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Onah MN, Onah RC, Onah FE. Linkages between women's empowerment, religion, marriage type, and uptake of antenatal care visits in 13 West African countries. PLOS Glob Public Health 2023; 3:e0000406. [PMID: 37339104 DOI: 10.1371/journal.pgph.0000406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 04/18/2023] [Indexed: 06/22/2023]
Abstract
Characteristics which reflect a particular context and unique to individuals, households, and societies have been suggested to have an impact on the association between women's empowerment and women's well-being indicators. However, there is limited empirical evidence of this effect. We used access to antenatal care (ANC) to examine the main and interaction effects of women's empowerment, religion, marriage type, and uptake of services in 13 West African countries. Data was extracted from Phase 6 and 7 of the Demographic and Health Survey, and we measured women's empowerment using the survey-based women's empowerment (SWPER) index for women's empowerment in Africa. ANC visits as the outcome variable was analyzed as a count variable and the SWPER domains, religion, and marriage type were the key independent variables. We utilised ordinary least square (OLS) and Poisson regression models where appropriate to examine main and interaction effects and analyses were appropriately weighted and key control variables were applied. Statistical significance was established at 95% confidence interval. Findings suggest that being Muslim or in a polygynous household was consistently associated with disempowerment in social independence, attitude toward violence, and decision-making for women. Although less consistent, improved social independence and decision-making for women were associated with the probability of increased ANC visits. Polygyny and Islamic religion were negatively associated with increased number of ANC visits. Decision-making for Muslim women appear to increase the probability of increased number of ANC visits. Improving the conditions that contribute towards women's disempowerment especially for Muslim women and to a lesser extent for those who reside in polygynous households is key towards better uptake of antenatal care services. Furthermore, targeting of interventions and polices that could empower women towards better access to health services should be tailored on existing contextual factors including religion and marriage type.
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Affiliation(s)
- Michael Nnachebe Onah
- Institute of Public Policy and Administration, Graduate School of Development, University of Central Asia, Bishkek, Kyrgyzstan
| | - Roseline Chinwe Onah
- Department of Public Administration and Local Government, Faculty of Social Sciences, University of Nigeria Nsukka, Nsukka, Enugu State, Nigeria
| | - Felix Ezema Onah
- Department of Economics, Caritas University, Amorji-Nike, Enugu State, Nigeria
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Akseer N, Tasic H, Nnachebe Onah M, Wigle J, Rajakumar R, Sanchez-Hernandez D, Akuoku J, Black RE, Horta BL, Nwuneli N, Shine R, Wazny K, Japra N, Shekar M, Hoddinott J. Economic costs of childhood stunting to the private sector in low- and middle-income countries. EClinicalMedicine 2022; 45:101320. [PMID: 35308896 PMCID: PMC8927824 DOI: 10.1016/j.eclinm.2022.101320] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 02/01/2022] [Accepted: 02/09/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Stunting during childhood has long-term consequences on human capital, including decreased physical growth, and lower educational attainment, cognition, workforce productivity and wages. Previous research has quantified the costs of stunting to national economies however beyond a few single-country datasets there has been a limited number of which have used diverse datasets and have had a dedicated focus on the private sector, which employs nearly 90% of the workforce in many low- and middle-income countries (LMICs). We aimed to examine (i) the impact of childhood stunting on income loss of private sector workforce in LMICs; (ii) to quantify losses in sales to private firms in LMICs due to childhood stunting; and (iii) to estimate potential gains (benefit-cost ratios) if stunting levels are reduced in select high prevalence countries. METHODS This multiple-methods study engaged multi-disciplinary technical advisers, executed several literature reviews, used innovative statistical methods, and implemented health and labor economic models. We analyzed data from seven longitudinal datasets (up to 30+ years of follow-up; 1982-2016; Peru, Ethiopia, India, Vietnam, Philippines, Tanzania, Brazil), 108 private firm datasets (spanning 2008-2020), and many global datasets including Joint Malnutrition Estimates, and World Development Indicators to produce estimates for 120+ LMICs (with estimates up to 2021). We studied the impact of childhood stunting on adult cognition, education, and height as pathways to wages/productivity in adulthood. We employed cloud-based artificial intelligence (AI) platforms, and conducted comparative analyses using three analytic approaches: traditional frequentist statistics, Bayesian inferential statistics and machine learning. We employed labour and health economic models to estimate wage losses to the private sector worker and firm revenue losses due to stunting. We also estimated benefit-cost ratios for countries investing in nutrition-specific interventions to prevent stunting. FINDINGS Across 95 LMICs, childhood stunting costs the private sector at least US$135.4 billion in sales annually. Firms from countries in Latin America and the Caribbean and East Asia and Pacific regions had the greatest losses. Totals sales losses to the private sector accumulated to 0.01% to 1.2% of national GDP across countries. Sectors most affected by childhood stunting were manufacturing (non-metallic mineral, fabricated metal, other), garments and food sectors. Sale losses were highest for larger sized private firms. Across regions (representing 123 LMICs), US$700 million (Middle East and North Africa) to US$16.5 billion (East Asia and Pacific) monthly income was lost among private sector workers. Investing in stunting reduction interventions yields gains from US$2 to US$81 per $1 invested annually (or 100% to 8000% across countries). Across sectors, the highest returns were in elementary occupations (US$46) and the lowest were among agricultural workers (US$8). By gender, women incurred a higher income penalty from childhood stunting and earned less than men; due to their relatively higher earnings, the returns for investing in stunting reduction were consistently higher for men across most countries studied. INTERPRETATION Childhood stunting costs the private sector in LMICs billions of dollars in sales and earnings for the workforce annually. Returns to nutrition interventions show that there is an economic case to be made for investing in childhood nutrition, alongside a moral one for both the public and private sector. This research could be used to motivate strong public-private sector partnerships to invest in childhood undernutrition for benefits in the short and long-term.
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Affiliation(s)
- Nadia Akseer
- Johns Hopkins Bloomberg School of Public Health, USA
- Modern Scientist Global, Canada
- Corresponding author at: Johns Hopkins Bloomberg School of Public Health, USA.
| | | | | | | | | | | | | | | | | | - Ndidi Nwuneli
- Sahel Consulting Agriculture and Nutrition Ltd., Nigeria
| | - Ritta Shine
- Global Alliance for Improved Nutrition, Switzerland
| | - Kerri Wazny
- Johns Hopkins Bloomberg School of Public Health, USA
- The Power of Nutrition, UK
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Onah MN, Horton S, Hoddinott J. What empowerment indicators are important for food consumption for women? Evidence from 5 sub-Sahara African countries. PLoS One 2021; 16:e0250014. [PMID: 33882089 PMCID: PMC8059862 DOI: 10.1371/journal.pone.0250014] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 03/29/2021] [Indexed: 01/13/2023] Open
Abstract
This paper draws on data from five sub-Sahara African countries; Uganda, Rwanda, Malawi, Zambia, and Mozambique consisting of 10,041 married women who were cohabitating with a male spouse. The study aim was to investigate the relationship between women's empowerment and women's dietary diversity and consumption of different food items. Women's empowerment was measured using the indicators in the five domains of Women's Empowerment in Agriculture index (WEAI) and women's dietary diversity and food consumption was examined using the women's dietary diversity score (WDDS) measure. OLS and LPM regressions were used and analyses were confirmed using marginal effects from Poisson and logistic regressions. Results suggest that three out of the 10 WEAI indicators of empowerment showed different magnitude and direction in significant associations with improved WDDS and varied associations were found in three out of the five countries examined. In addition, the three significant empowerment indicators were associated with the consumption of different food groups in three out of the five countries examined suggesting that diverse food groups account for the association between the WEAI and WDDS. Improved autonomy, and input in production were associated with improved likelihoods of consumption of dairy products, and fruits and vegetables including vitamin A-rich produce. Empowerment in public speaking was associated with improved consumption of other fruits and vegetables including vitamin A-rich produce. The varied nature of empowerment indicators towards improving women's dietary diversity and food consumption suggests that different empowerment strategies might confer different benefits towards the consumption of different food groups. Further, findings imply that interventions that seek to empower women should tailor their strategies on existing contextual factors that impact on women.
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Affiliation(s)
- Michael Nnachebe Onah
- School of Public Health and Health Systems, Faculty of Applied Health Sciences, University of Waterloo, Ontario, Canada
- Institute of Public Policy and Administration, Graduate School of Development, University of Central Asia, Bishkek, Kyrgyzstan
| | - Sue Horton
- School of Public Health and Health Systems, Faculty of Applied Health Sciences, University of Waterloo, Ontario, Canada
| | - John Hoddinott
- Division of Nutritional Sciences, Cornell Institute of Public Affairs, Cornell University, Ithaca, New York, United States of America
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Onah MN. Women's empowerment and child nutrition in South-Central Asia; how important is socioeconomic status? SSM Popul Health 2021; 13:100718. [PMID: 33426264 PMCID: PMC7779324 DOI: 10.1016/j.ssmph.2020.100718] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/06/2020] [Accepted: 12/09/2020] [Indexed: 12/19/2022] Open
Abstract
Women's empowerment has been identified as an important strategy for improving children's nutrition outcomes in many settings. Empowerment indexes that are built from cross-country routine surveys are increasingly being developed, and further disaggregated analyses of such indexes are needed to examine in-depth, the relationship between women's empowerment and outcomes including children's nutrition. The Demographic and Health Surveys across five countries in South-Central Asia was used to examine the relationship between women's empowerment and children's nutrition outcomes. Empowerment was measured using the three domains (attitude to violence, social independence, and decision-making) in the Survey-based Women's emPowERment (SWPER) index. Main and interaction effects between the SWPER domains and women's wealth index were examined to check if there is a differential positive impact of empowerment for poorer women on children's nutrition outcomes. Outcome measures were children's height-for-age, weight-for-age, and weight-for-height z-scores. Marginal effects of logistic regression and OLS were used to examine main effects and linear probability models and OLS for interaction effects. Analyses were cluster-adjusted, sample-weighted, and important control variables were included. Significance was established at 95% and 99% confidence intervals. In South-Central Asia, to reduce stunting wasting and underweight rates, empowering women through improving their social independence and decision-making power might be important. Furthermore, targeting poorer women for empowerment in social independence and decision-making appears to confer positive benefits towards the reduction of stunting, wasting, and underweight rates in children. However, the main and interaction effects of women's empowerment and wealth index on children's nutrition outcomes vary across the countries examined. These variations suggests that exogenous contextual factors might play a role in the empowerment-nutrition and empowerment-wealth-nutrition associations and interactions.
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Affiliation(s)
- Michael Nnachebe Onah
- Institute of Public Policy and Administration, Graduate School of Development, University of Central Asia, Bishkek, Kyrgyzstan
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Iamshchikova M, Mogilevskii R, Onah MN. Trends in out of pocket payments and catastrophic health expenditure in the Kyrgyz Republic post "Manas Taalimi" and "Den Sooluk" health reforms, 2012-2018. Int J Equity Health 2021; 20:30. [PMID: 33430869 PMCID: PMC7798228 DOI: 10.1186/s12939-020-01358-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Over the years, the Kyrgyz Republic has implemented health reforms that target health financing with the aim of removing financial barriers to healthcare including out-of-pocket health payments (OOPPs). This study examines the trends in OOPPs, and the incidence of catastrophic health expenditure (CHE) post the "Manas Taalimi" and "Den Sooluk" health reforms. METHODS We used data from the Kyrgyzstan Integrated Household Surveys (2012-2018). Population-weighted descriptive statistics were used to examine the trends in OOPPs and CHE at three thresholds; 10 percent of total household consumption expenditure (Cata10), 25 percent of total household consumption expenditure (Cata25) and 40 percent of total household non-food consumption expenditure (Cata40). Panel and cross-sectional logistic regression with marginal effects were used to examine the predictors of Cata10 and Cata40. FINDINGS Between 2012 and 2018, OOPPs increased by about US $6 and inpatient costs placed the highest cost burden on users (US $13.6), followed by self-treatment (US $10.7), and outpatient costs (US $9). Medication continues to predominantly drive inpatient, outpatient, and self-treatment OOPPs. About 0.378 to 2.084 million people (6 - 33 percent) of the population incurred catastrophic health expenditure at the three thresholds between 2012 and 2018. Residing in households headed by a widowed or single head, or residing in rural regions, increases the likelihood of incurring catastrophic health expenditure. CONCLUSIONS The initial gains in the reduction of OOPPs and catastrophic health expenditure appear to gradually erode since costs continue to increase after an initial decline and catastrophic health expenditure continues to rise unabated. This implies that households are increasingly incurring economic hardship from seeking healthcare. Considering that this could result to forgone expenditure on essential items including food and education, efforts should target the sustainability of these health reforms to maintain and grow the reduction of catastrophic health payments and its dire consequences.
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Affiliation(s)
- Mariia Iamshchikova
- Institute of Public Policy and Administration, Graduate School of Development, University of Central Asia, Bishkek, Kyrgyzstan
| | - Roman Mogilevskii
- Institute of Public Policy and Administration, Graduate School of Development, University of Central Asia, Bishkek, Kyrgyzstan
| | - Michael Nnachebe Onah
- Institute of Public Policy and Administration, Graduate School of Development, University of Central Asia, Bishkek, Kyrgyzstan.
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Onah MN, Horton S. Male-female differences in households' resource allocation and decision to seek healthcare in south-eastern Nigeria: Results from a mixed methods study. Soc Sci Med 2018; 204:84-91. [PMID: 29602090 DOI: 10.1016/j.socscimed.2018.03.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 03/16/2018] [Accepted: 03/22/2018] [Indexed: 10/17/2022]
Abstract
Ability to influence household decision-making has been shown to increase with improved social capital and power and is linked to better access to household financial resources and other services outside the household including healthcare. To examine the male-female differences in household custody of financial resources, decision-making, and type of healthcare utilised, we used a mixed methods approach of cross-sectional household surveys and focus-group discussions (FGDs). Data was collected between 10 January-28 February 2011. We analyzed a sample of 411 households and a sub-sample of 223 households with a currently married head. We conducted six single-sex FGDs in 3 communities (1 urban, 2 rural) among a random sub-sample of participants in the survey. We performed univariate, bivariate, and logistic regression analyses with a 95% confidence interval. For the qualitative data, we performed thematic analysis where broad themes relevant to the research objective were abstracted. In all households and in those with a married head, sick male members were less likely to forgo healthcare (aORall0.87, 95% CI 0.80-0.90; aORmarried0.52, 95% CI 0.18-0.83) and more likely to utilise formal healthcare relative to female sick members (aORall3.36, 95% CI 3.20-3.87; aORmarried19.50, 95% CI 9.62-39.52). Formal healthcare providers are medically trained while informal providers are untrained vendors that dispense medications for profit. There were more reports of sole custody of household resources among men within households with married heads. Joint decision-making on healthcare expenditure improved women's access to healthcare but is not reflective of unhindered access to household financial resources. Qualitatively, women spoke of seeking permission from male household head before expenditure was incurred, while male heads spoke of concealing household financial resources from their spouse. Gender constructs and male-female differences have important effects on household resource allocation and healthcare utilisation.
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Affiliation(s)
- Michael Nnachebe Onah
- School of Public Health and Health Systems, Faculty of Applied Health Sciences, University of Waterloo, Canada.
| | - Susan Horton
- School of Public Health and Health Systems, Faculty of Applied Health Sciences, University of Waterloo, Canada
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Abstract
Pregnant women are at increased risk for suicidal ideation and behaviours (SIB) compared to the general population. To date, studies have focused on the psychiatric correlates of SIB with lesser attention given to the associated contextual risk factors, particularly in low- and middle-income countries. We investigated the prevalence and associated psychiatric and socio-economic contextual factors for SIB among pregnant women living in low resource communities in South Africa. Three hundred seventy-six pregnant women were evaluated using a range of tools to collect data on socio-economic and demographic factors, social support, life events, interpersonal violence and mental health diagnoses. We examined the significant risk factors for SIB using univariate, bivariate and logistic regression analyses (p ≤ 0.05). The 1-month prevalence of SIB was 18%. SIB was associated with psychiatric illness, notably major depressive episode (MDE) and any anxiety disorder. However, 67% of pregnant women with SIB had no MDE diagnosis, and 65% had no anxiety disorder, while 54% had neither MDE nor anxiety disorder diagnoses. Factors associated with SIB included lower socio-economic status, food insecurity, interpersonal violence, multiparousity, and lifetime suicide attempt. These findings focus attention on the importance of socio-economic and contextual factors in the aetiology of SIB and lend support to the idea that suicide risk should be assessed independently of depression and anxiety among pregnant women.
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Affiliation(s)
- Michael Nnachebe Onah
- Perinatal Mental Health Project, Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Building B, Rondebosch, Cape Town, 7700 South Africa
| | - Sally Field
- Perinatal Mental Health Project, Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Building B, Rondebosch, Cape Town, 7700 South Africa
| | - Jason Bantjes
- Department of Psychology, University of Stellenbosch, Stellenbosch, South Africa
| | - Simone Honikman
- Perinatal Mental Health Project, Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Building B, Rondebosch, Cape Town, 7700 South Africa
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Onah MN, Field S, van Heyningen T, Honikman S. Predictors of alcohol and other drug use among pregnant women in a peri-urban South African setting. Int J Ment Health Syst 2016; 10:38. [PMID: 27148402 PMCID: PMC4855353 DOI: 10.1186/s13033-016-0070-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 04/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Alcohol and other drugs (AOD) use among pregnant women have been associated with adverse health outcomes for mother and child, during and after pregnancy. Factors associated with AOD use among women include age, poverty, unemployment, and interpersonal conflict. Few studies have looked at demographic, economic, and psychosocial factors as predictors of AOD use among pregnant women in low-income, peri-urban settings. The study aimed to determine the association between these risk factors and alcohol and drug use among pregnant women in Hanover Park, Cape Town. METHODS The study was undertaken at a Midwife Obstetric Unit providing primary-level maternity services in a resource-scarce area of South Africa. 376 adult women attending the unit were recruited and a multi-tool questionnaire administered. Demographic, socioeconomic and life events data were collected. The Expanded Mini-International Neuropsychiatric Interview Version 5.0.0 was used to assess alcohol abuse and other drugs use, depression, anxiety, and suicidal ideation. Descriptive and bivariate analyses were conducted to examine the associations between predictor variables. Non-parametric tests, Wilcoxon sum of rank test, Fisher Exact and two sample T test and multicollinearity tests were performed. Logistic regression was conducted to identify associations between the outcome of interest and key predictors. A probability value of p ≤ 0.05 was selected. RESULTS Of the total number of pregnant women sampled, 18 % reported current AOD use. Of these, 18 % were currently experiencing a major depressive episode, 19 % had a current anxiety diagnosis, and 22 % expressed suicidal ideation. Depression, anxiety, suicidality, food insecurity, interpersonal violence, relationship dynamics, and past mental health problems were predictors of AOD use. CONCLUSIONS This study has confirmed the vulnerability of pregnant women in low-income, peri-urban settings to alcohol abuse and other drugs use. Further, the association between diagnosed depression and anxiety, suicidality, and AOD use among these women may reflect how complex environmental factors support the coexistence of multiple mental health problems. These problems place mothers and their infants at high risk for poor health and development outcomes. The results have implications for planning appropriate interventions.
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Affiliation(s)
- Michael Nnachebe Onah
- Perinatal Mental Health Project, Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Sally Field
- Perinatal Mental Health Project, Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Thandi van Heyningen
- Perinatal Mental Health Project, Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Simone Honikman
- Perinatal Mental Health Project, Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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