- Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA. .,Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda. .,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.
| | | | | | - Peter Drobac
- Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA.,Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | | | | | | | | | - Hema Magge
- Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA.,Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | | | | | | | | | - Megan Murray
- Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
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AMINI RARANI M, RASHIDIAN A, ARAB M, KHOSRAVI A, ABBASIAN E. Measuring Socioeconomic Inequality Changes in Child Mortality in Iran: Two National Surveys Inequality Analysis. IRANIAN JOURNAL OF PUBLIC HEALTH 2018; 47:1379-1387. [PMID: 30320013 PMCID: PMC6174055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND We aimed to measure changes in socioeconomic inequality in child mortality in Iran. METHODS A secondary data analysis of two Demographic and Health Surveys (DHS 2000 and 2010) was undertaken. Neonatal, infant and under-5 mortality rates were estimated directly from complete birth history. Economic quintiles were constructed using principal component analysis. Changes in inequality were measured using odds ratios, mortality rates, and concentration curves and indices. RESULTS Based on the compared measures, inequalities in neonatal, infant, and under-5 mortality declined between the two surveys. The poorest-to-richest neonatal, infant and under-5 mortality odds ratios in 2000 were 1.69 (95% CI= 1.3-2.07), 2.85 (95% CI= 1.96-4.1) and 1.98 (95% CI= 1.64-2.3), respectively. Whereas these mortality odds ratios in 2010 had fallen to 1.65 (95% CI= 0.95-2.9), 1.47 (95% CI=0.5-4) and 1.85 (95% CI=1.13-3), respectively. Moreover, mortality rates in all economic quintiles experienced a decreasing trend. Neonatal, infant, and under-5 mortality concentration indices in 2000 were -0.15, -0.26, and -0.17 respectively. Whereas concentration indices in 2010 had dropped to -0.13, -0.11, and -0.14, respectively. Concentration curves dominance test revealed that there was a statistically significant reduction in inequality in infant and under-5 mortalities. CONCLUSION Despite substantial reduction in child mortality rates and narrowing of the gap between poor and rich people, socioeconomic inequality in child mortalities disfavoring worse-off groups still exists. Combination of child health-related efforts that aim to reach to those children born in poor households alongside with pro-equity programs in other sectors of society may further reduce infant, under-5, and particularly neonatal mortality across economic quintiles in Iran.
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Affiliation(s)
- Mostafa AMINI RARANI
- Dept. of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Arash RASHIDIAN
- Dept. of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran,Corresponding Author:
| | - Mohammad ARAB
- Dept. of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Ardeshir KHOSRAVI
- Deputy of Public Health, Ministry of Health and Medical Education, Tehran, Iran
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10
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Chao F, You D, Pedersen J, Hug L, Alkema L. National and regional under-5 mortality rate by economic status for low-income and middle-income countries: a systematic assessment. LANCET GLOBAL HEALTH 2018; 6:e535-e547. [PMID: 29653627 PMCID: PMC5905403 DOI: 10.1016/s2214-109x(18)30059-7] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 01/23/2018] [Accepted: 02/01/2018] [Indexed: 11/15/2022]
Abstract
Background The progress to achieve the fourth Millennium Development Goal in reducing mortality rate in children younger than 5 years since 1990 has been remarkable. However, work remains to be done in the Sustainable Development Goal era. Estimates of under-5 mortality rates at the national level can hide disparities within countries. We assessed disparities in under-5 mortality rates by household economic status in low-income and middle-income countries (LMICs). Method We estimated country-year-specific under-5 mortality rates by wealth quintile on the basis of household wealth indices for 137 LMICs from 1990 to 2016, using a Bayesian statistical model. We estimated the association between quintile-specific and national-level under-5 mortality rates. We assessed the levels and trends of absolute and relative disparity in under-5 mortality rate between the poorest and richest quintiles, and among all quintiles. Findings In 2016, for all LMICs (excluding China), the aggregated under-5 mortality rate was 64·6 (90% uncertainty interval [UI] 61·1–70·1) deaths per 1000 livebirths in the poorest households (first quintile), 31·3 (29·5–34·2) deaths per 1000 livebirths in the richest households (fifth quintile), and in between those outcomes for the middle quintiles. Between 1990 and 2016, the largest absolute decline in under-5 mortality rate occurred in the two poorest quintiles: 77·6 (90% UI 71·2–82·6) deaths per 1000 livebirths in the poorest quintile and 77·9 (72·0–82·2) deaths per 1000 livebirths in the second poorest quintile. The difference in under-5 mortality rate between the poorest and richest quintiles decreased significantly by 38·8 (90% UI 32·9–43·8) deaths per 1000 livebirths between 1990 and 2016. The poorest to richest under-5 mortality rate ratio, however, remained similar (2·03 [90% UI 1·94–2·11] in 1990, 1·99 [1·91–2·08] in 2000, and 2·06 [1·92–2·20] in 2016). During 1990–2016, around half of the total under-5 deaths occurred in the poorest two quintiles (48·5% in 1990 and 2000, 49·5% in 2016) and less than a third were in the richest two quintiles (30·4% in 1990, 30·5% in 2000, 29·9% in 2016). For all regions, differences in the under-5 mortality rate between the first and fifth quintiles decreased significantly, ranging from 20·6 (90% UI 15·9–25·1) deaths per 1000 livebirths in eastern Europe and central Asia to 59·5 (48·5–70·4) deaths per 1000 livebirths in south Asia. In 2016, the ratios of under-5 mortality rate in the first quintile to under-5 mortality rate in the fifth quintile were significantly above 2·00 in two regions, with 2·49 (90% UI 2·15–2·87) in east Asia and Pacific (excluding China) and 2·41 (2·05–2·80) in south Asia. Eastern and southern Africa had the smallest ratio in 2016 at 1·62 (90% UI 1·48–1·76). Our model suggested that the expected ratio of under-5 mortality rate in the first quintile to under-5 mortality rate in the fifth quintile increases as national-level under-5 mortality rate decreases. Interpretation For all LMICs (excluding China) combined, the absolute disparities in under-5 mortality rate between the poorest and richest households have narrowed significantly since 1990, whereas the relative differences have remained stable. To further narrow the rich-and-poor gap in under-5 mortality rate on the relative scale, targeted interventions that focus on the poorest populations are needed. Funding National University of Singapore, UN Children's Fund, United States Agency for International Development, and the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Fengqing Chao
- Institute of Policy Studies, Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore.
| | - Danzhen You
- Division of Data, Research, and Policy, United Nations Children's Fund, New York, NY, USA
| | | | - Lucia Hug
- Division of Data, Research, and Policy, United Nations Children's Fund, New York, NY, USA
| | - Leontine Alkema
- Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, USA
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11
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Amoroso CL, Nisingizwe MP, Rouleau D, Thomson DR, Kagabo DM, Bucyana T, Drobac P, Ngabo F. Next wave of interventions to reduce under-five mortality in Rwanda: a cross-sectional analysis of demographic and health survey data. BMC Pediatr 2018; 18:27. [PMID: 29402245 PMCID: PMC5799916 DOI: 10.1186/s12887-018-0997-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 01/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sustained investments in Rwanda's health system have led to historic reductions in under five (U5) mortality. Although Rwanda achieved an estimated 68% decrease in the national under U5 mortality rate between 2002 and 2012, according to the national census, 5.8% of children still do not reach their fifth birthday, requiring the next wave of child mortality prevention strategies. METHODS This is a cross-sectional study of 9002 births to 6328 women age 15-49 in the 2010 Rwanda Demographic and Health Survey. We tested bivariate associations between 29 covariates and U5 mortality, retaining covariates with an odds ratio p < 0.1 for model building. We used manual backward stepwise logistic regression to identify correlates of U5 mortality in all children U5, 0-11 months, and 12-59 months. Analyses were performed in Stata v12, adjusting for complex sample design. RESULTS Of 14 covariates associated with U5 mortality in bivariate analysis, the following remained associated with U5 mortality in multivariate analysis: household being among the poorest of the poor (OR = 1.98), child being a twin (OR = 2.40), mother having 3-4 births in the past 5 years (OR = 3.97) compared to 1-2 births, mother being HIV positive (OR = 2.27), and mother not using contraceptives (OR = 1.37) compared to using a modern method (p < 0.05 for all). Mother experiencing physical or sexual violence in the last 12 months was associated with U5 mortality in children ages 1-4 years (OR = 1.48, p < 0.05). U5 survival was associated with a preceding birth interval 25-50 months (OR = 0.67) compared to 9-24 months, and having a mosquito net (OR = 0.46) (p < 0.05 for both). CONCLUSIONS In the past decade, Rwanda rolled out integrated management of childhood illness, near universal coverage of childhood vaccinations, a national community health worker program, and a universal health insurance scheme. Identifying factors that continue to be associated with childhood mortality supports determination of which interventions to strengthen to reduce it further. This study suggests that Rwanda's next wave of U5 mortality reduction should target programs in improving neonatal outcomes, poverty reduction, family planning, HIV services, malaria prevention, and prevention of intimate partner violence.
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Affiliation(s)
- Cheryl L Amoroso
- Inshuti Mu Buzima/Partners in Health-Rwanda, Rwinkwavu, Rwanda. .,USAID Global Health Fellows II, Public Health Institute, Washington DC, USA.
| | | | | | - Dana R Thomson
- School of Public Health, College of Medicine and Health Science, University of Rwanda, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Daniel M Kagabo
- Inshuti Mu Buzima/Partners in Health-Rwanda, Rwinkwavu, Rwanda
| | | | - Peter Drobac
- Inshuti Mu Buzima/Partners in Health-Rwanda, Rwinkwavu, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
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12
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Kagabo DM, Kirk CM, Bakundukize B, Hedt-Gauthier BL, Gupta N, Hirschhorn LR, Ingabire WC, Rouleau D, Nkikabahizi F, Mugeni C, Sayinzoga F, Amoroso CL. Care-seeking patterns among families that experienced under-five child mortality in rural Rwanda. PLoS One 2018; 13:e0190739. [PMID: 29320556 PMCID: PMC5761861 DOI: 10.1371/journal.pone.0190739] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 12/11/2017] [Indexed: 02/03/2023] Open
Abstract
Background Over half of under-five deaths occur in sub-Saharan Africa and appropriate, timely, quality care is critical for saving children’s lives. This study describes the context surrounding children’s deaths from the time the illness was first noticed, through the care-seeking patterns leading up to the child’s death, and identifies factors associated with care-seeking for these children in rural Rwanda. Methods Secondary analysis of a verbal and social autopsy study of caregivers who reported the death of a child between March 2013 to February 2014 that occurred after discharge from the child’s birth facility in southern Kayonza and Kirehe districts in Rwanda. Bivariate analyses using Fisher’s exact tests were conducted to identify child, caregiver, and household factors associated with care-seeking from the formal health system (i.e., community health worker or health facility). Factors significant at α = 0.10 significance level were considered for backwards stepwise multivariate logistic regression, stopping when remaining factors were significantly associated with care-seeking at α = 0.05 significance level. Results Among the 516 eligible deaths among children under-five, 22.7% (n = 117) did not seek care from the health system. For those who did, the most common first point of contact was community health workers (45.8%). In multivariate logistic regression, higher maternal education (OR = 3.36, 95% CI: 1.89, 5.98), having diarrhea (OR = 4.21, 95%CI: 1.95, 9.07) or fever (OR = 2.03, 95%CI: 1.11, 3.72), full household insurance coverage (3.48, 95%CI: 1.79, 6.76), and longer duration of illness (OR = 22.19, 95%CI: 8.88, 55.48) were significantly associated with formal care-seeking. Conclusion Interventions such as community health workers and insurance promote access to care, however a gap remains as many children had no contact with the health system prior to death and those who sought formal care still died. Further efforts are needed to respond to urgent cases in communities and further understand remaining barriers to accessing appropriate, quality care.
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Affiliation(s)
- Daniel M. Kagabo
- Partners in Health/Inshuti Mu Buzima (PIH/IMB), Rwinkwavu, Rwanda
- * E-mail:
| | | | | | - Bethany L. Hedt-Gauthier
- Partners in Health/Inshuti Mu Buzima (PIH/IMB), Rwinkwavu, Rwanda
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Neil Gupta
- Partners in Health/Inshuti Mu Buzima (PIH/IMB), Rwinkwavu, Rwanda
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Lisa R. Hirschhorn
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | | | | | | | | | - Felix Sayinzoga
- Rwanda Biomedical Center, Ministry of Health, Kigali, Rwanda
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13
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Rai SK, Kant S, Srivastava R, Gupta P, Misra P, Pandav CS, Singh AK. Causes of and contributors to infant mortality in a rural community of North India: evidence from verbal and social autopsy. BMJ Open 2017; 7:e012856. [PMID: 28801384 PMCID: PMC5577880 DOI: 10.1136/bmjopen-2016-012856] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To identify the medical causes of death and contribution of non-biological factors towards infant mortality by a retrospective analysis of routinely collected data using verbal and social autopsy tools. SETTING The study site was Health and Demographic Surveillance System (HDSS), Ballabgarh, North India PARTICIPANTS: All infant deaths during the years 2008-2012 were included for verbal autopsy and infant deaths from July 2012 to December 2012 were included for social autopsy. OUTCOME MEASURES Cause of death ascertained by a validated verbal autopsy tool and level of delay based on a three-delay model using the INDEPTH social autopsy tool were the main outcome measures. The level of delay was defined as follows: level 1, delay in identification of danger signs and decision making to seek care; level 2, delay in reaching a health facility from home; level 3, delay in getting healthcare at the health facility. RESULTS The infant mortality rate during the study period was 46.5/1000 live births. Neonatal deaths contributed to 54.3% of infant deaths and 39% occurred on the first day of life. Birth asphyxia (31.5%) followed by low birth weight (LBW)/prematurity (26.5%) were the most common causes of neonatal death, while infection (57.8%) was the most common cause of post-neonatal death. Care-seeking was delayed among 50% of neonatal deaths and 41.2% of post-neonatal deaths. Delay at level 1 was most common and occurred in 32.4% of neonatal deaths and 29.4% of post-neonatal deaths. Deaths due to LBW/prematurity were mostly followed by delay at level 1. CONCLUSION A high proportion of preventable infant mortality still exists in an area which is under continuous health and demographic surveillance. There is a need to enhance home-based preventive care to enable the mother to identify and respond to danger signs. Verbal autopsy and social autopsy could be routinely done to guide policy interventions aimed at reduction of infant mortality.
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Affiliation(s)
- Sanjay Kumar Rai
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
- INDEPTH Network, Accra, Ghana
| | - Shashi Kant
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
- INDEPTH Network, Accra, Ghana
| | | | - Priti Gupta
- Centre for Chronic Disease Control, Gurgaon, India
| | - Puneet Misra
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
- INDEPTH Network, Accra, Ghana
| | | | - Arvind Kumar Singh
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Persson LÅ, Rahman A, Peña R, Perez W, Musafili A, Hoa DP. Child survival revolutions revisited - lessons learned from Bangladesh, Nicaragua, Rwanda and Vietnam. Acta Paediatr 2017; 106:871-877. [PMID: 28295602 PMCID: PMC5450127 DOI: 10.1111/apa.13830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 02/05/2017] [Accepted: 03/07/2017] [Indexed: 11/30/2022]
Abstract
Analysing child mortality may enhance our perspective on global achievements in child survival. We used data from surveillance sites in Bangladesh, Nicaragua and Vietnam and Demographic Health Surveys in Rwanda to explore the development of neonatal and under‐five mortality. The mortality curves showed dramatic reductions over time, but child mortality in the four countries peaked during wars and catastrophes and was rapidly reduced by targeted interventions, multisectorial development efforts and community engagement. Conclusion: Lessons learned from these countries may be useful when tackling future challenges, including persistent neonatal deaths, survival inequalities and the consequences of climate change and migration.
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Affiliation(s)
- Lars Åke Persson
- International Maternal and Child Health (IMCH); Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
- Department of Disease Control; Faculty of Infectious and Tropical Diseases; London School of Hygiene and Tropical Medicine; London UK
| | - Anisur Rahman
- International Centre for Diarrhoeal Disease Research (icddr,b); Dhaka Bangladesh
| | - Rodolfo Peña
- International Maternal and Child Health (IMCH); Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
- Pan American Health Organization; San Salvador El Salvador
| | - Wilton Perez
- International Maternal and Child Health (IMCH); Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
| | - Aimable Musafili
- International Maternal and Child Health (IMCH); Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
- Pediatric and Child Health Department; University of Rwanda; Kigali Rwanda
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15
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Amini Rarani M, Rashidian A, Khosravi A, Arab M, Abbasian E, Khedmati Morasae E. Changes in Socio-Economic Inequality in Neonatal Mortality in Iran Between 1995-2000 and 2005-2010: An Oaxaca Decomposition Analysis. Int J Health Policy Manag 2017; 6:219-218. [PMID: 28812805 PMCID: PMC5384984 DOI: 10.15171/ijhpm.2016.127] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 09/17/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Exploring changes in health inequality and its determinants over time is of policy interest. Accordingly, this study aimed to decompose inequality in neonatal mortality into its contributing factors and then explore changes from 1995-2000 to 2005-2010 in Iran. METHODS Required data were drawn from two Iran's demographic and health survey (DHS) conducted in 2000 and 2010. Normalized concentration index (CI) was used to measure the magnitude of inequality in neonatal mortality. The contribution of various determinants to inequality was estimated by decomposing concentration indices in 1995-2000 and 2005-2010. Finally, changes in inequality were investigated using Oaxaca-type decomposition technique. RESULTS Pro-rich inequality in neonatal mortality was declined by 16%, ie, the normalized CI dropped from -0.1490 in 1995-2000 to -0.1254 in 2005-2010. The largest contribution to inequality was attributable to mother's education (32%) and household's economic status (49%) in 1995-2000 and 2005-2010, respectively. Changes in mother's educational level (121%), use of skilled birth attendants (79%), mother's age at the delivery time (25-34 years old) (54%) and using modern contraceptive (29%) were mainly accountable for the decrease in inequality in neonatal mortality. CONCLUSION Policy actions on improving households' economic status and maternal education, especially in rural areas, may have led to the reduction in neonatal mortality inequality in Iran.
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Affiliation(s)
- Mostafa Amini Rarani
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
- Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Arash Rashidian
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Ardeshir Khosravi
- Deputy of Public Health, Ministry of Health and Medical Education, Tehran, Iran
| | - Mohammad Arab
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Esmaeil Khedmati Morasae
- Department of Public Health, Qom University of Medical Sciences, Qom, Iran
- Centre for System Studies (CSS), Hull University Business School (HUBS), Hull York Medical School (HYMS), University of Hull, Hull, UK
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Lartey ST, Khanam R, Takahashi S. The impact of household wealth on child survival in Ghana. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2016; 35:38. [PMID: 27876090 PMCID: PMC5120443 DOI: 10.1186/s41043-016-0074-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 11/03/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Improving child health is one of the major policy agendas for most of the governments, especially in the developing countries. These governments have been implementing various strategies such as improving healthcare financing, improving access to health, increasing educational level, and income level of the household to improve child health. Despite all these efforts, under-five and infant mortality rates remain high in many developing nations. Some previous studies examined how economic development or household's economic condition contributes to child survival in developing countries. In Ghana, the question as to what extent does economic circumstances of households reduces infant and child mortality still remain largely unanswered. Thus, the purpose of this study is to investigate the extent to which wealth affects the survival of under-five children, using data from the Demographic and Health Survey (DHS) of Ghana. METHODS In this study, we use four waves of data from Demographic and Health Surveys (DHS) of Ghana from 1993 to 2008. The DHS is a detailed data set that provides comprehensive information on households and their demographic characteristics in Ghana. Data was obtained by distributing questionnaires to women (from 6000 households) of reproductive age between 15 and 49 years, which asked, among other things, their birth history information. The Weibull hazard model with gamma frailty was used to estimate wealth effect, as well as the trend of wealth effect on child's survival probability. RESULTS We find that household wealth status has a significant effect on the child survival in Ghana. A child is more likely to survive when he/she is from a household with high wealth status. Among other factors, birth spacing and parental education were found to be highly significant to increase a child's survival probability. CONCLUSIONS Our findings offer plausible mechanisms for the association of household wealth and child survival. We therefore suggest that the Government of Ghana strengthens and sustains improved livelihood programs, which reduce poverty. They should also take further initiatives that will increase adult education and improve health knowledge. To the best of our knowledge, this is the first study in Ghana that combines four cross sectional data sets from DHS to study a policy-relevant question. We extend Standard Weibull hazard model into Weibull hazard model with gamma frailty, which gives us a more accurate estimation. Finally, the findings of this study are of interest not only because they provide insights into the determinants of child health in Ghana and other developing countries, but they also suggest policies beyond the scope of health.
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Affiliation(s)
| | - Rasheda Khanam
- School of Commerce, Faculty of Business, Education, Law and Arts, University of Southern Queensland, Toowoomba, Queensland 4350 Australia
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Blackstone SR, Nwaozuru U, Iwelunmor J. An examination of the maternal social determinants influencing under-5 mortality in Nigeria: Evidence from the 2013 Nigeria Demographic Health Survey. Glob Public Health 2016; 12:744-756. [DOI: 10.1080/17441692.2016.1211166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Sarah R. Blackstone
- Department of Kinesiology and Community Heath, College of Applied Health Sciences, University of Illinois Urbana-Champaign, Champaign, IL, USA
| | - Ucheoma Nwaozuru
- Department of Kinesiology and Community Heath, College of Applied Health Sciences, University of Illinois Urbana-Champaign, Champaign, IL, USA
| | - Juliet Iwelunmor
- Department of Kinesiology and Community Heath, College of Applied Health Sciences, University of Illinois Urbana-Champaign, Champaign, IL, USA
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