School of Public Health (Journal Articles)

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    Death of preceding child and maternal healthcare services utilisation in Nigeria: investigation using lagged logit models
    (BioMed Central, 2018-11) Akinyemi, Joshua O.; Bolajoko, Izzatullah; Gbadebo, Babatunde M.
    Background: One of the factors responsible for high level of childhood mortality in Nigeria is poor utilization of maternal healthcare (MHC) services. Another important perspective which has been rarely explored is the influence of childhood death on MHC service utilization. In this study, we examined the relationship between death of preceding child and MHC services utilization [antenatal care (ANC), skilled attendant at birth (SAB), and postnatal care (PNC)] among Nigerian women and across the six geo-political zones of the country. Methodology: We analyzed reproductive history dataset for 16,747 index births extracted from the 2013 Nigeria Demographic and Health Survey. The main explanatory variable was survival status of preceding child; therefore, only second or higher order births were considered. Analysis involved the use of descriptive statistics and lagged logit models fitted for each measure of MHC utilization. Association and statistical significance were expressed as adjusted odds ratio (AOR) with 95% confidence interval. Results: The use of MCH services for most recent births in the 2013 Nigeria DHS were ANC (56.0%), SAB (34.7%), and PNC (27.3%). Univariate models revealed that the death of preceding child was associated with lesser likelihood of ANC (OR = 0.64, CI 0.57–0.71), SAB (OR = 0.56, CI 0.50–0.63), and PNC (OR = 0.65, CI 0.55–0.69). Following adjustment for maternal socio-economic and bio-demographic variables, statistical significance in the relationship disappeared for the three MHC indicators: ANC (AOR = 1.00, CI 0.88–1.14), SAB (AOR = 0.97, CI 0.81–1.15), and PNC (AOR = 0.95, CI 0.83–1.11). There were no significant variations across the six geo-political regions in Nigeria. The likelihood of ANC utilization was higher when the preceding child died in Northcentral (AOR = 1.19, CI 0.84–1.70), Northeast (AOR = 1.26, CI 0.99–1.59), and South-south (AOR = 1.19, CI 0.72–1.99) regions while the reverse is the case in Southeast (AOR = 0.39, CI 0.23–0.60). For the Southeast, similar result was obtained for ANC, SAB, and PNC. Conclusion: Death of a preceding child does not predict MHC services use in Nigeria especially when maternal socio-economic characteristics are controlled. Variations across the Northern and Southern regions did not attain statistical significance. Interventions are needed to reverse the pattern such that greater MHC utilization is recorded among women who have experienced child death.
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    Use of contraceptives, high risk births and under-five mortality in Sub Saharan Africa: evidence from Kenyan (2014) and Zimbabwean (2011) demographic health surveys
    (BioMed Central, 2018-10) Chikandiwa, Admire; Burgess, Emma; Otwombe, Kennedy; Chimoyi, Lucy
    Background: Increasing uptake of modern contraception is done to alleviate maternal and infant mortality in poor countries. We describe prevalence of contraceptive use, high risk births, under-five mortality and their risk factors in Kenya and Zimbabwe. Methods: This was a cross-sectional analysis on DHS data from Kenya (2014) and Zimbabwe (2011) for women aged 15–49. Geospatial mapping was used to compare the proportions of the following outcomes: current use of contraceptives, high-risk births, and under-5 mortality at regional levels after applying sample weights to account for disproportionate sampling and non-responses. Multivariate risk factors for the outcomes were evaluated by multilevel logistic regression and reported as adjusted odds ratios (aOR). Results: A total of 40,250 (31,079 Kenya vs. 9171 Zimbabwe) women were included in this analysis. Majority were aged 18–30 years (47%), married/cohabiting (61%) and unemployed (60%). Less than half were using contraceptives (36% Kenya vs. 41% Zimbabwe). Spatial maps, especially in the Kenyan North-eastern region, showed an inverse correlation in the current use of contraceptives with high risk births and under-5 mortality. At individual level, women that had experienced high risk births were likely to have attained secondary education in both Kenya (aOR = 5.20, 95% CI: 3.86–7.01) and Zimbabwe (aOR = 1.63, 95% CI: 1.08–2.25). In Kenya, high household wealth was associated with higher contraceptive use among both women who had high risk births (aOR: 1.72, 95% CI: 1.41–2.11) and under-5 mortality (aOR: 1.66, 95% CI: 1.27–2.16). Contraceptive use was protective against high risk births in Zimbabwe only (aOR: 0.79, 95% CI: 0.68–0.92) and under-five mortality in both Kenya (aOR: 0.79, 95% CI: 0.70–0.89) and Zimbabwe (aOR: 0.71, 95% CI: 0.61–0.83). Overall, community levels factors were not strong predictors of the three main outcomes. Conclusions: There is a high unmet need of contraception services. Geospatial mapping might be useful to policy makers in identifying areas of greatest need. Increasing educational opportunities and economic empowerment for women could yield better health outcomes.
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    HIV testing and counselling experiences: a qualitative study of older adults living with HIV in western Kenya
    (BioMed Central, 2018-10) Kiplagat, Jepchirchir; Huschke, Susann
    Background: Finding HIV infected persons and engaging them in care is crucial in achieving UNAIDS 90–90-90 targets; diagnosing 90% of those infected with HIV, initiating 90% of the diagnosed on ART and achieving viral suppression in 90% of those on ART. To achieve the first target, no person should be left behind in their access to HIV testing services. In Kenya, HIV prevention and testing services give less emphasis on older adults. This article describes HIV testing experiences of older adults living with HIV and how their age shaped their interaction and treatment received during HIV testing and diagnosis. Methods: We conducted a qualitative study in two HIV clinics (rural and urban) in western Kenya, and recruited 57 HIV infected persons aged ≥50 years. We conducted in depth interviews (IDIs) with 25 participants and 4 focus group discussions (FGDs) with a total of 32 participants and audio recorded all the sessions. Participants recruited were aged between 54 and 79 years with 43% being females. We transcribed audio records and analyzed the data using thematic content analysis method. Results: Older persons’ experiences with HIV testing depended on where they tested (hospital or community setting); whether they actively sought the testing or not; and the age and gender of the healthcare provider who conducted the test. Participants expressed concerns with ageist discrimination when actively seeking HIV care testing services in hospital settings, characterized by providers’ reluctance or refusal to test. The testing and counseling sessions were described as short and hurried within the hospital settings, whereas the interactions with service providers in home-based testing were experienced as appropriate and supportive. Participants in this study expressed preference for healthcare providers who were older and of similar gender. Conclusion: HIV testing services are still not tailored to target older adults’ needs in our setting resulting in late diagnosis among older persons. We argue that a scale-up of community level testing services that provide adequate testing and counselling time and actively reach out to older adults is key to attaining the UNAIDS targets of having 90% of PLWH know their status.
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    Performance management in times of change: experiences of implementing a performance assessment system in a district in South Africa
    (BioMed Central, 2018-09) Nxumalo, Nonhlanhla; Goudge, Jane; Eyles, John; Gilson, Lucy
    Background: Health systems globally are under pressure to ensure value for money, and the people working within the system determine the extent and nature of health services provided. A performance assessment (PA); an important component of a performance management system (PMS) is deemed important at improving the performance of human resources for health. An effective PA motivates and improves staff engagement in their work. The aim of this paper is to describe the experiences of implementing a PA practice at a district in South Africa. It highlights factors that undermine the intention of the process and reflects on factors that can enable implementation to improve the staff performance for an effective and efficient district health service. Methods: Data was collected through in-depth interviews, observations and reflective engagements with managers at a district in one of the Provinces in South Africa. The study examined the managers’ experiences of implementing the PA at the district level. Results: Findings illuminate that a range of factors influence the implementation of the PA system. Most of it is attributed to context and organizational culture including management and leadership capacity. The dominance of autocratic approaches influence management and supervision of front-line managers. Management and leadership capacity is constrained by factors such as insufficient management skills due to lack of training. The established practice of recruiting from local communities facilitates patronage - compromising supervisor-subordinate relationships. In addition, organizational constraints and the constant policy changes and demands have compromised the implementation of the overall Performance Management and Development System (PMDS) – indirectly affecting the assessment component. Conclusion: To strengthen district health services, there should be improvement of processes that enhance the performance of the health system. Implementation of the PA system relies on the extent of management skills at the local level. There is a need to develop managers who have the ability to manage in a transforming and complex environment. This means developing both hard skills such as planning, co-ordination and monitoring and soft skills where one is able to focus on relationships and communication, therefore allowing collaborative and shared management as opposed to authoritarian approaches.
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    Oppression, liberation, wellbeing, and ecology: organizing metaphors for understanding health workforce migration and other social determinants of health
    (BioMed Central, 2018-08) Tankwanchi, Akhenaten Benjamin Siankam
    Background: The Commission on Social Determinants of Health (CSDH) identifies the maldistribution of power, money, and resources as main drivers of health inequities. The CSDH further observes that tackling these drivers effectively requires interventions to focus at local, national, and global levels. Consistent with the CSDH’s observation, this paper describes the eco-psychopolitical validity (EPV) paradigm, a multilevel and transdisciplinary model for research and action, thus far insufficiently tapped, but with the potential to systematize the exploration of the social determinants of health. Results: Using the physician migration from Sub-Saharan Africa (SSA) to the United States as illustration, this paper articulates how the EPV model can be applied to the systematic analysis of a complex social problem with health inequity implications. To help explore potential determinants of physician migration, a comprehensive coding matrix is developed; with the organizing metaphors of the EPV model–namely oppression, liberation, and wellbeing–serving as analytical categories. Through the lens of the EPV model, migrating physicians are revealed as both ecological subjects enmeshed in a vast web of transnational processes linking source and destination countries, and potential change agents pursuing liberation and wellbeing. While migration may expand the opportunities of émigré physicians, it is argued that, the pursuit of wellbeing by way of migration cannot fully materialize abroad without some efforts to return home, physically or socially. Conclusion: Clarifying the relationship between various social determinants of health and health inequities at different levels of analysis is a more complex but essential endeavor to knowledge generation than using a one-dimensional frame. With its roots in interdisciplinary thinking and its emphasis on both individual and contextual factors, the EPV paradigm holds promise as a model for examining the social determinants of health.
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    Implementation of district-based clinical specialist teams in South Africa: Analysing a new role in a transforming system
    (2018-08) Oboirien, Kafayat; Harris, Bronwyn; Goudge, Jane; Eyles, John
    Background: Improving the quality of health care is a national priority in many countries to help reduce unacceptable levels of variation in health system practices, performance and outcomes. In 2012, South Africa introduced district-based clinical specialist teams (DCSTs) to enhance clinical governance at the lowest level of the health system. This paper examines the expectations and responses of local health system actors in the introduction and early implementation of this new DCST role. Methods: Between 2013 and 2015, we carried out 258 in-depth interviews and three focus group discussions with managers, implementers and intended beneficiaries of the DCST innovation. Data were collected in three districts using a theory of change approach for programme evaluation. We also embarked on role charting through policy document review. Guided by role theory, we analysed data thematically and compared findings across the three districts. Results: We found role ambiguity and conflict in the implementation of the new DCST role. Individual, organisational and systemic factors influenced actors’ expectations, behaviours, and adjustments to the new clinical governance role. Local contextual factors affected the composition and scope of DCSTs in each site, while leadership and accountability pathways shaped system adaptiveness across all three. Two key contributions emerge; firstly, the responsiveness of the system to an innovation requires time in planning, roll-out, phasing, and monitoring. Secondly, the interconnectedness of quality improvement processes adds complexity to innovation in clinical governance and may influence the (in) effectiveness of service delivery. Conclusion: Role ambiguity and conflict in the DCST role at a system-wide level suggests the need for effective management of implementation systems. Additionally, improving quality requires anticipating and addressing a shortage of inputs, including financing for additional staff and skills for health care delivery and careful integration of health care policy guidelines.
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    Adult mortality in sub-Saharan Africa using 2001—2009 census data: does estimation method matter?
    (Springer Open, 2018-08) Odimegwu, Clifford; Chisumpa, Vesper H.; Somefun, Oluwaseyi Dolapo
    Adult mortality is an important development and public health issue that continues to attract the attention of demographers and public health researchers. Controversies exist about the accurate level of adult mortality in sub-Saharan Africa (SSA), due to different data sources and errors in data collection. To address this shortcoming, methods have been developed to accurately estimate levels of adult mortality. Using three different methods (orphanhood, widowhood, and siblinghood) of indirect estimation and the direct siblinghood method of adult mortality, we examined the levels of adult mortality in 10 countries in SSA using 2001–2009 census and survey data. Results from the different methods vary. Estimates from the orphanhood data show that adult mortality rates for males are in decline in South Africa and West African countries, whilst there is an increase in adult mortality in the East African countries, for the period examined. The widowhood estimates were the lowest and reveal a marked increase in female adult mortality rates compared to male. A notable difference was observed in adult mortality estimates derived from the direct and indirect siblinghood methods. The method of estimation, therefore, matters in establishing the level of adult mortality in SSA.
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    Association between internal migration and epidemic dynamics: an analysis of cause-specific mortality in Kenya and South Africa using health and demographic surveillance data
    (BioMed Central, 2018-07) Ginsburg, Carren; Bocquier, Philippe; Kahn, Kathleen; Collinson, Mark A.; Béguy, Donatien; Afolabi, Sulaimon; Obor, David; Tanser, Frank; Tomita, Andrew; Wamukoya, Marylene
    Background: Many low- and middle-income countries are facing a double burden of disease with persisting high levels of infectious disease, and an increasing prevalence of non-communicable disease (NCD). Within these settings, complex processes and transitions concerning health and population are underway, altering population dynamics and patterns of disease. Understanding the mechanisms through which changing socioeconomic and environmental contexts may influence health is central to developing appropriate public health policy. Migration, which involves a change in environment and health exposure, is one such mechanism. Methods: This study uses Competing Risk Models to examine the relationship between internal migration and premature mortality from AIDS/TB and NCDs. The analysis employs 9 to 14 years of longitudinal data from four Health and Demographic Surveillance Systems (HDSS) of the INDEPTH Network located in Kenya and South Africa (populations ranging from 71 to 223 thousand). The study tests whether the mortality of migrants converges to that of non-migrants over the period of observation, controlling for age, sex and education level. Results: In all four HDSS, AIDS/TB has a strong influence on overall deaths. However, in all sites the probability of premature death (45q15) due to AIDS/TB is declining in recent periods, having exceeded 0.39 in the South African sites and 0.18 in the Kenyan sites in earlier years. In general, the migration effect presents similar patterns in relation to both AIDS/TB and NCD mortality, and shows a migrant mortality disadvantage with no convergence between migrants and non-migrants over the period of observation. Return migrants to the Agincourt HDSS (South Africa) are on average four times more likely to die of AIDS/TB or NCDs than are non-migrants. In the Africa Health Research Institute (South Africa) female return migrants have approximately twice the risk of dying from AIDS/TB from the year 2004 onwards, while there is a divergence to higher AIDS/TB mortality risk amongst female migrants to the Nairobi HDSS from 2010. Conclusion: Results suggest that structural socioeconomic issues, rather than epidemic dynamics are likely to be associated with differences in mortality risk by migrant status. Interventions aimed at improving recent migrant’s access to treatment may mitigate risk.
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    Using a cascade approach to assess condom uptake in female sex workers in India: a review of the Avahan data
    (BioMed Central, 2018-07) Weiner, Renay; Fineberg, Micah; Dube, Bridget; Goswami, Prabuddhagopal; Mathew, Shajan; Dallabetta, Gina; Johnson, Saul
    Background: The Avahan India AIDS Initiative was implemented to provide HIV prevention services to key populations including female sex workers (FSWs) who carry the burden of India’s concentrated HIV epidemic. Established in 2003 and handed over to the Indian government in 2009, the Initiative included peer-led outreach education, condom promotion and distribution and STI treatment. This study aimed to determine if HIV prevention cascades could be generated using routine monitoring and evaluation data from the Avahan program and to assess their value in identifying and responding to program gaps for FSWs. Methods: Two data sources were used namely the Integrated Behavioural and Biological Assessment reports and the Centralized Management Information System dataset. Indicators selected for the cascades were: FSWs at risk, belief that HIV can be prevented, condom access and consistent condom use with an occasional partner. Six districts were selected and stratified by HIV prevalence at baseline and two cascades were generated per district reflecting changes over time. Results: Consistent condom use with occasional partners in this population increased in all six districts during program implementation, with statistically significant increases in four of the six. No patterns in the cascades were detected according to HIV prevalence either at baseline (2005) or at follow-up (2009). Cascades were able to identify key programmatic bottlenecks at baseline that could assist with focusing program efforts and direct resources at district levels. In some districts the belief that HIV could not be prevented contributed to inconsistent condom use, while in others, low levels of condom access were a more important barrier to consistent condom use. Conclusion: This HIV prevention cascade analysis among FSWs in India suggests that cascades could assist in identifying program gaps, focus intervention efforts and monitor their effect. However, cascades cannot replace a detailed understanding of the multiple factors at individual, community and structural levels that lead to consistent condom use in this key population. Careful indicator selection coupled with innovative data collection methods will be required. Pilot projects are proposed to formally evaluate the value of HIV prevention cascades at district level.
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    Private retail drug shops: what they are, how they operate, and implications for health care delivery in rural Uganda
    (BioMed Central, 2018-07) Mayora, Chrispus; Kandala, Ngianga-Bakwin; Kitutu, Freddy Eric; Ekirapa-Kiracho, Elizabeth; Peterson, Stefan Swartling; Wamani, Henry
    Background: Retail drug shops play a significant role in managing pediatric fevers in rural areas in Uganda. Targeted interventions to improve drug seller practices require understanding of the retail drug shop market and motivations that influence practices. This study aimed at describing the operational environment in relation to the Uganda National Drug Authority guidelines for setup of drug shops; characteristics, and dispensing practices of private retail drug shops in managing febrile conditions among under-five children in rural western Uganda. Methods: Cross sectional survey of 74 registered drug shops, observation checklist, and 428 exit interviews using a semi-structured questionnaire with care-seekers of children under five years of age, who sought care at drug shops during the survey period. The survey was conducted in Mbarara and Bushenyi districts, South Western Uganda, in May 2013. Results: Up to 90 and 79% of surveyed drug shops in Mbarara and Bushenyi, largely operate in premises that meet National Drug Authority requirements for operational suitability and ensuring medicines safety and quality. Drug shop attendants had some health or medical related training with 60% in Mbarara and 59% in Bushenyi being nurses or midwives. The rest were clinical officers, pharmacists. The most commonly stocked medicines at drug shops were Paracetamol, Quinine, Cough syrup, ORS/Zinc, Amoxicillin syrup, Septrin® syrup, Artemisinin-based combination therapies, and multivitamins, among others. Decisions on what medicines to stock were influenced by among others: recommended medicines from Ministry of Health, consumer demand, most profitable medicines, and seasonal disease patterns. Dispensing decisions were influenced by: prescriptions presented by client, patients’ finances, and patient preferences, among others. Most drug shops surveyed had clinical guidelines, iCCM guidelines, malaria and diarrhea treatment algorithms and charts as recommended by the Ministry of Health. Some drug shops offered additional services such as immunization and sold non-medical goods, as a mechanism for diversification. Conclusion: Most drug shops premises adhered to the recommended guidelines. Market factors, including client demand and preferences, pricing and profitability, and seasonality largely influenced dispensing and stocking practices. Improving retail drug shop practices and quality of services, requires designing and implementing both supply-side and demand side strategies.