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Jacobs C, Musukuma M, Hamoonga R, Sikapande B, Chooye O, Wehrmeister FC, Michelo C, Blanchard AK. Trends and Inequalities in Maternal and Newborn Health Services for Unplanned Settlements of Lusaka City, Zambia. J Urban Health 2024:10.1007/s11524-024-00837-z. [PMID: 38459401 DOI: 10.1007/s11524-024-00837-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 03/10/2024]
Abstract
Living conditions and other factors in urban unplanned settlements present unique challenges for improving maternal and newborn health (MNH), yet MNH inequalities associated with such challenges are not well understood. This study examined trends and inequalities in coverage of MNH services in the last 20 years in unplanned and planned settlements of Lusaka City, Zambia. Geospatial information was used to map Lusaka's settlements and health facilities. Zambia Demographic Health Surveys (ZDHS 2001, 2007, 2013/2014, and 2018) were used to compare antenatal care (ANC), institutional delivery, and Cesarean section (C-section) coverage, and neonatal mortality rates between the poorer 60% and richer 40% households. Health Management Information System (HMIS) data from 2018 to 2021 were used to compute service volumes and coverage rates for ANC1 and ANC4, and institutional delivery and C-sections by facility level and type in planned and unplanned settlements. Although the correlation is not exact, our data analysis showed close alignment; and thus, we opted to use the 60% poorer and 40% richer groups as a proxy for households in unplanned versus planned settlements. Unplanned settlements were serviced by primary centers or first-level hospitals. ZDHS findings show that by 2018, at least one ANC visit and institutional delivery became nearly universal throughout Lusaka, but early and four or more ANC visits, C-sections, and neonatal mortality rates remained worse among poorer than richer women in ZDHS. In HMIS, ANC and institutional delivery volumes were highest in public facilities, especially in unplanned settlements. The volume of C-sections was much greater within facilities in planned than unplanned settlements. Our study exposed persistent gaps in timing and use of ANC and emergency obstetric care between unplanned and planned communities. Closing such gaps requires strengthening outreach early and consistently in pregnancy and increasing emergency obstetric care capacities and referrals to improve access to important MNH services for women and newborns in Lusaka's unplanned settlements.
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Affiliation(s)
- Choolwe Jacobs
- Department of Epidemiology and Biostatistics, School of Public Health, University of Zambia, Lusaka, Zambia.
| | - Mwiche Musukuma
- Department of Epidemiology and Biostatistics, School of Public Health, University of Zambia, Lusaka, Zambia
| | | | | | | | - Fernando C Wehrmeister
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | | | - Andrea K Blanchard
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
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Blanchard AK, Jacobs C, Musukuma M, Chooye O, Sikapande B, Michelo C, Boerma T, Wehrmeister FC. Going deeper with health equity measurement: how much more can surveys reveal about inequalities in health intervention coverage and mortality in Zambia? Int J Equity Health 2023; 22:109. [PMID: 37268969 DOI: 10.1186/s12939-023-01901-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/26/2022] [Accepted: 04/27/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Although Zambia has achieved notable improvements in reproductive, maternal, newborn and child health (RMNCH), continued efforts to address gaps are essential to reach the Sustainable Development Goals by 2030. Research to better uncover who is being most left behind with poor health outcomes is crucial. This study aimed to understand how much more demographic health surveys can reveal about Zambia's progress in reducing inequalities in under-five mortality rates and RMNCH intervention coverage. METHODS Using four nationally-representative Zambia Demographic Health Surveys (2001/2, 2007, 2013/14, 2018), we estimated under-five mortality rates (U5MR) and RMNCH composite coverage indices (CCI) comparing wealth quintiles, urban-rural residence and provinces. We further used multi-tier measures including wealth deciles and double disaggregation between wealth and region (urban residence, then provinces). These were summarised using slope indices of inequality, weighted mean differences from overall mean, Theil and concentration indices. RESULTS Inequalities in RMNCH coverage and under-five mortality narrowed between wealth groups, residence and provinces over time, but in different ways. Comparing measures of inequalities over time, disaggregation with multiple socio-economic and geographic stratifiers was often valuable and provided additional insights compared to conventional measures. Wealth quintiles were sufficient in revealing mortality inequalities compared to deciles, but comparing CCI by deciles provided more nuance by showing that the poorest 10% were left behind by 2018. Examining wealth in only urban areas helped reveal closing gaps in under-five mortality and CCI between the poorest and richest quintiles. Though challenged by lower precision, wealth gaps appeared to close in every province for both mortality and CCI. Still, inequalities remained higher in provinces with worse outcomes. CONCLUSIONS Multi-tier equity measures provided similarly plausible and precise estimates as conventional measures for most comparisons, except mortality among some wealth deciles, and wealth tertiles by province. This suggests that related research could readily use these multi-tier measures to gain deeper insights on inequality patterns for both health coverage and impact indicators, given sufficient samples. Future household survey analyses using fit-for-purpose equity measures are needed to uncover intersecting inequalities and target efforts towards effective coverage that will leave no woman or child behind in Zambia and beyond.
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Affiliation(s)
- Andrea K Blanchard
- Institute for Global Public Health, University of Manitoba, R070-771 McDermot Ave, Winnipeg, R3E 0T6, Canada.
| | - Choolwe Jacobs
- School of Public Health, University of Zambia, Lusaka, Zambia
| | - Mwiche Musukuma
- School of Public Health, University of Zambia, Lusaka, Zambia
| | - Ovost Chooye
- Monitoring and Evaluation Division, Ministry of Health, Lusaka, Zambia
| | - Brivine Sikapande
- Monitoring and Evaluation Division, Ministry of Health, Lusaka, Zambia
| | - Charles Michelo
- School of Public Health, University of Zambia, Lusaka, Zambia
| | - Ties Boerma
- Institute for Global Public Health, University of Manitoba, R070-771 McDermot Ave, Winnipeg, R3E 0T6, Canada
| | - Fernando C Wehrmeister
- Institute for Global Public Health, University of Manitoba, R070-771 McDermot Ave, Winnipeg, R3E 0T6, Canada
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
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Jacobs C, Musukuma M, Sikapande B, Chooye O, Wehrmeister FC, Boerma T, Michelo C, Blanchard AK. How Zambia reduced inequalities in under-five mortality rates over the last two decades: a mixed-methods study. BMC Health Serv Res 2023; 23:170. [PMID: 36805693 PMCID: PMC9940360 DOI: 10.1186/s12913-023-09086-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 01/19/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Zambia experienced a major decline in under-five mortality rates (U5MR), with one of the fastest declines in socio-economic disparities in sub-Saharan Africa in the last two decades. We aimed to understand the extent to which, and how, Zambia has reduced socio-economic inequalities in U5MR since 2000. METHODS Using nationally-representative data from Zambia Demographic Health Surveys (2001/2, 2007, 2013/14 and 2018), we examined trends and levels of inequalities in under-five mortality, intervention coverage, household water and sanitation, and fertility. This analysis was integrated with an in-depth review of key policy and program documents relevant to improving child survival in Zambia between 1990 and 2020. RESULTS The under-five mortality rate (U5MR) declined from 168 to 64 deaths per 1000 live births between 2001/2 and 2018 ZDHS rounds, particularly in the post-neonatal period. There were major reductions in U5MR inequalities between wealth, education and urban-rural residence groups. Yet reduced gaps between wealth groups in estimated absolute income or education levels did not simultaneously occur. Inequalities reduced markedly for coverage of reproductive, maternal, newborn and child health (RMNCH), malaria and human immunodeficiency virus interventions, but less so for water or sanitation and fertility levels. Several policy and health systems drivers were identified for reducing RMNCH inequalities: policy commitment to equity in RMNCH; financing with a focus on disadvantaged groups; multisectoral partnerships and horizontal programming; expansion of infrastructure and human resources for health; and involvement of community stakeholders and service providers. CONCLUSION Zambia's major progress in reducing inequalities in child survival between the poorest and richest people appeared to be notably driven by government policies and programs that centrally valued equity, despite ongoing gaps in absolute income and education levels. Future work should focus on sustaining these gains, while targeting families that have been left behind to achieve the sustainable development goal targets.
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Affiliation(s)
- Choolwe Jacobs
- School of Public Health, University of Zambia, Box 50110, Lusaka, Zambia.
| | - Mwiche Musukuma
- School of Public Health, University of Zambia, Box 50110, Lusaka, Zambia
| | | | | | | | | | - Charles Michelo
- School of Public Health, University of Zambia, Box 50110, Lusaka, Zambia
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Amouzou A, Maïga A, Faye CM, Chakwera S, Melesse DY, Mutua MK, Thiam S, Abdoulaye IB, Afagbedzi SK, Ag Iknane A, Ake-Tano OS, Akinyemi JO, Alegana V, Alhassan Y, Sam AE, Atweam DK, Bajaria S, Bawo L, Berthé M, Blanchard AK, Bouhari HA, Boulhassane OMA, Bulawayo M, Chooye O, Coulibaly A, Diabate M, Diawara F, Esleman O, Gajaa M, Garba KHA, Getachew T, Jacobs C, Jacobs GP, James F, Jegede AS, Joachim C, Kananura RM, Karimi J, Kiarie H, Kpebo D, Lankoandé B, Lawanson AO, Mahamadou Y, Mahundi M, Manaye T, Masanja H, Millogo MR, Mohamed AK, Musukuma M, Muthee R, Nabié D, Nyamhagata M, Ogwal J, Orimadegun A, Ovuoraye A, Pongathie AS, Sable SP, Saydee GS, Shabini J, Sikapande BM, Simba D, Tadele A, Tadlle T, Tarway-Twalla AK, Tassembedo M, Tehoungue BZ, Terera I, Traoré S, Twalla MP, Waiswa P, Wondirad N, Boerma T. Health service utilisation during the COVID-19 pandemic in sub-Saharan Africa in 2020: a multicountry empirical assessment with a focus on maternal, newborn and child health services. BMJ Glob Health 2022; 7:bmjgh-2021-008069. [PMID: 35501068 PMCID: PMC9062456 DOI: 10.1136/bmjgh-2021-008069] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/04/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION There are concerns about the impact of the COVID-19 pandemic on the continuation of essential health services in sub-Saharan Africa. Through the Countdown to 2030 for Women's, Children's and Adolescents' Health country collaborations, analysts from country and global public health institutions and ministries of health assessed the trends in selected services for maternal, newborn and child health, general service utilisation. METHODS Monthly routine health facility data by district for the period 2017-2020 were compiled by 12 country teams and adjusted after extensive quality assessments. Mixed effects linear regressions were used to estimate the size of any change in service utilisation for each month from March to December 2020 and for the whole COVID-19 period in 2020. RESULTS The completeness of reporting of health facilities was high in 2020 (median of 12 countries, 96% national and 91% of districts ≥90%), higher than in the preceding years and extreme outliers were few. The country median reduction in utilisation of nine health services for the whole period March-December 2020 was 3.9% (range: -8.2 to 2.4). The greatest reductions were observed for inpatient admissions (median=-17.0%) and outpatient admissions (median=-7.1%), while antenatal, delivery care and immunisation services generally had smaller reductions (median from -2% to -6%). Eastern African countries had greater reductions than those in West Africa, and rural districts were slightly more affected than urban districts. The greatest drop in services was observed for March-June 2020 for general services, when the response was strongest as measured by a stringency index. CONCLUSION The district health facility reports provide a solid basis for trend assessment after extensive data quality assessment and adjustment. Even the modest negative impact on service utilisation observed in most countries will require major efforts, supported by the international partners, to maintain progress towards the SDG health targets by 2030.
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Affiliation(s)
- Agbessi Amouzou
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Abdoulaye Maïga
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Cheikh Mbacké Faye
- African Population Health Research Centre, Dakar, Senegal.,School of Public Health, University of Witwatersrand, Johannesburg, Gauteng, South Africa
| | | | - Dessalegn Y Melesse
- Community Health Science, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Sokhna Thiam
- African Population Health Research Centre, Dakar, Senegal
| | | | | | | | | | | | - Victor Alegana
- School of Geography and Environmental Sciences, University of Southampton, Southampton, UK.,Kenya Medical Research Institute, Nairobi, Kenya
| | - Yakubu Alhassan
- University of Ghana School of Public Health, Accra, Greater Accra, Ghana
| | | | | | - Shraddha Bajaria
- Ifakara Health Institute, Ifakara, Morogoro, Tanzania, United Republic of
| | - Luke Bawo
- Ministry of Health, Monrovia, Montserrado, Liberia
| | | | | | | | | | - Maio Bulawayo
- Department of Health Policy and Management, University of Zambia, Lusaka, Zambia
| | | | - Amed Coulibaly
- Institut National de Santé Publique, Abidjan, Côte d'Ivoire
| | - Mamatou Diabate
- Ministère de la Santé et de l'Hygiène Publique du Mali, Bamako, Mali
| | | | | | - Mulugeta Gajaa
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Oromia, Ethiopia
| | | | - Theodros Getachew
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Oromia, Ethiopia.,College of Medicine and Health Science, Institute of Public Health, University of Gondar College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Choolwe Jacobs
- Epidemiology and Biostatistics, University of Zambia, Lusaka, Zambia
| | | | | | | | | | | | | | | | - Denise Kpebo
- Institut National de Santé Publique, Abidjan, Côte d'Ivoire
| | - Bruno Lankoandé
- Institut Superieur des Sciences de la Population, Ouagadougou, Centre, Burkina Faso
| | | | | | - Masoud Mahundi
- University of Dar es Salaam, Dar es Salaam, Tanzania, United Republic of
| | | | - Honorati Masanja
- Ifakara Health Institute, Ifakara, Morogoro, Tanzania, United Republic of
| | | | | | - Mwiche Musukuma
- University of Zambia School of Public Health, Lusaka, Zambia
| | | | - Douba Nabié
- Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso
| | | | | | - Adebola Orimadegun
- Institute of Child Health, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
| | | | | | | | | | - Josephine Shabini
- Bagamoyo Research and Training Centre, Ifakara Health Institute, Bagamayo, Tanzania, United Republic of
| | | | - Daudi Simba
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Ashenif Tadele
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Oromia, Ethiopia
| | - Tefera Tadlle
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Oromia, Ethiopia
| | | | | | | | | | | | - Musu P Twalla
- University of Liberia, Monrovia, Montserrado, Liberia
| | - Peter Waiswa
- School of Public Health, Makerere University, Kampala, Uganda
| | - Naod Wondirad
- Federal Ministry of Health, Addis Ababa, Ethiopia.,Clinical Services Directorate, Ethiopia Ministry of Health, Addis Ababa, Lideta, Ethiopia
| | - Ties Boerma
- Community Health Science, University of Manitoba, Winnipeg, Manitoba, Canada
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Fisa R, Musukuma M, Sampa M, Musonda P, Young T. Effects of interventions for preventing road traffic crashes: an overview of systematic reviews. BMC Public Health 2022; 22:513. [PMID: 35296294 PMCID: PMC8925136 DOI: 10.1186/s12889-021-12253-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [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: 12/10/2020] [Accepted: 11/17/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Road traffic crashes (RTCs) are among the eight-leading causes of death globally. Strategies and policies have been put in place by many countries to reduce RTCs and to prevent RTCs and related injuries/deaths. METHODS In this review, we searched the following databases Ovid Medline, Embase, Cochrane Database of Systematic Reviews, Epistemonikos, Web of Science, and LILACS for reviews matching our inclusion criteria between periods January 1950 and March 2020. We did not apply language or publication restrictions in the searches. We, however, excluded reviews that focused primarily on injury prevention and reviews that looked at crashes not involving a motor vehicle. RESULTS We identified 35 systematic reviews matching our inclusion criteria and most of the reviews (33/35) included studies strictly from high-income countries. Most reviews were published before 2015, with only 5 published between 2015 and 2020. Methodological quality varied between reviews. Most reviews focused on enforcement intervention. There was strong evidence that random breath testing, selective breath testing, and sobriety checkpoints were effective in reducing alcohol-related crashes and associated fatal and nonfatal injuries. Other reviews found that sobriety checkpoints reduced the number of crashes by 17% [CI: (- 20, - 14)]. Road safety campaigns were found to reduce the numbers of RTCs by 9% [CI: (- 11, - 8%)]. Mass media campaigns indicated some median decrease in crashes across all studies and all levels of crash severity was 10% (IQR: 6 to 14%). Converting intersections to roundabouts was associated with a reduction of 30 to 50% in the number of RTCs resulting in injury and property damage. Electronic stability control measure was found to reduce single-vehicle crashes by - 49% [95% CI: (- 55, - 42%)]. No evidence was found to indicate that post-license driver education is effective in preventing road traffic injuries or crashes. CONCLUSION There were many systematic reviews of varying quality available which included studies that were conducted in high-income settings. The overview has found that behavioural based interventions are very effective in reducing RTCs.
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Affiliation(s)
- Ronald Fisa
- Department of Epidemiology and Biostatistics, The University of Zambia, School of Public Health, Ridgeway Campus, Nationalist Road, Lusaka, Zambia.
| | - Mwiche Musukuma
- Department of Epidemiology and Biostatistics, The University of Zambia, School of Public Health, Ridgeway Campus, Nationalist Road, Lusaka, Zambia
| | - Mutale Sampa
- Department of Epidemiology and Biostatistics, The University of Zambia, School of Public Health, Ridgeway Campus, Nationalist Road, Lusaka, Zambia
| | - Patrick Musonda
- Department of Epidemiology and Biostatistics, The University of Zambia, School of Public Health, Ridgeway Campus, Nationalist Road, Lusaka, Zambia.,Centre for Intervention Science in Maternal and Child health (CISMAC), Centre for International Health (CIH), University of Bergen, Bergen, Norway
| | - Taryn Young
- Centre for Evidence-based Health Care (CEBHC), Department of Global Health, Stellenbosch University, Cape Town, South Africa
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