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1.  Orphans in Three Sahelian Countries: Exploratory Analyses from Census Data 
Canadian studies in population  2010;37(1-2):245-267.
Important investments in Africa have reduced slightly the levels child mortality but life expectancy still very low. The number of children without surviving biological parents is increasing and orphans are becoming an important social problem. Because Sahelian societies are mostly patriarchal, becoming fatherless or motherless will have different effects on the well being of the child. This paper examines the levels and trends of the survival status of the parents and then, living arrangements of orphans. We describe characteristics of these children with a special focus on education and economic activities. The paper uses the censuses from Chad, Niger and Senegal made available by the African Census Analysis Project (ACAP) held at University of Pennsylvania. These countries collected information on survival status of each biological parent to estimate adult mortality but the potential of this information for research on child well-being is rarely exploited.
PMCID: PMC3049924  PMID: 21394220
Childhood; orphan; Africa; census data; family demography
2.  Mortality and socioeconomic deprivation in census tracts of an urban setting in Southern Europe 
In southern European cities, research on deprivation and mortality inequalities using small-area analysis is recent. In many countries, the census tract (CT) is the smallest territorial unit for which population data are available. The aim of this study was to examine the association between mortality from all causes and socioeconomic deprivation in CTs in Barcelona (Spain). A cross-sectional ecologic study was carried out using mortality data for 1987–1995 and 1991 census variables. Mortality data were obtained from death certificates. Socioeconomic deprivation indicators were drawn from the census and included unemployment, inadequate education, and low social class. They were correlated, and a deprivation index was elaborated with them. The analysis was descriptive, and multivariate Poisson regression models were adjusted. The most deprived CTs tend to present higher mortality (49.7% of CT in the quartile associated with greatest deprivation were included in the top male mortality quartile and 40.4% in the top female mortality quartile), whereas the less deprived ones present lower mortality. For male mortality, the risk of dying among those in the quartile representing most deprivation is from 25 to 29% higher (depending on the indicator chosen) than the least deprived quartile, and for women, it is from 12 to 14% higher. We concluded that the mortality from all causes in the CT of a southern European city has shown a clear positive association with a variety of socioeconomic deprivation indicators drawn from the census. Studies of this nature may help to orient more specific studies in which CTs are grouped together as a function of particular population and/or health characteristics.
doi:10.1093/jurban/jti047
PMCID: PMC3456560  PMID: 15888637
Census; Health inequalities; Mortality; Small areas; Socioeconomic factors
3.  Global health inequalities: an international comparison 
Objective
To study cross‐national inequalities in mortality of adults and of children aged <5 years using a novel approach, with clustering techniques to stratify countries into mortality groups (better‐off, worse‐off, mid‐level) and to examine risk factors associated with inequality.
Design, setting and participants
Analysis of data from the World Development Indicators 2003 database, compiled by the World Bank.
Main outcome measures
Adult and child mortality among countries placed into distinct mortality categories by cluster analysis.
Results
29 countries had a high adult mortality (mean 584/1000; range 460/1000 to 725/1000) and 23 had a high child mortality (mean 207/1000, range 160/1000 to 316/1000). All these countries were in western and sub‐Saharan Africa and Afghanistan. Bivariate analyses showed that relative to countries with low child mortality, those with high child mortality had significantly higher rates of extreme poverty (p<0.001), populations living in rural areas (p<0.001) and female illiteracy (p<0.001), significantly lower per capita expenditure on healthcare (p<0.001), outpatient visits, hospital beds and doctors, and lower rates of access to improved water (p<0.001), sanitation (p<0.001) and immunisations. In multivariate analyses, countries with high adult mortality had a higher prevalence of HIV infection (odds ratio per 1% increase 18.6; 95% CI 0.3 to 1135.5). Between 1960 and 2000, adult male mortality in countries with high mortality increased at >4 times the rate in countries with low mortality. For child mortality, the worse‐off group made slower progress in reducing <5 mortality than the better‐off group.
Conclusions
Inequalities in child and adult mortality are large, are growing, and are related to several economic, social and health sector variables. Global efforts to deal with this problem require attention to the worse‐off countries, geographic concentrations, and adopt a multidimensional approaches to development.
doi:10.1136/jech.2005.041954
PMCID: PMC2465481  PMID: 17053281
4.  First do no harm: the impact of recent armed conflict on maternal and child health in Sub-Saharan Africa 
Objectives To compare the rates of under-5 mortality, malnutrition, maternal mortality and other factors which influence health in countries with and without recent conflict. To compare central government expenditure on defence, education and health in countries with and without recent conflict. To summarize the amount spent on SALW and the main legal suppliers to countries in Sub-Saharan African countries (SSA), and to summarize licensed production of Small Arms and Light Weapons (SALW) in these countries.
Design We compared the under-5 mortality rate in 2004 and the adjusted maternal mortality ratio in SSA which have and have not experienced recent armed conflict (post-1990). We also compared the percentage of children who are underweight in both sets of countries, and expenditure on defence, health and education.
Setting Demographic data and central government expenditure details (1994-2004) were taken from UNICEF's The State of the World's Children 2006 report.
Main outcome measures Under-5 mortality, adjusted maternal mortality, and government expenditure.
Results 21 countries have and 21 countries have not experienced recent conflict in this dataset of 42 countries in SSA. Median under-5 mortality in countries with recent conflict is 197/1000 live births, versus 137/1000 live births in countries without recent conflict. In countries which have experienced recent conflict, a median of 27% of under-5s were moderately underweight, versus 22% in countries without recent conflict. The median adjusted maternal mortality in countries with recent conflict was 1000/100,000 births versus 690/100,000 births in countries without recent conflict. Median reported maternal mortality ratio is also significantly higher in countries with recent conflict. Expenditure on health and education is significantly lower and expenditure on defence significantly higher if there has been recent conflict.
Conclusions There appears to be an association between recent conflict and higher rates of under-5 mortality, malnutrition and maternal mortality. Governments spend more on defence and less on health and education if there has been a recent conflict. SALW are the main weapon used and France and the UK appear to be the two main suppliers of SALW to SSA.
PMCID: PMC2121626  PMID: 18065709
5.  Assessing the impact of mass rape on the incidence of HIV in conflict-affected countries 
AIDS (London, England)  2010;24(18):2841-2847.
Objectives
To quantify the potential impact of mass rape on HIV incidence in seven conflict-afflicted-countries (CACs), with severe HIV epidemics, in Sub-Saharan Africa.
Design
Uncertainty analysis of a risk equation model.
Methods
A mathematical model was used to evaluate the potential impact of mass rape on increasing HIV incidence in women and girls in: Burundi, Democratic Republic of Congo (DRC), Rwanda, Sierra Leone, Somalia, southern Sudan and Uganda. The model was parameterized with data from UNAIDS/WHO and the US Census Bureau’s International Data Base. Incidence data from UNAIDS/WHO were used for calibration.
Results
Mass rape could cause ~five HIV infections per 100,000 females per year in the DRC, Sudan, Somalia and Sierra Leone, double that in Burundi and Rwanda, and quadruple that in Uganda. The number of females infected per year due to mass rape is likely to be relatively low in Somalia and Sierra Leone, 127 (median: Inter-Quartile-Range (IQR) 55–254) and 156 (median: IQR 69–305), respectively. Numbers could be high in the DRC and Uganda: 1,120 (median: IQR 527–2,360) and 2,172 (median: IQR 1,031–4,668), respectively. In Burundi, Rwanda and Sudan numbers are likely to be intermediate. Under extreme conditions 10,000 women and girls could be infected per year in the DRC, and 20,000 women and girls in Uganda. Mass rape could increase annual incidence by ~ 7% (median: IQR 3–15).
Conclusions
Interventions and treatment targeted to rape survivors during armed conflicts could reduce HIV incidence. Support should be provided both on the basis of human rights and public health.
doi:10.1097/QAD.0b013e32833fed78
PMCID: PMC2978669  PMID: 20859191
Risk equation model; Mass rape; Incidence; HIV; conflict-affected countries; Sub-Saharan Africa
6.  Geographical patterns of excess mortality in Spain explained by two indices of deprivation 
STUDY OBJECTIVE: To analyse the geographical patterns and the magnitude of the association between deprivation and mortality in Spain. To estimate the excess of mortality in more deprived areas of the country by region. DESIGN: Cross sectional ecological study using 1991 census variables and mortality data for 1987-1992. SETTING: 2220 small areas in Spain. MAIN RESULTS: A geographical gradient from north east to south west was shown by both mortality and deprivation levels in Spain. Two dimensions of deprivation (that is, Index 1 and Index 2) obtained by exploratory factor analysis using four census indicators were found to predict mortality: mortality over 65 years of age was more associated with Index 1, while mortality under 65 years of age was more associated with Index 2. Excess mortality in the most deprived areas accounted for about 35,000 deaths. CONCLUSIONS: Two indices of deprivation strongly predict mortality in two age groups. Excess number of deaths in the most deprived geographical areas account for 10% of total number of deaths annually. In Spain there is great potential for reducing mortality if the excess risk in more deprived areas fell to the level of the most affluent areas.
 
PMCID: PMC1756931  PMID: 10492736
7.  Exploring changes in open defecation prevalence in sub-Saharan Africa based on national level indices 
BMC Public Health  2013;13:527.
Background
In sub-Saharan Africa, it is estimated that 215 million people continue to engage in open defecation. This practice facilitates the transmission of diarrheal diseases – one of the leading causes of mortality in children under 5 in sub-Saharan Africa. The main purpose of this study is to: estimate changes in open defecation prevalence between 2005 and 2010 across countries in sub-Saharan Africa; examine the association between national level indices and changes in open defecation prevalence; and assess how many countries can achieve ‘open defecation free status’ by 2015.
Methods
After applying selection criteria, this study analyzed country-level data for 34 sub-Saharan African countries. Seven country-level indices were collected: 1) presence of a national sanitation policy; 2) budget line for sanitation; 3) budget allocated to sanitation; 4) annual per capita GDP; 5) GDP growth; 6) implementation of total sanitation approaches; and 7) per capita aid disbursement for water supply and sanitation. The relationships between these country-level indices and the change in open defecation from 2005 to 2010 were investigated using Wilcoxon Signed-Rank test and Spearman's rank correlation test.
Results
Only 3 countries (i.e. Ethiopia, Angola and Sao Tome and Principe) decreased open defecation by 10% or more between 2005 and 2010. No significant associations were observed between the change in open defecation prevalence and all of national level indices except per capita aid disbursement. Per capita aid disbursement for water and sanitation was positively associated with a reduction in open defecation (p-value = 0.02) for a subset of 29 low-income countries from 2005 to 2010. Only one country in our analysis, Angola, is on track to end open defecation by 2015 based on their performance between 2000 and 2010.
Conclusions
Most of the national level indices, including a country’s economic status, were not associated with the change in the open defecation prevalence. Based on current trends, the goal of ending open defecation in the majority of sub-Saharan African countries by 2015 will not be achieved. Our findings may be limited by the exploratory nature of this analysis, and future research is required to identify and characterize national level factors specific to reducing open defecation in sub-Saharan Africa.
doi:10.1186/1471-2458-13-527
PMCID: PMC3679748  PMID: 23721324
Open defecation; Sanitation; Sub-Saharan Africa; Sanitation policy; Economic development; Total sanitation
8.  Widespread rape does not directly appear to increase the overall HIV prevalence in conflict-affected countries: so now what? 
Background
Sub-Saharan Africa (SSA) is severely affected by HIV/AIDS and conflict. Sexual violence as a weapon of war has been associated with concerns about heightened HIV incidence among women. Widespread rape by combatants has been documented in Burundi, Sierra Leone, Rwanda, Democratic Republic of Congo, Liberia, Sudan and Uganda. To examine the assertion that widespread rape may not directly increase HIV prevalence at the population level, we built a model to determine the potential impact of varying scenarios of widespread rape on HIV prevalence in the above seven African countries.
Discussion
Our findings show that even in the most extreme situations, where 15% of the female population was raped, where HIV prevalence among assailants was 8 times the country population prevalence, and where the HIV transmission rate was highest at 4 times the average high rate, widespread rape increased the absolute HIV prevalence of these countries by only 0.023%. These projections support the finding that widespread rape in conflict-affected countries in SSA has not incurred a major direct population-level change in HIV prevalence. However, this must not be interpreted to say that widespread rape does not pose serious problems to women's acquisition of HIV on an individual basis or in specific settings. Furthermore, direct and indirect consequences of sexual violence, such as physical and psychosocial trauma, unwanted pregnancies, and stigma and discrimination cannot be understated.
Summary
The conclusions of this article do not significantly change current practices in the field from an operational perspective. Proper care and treatment must be provided to every survivor of rape regardless of the epidemiological effects of HIV transmission at the population level. Sexual violence must be treated as a protection issue and not solely a reproductive health and psychosocial issue. It is worth publishing data and conclusions that could be misconstrued and may not make much of a programmatic difference in the field. Data, if collected, analysed and interpreted carefully, help to improve our understanding of complicated and nuanced situations. Ultimately, our understanding of what the outcomes of such interventions can achieve will be more realistic. It also helps decision-makers prioritise their funding and interventions.
doi:10.1186/1742-7622-5-11
PMCID: PMC2527307  PMID: 18664265
9.  Estimating the impact of expanded access to antiretroviral therapy on maternal, paternal and double orphans in sub-Saharan Africa, 2009-2020 
Background
HIV/AIDS has orphaned 11.6 million children in sub-Saharan Africa. Expanded antiretroviral therapy (ART) use may reduce AIDS orphanhood by decreasing adult mortality and population-level HIV transmission.
Methods
We modeled two scenarios to measure the impact of adult ART use on the incidence of orphanhood in 10 sub-Saharan African countries, from 2009 to 2020. Demographic model data inputs were obtained from cohort studies, UNAIDS, UN Population Division, WHO and the US Census Bureau.
Results
Compared to current rates of ART uptake, universal ART access averted 4.37 million more AIDS orphans by year 2020, including 3.15 million maternal, 1.89 million paternal and 0.75 million double orphans. The number of AIDS orphans averted was highest in South Africa (901.71 thousand) and Nigeria (839.01 thousand), and lowest in Zimbabwe (86.96 thousand) and Côte d'Ivoire (109.12 thousand).
Conclusion
Universal ART use may significantly reduce orphanhood in sub-Saharan Africa.
doi:10.1186/1742-6405-8-13
PMCID: PMC3063201  PMID: 21385370
10.  Choosing area based socioeconomic measures to monitor social inequalities in low birth weight and childhood lead poisoning: The Public Health Disparities Geocoding Project (US) 
Study objectives: To determine which area based socioeconomic measures can meaningfully be used, at which level of geography, to monitor socioeconomic inequalities in childhood health in the US.
Design: Cross sectional analysis of birth certificate and childhood lead poisoning registry data, geocoded and linked to diverse area based socioeconomic measures that were generated at three geographical levels: census tract, block group, and ZIP code.
Setting: Two US states: Massachusetts (1990 population=6 016 425) and Rhode Island (1990 population=1 003 464).
Participants: All births born to mothers ages 15 to 55 years old who were residents of either Massachusetts (1989–1991; n=267 311) or Rhode Island (1987–1993; n=96 138), and all children ages 1 to 5 years residing in Rhode Island who were screened for lead levels between 1994 and 1996 (n=62 514 children, restricted to first test during the study period).
Main results: Analyses of both the birth weight and lead data indicated that: (a) block group and tract socioeconomic measures performed similarly within and across both states, while ZIP code level measures tended to detect smaller effects; (b) measures pertaining to economic poverty detected stronger gradients than measures of education, occupation, and wealth; (c) results were similar for categories generated by quintiles and by a priori categorical cut off points; and (d) the area based socioeconomic measures yielded estimates of effect equal to or augmenting those detected, respectively, by individual level educational data for birth outcomes and by the area based housing measure recommended by the US government for monitoring childhood lead poisoning.
Conclusions: Census tract or block group area based socioeconomic measures of economic deprivation could be meaningfully used in conjunction with US public health surveillance systems to enable or enhance monitoring of social inequalities in health in the United States.
doi:10.1136/jech.57.3.186
PMCID: PMC1732402  PMID: 12594195
11.  Net Benefits: A Multicountry Analysis of Observational Data Examining Associations between Insecticide-Treated Mosquito Nets and Health Outcomes 
PLoS Medicine  2011;8(9):e1001091.
Stephen Lim and colleagues report findings from a multi-country analysis of household survey data on the association between possession of insecticide-treated mosquito nets and child mortality and parasitemia. Scale-up of net coverage was associated with a substantial reduction in childhood mortality and in parasitemia prevalence.
Background
Several sub-Saharan African countries have rapidly scaled up the number of households that own insecticide-treated mosquito nets (ITNs). Although the efficacy of ITNs in trials has been shown, evidence on their impact under routine conditions is limited to a few countries and the extent to which the scale-up of ITNs has improved population health remains uncertain.
Methods and Findings
We used matched logistic regression to assess the individual-level association between household ITN ownership or use in children under 5 years of age and the prevalence of parasitemia among children using six malaria indicator surveys (MIS) and one demographic and health survey. We used Cox proportional hazards models to assess the relationship between ITN household ownership and child mortality using 29 demographic and health surveys. The pooled relative reduction in parasitemia prevalence from random effects meta-analysis associated with household ownership of at least one ITN was 20% (95% confidence interval [CI] 3%–35%; I2 = 73.5%, p<0.01 for I2 value). Sleeping under an ITN was associated with a pooled relative reduction in parasitemia prevalence in children of 24% (95% CI 1%–42%; I2 = 79.5%, p<0.001 for I2 value). Ownership of at least one ITN was associated with a pooled relative reduction in mortality between 1 month and 5 years of age of 23% (95% CI 13–31%; I2 = 25.6%, p>0.05 for I2 value).
Conclusions
Our findings across a number of sub-Saharan African countries were highly consistent with results from previous clinical trials. These findings suggest that the recent scale-up in ITN coverage has likely been accompanied by significant reductions in child mortality and that additional health gains could be achieved with further increases in ITN coverage in populations at risk of malaria.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Malaria is a major public health problem. Half the world's population is at risk of this parasitic disease, which kills a million people (mainly children living in sub-Saharan Africa) every year. Malaria is transmitted to people through the bites of infected night-flying mosquitoes. Soon after entering the human body, the parasite begins to replicate in red blood cells, bursting out every 2–3 days and infecting more red blood cells. The presence of the parasite in the bloodstream (parasitemia) causes malaria's characteristic fever and can cause fatal organ damage. Malaria can be prevented by controlling the mosquitoes that spread the parasite and by owning and sleeping under insecticide-treated nets (ITNs) to avoid mosquito bites. In trials, ITN use reduced parasitemia in young children by about 13% and deaths among children by about 18%. Consequently, the widespread provision of ITNs is a mainstay of the World Health Organization's efforts to control malaria, and in 2005 the World Health Assembly agreed a target of providing ITNs for 80% of the people at risk of malaria by 2010.
Why Was This Study Done?
Although progress towards this goal has been variable, several sub-Saharan African countries have rapidly scaled up the fraction of households that own ITNs from near zero to more than 60% with the support of international donors. But has this scale-up of ITN coverage been accompanied by improvements in health outcomes similar to those seen in the trials of ITNs? ITNs may not work as well under routine conditions as in trials because of, for example, the use of nets that are no longer impregnated with active insecticide; nets have to be retreated regularly with insecticide to maintain their protection against mosquitoes. Unfortunately, in many countries in sub-Saharan Africa, health information systems are weak and incomplete records of deaths are kept, which makes it impossible to determine the rates of malaria-specific morbidity (illness) and mortality (deaths) accurately. In this study, the researchers use data collected in household surveys to examine the association between ITN ownership in a number of sub-Saharan African countries and two specific outcomes—the proportion of the population with parasitemia, and child mortality.
What Did the Researchers Do and Find?
The researchers used a statistical method to assess the association between household ITN ownership or use in young children and the prevalence of parasitemia among children using data from a set of household surveys. They looked specifically at the relationship between ITN household ownership and child mortality using data from 29 surveys undertaken in 22 sub-Saharan African countries. They then pooled the results of the individual surveys. The pooled relative reduction in parasitemia prevalence among children associated with household ownership of at least one ITN was 20%. That is, averaged out over the countries studied, household ITN ownership was associated with a reduction of around a fifth in the prevalence of parasitemia. The pooled relative reduction of parasitemia prevalence associated with children sleeping under an ITN was 24%. Finally, the pooled relative reduction in mortality between 1 month and 5 years old associated with household ITN ownership was 23%.
What Do These Findings Mean?
These findings suggest that the rapid scale-up in ITN coverage that has occurred in several sub-Saharan African countries has been accompanied by significant reductions in child deaths. Importantly, these findings are highly consistent with those from trials of ITNs. The accuracy of these findings may be affected by some aspects of the study design. For example, because the study uses observational data, it is possible that people who own ITNs share other characteristics that are actually responsible for the reduction in parasitemia prevalence and childhood deaths. Nevertheless, these findings add to the body of evidence that ITNs are effective in routine use. Thus, they support continued efforts to scale-up ITN coverage in sub-Saharan Africa and highlight the importance of maintaining ITN coverage in countries that have already successfully scaled up coverage.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001091.
The Institute for Health Metrics and Evaluation provides visualizations and datasets for a range of global health indicators including child mortality and insecticide treated bed net coverage
Information is available from the World Health Organization on malaria (in several languages); the 2010 World Malaria Report provides details of the current global malaria situation
The US Centers for Disease Control and Prevention provide information on malaria and on insecticide-treated bed nets
The Roll Back Malaria Partnership provides information on the global control of malaria, malaria in Africa and insecticide-treated bed nets, and access to Malaria Indicator Survey datasets
Information is also available about the Demographic and Health Surveys
MedlinePlus provides links to additional information on malaria (in English and Spanish)
doi:10.1371/journal.pmed.1001091
PMCID: PMC3167799  PMID: 21909249
12.  Infant mortality in South Africa - distribution, associations and policy implications, 2007: an ecological spatial analysis 
Background
Many sub-Saharan countries are confronted with persistently high levels of infant mortality because of the impact of a range of biological and social determinants. In particular, infant mortality has increased in sub-Saharan Africa in recent decades due to the HIV/AIDS epidemic. The geographic distribution of health problems and their relationship to potential risk factors can be invaluable for cost effective intervention planning. The objective of this paper is to determine and map the spatial nature of infant mortality in South Africa at a sub district level in order to inform policy intervention. In particular, the paper identifies and maps high risk clusters of infant mortality, as well as examines the impact of a range of determinants on infant mortality. A Bayesian approach is used to quantify the spatial risk of infant mortality, as well as significant associations (given spatial correlation between neighbouring areas) between infant mortality and a range of determinants. The most attributable determinants in each sub-district are calculated based on a combination of prevalence and model risk factor coefficient estimates. This integrated small area approach can be adapted and applied in other high burden settings to assist intervention planning and targeting.
Results
Infant mortality remains high in South Africa with seemingly little reduction since previous estimates in the early 2000's. Results showed marked geographical differences in infant mortality risk between provinces as well as within provinces as well as significantly higher risk in specific sub-districts and provinces. A number of determinants were found to have a significant adverse influence on infant mortality at the sub-district level. Following multivariable adjustment increasing maternal mortality, antenatal HIV prevalence, previous sibling mortality and male infant gender remained significantly associated with increased infant mortality risk. Of these antenatal HIV sero-prevalence, previous sibling mortality and maternal mortality were found to be the most attributable respectively.
Conclusions
This study demonstrates the usefulness of advanced spatial analysis to both quantify excess infant mortality risk at the lowest administrative unit, as well as the use of Bayesian modelling to quantify determinant significance given spatial correlation. The "novel" integration of determinant prevalence at the sub-district and coefficient estimates to estimate attributable fractions further elucidates the "high impact" factors in particular areas and has considerable potential to be applied in other locations. The usefulness of the paper, therefore, not only suggests where to intervene geographically, but also what specific interventions policy makers should prioritize in order to reduce the infant mortality burden in specific administration areas.
doi:10.1186/1476-072X-10-61
PMCID: PMC3250938  PMID: 22093084
infant mortality; HIV; spatial analysis; social determinants; attributable fractions; policy implications; Bayesian analysis
13.  Uses of population census data for monitoring geographical imbalance in the health workforce: snapshots from three developing countries 
Background
Imbalance in the distribution of human resources for health (HRH), eventually leading to inequities in health services delivery and population health outcomes, is an issue of social and political concern in many countries. However, the empirical evidence to support decision-making is often fragmented, and many standard data sources that can potentially produce statistics relevant to the issue remain underused, especially in developing countries. This study investigated the uses of demographic census data for monitoring geographical imbalance in the health workforce for three developing countries, as a basis for formulation of evidence-based health policy options.
Methods
Population-based indicators of geographical variations among HRH were extracted from census microdata samples for Kenya, Mexico and Viet Nam. Health workforce statistics were matched against international standards of occupational classification to control for cross-national comparability. Summary measures of inequality were calculated to monitor the distribution of health workers across spatial units and by occupational group.
Results
Strong inequalities were found in the geographical distribution of the health workforce in all three countries, with the highest densities of HRH tending to be found in the capital areas. Cross-national differences were found in the magnitude of distributional inequality according to occupational group, with health professionals most susceptible to inequitable distribution in Kenya and Viet Nam but less so in Mexico compared to their associate professional counterparts. Some discrepancies were suggested between mappings of occupational information from the raw data with the international system, especially for nursing and midwifery specializations.
Conclusions
The problem of geographical imbalance among HRH across countries in the developing world holds important implications at the local, national and international levels, in terms of constraints for the effective deployment, management and retention of HRH, and ultimately for the equitable delivery of health services. A number of advantages were revealed of using census data in health research, notably the potential for producing detailed statistics on health workforce characteristics at the sub-national level. However, lack of consistency in the compilation and processing of occupational information over time and across countries continues to hamper comparative analyses for HRH policy monitoring and evaluation.
doi:10.1186/1475-9276-2-11
PMCID: PMC324414  PMID: 14697099
14.  Determinants of diarrhoea and acute respiratory infection among under-fives in Uganda 
The Australasian Medical Journal  2011;4(7):400-409.
Background
Diarrhoea and acute respiratory infection (ARI) are leading causes of mortality and morbidity in children under the age of five in developing countries. On the African continent, pneumonia (14%) and diarrhoea (17%) cause more child deaths than Malaria (16%), HIV/AIDS (4%), and measles (1%) combined. This paper set out to investigate the factors associated with the occurrence of diarrhoea and ARI incidence for children under five years in Uganda.
Method
We used a nationally representative Uganda Demographic and Health Survey (UDHS) (2006). Sampling was done in two stages. In the first stage 321 clusters were selected from among a list of clusters sampled in the 2005/06 Uganda National Household Survey (UNHS), 17 clusters from the 2002 Census frame from Karamoja, and 30 internally displaced camps (IDPs). In the second stage, households in each cluster were selected as per UNHS listing. In addition 20 households were randomly selected in each cluster.
Questionnaires were used during data collection. During the analysis, a maximum likelihood probit model was used in order to ascertain the probability of occurrence of diseases.
Results
On average, 32% and 48% of children in the survey suffered from diarrhoea and ARI in the two weeks prior to the survey date. The occurrence was concentrated amongst children aged 0–24 months. Mother's education, especially at postsecondary level, reduced the probability of diarrhoea occurrence but had no effect on ARI occurrence. First hour initiation and exclusive breastfeeding reduced the probability occurrence of both diarrhoea and ARI. Other significant factors associated with the occurrence of both diseases include: regional and location differentials, wealth status, type of dwelling, mother's occupation, child age, and child nutritional status.
Conclusion
Policy interventions should target female education, eliminate location and regional disadvantages, and educate the population to adopt breastfeeding practices recommended by the World Health Organization (WHO). The government should also ensure proper dwelling places for the population that are associated with favourable health outcomes. Other proper feeding practices together with breastfeeding (after six months), should be made known to the masses so as to reduce the number of children that are malnourished and growth retarded.
doi:10.4066/AMJ.2011.723
PMCID: PMC3562942  PMID: 23393526
Diarrhoea; acute respiratory infections; children; under-five years; Uganda
15.  Demand for long acting and permanent contraceptive methods and associated factors among married women of reproductive age group in Debre Markos Town, North West Ethiopia 
BMC Women's Health  2014;14:46.
Background
Ethiopia is the second most populous country in sub Saharan Africa with high total fertility rate, and high maternal and child mortality rates. In sub Saharan African countries, including Ethiopia, even though studies show that demand for contraception is high, the practice is low. Particularly, in Ethiopia, despite the fact that practices on long acting and permanent methods are believed to be low, there are limited evidences on the real magnitude of demand for the methods.
Methods
To assess demand for long acting and permanent contraceptive methods and associated factors among married women of reproductive age group in Debre Markos town, Amhara Regional State, North West Ethiopia, A community based cross sectional study was conducted, from April 08–19, 2012. Systematic sampling technique was used to select 523 study participants. Pre tested structured Amharic version questionnaire was used to collect the data through interview. Both bivariate and multiple logistic regressions were used to identify associated factors.
Results
Among 519 respondents, 323 (62.2%) were using modern family planning (FP) methods in which 101 (19.5%) were using long acting and permanent contraceptive methods (LAPMs). Among all respondents, 171 (32.9%) had unmet need for LAPMs. The total demand for LAPMs was 272 (52.4%) of which 37.1% were satisfied and 62.9% unsatisfied demand. Being in the older age group (40-44 years) [AOR = 2.8; 95% CI:1.12, 9.55], having no desire for more child [AOR = 20.37; 95% CI:9.28, 44.72], desire to have a child after 2 years [AOR = 6.4; 95%CI:3.04,13.47], not ever heard of modern FP [AOR = 5.73; 95% CI:1.26, 25.91], not ever using of modern FP [AOR = 1.89; 95% CI:1.01, 3.55] and having no spousal discussion in the last six month [AOR = 1.642, 95% CI: 1.049, 2.57) were some of the factors significantly associated with demand for LAPMs.
Conclusions
Demand and unmet need for LAPMs were high in the study area. Therefore raising awareness of the community, counseling/discussion about the methods with all clients, encouraging spousal involvement are fundamental areas of intervention. Moreover, increasing the availability and accessibility of LAPMs is required to meet the unmet needs.
doi:10.1186/1472-6874-14-46
PMCID: PMC3975156  PMID: 24625360
16.  Exploring Household Economic Impacts of Childhood Diarrheal Illnesses in 3 African Settings 
Beyond the morbidity and mortality burden of childhood diarrhea in sub-Saharan African are significant economic costs to affected households. Using survey data from 3 of the 4 sites in sub-Saharan Africa (Gambia, Kenya, Mali) participating in the Global Enteric Multicenter Study (GEMS), we estimated the direct medical, direct nonmedical, and indirect (productivity losses) costs borne by households due to diarrhea in young children. Mean cost per episode was $2.63 in Gambia, $6.24 in Kenya, and $4.11 in Mali. Direct medical costs accounted for less than half of these costs. Mean costs understate the distribution of costs, with 10% of cases exceeding $6.50, $11.05, and $13.84 in Gambia, Kenya, and Mali. In all countries there was a trend toward lower costs among poorer households and in 2 of the countries for diarrheal illness affecting girls. For poor children and girls, this may reflect reduced household investment in care, which may result in increased risks of mortality.
doi:10.1093/cid/cis763
PMCID: PMC3502313  PMID: 23169944
17.  Limited Progress in Increasing Coverage of Neonatal and Child-health Interventions in Africa and Asia 
The study was conducted to analyze recent trends in the coverage of selected child-survival interventions. A systematic analysis of the coverage of six key child-health interventions in 29 African and Asian countries that had two recent demographic and health surveys—the latest one carried out in 2001 onwards and the immediately preceding survey conducted after 1990—was undertaken. A regression model was used for examining the relationship between the changes in the coverage of interventions and the changes in rates of mortality among children aged less than five years (under-five mortality). A limited increase in the coverage of key child-health interventions occurred in the past 5–10 years in these 29 countries in sub-Saharan Africa and Asia. More than half of the countries had no significant improvement or a significant reduction in the coverage of oral rehydration therapy (ORT) for diarrhoea (17/29) and care-seeking for acute respiratory infection (ARI) (16/29). Results of multivariate analysis revealed that increases in the coverage of early initiation of breastfeeding, ORT for diarrhoea, and care-seeking for ARI were significantly associated with reductions in under-five mortality. The results of this analysis should serve as a wake-up call for policy-makers and programme managers in countries, donors, and international agencies to accelerate efforts to increase the coverage of key child-survival interventions. The following three main actions are proposed: setting of the clear target; mobilization of resources for increasing skilled birth attendants and health workers trained in integrated management of childhood illness; and implementation of community-based approaches.
PMCID: PMC2928119  PMID: 20099759
Child health; Child survival; Infant health; Infant survival; Interventions; Asia; Africa
18.  Interrelations between three proxies of health care need at the small area level: an urban/rural comparison 
Study objective: To examine the relations between geographical variations in mortality, morbidity, and deprivation at the small area level in the south west of England and to assess whether these relations vary between urban and rural areas.
Design: A geographically based cross sectional study using 1991 census data on premature limiting long term illness (LLTI) and socioeconomic characteristics, and 1991–1996 data on all cause premature mortality. The interrelations between the three widely used proxies of health care need are examined using correlation coefficients and scatterplots. The distribution of standardised LLTI residuals from a regression analysis on mortality are mapped and compared with the distribution of urban and rural areas. Multilevel Poisson modelling investigates whether customised deprivation profiles improve upon a generic deprivation index in explaining the spatial variation in morbidity and mortality after controlling for age and sex. These relations are examined separately for urban, fringe, and rural areas.
Setting: Nine counties in the south west of England.
Participants: Those aged between 0–64 who reported having a LLTI in the 1991 census, and those who died during 1991–1996 aged 0–74.
Main results: Relations between both health outcomes and generic deprivation indices are stronger in urban than rural areas. The replacement of generic with customised indices is an improvement in all area types, especially for LLTI in rural areas. The relation between mortality and morbidity is stronger in urban than rural areas, with levels of LLTI appearing to be greater in rural areas than would be predicted from mortality rates. Despite the weak direct relations between mortality and morbidity, there are strong relations between the customised deprivation indices computed to predict these outcomes in all area types.
Conclusions: The improvement of the customised deprivation indices over the generic indices, and the similarity between the mortality and morbidity customised indices within area types highlights the importance of modelling urban and rural areas separately. Stronger relations between mortality and morbidity have been revealed at the local authority level in previous research providing empirical evidence that the inadequacy of mortality as a proxy for morbidity becomes more marked at lower levels of aggregation, especially in rural areas. Higher levels of LLTI than expected in rural areas may reflect different perceptions or differing patterns of illness. The stronger relations between the three proxies in urban than rural areas suggests that the choice of indicator will have less impact in urban than rural areas and strengthens the argument to develop better measures of health care need in rural areas.
doi:10.1136/jech.56.10.754
PMCID: PMC1732023  PMID: 12239201
19.  Mapping the Risk of Anaemia in Preschool-Age Children: The Contribution of Malnutrition, Malaria, and Helminth Infections in West Africa 
PLoS Medicine  2011;8(6):e1000438.
Ricardo Soares Magalhães and colleagues used national cross-sectional household-based demographic health surveys to map the distribution of anemia risk in preschool children in Burkina Faso, Ghana, and Mali.
Background
Childhood anaemia is considered a severe public health problem in most countries of sub-Saharan Africa. We investigated the geographical distribution of prevalence of anaemia and mean haemoglobin concentration (Hb) in children aged 1–4 y (preschool children) in West Africa. The aim was to estimate the geographical risk profile of anaemia accounting for malnutrition, malaria, and helminth infections, the risk of anaemia attributable to these factors, and the number of anaemia cases in preschool children for 2011.
Methods and Findings
National cross-sectional household-based demographic health surveys were conducted in 7,147 children aged 1–4 y in Burkina Faso, Ghana, and Mali in 2003–2006. Bayesian geostatistical models were developed to predict the geographical distribution of mean Hb and anaemia risk, adjusting for the nutritional status of preschool children, the location of their residence, predicted Plasmodium falciparum parasite rate in the 2- to 10-y age group (Pf PR2–10), and predicted prevalence of Schistosoma haematobium and hookworm infections. In the four countries, prevalence of mild, moderate, and severe anaemia was 21%, 66%, and 13% in Burkina Faso; 28%, 65%, and 7% in Ghana, and 26%, 62%, and 12% in Mali. The mean Hb was lowest in Burkina Faso (89 g/l), in males (93 g/l), and for children 1–2 y (88 g/l). In West Africa, severe malnutrition, Pf PR2–10, and biological synergisms between S. haematobium and hookworm infections were significantly associated with anaemia risk; an estimated 36.8%, 14.9%, 3.7%, 4.2%, and 0.9% of anaemia cases could be averted by treating malnutrition, malaria, S. haematobium infections, hookworm infections, and S. haematobium/hookworm coinfections, respectively. A large spatial cluster of low mean Hb (<80 g/l) and maximal risk of anaemia (>95%) was predicted for an area shared by Burkina Faso and Mali. We estimate that in 2011, approximately 6.7 million children aged 1–4 y are anaemic in the three study countries.
Conclusions
By mapping the distribution of anaemia risk in preschool children adjusted for malnutrition and parasitic infections, we provide a means to identify the geographical limits of anaemia burden and the contribution that malnutrition and parasites make to anaemia. Spatial targeting of ancillary micronutrient supplementation and control of other anaemia causes, such as malaria and helminth infection, can contribute to efficiently reducing the burden of anaemia in preschool children in Africa.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Global estimates for the time period 1993–2005 suggest that that worldwide, nearly 300 million children had anemia, that is, hemoglobin levels less than 110 g/l. In sub-Saharan Africa, two-thirds of all children were anemic, representing 83.5 million children. These statistics are important because anemia in infancy and childhood is associated with poor cognitive development, reduced growth, problems with immune function—and ultimately, decreased survival. Malnutrition (including micronutrient deficiency, especially of iron, vitamin A, vitamin C, and folate), undernutrition, and infectious diseases, particularly HIV, malaria, and helminth infections (caused by hookworm and Schistosoma haematobium—which causes urinary schistosomiasis), are major causes of anemia in children. Although iron supplementation can often correct anemia, in some circumstances, iron deficiency can protect against common infectious agents, and giving iron can, on occasion, increase the severity of infectious disease in some children. Focusing on the treatment and prevention of infectious diseases that cause anemia is therefore an important alternative strategy in the treatment of anemia.
Why Was This Study Done?
Control tools for targeting interventions for malaria and helminth infection in sub-Saharan Africa include modern spatial risk prediction methods that combine statistical models with geographical information systems (similar to those used in car navigation systems). However, to date no studies have used these tools to spatially predict the risk of anemia. Furthermore, the contribution that malnutrition and infections make to the overall anemia burden in Africa is largely unknown. In this study the researchers used these tools to predict the prevalence of anemia in three West African countries and to estimate the attributable risk of anemia due to malnutrition, malaria, and helminth infections.
What Did the Researchers Do and Find?
The researchers used geographically linked data from the most recent Demographic and Health Surveys (DHS) in Burkina Faso (2003), Ghana (2003), and Mali (2006), which included capillary blood sampling and testing and detailed anthropometric (height and weight) measurements. A total of 7,147 children aged 1–4 years (3,477 girls and 3,670 boys) in the three countries were included in the analysis. The researchers mapped DHS survey locations in the three study countries using DHS cluster coordinates in a geographic information system. Using data from the Malaria Atlas Project, the researchers extracted spatially predicted values of Plasmodium falciparum parasite rate for each DHS cluster using a geographical information system and used previously reported parasitological survey data of hookworm and S. haematobium infections to predict helminth infection risk across the region. Then the researchers developed spatial prediction models using Bayesian statistics to estimate of the population attributable fraction for specific predictors for anemia. Data from the DHS showed that the prevalence of mild, moderate, and severe anemia was 21%, 66%, and 13% in Burkina Faso; 28%, 65%, and 7% in Ghana, and 26%, 62%, and 12% in Mali. The prevalence of stunting, wasting, and being underweight in the study area was 87.8%, 89.7%, and 71.2%, respectively, and the mean P. falciparum parasite rate, and rates of S. haematobium infection, hookworm infection, and S. haematobium/hookworm coinfection for the study area were 52.0%, 26.8%, 8.2%, and 3.6%, respectively. The overall results indicate that in the three countries, approximately 6.7 million children aged 1–4 years have anemia. Severe malnutrition, P. falciparum infection, hookworm infection, S. haematobium infection, and hookworm/S. haematobium coinfection were responsible for an estimated 2.5 million, 1.0 million, 250,000, 285,000, and 61,000 anemia cases, respectively. Central Burkina Faso and southern Ghana had the highest number of anemic children.
What Do These Findings Mean?
These results add insight and detail to anemia prevalence and anemia severity within different geographical areas in three West African countries. The combination of anemia and mean hemoglobin predictive maps identifies communities in West Africa where preschool-age children are at increased risk of morbidity. The use of anemia maps has important practical implications for targeted control in these countries, such as guiding the efficient allocation of nutrient supplements and fortified foods, and enabling risk assessment of anemia due to different causes, which would in turn constitute an evidence base to calculate the best balance between interventions.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000438.
This study is further discussed in a PLoS Medicine Perspective by Abdisalan Noor
The WHO Web site has comprehensive information on the worldwide prevalence of anemia
More information on Demographic Health Surveys is available
More information on global predictions of malaria is available
doi:10.1371/journal.pmed.1000438
PMCID: PMC3110251  PMID: 21687688
20.  Adolescence As Risk Factor for Adverse Pregnancy Outcome in Central Africa – A Cross-Sectional Study 
PLoS ONE  2010;5(12):e14367.
Background
Sub-Saharan Africa has the highest rates of maternal and neonatal mortality worldwide. Young maternal age at delivery has been proposed as risk factor for adverse pregnancy outcome, yet there is insufficient data from Sub-Saharan Africa. The present study aimed to investigate the influence of maternal adolescence on pregnancy outcomes in the Central African country Gabon.
Methodology and Principal Findings
Data on maternal age, parity, birth weight, gestational age, maternal Plasmodium falciparum infection, use of bednets, and intake of intermittent preventive treatment of malaria in pregnancy were collected in a cross-sectional survey in 775 women giving birth in three mother-child health centers in Gabon. Adolescent women (≤16 years of age) had a significantly increased risk to deliver a baby with low birth weight in univariable analysis (22.8%, 13/57, vs. 9.3%, 67/718, OR: 2.9, 95% CI: 1.5–5.6) and young maternal age showed a statistically significant association with the risk for low birth weight in multivariable regression analysis after correction for established risk factors (OR: 2.7; 95% CI: 1.1–6.5). In further analysis adolescent women were shown to attend significantly less antenatal care visits than adult mothers (3.3±1.9 versus 4.4±1.9 mean visits, p<0.01, n = 356) and this difference accounted at least for part of the excess risk for low birth weight in adolescents.
Conclusion
Our data demonstrate the importance of adolescent age as risk factor for adverse pregnancy outcome. Antenatal care programs specifically tailored for the needs of adolescents may be necessary to improve the frequency of antenatal care visits and pregnancy outcomes in this risk group in Central Africa.
doi:10.1371/journal.pone.0014367
PMCID: PMC3004789  PMID: 21188301
21.  Evidence for an African Cluster of Human Head and Body Lice with Variable Colors and Interbreeding of Lice between Continents 
PLoS ONE  2012;7(5):e37804.
Background
Human head lice and body lice have been classified based on phenotypic characteristics, including geographical source, ecotype (preferred egg laying site hair or clothes), shape and color. More recently, genotypic studies have been based on mitochondrial genes, nuclear genes and intergenic spacers. Mitochondrial genetic analysis reclassified lice into three genotypes (A, B and C). However, no previous study has attempted to correlate both genotypic and phenotypic data.
Materials and Methods
Lice were collected in four African countries: Senegal, Burundi, Rwanda and Ethiopia and were photographed to compare their colors. The Multi-Spacer-Typing (MST) method was used to genotype lice belonging to the worldwide Clade A, allowing a comparison of phenotypic and genotypic data.
Results
No congruence between louse color and genotype has been identified. Phylogenetic analysis of the spacer PM2, performed including lice from other sources, showed the existence of an African cluster of human lice. However, the analysis of other spacers suggested that lice from different areas are interbreeding.
Conclusions
We identified two geotypes of Clade A head and body lice including one that is specifically African, that can be either black or grey and can live on the head or in clothing. We also hypothesized that lice from different areas are interbreeding.
doi:10.1371/journal.pone.0037804
PMCID: PMC3360600  PMID: 22662229
22.  Geographical Inequalities in Use of Improved Drinking Water Supply and Sanitation across Sub-Saharan Africa: Mapping and Spatial Analysis of Cross-sectional Survey Data 
PLoS Medicine  2014;11(4):e1001626.
Using cross-sectional survey data, Rachel Pullan and colleagues map geographical inequalities in use of improved drinking water supply and sanitation across sub-Saharan Africa.
Please see later in the article for the Editors' Summary
Background
Understanding geographic inequalities in coverage of drinking-water supply and sanitation (WSS) will help track progress towards universal coverage of water and sanitation by identifying marginalized populations, thus helping to control a large number of infectious diseases. This paper uses household survey data to develop comprehensive maps of WSS coverage at high spatial resolution for sub-Saharan Africa (SSA). Analysis is extended to investigate geographic heterogeneity and relative geographic inequality within countries.
Methods and Findings
Cluster-level data on household reported use of improved drinking-water supply, sanitation, and open defecation were abstracted from 138 national surveys undertaken from 1991–2012 in 41 countries. Spatially explicit logistic regression models were developed and fitted within a Bayesian framework, and used to predict coverage at the second administrative level (admin2, e.g., district) across SSA for 2012. Results reveal substantial geographical inequalities in predicted use of water and sanitation that exceed urban-rural disparities. The average range in coverage seen between admin2 within countries was 55% for improved drinking water, 54% for use of improved sanitation, and 59% for dependence upon open defecation. There was also some evidence that countries with higher levels of inequality relative to coverage in use of an improved drinking-water source also experienced higher levels of inequality in use of improved sanitation (rural populations r = 0.47, p = 0.002; urban populations r = 0.39, p = 0.01). Results are limited by the quantity of WSS data available, which varies considerably by country, and by the reliability and utility of available indicators.
Conclusions
This study identifies important geographic inequalities in use of WSS previously hidden within national statistics, confirming the necessity for targeted policies and metrics that reach the most marginalized populations. The presented maps and analysis approach can provide a mechanism for monitoring future reductions in inequality within countries, reflecting priorities of the post-2015 development agenda.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Access to a safe drinking-water supply (a water source that is protected from contamination) and to adequate sanitation facilities (toilets, improved latrines, and other facilities that prevent people coming into contact with human urine and feces) is essential for good health. Unimproved drinking-water sources and sanitation are responsible for 85% of deaths from diarrhea and 1% of the global burden of disease. They also increase the transmission of parasitic worms and other neglected tropical diseases. In 2000, world leaders set a target of reducing the proportion of the global population without access to safe drinking water and basic sanitation to half of the 1990 level by 2015 as part of Millennium Development Goal (MDG) 7 (“Ensure environmental sustainability”; the MDGs are designed to improve the social, economic, and health conditions in the world's poorest countries). Between 1990 and 2010, more than 2 billion people gained access to improved drinking-water sources and 1.8 billion gained access to improved sanitation. In 2011, 89% of the world's population had access to an improved drinking-water supply, 1% above the MDG target, and 64% had access to improved sanitation (the MDG target is 75%).
Why Was This Study Done?
Despite these encouraging figures, the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP) estimates that, globally, 768 million people relied on unimproved drinking-water sources, 2.5 billion people did not use an improved sanitation facility, and more than 1 billion people (15% of the global population) were defecating in the open in 2011. The JMP estimates for 2011 also reveal national and sub-national inequalities in drinking-water supply and sanitation coverage but a better understanding of geographic inequalities is needed to track progress towards universal coverage of access to improved water and sanitation and to identify the populations that need the most help to achieve this goal. Here, the researchers use cross-sectional household survey data and modern statistical approaches to produce a comprehensive map of the coverage of improved drinking-water supply and improved sanitation at high spatial resolution for sub-Saharan Africa and to investigate geographic inequalities in coverage. Cross-sectional household surveys collect health and other information from households at a single time-point, including data on use of safe water and improved sanitation.
What Did the Researchers Do and Find?
The researchers extracted data on reported household use of an improved drinking-water supply (for example, a piped water supply), improved sanitation facilities (for example, a flushing toilet), and open defecation from 138 national household surveys undertaken between 1991 and 2012 in 41 countries in sub-Saharan Africa. They developed statistical models to fit these data and used the models to estimate coverage at the district (second administrative) level across sub-Saharan Africa for 2012. For ten countries, the estimated coverage of access to improved drinking water at the district level within individual countries ranged from less than 25% to more than 75%. Within-country ranges of a similar magnitude were estimated for coverage of access to improved sanitation (21 countries) and for open defecation (16 countries). Notably, rural households in the districts with the lowest coverage of access to improved water supply and sanitation within a country were 1.5–8 times less likely to access improved drinking water, 2–18 times less likely to access improved sanitation, and 2–80 times more likely to defecate in the open than rural households in districts with the best coverage. Finally, countries with high levels of inequality in improved drinking-water source coverage also experienced high levels of inequality in improved sanitation coverage.
What Do These Findings Mean?
These findings identify important geographic inequalities in the coverage of access to improved water sources and sanitation that were previously hidden within national statistics. The accuracy of these findings depends on the accuracy of the data on water supplies and sanitation provided by household surveys, on the researchers' definitions for improved water supplies and sanitation, and on their statistical methods. Nevertheless, these findings confirm that, to achieve universal coverage of access to improved drinking-water sources and sanitation, strategies that target the areas with the lowest coverage are essential. Moreover, the maps and the analytical approach presented here provide the means for monitoring future reductions in inequalities in the coverage of access to improved water sources and sanitation and thus reflect a major priority of the post-2015 development agenda.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001626.
A PLOS Medicine Collection on water and sanitation is available
The World Health Organization (WHO) provides information on water, sanitation, and health (in several languages)
The WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation is the official United Nations mechanism tasked with monitoring progress toward MDG7, Target 7B; the JMP 2013 update report is available online (also available in French and Spanish through the JMP website)
The sub-national predictions resulting from this study and the final sub-national maps are available as a resource for researchers and planners
doi:10.1371/journal.pmed.1001626
PMCID: PMC3979660  PMID: 24714528
23.  ETHNIC RESIDENTIAL PATTERNS AS PREDICTORS OF INTRA-URBAN CHILD MORTALITY INEQUALITY IN ACCRA, GHANA1 
Urban geography  2006;27(6):526-548.
As cities of developing nations absorb an increasing fraction of the world’s population increase, questions have arisen about the potential for emerging inequalities in health within places that are already suffering from inadequate infrastructure. In this paper we explore the pattern of child mortality inequalities (as a proxy for overall health levels) within a large sub-Saharan African city—Accra, Ghana—and then we examine the extent to which existing residential patterns by ethnicity may be predictive of any observed intra-urban inequalities in child mortality. We find that the spatial variability in child mortality in Accra is especially associated with the pattern of residential separation of the Ga from other ethnic groups, with the Ga having higher levels of mortality than other ethnic groups. Being of Ga ethnicity exposes a woman and her children to characteristics of the places in Accra where the Ga live, in which one-room dwellings and poor infrastructure predominate. At the individual level, we find that regardless of where a woman lives, if she is of Ga ethnicity and/or is non-Christian, and if she is not married, her risks of having lost a child are elevated.
PMCID: PMC2758568  PMID: 19816546
ethnicity; residential patterns; child mortality; urban; Accra; Ghana
24.  The financial cost of doctors emigrating from sub-Saharan Africa: human capital analysis 
Objective To estimate the lost investment of domestically educated doctors migrating from sub-Saharan African countries to Australia, Canada, the United Kingdom, and the United States.
Design Human capital cost analysis using publicly accessible data.
Settings Sub-Saharan African countries.
Participants Nine sub-Saharan African countries with an HIV prevalence of 5% or greater or with more than one million people with HIV/AIDS and with at least one medical school (Ethiopia, Kenya, Malawi, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe), and data available on the number of doctors practising in destination countries.
Main outcome measures The financial cost of educating a doctor (through primary, secondary, and medical school), assuming that migration occurred after graduation, using current country specific interest rates for savings converted to US dollars; cost according to the number of source country doctors currently working in the destination countries; and savings to destination countries of receiving trained doctors.
Results In the nine source countries the estimated government subsidised cost of a doctor’s education ranged from $21 000 (£13 000; €15 000) in Uganda to $58 700 in South Africa. The overall estimated loss of returns from investment for all doctors currently working in the destination countries was $2.17bn (95% confidence interval 2.13bn to 2.21bn), with costs for each country ranging from $2.16m (1.55m to 2.78m) for Malawi to $1.41bn (1.38bn to 1.44bn) for South Africa. The ratio of the estimated compounded lost investment over gross domestic product showed that Zimbabwe and South Africa had the largest losses. The benefit to destination countries of recruiting trained doctors was largest for the United Kingdom ($2.7bn) and United States ($846m).
Conclusions Among sub-Saharan African countries most affected by HIV/AIDS, lost investment from the emigration of doctors is considerable. Destination countries should consider investing in measurable training for source countries and strengthening of their health systems.
doi:10.1136/bmj.d7031
PMCID: PMC3223532  PMID: 22117056
25.  The Index of Multiple Deprivation 2000 and accessibility effects on health 
Study objective: To investigate whether the Index of Multiple Deprivation 2000 (IMD) is more strongly related to inequalities in health in rural areas than traditional deprivation indices. To explore the contribution of the IMD domain "geographical access to services" to understanding rural health variations.
Design: A geographically based cross sectional study.
Setting: Nine counties in the south west region of England.
Participants: All those aged below 65 who reported a limiting long term illness in the 1991 census, and all those who died during 1991–96, aged less than 65 years.
Main results: The IMD is comparable with the Townsend score in its overall correlation with premature mortality (r2 = 0.44 v 0.53) and morbidity (r2 = 0.79 v 0.76). Correlation between the Townsend score and population health is weak in rural areas but the IMD maintains a strong correlation with rates of morbidity (r2 = 0.70). The "geographical access to services" domain of the IMD is not strongly correlated with rates of morbidity in rural areas (r2 = 0.04), and in urban areas displays a negative correlation (r2 = -0.47).
Conclusions: The IMD has a strong relation with health in both rural and urban areas. This is likely to be the result of the inclusion of data in the IMD on the numbers of people claiming benefits related to ill health and disability. The domain "geographical access to services" is not associated with health in rural areas, although it displays some association in urban areas. This domain is potentially important but, as yet, inadequately specified in the IMD for the purposes of health research.
doi:10.1136/jech.2003.013011
PMCID: PMC1732697  PMID: 14966241

Results 1-25 (715237)