The impact of the Boko Haram insurgency in Northeast Nigeria on childhood wasting: a double-difference study

Armed conflict, insecurity, and attitudes toward women's and girls' reproductive autonomy in Nigeria

BACKGROUND

Armed conflict and insecurity have been linked to deteriorations in reproductive health and rights globally. In Nigeria, armed violence has taken a significant toll on women's and girls' health and safety. However, knowledge is limited about how conflict shapes attitudes surrounding their ability to make autonomous decisions on relationships and childbearing. Drawing on a socioecological framework and terror management theory, we aimed to investigate the association between conflict, insecurity, and attitudes toward women's and girls' reproductive autonomy in Nigeria.

METHODS

We conducted a cross-sectional study using data from two sources: the World Values Survey (WVS) and the Uppsala Conflict Data Program-Georeferenced Event Dataset (UCDP-GED). Nationally representative data on attitudes of 559 men and 534 women was collected by WVS in 2017-2018. Linear probability models estimated the association between attitudes toward five dimensions of women and girl's reproductive autonomy (contraception, safe abortion, marital decision-making, delayed childbearing, early marriage), respondents' perceptions of neighborhood insecurity using WVS data, and geospatial measures of conflict exposure drawn from UCDP-GED.

RESULTS

Exposure to armed conflict and perceived neighborhood insecurity were associated with more supportive attitudes toward access to safe abortion among both men and women. Among women, conflict exposure was associated with higher support for contraception and the perception that early marriage can provide girls with security. Conflict-affected men were more likely to support a delay in girls' childbearing.

CONCLUSION

Our findings suggest that conflict and insecurity pose a threat to, but also facilitate opportunities for, women's and girls' reproductive autonomy. Contraception, abortion, early marriage, and postponement or childbearing may be perceived as risk-aversion strategies in response to mortality threats, livelihood losses, and conflict-driven sexual violence. Our findings foreshadow changes in fertility and relationship patterns in conflict-affected Nigeria and highlight the need for health programming to ensure access to contraception and safe abortion services.

Climate variability, armed conflicts and child malnutrition in sub-saharan Africa: A spatial analysis in Ethiopia, Kenya and Nigeria

Background

Sub-Saharan Africa (SSA) has one of the highest prevalence of malnutrition among children under 5 in the world. It is also the region most vulnerable to the adverse effect of climate change, and the one that records the most armed conflicts. The chains of causality suggested in the literature on the relationship between climate change, armed conflict, and malnutrition have rarely been supported by empirical evidence for SSA countries.

Methods

This study proposes to highlight, under the hypothesis of spatial non-stationarity, the influence of climatic variations and armed conflicts on malnutrition in children under 5 in Ethiopia, Kenya, and Nigeria. To do this, we use spatial analysis on data from Demographic and Health Surveys (DHS), Uppsala Conflict Data Program Georeferenced Event Dataset (UCDP GED), Climate Hazards center InfraRed Precipitation with Station data (CHIRPS) and Moderate Resolution Imaging Spectroradiometer (MODIS).

Results

The results show that there is a spatial autocorrelation of malnutrition measured by the prevalence of underweight children in the three countries. Also, local geographically weighted analysis shows that armed conflict, temperature and rainfall are positively associated with the prevalence of underweight children in localities of Somali in Ethiopia, Mandera and Turkana of Wajir in Kenya, Borno and Yobe in Nigeria.

Conclusion

In conclusion, the results of our spatial analysis support the implementation of conflict-sensitive climate change adaptation strategies.

Childhood and Infant exposure to famine in the Biafran war is associated with hypertension in later life: the Abia NCDS study

There are very few studies in Africans investigating the association between early life exposure to malnutrition and subsequent hypertension in adulthood. We set out to investigate this potential association within an adult cohort who were born around the time of the Biafran War (1968-1970) and subsequent famine in Nigeria. This was a retrospective analysis of Abia State Non-Communicable Diseases and Cardiovascular Risk Factors (AS-NCD-CRF) Survey, a community-based, cross-sectional study that profiled 386 adults (47.4% men) of Igbo ethnicity born in the decade between January 1965 and December 1974. Based on their date of birth and the timing of the famine, participants were grouped according to their exposure to famine as children (Child-Fam) or in-utero fetus/infant (Fet-Inf-Fam) or no exposure (No-Fam). Binomial logit regression models were fitted to determine the association between famine exposure and hypertension in adulthood. Overall, 130 participants had hypertension (33.7%). Compared to the No-Fam group (24.4%), the prevalence of hypertension was significantly elevated in both the Child-Fam (43% - adjusted OR 2.47, 95% CI 1.14-5.36) and Fet-Inf-Fam (44.6% - adjusted OR 2.54, 95% CI 1.33-4.86) groups. The risk of hypertension in adulthood was highest among females within the Child-Fam group. However, within the Fet-Inf-Fam group males had a equivalently higher risk than females. These data suggest that early life exposure to famine and malnutrition in Africa is associated with a markedly increased risk of hypertension in adulthood; with sex-based differences evident. Thus, the importance of avoiding armed conflicts and food in-security in the region cannot be overstated. The legacy effects of the Biafran War clearly show the wider need for ongoing programs that support the nutritional needs of African mothers, infants and children as well as proactive surveillance programs for the early signs of hypertension in young Africans.

Impact of Sickle Cell Disease on Affected Individuals in Nigeria: A Critical Review

Sickle cell disease is an autosomal recessive disorder of the beta-globin gene, with resultant deformation of the red blood cells and variable clinical outcomes. Nigeria is recognised as the country with the highest burden of sickle cell disease globally. This study aimed at critically reviewing available literature on impact of sickle cell disease in Nigeria. A literature search was carried out on four databases, and a total of 116 articles that met the inclusion criteria were included in the critical review. It was observed that majority of the studies were carried out in South-Western part of Nigeria (47.4%), whilst the North-East had the least number of studies undertaken in this area, more than a quarter of the studies (27.6%) were related to hematologic and serologic screening. Major themes that emerged from this review were morbidity and mortality; prevalence of sickle cell disease; issues relating to blood transfusion; psychosocial impact; and anatomical dysfunction in sickle cell disease. Intervention programs from both government and non-governmental organizations aimed at reducing the burden of sickle cell disease and its socio-economic impact were identified as key to strategies aimed at overcoming challenges associated with the disease. Findings from this study also revealed that education and awareness interventions were central to reducing the prevalence of sickle cell disease in this setting.

Terrorist Attacks in Sub-Saharan Africa from 1970 through 2020: Analysis and Impact from a Counter-Terrorism Medicine Perspective

BACKGROUND

Sub-Saharan Africa (SSA) has become a hotspot for global terrorism, with nearly 50% of global terror-related deaths occurring in SSA in 2021. With a large population and complex geopolitical and social climate, terrorist activity further burdens an already strained medical system. This study provides a retrospective descriptive analysis of terrorist-related activity in SSA from 1970-2020.

METHODS

A retrospective analysis of the Global Terrorism Database (GTD) was performed for the region of SSA from 1970-2020. Data were filtered using the internal database search function for all events in the following countries: Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Comoros, the Democratic Republic of the Congo, Djibouti, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Namibia, Niger, Nigeria, People's Republic of the Congo, Republic of the Congo, Rhodesia, Rwanda, Senegal, Seychelles, Sierra Leone, Somalia, South Africa, South Sudan, Sudan, Swaziland, Tanzania, Togo, Uganda, Zaire, Zambia, and Zimbabwe. Number of attacks, deaths, and injuries, as well as primary weapons types, country where attacks occurred, and primary target types, were collated and analyzed.

RESULTS

A total 19,320 attacks were recorded, resulting in 77,565 deaths and 52,986 injuries. Firearms were the most frequent weapons used (8,745), followed by explosives (6,031), unknown (2,615), and incendiary (1,246), with all others making up the remainder (683.) Private citizens and property were the most frequently targeted entities (8,031), followed by general government facilities (2,582), police (1,854), business (1,446), military (805), diplomatic government facilities (741), and religious figures/institution (678), with all other targets making up the remainder (3,183).

CONCLUSION

The majority of deaths from terrorism in SSA are the result of firearm attacks and explosions. Nigeria, Somalia, South Africa, The Democratic Republic of the Congo, and Sudan have had the largest number of attacks since 1970, and Nigeria has the largest number of people killed and injured. The health implications of terrorist attacks are often compounded by violence and pose unique challenges to governments, populations, and aid organizations. By understanding the impact and scope of terrorist activity in SSA, Counter-Terrorism Medicine (CTM) initiatives can be employed to improve health care outcomes.

Childhood exposure to armed conflict and nutritional health outcomes in Nigeria

BACKGROUND

Armed conflicts are associated with an increased risk of food insecurity, the leading cause of malnutrition in low-and-middle-income countries. Multiple studies have uncovered significant influences of childhood malnutrition on children's overall health and development. As a result, it is increasingly important to understand how childhood experience of armed conflict intersects with childhood malnutrition in conflict-prone countries like Nigeria. This study examined the association between different measures of childhood experiences of armed conflicts and the nutritional health outcomes of children aged 36-59 months.

METHODS

We used data from the Nigeria Demographic and Health Survey linked with Uppsala Conflict Data Program Geo-Referenced Events Dataset using geographic identifiers. Multilevel regression models were fitted on a sample of 4226 children aged 36-59 months.

RESULTS

The prevalence of stunting, underweight and wasting was 35%, 20% and 3%, respectively. Armed conflicts were mostly recorded in the North-eastern states of Borno (222 episodes) and Adamawa (24 episodes). Exposure to armed conflicts ranged from 0 (no experience of armed conflict) to 3.75 conflicts per month since the child's birth. An increase in the frequency of armed conflicts is associated with increased odds of childhood stunting [AOR = 2.52, 95%CI: 1.96-3.25] and underweight [AOR = 2.33, 95%CI: 1.19-4.59] but not wasting. The intensity of armed conflict was only marginally associated with stunting and underweight but not wasting. Longer conflicts that occurred in the last year were also associated with the odds of stunting [AOR = 1.25, 95%CI: 1.17-1.33] and underweight [AOR = 1.19, 95%CI: 1.11-1.26] but not wasting.

CONCLUSION

Childhood exposure to armed conflict is associated with long-term malnutrition in children aged 36-59 months in Nigeria. Strategies that aim to end childhood malnutrition could target children exposed to armed conflicts.

Household behavior and vulnerability to acute malnutrition in Kenya

Anticipating those most at-risk of being acutely malnourished significantly shapes decisions that pertain to resource allocation and intervention in times of food crises. Yet, the assumption that household behavior in times of crisis is homogeneous-that households share the same capacity to adapt to external shocks-ostensibly prevails. This assumption fails to explain why, in a given geographical context, some households remain more vulnerable to acute malnutrition relative to others, and why a given risk factor may have a differential effect across households? In an effort to explore how variation in household behavior influences vulnerability to malnutrition, we use a unique household dataset that spans 23 Kenyan counties from 2016 to 2020 to seed, calibrate, and validate an evidence-driven computational model. We use the model to conduct a series of counterfactual experiments on the relationship between household adaptive capacity and vulnerability to acute malnutrition. Our findings suggest that households are differently impacted by given risk factors, with the most vulnerable households typically being the least adaptive. These findings further underscore the salience of household adaptive capacity, in particular, that adaption is less effective for economic vis-à-vis climate shocks. By making explicit the link between patterns of household behavior and vulnerability in the short- to medium-term, we underscore the need for famine early warning to better account for variation in household-level behavior.

Can nutrition-sensitive intervention and programmes reduce household's food insecurity among the communities affected by Boko-Haram insurgency in Nigeria?

Dwindling food security situations that arose from Boko-haram insurgence experienced in the northeast of Nigeria has led to an urgent need to respond to the food and livelihood requirements of families who were affected by the conflicts in this region. This is necessary in order to enhance their food and nutritional security and livelihood activities. Thus, examining the status of malnutrition of households in the intervening communities is imperative. Therefore, primary data were collected from some selected households within the region using multi-stage sampling procedure. Descriptive statistics, Dietary Diversity Score (DSS), Heckman and Tobit Models were the analytical tools employed. The study revealed that food aid constitutes an integral proportion of the total expenditure of households on food in the intervening communities. Level of malnutrition also reduces from 40.58 to 16.7% due to the impact of the sensitization programme on households' consumption of nutritious foods. However, there is still a high level of malnutrition (68.79%) among the children that are 5 years and below. Social capital formation and group-specific nutritional policy strategies directed at the internally displaced persons (IDPs) and children that are 5 years and below are panacea to reducing malnutrition in the region.

The health consequences of civil wars: evidence from Afghanistan

This study examines the effects of long-run civil wars on healthcare, which is an important component of human capital development and their causality nexus in Afghanistan using the MVAR (modified vector autoregressive) approach and the Granger non-causality model covering data period 2002Q3-2020Q4. The primary results support a significant long-run relationship between variables, while the results of the MVAR model indicate the per capita cost of war, per capita GDP, and age dependency ratio have significantly positive impacts on per capita health expenditures, whereas child mortality rate and crude death rate have negative impacts. The results of the Granger non-causality approach demonstrate that there is a statistically significant bidirectional causality nexus between per capita health expenditure, per capita cost of war, per capita GDP, child mortality rate, crude death rate, and age dependency ratio, while it also supports the existence of strong and significant interconnectivity and multidimensionality between per capita cost of war and per capita health expenditure, with a significantly strong feedback response from the control variables. Important policy implications sourced from the key findings are also discussed.

A review of noma cases in a tertiary hospital located in a conflict endemic region in Nigeria

Noma, a neglected tropical disease (NTD), is a preventable oro-facial gangrenous infection causing destruction of oro-facial tissues if untreated. This descriptive study was conducted in North-Eastern Nigeria which has witnessed armed insurgency increasing risk of noma. Data was obtained from patients' records at a tertiary hospital after a dental educational outreach using radio and visits to the hospital's ante/postnatal clinics. Data analysis was conducted at 95% confidence interval with p≤ 0.05 considered significant. Records of 49 patients were retrieved but 31 (63.3%) were utilised due to poor documentation. Age ranged from 2-63 years. Children (0-16 years) and Adults (17-59 years) were 67.7% and 25.8% respectively. Males were 13 (41.9%) and females, 18 (58.1%). Poor oral hygiene and malnutrition were common findings. Stage (WHO Staging System) 2 (51.6%) and 4 (22.6%) were the most common presentation. Successfully managed and referred cases were 51.6% and 48.4% respectively. Successful management was associated with early stages of noma (p = <0.001). Children were most vulnerable. Outreaches using radio and education to pregnant women and nursing mothers can boost early presentation and better outcomes. Attention to case documentation and inclusion of noma into the WHO list of NTDs are recommended.

Determinants of Under-Five Mortality in an Armed Conflict Setting: Empirical Findings from the Demographic and Health Surveys

Insurgencies like Boko Haram may impact the physical health and well-being of adults and children living in geographic areas under their political control. However, it is difficult to obtain reliable health data in conflict-affected areas. This study explored the potential to use data from the Demographic and Health Surveys (DHS) to examine the determinants of under-five mortality in Northern Nigeria. Data were derived from DHS conducted before and after the start of the Boko Haram insurgency in 2009. A multi-level mixed effects logistic regression model was used to identify predictors of under-five mortality in an armed conflict setting. Results were reported as adjusted odds ratios (aOR) and 95% confidence intervals (CI). Residence in an armed conflict setting was not significantly associated with under-five mortality (aOR = 1.06; 95% CI: 1.00, 1.10). However, twin gestation (aOR = 3.18; 95% CI:2.96, 3.42), wealth index of family (richest versus poorest: aOR = 0.42; 95% CI: 0.37, 0.47), religion of mother (Islam versus Christianity: aOR = 1.50; 95% CI: 1.43, 1.57); highest educational level of mother (higher versus none: aOR = 0.33; 95% CI: 0.29, 0.37), and parity of mother, significantly predicted death before the fifth birthday. Repeated studies are needed to assess the impact of Boko Haram insurgency on physical health outcomes, particularly in areas where primary data collection is difficult or impossible.

Conflict and Climate Factors and the Risk of Child Acute Malnutrition Among Children Aged 24-59 Months: A Comparative Analysis of Kenya, Nigeria, and Uganda

Acute malnutrition affects a sizeable number of young children around the world, with serious repercussions for mortality and morbidity. Among the top priorities in addressing this problem are to anticipate which children tend to be susceptible and where and when crises of high prevalence rates would be likely to arise. In this article, we highlight the potential role of conflict and climate conditions as risk factors for acute malnutrition, while also assessing other vulnerabilities at the individual- and household-levels. Existing research reflects these features selectively, whereas we incorporate all the features into the same study. The empirical analysis relies on integration of health, conflict, and environmental data at multiple scales of observation to focuses on how local conflict and climate factors relate to an individual child's health. The centerpiece of the analysis is data from the Demographic and Health Surveys conducted in several different cross-sectional waves covering 2003-2016 in Kenya, Nigeria, and Uganda. The results obtained from multi-level statistical models indicate that in Kenya and Nigeria, conflict is associated with lower weight-for-height scores among children, even after accounting for individual-level and climate factors. In Nigeria and Kenya, conflict lagged 1-3 months and occurring within the growing season tends to reduce WHZ scores. In Uganda, however, weight-for-height scores are primarily associated with individual-level and household-level conditions and demonstrate little association with conflict or climate factors. The findings are valuable to guide humanitarian policymakers and practitioners in effective and efficient targeting of attention, interventions, and resources that lessen burdens of acute malnutrition in countries prone to conflict and climate shocks.

Multisectoral intervention on food security in complex emergencies: a discourse on regional resilience praxis in Northeast Nigeria

Sustainable livelihood as an enabler of food security can be constrained by climate variability and violent conflicts, with dire consequences in regions with crude adaptation practices. The effects of such 'complex emergency crises' on food production and livelihoods in Northeast Nigeria impair human security and resilience, particularly, in the Boko Haram ravaged Borno, Yobe and Adamawa states, and the adjoining Lake Chad region. This study examines the efficacy of multisectoral interventions on food security and resilience in Northeast Nigeria, using the Sustainable Livelihoods Approach. Its thematic analysis of qualitative data was supported by the Cadre Harmonisé (CH) regional report of acute food insecurity assessment in the Sahel. It reveals that due to less collaborative and disjointed implementation of multi-stakeholder interventions across critical sectors, the humanitarian, food, and livelihood interventions marginally improve food security and resilience in the region. It recommends that livelihood outcomes and sustainability of the regional resource base be prioritised through diversification of food production, development aid and a holistic regional stabilisation programme. The impact of these mechanisms on agribusiness transformation and long-term food security in northeast Nigeria are significant for adaptation and sustainable livelihood in complex emergencies.

"Watching my family being killed by terrorists made me really depressed": Mental health experiences, challenges and needed support of young internally displaced persons in northern Nigeria

Background

Over 3.9 million people have been displaced in Nigeria as a result of the over one-decade-long Boko Haram insurgency and about 2.1 million of this population are internally displaced within the country. Young internally displaced persons (IDPs) are at higher risk of mental illness such as depression, anxiety, post-traumatic stress disorder (PTSD) among others, however, there are sparse studies on this population. Therefore, this study explored the mental health experiences, challenges, and needed support for young internally displaced persons in Durumi and New Kuchingoro Internally Displaced Persons Camps in Nigeria.

Methods

This qualitative study was conducted among young IDPs in Durumi and New Kuchingoro IDP camps in Northern Nigeria. Fourteen (14) focus group discussions comprising 89 participants and 30 in-depth interviews with 30 participants were conducted with young IDPs. The interviews were in Hausa and Pidgin English, audio-recorded, transcribed, translated into English, and applied thematic analysis was done using MAXQDA Analytics Pro 2020.

Results

A total of 89 participants consisting of 47 males and 42 females participated in the FGDs and IDIs. Five key themes emerged from the FGDs and IDI: (1) knowledge about mental health, (2) mental Health Experiences, (3) coping strategies, (4) availability of mental health and other health Support, and (5) needed support. Young IDPs had fair knowledge about mental healthcare. Participants reported their experience before displacement as being peaceful with members of the family together in a good environment while they experienced stress, trauma, shock, sadness, and symptoms of anxiety, depression, and PTSD during and post displacement. Personal coping strategies such as listening to music, engaging in sports, reading books, farming, and other economic activities were reported by participants. Participants reported the absence of structured and specialized mental health support in the IDP camps and solicited mental health, physical health, economic and educational support.

Conclusion

Young IDPs had negative experiences that led to symptoms of mental health disorders such as depression, anxiety disorders, PTSD among others with little or no access to quality mental healthcare. Hence, they require specialized and structured mental health support to lead healthy and productive lives. Policy and programs aimed at increasing access to mental health information and services for forced migrants are recommended.

Decisive or impulsive? Re-examining Africa's lockdown response to COVID-19

Due to the high transmission rate and mortality index of the current coronavirus pandemic, many settings in Africa instituted lockdowns to reduce its rate of spread and avert exponential growth rate. At the early stage, this measure seemed to heighten awareness of the virus and subsequently minimized exponential growth of cases. However, these lockdowns have had great consequences on the weak health systems and frail economy in place in many African countries. In this paper, we examine the impact of lockdown measures in these countries and provides key recommendations in dealing with present and future pandemics.

Conflict and Child Malnutrition: a Systematic Review of the Emerging Quantitative Literature

PURPOSE OF REVIEW

Reduction of child malnutrition in conflict settings is on top of the international agenda on sustainable development. This association between child malnutrition and conflict has been hypothesised in the academic literature but not rigorously examined empirically till recently. This paper reviews the emerging quantitative literature, including conflict as an explanatory variable to understand the aspects of child malnutrition studied and how violent events are associated with child nutritional status. Limitations are also highlighted.

RECENT FINDINGS

Child malnutrition is investigated into its three main dimensions of stunting, wasting and undernourishment computed as z-score. Conflict is mostly studied in terms of duration, number of events, typology and intensity. The emerging literature generally establishes a significant and negative association between conflict and child malnutrition. However, limitations persist and are mainly due to the type of available data.

Effects of terrorist attacks on access to maternal healthcare services: a national longitudinal study in Burkina Faso

INTRODUCTION

Most of the literature on terrorist attacks' health impacts has focused on direct victims rather than on distal consequences in the overall population. There is limited knowledge on how terrorist attacks can be detrimental to access to healthcare services. The objective of this study is to assess the impact of terrorist attacks on the utilisation of maternal healthcare services by examining the case of Burkina Faso.

METHODS

This longitudinal quasi-experimental study uses multiple interrupted time series analysis. Utilisation of healthcare services data was extracted from the National Health Information System in Burkina Faso. Data span the period of January 2013-December 2018 and include all public primary healthcare centres and district hospitals. Terrorist attack data were extracted from the Armed Conflict Location and Event Data project. Negative binomial regression models were fitted with fixed effects to isolate the immediate and long-term effects of terrorist attacks on three outcomes (antenatal care visits, of facility deliveries and of cesarean sections).

RESULTS

During the next month of an attack, the incidence of assisted deliveries in healthcare facilities is significantly reduced by 3.8% (95% CI 1.3 to 6.3). Multiple attacks have immediate effects more pronounced than single attacks. Longitudinal analysis show that the incremental number of terrorist attacks is associated with a decrease of the three outcomes. For every additional attack in a commune, the incidence of cesarean sections is reduced by 7.7% (95% CI 4.7 to 10.7) while, for assisted deliveries, it is reduced by 2.5% (95% CI 1.9 to 3.1) and, for antenatal care visits, by 1.8% (95% CI 1.2 to 2.5).

CONCLUSION

Terrorist attacks constitute a new barrier to access of maternal healthcare in Burkina Faso. The exponential increase in terrorist activities in West Africa is expected to have negative effects on maternal health in the entire region.

Linking armed conflict to malnutrition during pregnancy, breastfeeding, and childhood

BACKGROUND

Women in LMICs are important agricultural actors; however, these same women, and with their children, suffer high rates of acute malnutrition during armed conflicts.

METHODS AND FINDINGS

A review was undertaken of peer-reviewed literature to describe how armed conflict drives acute malnutrition in pregnant and breastfeeding women and their children. Armed conflict factors driving malnutrition were conceptualized as belonging to one of eight overarching drivers.

CONCLUSION

Future research must examine the effect of specific drivers on acute malnutrition in order to improve predictive models; emphasize inclusion of pregnant and breastfeeding participants in studies; elucidate the role of peacekeepers in mitigating the risk of acute malnutrition; explore how to support breastfeeding women living in armed conflict situations; and explore how displaced populations affect host communities' food systems.

The impact of antenatal care on under-five mortality in Ethiopia: a difference-in-differences analysis

Background

Sub-Saharan Africa, as opposed to other regions, has the highest under-five mortality rates yet makes the least improvement in reducing under-five mortality. Despite the decline, Ethiopia is among the top ten countries contributing the most to global under-five mortalities. This article examines the impact of the number of antenatal care and the timing of first antenatal care on child health outcomes. We specifically investigated if the utilization of antenatal care services positively affects the reduction of under-five mortality.

Methods

We employ a difference-in-differences design with propensity score matching to identify direct causal effects of antenatal care on under-five mortality based on the Ethiopian Demographic Health Survey data of 2011 and 2016. Our sample includes 22 295 women between the ages of 14–49 who had antenatal care visits at different times before delivery.

Results

The study revealed 1 481 cases of reported under-five mortality. 99.0% of that under-five mortality cases are women who had less than eight antenatal care visits, while only 1% of that is by women who had eight or more antenatal care visits. Antenatal care visit decreases the likelihood of under-five mortality in Ethiopia by 45.2% (CI = 19.2–71.3%, P-value < 0.001) while the timing of first antenatal care within the first trimester decreases the likelihood of under-five mortality by 10% (CI = 5.7–15.6%, P-value < 0.001).

Conclusions

To achieve a significant reduction in the under-five mortality rate, Intervention programs that encourages more antenatal care visits should be considered. This will improve child survival and help in attaining Sustainable Development Goal targets.

Schistosomiasis in Nigeria: Gleaning from the past to improve current efforts towards control

The effort to control schistosomiasis in Nigeria has been scaled up the past few years. Schistosomiasis affects all age groups, however, school children are at the highest risk of the disease. In the past years, global partners in schistosomiasis control have renewed their commitments. Many countries including few in Africa are working towards eliminating the disease. In Nigeria, the transmission of schistosomiasis is still active. This poses a serious health challenge as morbidity builds up in infected individuals. Mass drug administration (MDA) has helped to reduce morbidity but it is not adequate to abate transmission in many areas of the country. The integration of other aspects of control will provide a more sustainable result. This review attempted to discuss schistosomiasis transmission patterns in Nigeria in different eras. We identified some pitfalls in efforts towards the control of schistosomiasis in Nigeria. We recommended research priority in areas of neglect and advocated for integrated control.

Impact of political conflict on tuberculosis notifications in North-east Nigeria, Adamawa State: a 7-year retrospective analysis

OBJECTIVE

We assessed the impact of political conflict (Boko Haram) on tuberculosis (TB) case notifications in Adamawa State in North-east Nigeria.

DESIGN

A retrospective analysis of TB case notifications from TB registers (2010-2016) to describe changes in TB notification, sex and age ratios by the degree of conflict by local government area.

SETTING

Adamawa State.

PARTICIPANTS

21 076 TB cases notified.

RESULTS

21 076 cases (62% male) were notified between 2010 and 2016, of which 19 604 (93%) were new TB cases. Areas affected by conflict in 2014 and 2015 had decreased case notification while neighbouring areas reported increased case notifications. The male to female ratio of TB cases changed in areas in conflict with more female cases being notified. The young and elderly (1-14 and >65 years old) had low notifications in all areas, with a small increase in case notifications during the years of conflict.

CONCLUSION

TB case notifications decreased in conflict areas and increased in areas without conflict. More males were notified during peace times and more female cases were reported from areas in conflict. Young and elderly populations had decreased case notifications but experienced a slight increase during the conflict years. These changes are likely to reflect population displacement and a dissimilar effect of conflict on the accessibility of services. TB services in conflict areas deserve further study to identify resilient approaches that could reach affected populations.

A research vision for food systems in the 2020s: Defying the status quo

•Research and science should not only inform food and environmental policy but should be adopted and mainstreamed into actions at all levels.•Food systems are faced with grander and interconnected challenges and constraints that bring about new research questions.•Research has a vital role in charting a positive and sustainable direction for global food security, nutrition, and health.•The status quo must be challenged to shape food systems transformation to deliver sustainable, healthier diets.• Global Food Security provides a platform where evidence is shared in an accessible manner for those who need to act on it.

Applying the WHO ICD-PM classification system to stillbirths in a major referral Centre in Northeast Nigeria: a retrospective analysis from 2010-2018

Background

Lack of a unified and comparable classification system to unravel the underlying causes of stillbirth hampers the development and implementation of targeted interventions to reduce the unacceptably high stillbirth rates (SBR) in sub-Saharan Africa. Our aim was to track the SBR and the predominant maternal and fetal causes of stillbirths using the WHO ICD-PM Classification system.

Methods

This was a retrospective observational study in a major referral centre in northeast Nigeria between 2010 and 2018. Specialist Obstetricians and Gynaecologists assigned causes of stillbirths after an extensive audit of available stillbirths’ records. Cause of death was assigned via consensus using the ICD-PM classification system.

Results

There were 21,462 births between 1 January 2010 and 31 December 2018 in our study setting; of these, 1177 culminated in stillbirths with a total hospital SBR of 55 per 1000 births (95% CI: 52, 58). There were two peaks of stillbirths in 2012 [62 per 1000 births (95% CI: 53, 71)], and 2015 [65 per 1000 births (95% CI, 55, 76)]. Antepartum and intrapartum stillbirths were almost equally prevalent (48% vs 52%). Maternal medical and surgical conditions (M4) were the commonest (69.3%) cause of antepartum stillbirths while complications of placenta, cord and membranes (M3) accounted for the majority (45.8%) of intrapartum stillbirths and the trends were similar between 2010 and 2018. Antepartum and intrapartum fetal causes of stillbirths were mainly due to prematurity which is a disorder of fetal growth (A5 and I6).

Conclusions

Most causes of stillbirths in our setting are due to preventable causes and the trends have remained unabated between 2010 and 2018. Progress toward global SBR targets are off-track, requiring more interventions to halt and reduce the high SBR.

Empirical studies of factors associated with child malnutrition: highlighting the evidence about climate and conflict shocks

Children who experience poor nutrition during the first 1000 days of life are more vulnerable to illness and death in the near term, as well as to lower work capacity and productivity as adults. These problems motivate research to identify basic and underlying factors that influence risks of child malnutrition. Based on a structured search of existing literature, we identified 90 studies that used statistical analyses to assess relationships between potential factors and major indicators of child malnutrition: stunting, wasting, and underweight. Our review determined that wasting, a measure of acute malnutrition, is substantially understudied compared to the other indicators. We summarize the evidence about relationships between child malnutrition and numerous factors at the individual, household, region/community, and country levels. Our results identify only select relationships that are statistically significant, with consistent signs, across multiple studies. Among the consistent predictors of child malnutrition are shocks due to variations in climate conditions (as measured with indicators of temperature, rainfall, and vegetation) and violent conflict. Limited research has been conducted on the relationship between violent conflict and wasting. Improved understanding of the variables associated with child malnutrition will aid advances in predictive modeling of the risks and severity of malnutrition crises and enhance the effectiveness of responses by the development and humanitarian communities.

Development and validation of the neighborhood environment walkability scale for youth across six continents

BACKGROUND

The IPEN International Physical Activity and Environment Network Adolescent project was conducted using common study protocols to document the strength, shape, and generalizability of associations of perceived neighborhood environment attributes with adolescents' physical activity and overweight/obesity using data from 15 countries. Countries did not use identical versions of the Neighborhood Environment Walkability Scale for Youth (NEWS-Y) to measure perceived neighborhood environment attributes. Therefore, this study derived a measurement model for NEWS-Y items common to all IPEN Adolescent countries and developed a scoring protocol for the IPEN Adolescent version of the NEWS-Y (NEWS-Y-IPEN) that maximizes between-country comparability of responses. Additionally, this study examined between- and within-country variability, and construct validity of the NEWS-Y-IPEN subscales in relation to neighborhood-level socio-economic status and walkability.

METHODS

Adolescents and one of their parents (N = 5714 dyads) were recruited from neighborhoods varying in walkability and socio-economic status. To measure perceived neighborhood environment, 14 countries administered the NEWS-Y to parents and one country to adolescents. Confirmatory factor analysis was used to derive comparable country-specific measurement models of the NEWS-Y-IPEN. Country-specific standard deviations quantified within-country variability in the NEWS-Y-IPEN subscales, while linear mixed models determined the percentage of subscale variance due to between-country differences. To examine the construct validity of NEWS-Y-IPEN subscales, we estimated their associations with the categorical measures of area-level walkability and socio-economic status.

RESULTS

Final country-specific measurement models of the factor-analyzable NEWS-Y-IPEN items provided acceptable levels of fit to the data and shared the same factorial structure with five latent factors (Accessibility and walking facilities; Traffic safety; Pedestrian infrastructure and safety; Safety from crime; and Aesthetics). All subscales showed sufficient levels of within-country variability. Residential density had the highest level of between-country variability. Associations between NEWS-Y-IPEN subscales and area-level walkability and socio-economic status provided strong evidence of construct validity.

CONCLUSIONS

A robust measurement model and common scoring protocol of NEWS-Y for the IPEN Adolescent project (NEWS-Y-IPEN) were derived. The NEWS-Y-IPEN possesses good factorial and construct validity, and is able to capture between-country variability in perceived neighborhood environments. Future studies employing NEWS-Y-IPEN should use the proposed scoring protocol to facilitate cross-study comparisons and interpretation of findings.

Association of Exposure to Civil Conflict With Maternal Resilience and Maternal and Child Health and Health System Performance in Afghanistan

IMPORTANCE

Current studies examining the effects of Afghanistan's conflict transition on the performance of health systems, health service delivery, and health outcomes are outdated and small in scale and do not span all essential reproductive, maternal, newborn, and child health interventions.

OBJECTIVE

To evaluate associations of conflict severity with improvement of health system performance, use of health services, and child nutrition outcomes in Afghanistan during the 2003 to 2018 reconstruction period.

DESIGN, SETTING, AND PARTICIPANTS

This population-based survey study included a sequential cross-sectional analysis of individual-level panel data across 2 periods (2003-2010 and 2010-2018) and a difference-in-differences design. Surveys included the 2003 to 2004 and 2010 to 2011 Multiple Indicator Cluster Surveys and the 2018 Afghanistan Health Survey. Afghanistan's 2013 National Nutrition Survey was used to assess nutritional outcomes, and the annual Balanced Scorecard data sets were used to evaluate health system performance. Participants included girls and women aged 12 to 49 years and children younger than 5 years who completed nationally representative household surveys. All analyses were conducted from January 1 through April 30, 2019.

EXPOSURES

Provinces were categorized as experiencing minimal-, moderate-, and severe-intensity conflict using battle-related death data from the Uppsala Conflict Data Program.

MAIN OUTCOMES AND MEASURES

Health intervention coverage was examined using 10 standard indicators: contraceptive method (any or modern); antenatal care by a skilled health care professional; facility delivery; skilled birth attendance (SBA); bacille Calmette-Guérin vaccination (BCG); diphtheria, pertussis, and tetanus vaccination (DPT3) or DPT3 plus hepatitis B and poliomyelitis (penta); measles vaccination; care-seeking for acute respiratory infection; oral rehydration therapy for diarrhea; and the Composite Coverage Index. The health system performance was analyzed using the following standard Balanced Scorecard composite domains: client and community, human resources, physical capacity, quality of service provision, management systems, and overall mission. Child stunting, wasting, underweight, and co-occurrence of stunting and wasting were estimated using World Health Organization growth reference cutoffs.

RESULTS

Responses from 64 815 women (mean [SD] age, 31.0 [8.5] years) were analyzed. Provinces with minimal-intensity conflict had greater gains in contraceptive use (mean annual percentage point change [MAPC], 1.3% vs 0.5%; P < .001), SBA (MAPC, 2.7% vs 1.5%; P = .005), BCG vaccination (MAPC, 3.3% vs -0.5%; P = .002), measles vaccination (MAPC, 1.9% vs -1.0%; P = .01), and DPT3/penta vaccination (MAPC, 1.0% vs -2.0%; P < .001) compared with provinces with moderate- to severe-intensity conflict after controlling for confounders. Provinces with severe-intensity conflict fared significantly worse than those with minimal-intensity conflict in functioning infrastructure (MAPC, -1.6% [95% CI, -2.4% to -0.8%]) and the client background and physical assessment index (MAPC, -1.0% [95% CI, -0.8% to 2.7%]) after adjusting for confounders. Child wasting was significantly worse in districts with greater conflict severity (full adjusted β for association between logarithm of battle-related deaths and wasting, 0.33 [95% CI, 0.01-0.66]; P = .04).

CONCLUSIONS AND RELEVANCE

Associations between conflict and maternal and child health in Afghanistan differed by health care intervention and delivery domain, with several key indicators lagging behind in areas with higher-intensity conflict. These findings may be helpful for planning and prioritizing efforts to reach the United Nations' Sustainable Development Goals in Afghanistan.

Effect of armed conflict on vaccination: evidence from the Boko haram insurgency in northeastern Nigeria

Background

Armed conflicts can have severe adverse effects on population health, both directly and indirectly, through the destruction of health care systems. This paper evaluates the causal effect of the Boko Haram insurgency in northeastern Nigeria on the vaccination rate.

Methods

By matching children’s birth months and the months of armed conflict, we evaluate the effect of armed conflict on the vaccination rate of children. We use two datasets: the Nigeria Demographic and Health Survey (DHS) for vaccinations and the Uppsala Conflict Data Program (UCDP) Georeferenced Event Dataset (UCDP GED) for armed-conflict events.

Results

We find a large negative effect of conflict events on the likelihood of vaccination; if an armed conflict occurs within 10 km from where a child resides, the odds that child receives any vaccination are 47.2% lower. Odds ratio for BCG and DPT1 is 0.55 and 0.52 respectively. We also find that armed conflicts have more impact among the non-educated population than among the educated.

Conclusion

Overall, armed conflicts had a devastating effect on the vaccination of young children who were born at the time of these conflicts in northeastern Nigeria. A reduced vaccination rate puts the vulnerable population in affected areas at risk of contracting vaccine-preventable diseases.

Survival Analysis of Cancer Patients in North Eastern Nigeria from 2004 - 2017 - A Kaplan - Meier Method

BACKGROUND:

Cancer is a deadly malignant disease and is prevalent in Sub Saharan Africa. The North East part of Nigeria in particular and the country, in general, are struggling to cope with the increasing burden of cancer and other communicable and non-communicable diseases. The situation is worsened by the ongoing insurgency and terrorist activities in the area.

AIM:

The aim of this paper is to present the research findings from a cohort study aimed at the analysis of the estimation of the survivorship time of the real data of cancer patients in the North-eastern part of Nigeria and to establish if the insurgency in the region has contributed negatively to the life expectancy of its inhabitants.

MATERIAL AND METHODS:

The record of 1,090 patients from medical records departments of the University of Maiduguri Teaching Hospital (UMTH), located in Maiduguri, the capital city of Borno State in northeast Nigeria was obtained. The record showed patients that were diagnosed and died of one type of cancer or the other from 2004 to 2017. All the cancer cases included in the present study were grouped into sex, age, marital status, occupation, date admitted and date of death/discharge. Descriptive statistics and Kaplan-Meier method were used to analyse the data using SPSS version 23 while Microsoft EXCEL and Minitab 16.0 were used for data cleansing and organisation.

RESULTS:

Of the 1,090 patients analysed, 920 (84.40%) experienced the event, i.e. death, while 170 (15.60%) patients were censored. The data were analysed based on the ages and sex of the patients. 50.20% of the patients were of ages 21-50 years. The proportions of patients in this age bracket surviving past 7 days are 75%, while those between ages 80 years and above is 12 days. Others are of survival time of 5 days (ages 0-20 years) and 7 days (51-79 years). Using sex, 75% of the patients’ survival time is 7 days in the case of male and 6 days for females. It is safe to say that the survival time for cancer patients of the university the Maiduguri is 6 days and the result reflects the Northeastern part of Nigeria. This is because the hospital is one of few tertiary healthcare facilities in that area and consequently, cancer cases are often referred there.

CONCLUSION:

Cancer incidence is high, and the probability of survival reduces as the survival time increases. This is a dire situation in need of urgent intervention from the government, groups and individuals to tackle the scourge of cancer, thereby improving on the life expectancy battered by the ongoing Boko Haram insurgency in that region.

High burden of co-morbidity and mortality among severely malnourished children admitted to outpatient therapeutic programme facilities in the conflict setting of Borno, Nigeria: a retrospective review

OBJECTIVE

To present evidence on the burden and outcomes of co-morbidities among severely malnourished (SAM) children admitted to outpatient therapeutic programme (OTP) facilities in the conflict setting of Borno, Nigeria.

DESIGN

Retrospective medical chart review.

SETTING

Facility-based study.ParticipantsChildren aged 6-59 months with SAM enrolled in OTP between June and November 2016 whose medical records were analysed. Only pneumonia and diarrhoea were examined due to data limitations. Stata software was used for descriptive, multivariate and survival analyses.

RESULTS

Records of 396 children with median age of 15 months were identified and analysed from the date of enrolment to exit from OTP. Mean length of stay in OTP was 61d, with co-infected SAM children having shorter stay (P=0·006). Of the total, 148 (37·4 %) had at least one co-morbidity (pneumonia or diarrhoea), of which thirty-nine (26·4 %) had both. Cumulative rate of mortality during follow-up time was 9·5 (95 % CI 6·0, 15·1) per 10 000 child-days; SAM children with co-morbidities were ten times more likely to die than those without (hazard ratio=10·2; 95 % CI 3·4, 31·0). In multivariable analysis, co-morbidity (P=0·01), oedema (P=0·003), dehydration (P=0·02) and weight on admission (P=0·01) were associated with mortality. Both recovery and defaulter rates (57·8 and 36·1 %, respectively) did not meet SPHERE standards.

CONCLUSIONS

Children with SAM and co-morbidities are less likely to survive, presenting a significant barrier in improving child survival. The findings call for integrated OTP models that incorporate clinical algorithms and ensure prompt referral for SAM children with co-morbidity.

On the Epidemiology and Statistical Analysis of HIV/AIDS Patients in the Insurgency Affected States of Nigeria

BACKGROUND:

The effect of insurgencies on a nation regarding the economy, education, health and infrastructure cannot be overemphasised.

AIM:

This research is therefore focused on analysing the incidence of HIV/AIDS disease in states affected by the activities of the Boko Haram insurgency in Nigeria.

MATERIAL AND METHODS:

The data collected refer to the period from 2004 to 2017, reporting information on 16,102 patients and including the age, gender, year of diagnosing and status of the patients. Descriptive, Chi-square test of independence and Correlation analyses were performed using Statistical Package for Social Sciences (SPSS) version 20.

RESULTS:

It was discovered that the majority of those living with HIV/AIDS in these Boko Haram ravaged areas are females between the age group of 30 years to 39 years. Reported cases of HIV/AIDS started increasing significantly from age 20, and the highest number of reported cases of HIV/AIDS was recorded in the year 2017.

CONCLUSION:

The status of the patient was found to be dependent on both the gender and age of the patients’ treatment, though the strength of the linear relationship between status and age is not significantly different from zero.

INJURIES OF BOKO HARAM INSURGENCY IN SOUTH-EAST NIGER REPUBLIC

BACKGROUND

Currently, wounds of wars, terrorism and criminality are increasing and constitute major public health problem worldwide.

AIM

To present the epidemiological, clinical and therapeutic characteristics of the wounds observed during the Boko Haram (BH) insurgency in the South-east of the Republic of Niger.

METHODOLOGY

This was a cross-sectional study from December 2014 to December 2016 at Diffa Regional Hospital, Diffa, Niger of individuals whose injuries were as a result of Boko Haram insurgency.

RESULTS

In the period of this study, 573 injuries from Boko Haram insurgency were managed at the Regional Hospital at Diffa. The majority, 513(89.5%), were males while females constituted 60(10.5%) with a male/female ratio of 8.55. The mean age was 30,94(SD24,91) years (range 1 to 97 years). Civilian victims accounted for 379 (66.1%) while Nigerien soldiers accounted for 160(27.9%) and 34 (5.9%) were Boko Haram fighters. Firearms and explosives accounted for injuries in 489 (85.3%) and 7(1.2%) of patients respectively; 42 (7.3%) suffered injuries from a variety of traditional weapons. Injuries to limbs accounted for 361(63%) of cases and polytrauma in 65(11.34%). The main surgical management included wound debridement in 409 (71.4%), external bone fixation in 38 (6.6%), laparotomy in 30 (5.2%), thoracic drainage in 27 (4.7%), and major limb amputations in 13 (2.3%) cases.Postoperative follow-up was uneventful in 460 (80.28%) of cases; there were 29 deaths, giving a mortality rate of 5.1%. Predictors of death after injuries of Boko Haram terrorism in this study included: being civilian patients (OR = 3.38 [1.15-9.85], p=0.018), injuries to head, neck, trunk or spine (OR 3.45[1.58-7.58], p= 0.001) or the presence of polytrauma on admission (OR = 17.30 [7.72-38.80], p<0.0001).

CONCLUSION

This study has shown that injuries sustained in Boko Haram insurgency in Niger were mainly firearm injuries and injuries from the use of traditional weapons, affecting mostly young civilian males. The part of the body most commonly involved were the extremities, with mainly soft tissue injuries. Wound debridement was the commonest surgical procedure performed and the mortality rate was 5.1%. Predictors of mortality were being civilian patients, injuries of head, neck, trunk or spine and polytrauma. The ICRC has played a major role in strengthening our hospital for the task of caring for the victims, in terms of provision of material resources and in the further training of our personnel.