[Show abstract][Hide abstract] ABSTRACT: It is a recognized child right to acquire a name and a nationality, and birth registration may be necessary to allow access to services, but the level of birth registration is low in Nigeria. A household survey about management of childhood illnesses provided an opportunity to examine actionable determinants of birth registration of children in Bauchi and Cross River states of Nigeria.
Trained field teams visited households in a stratified random cluster sample of 90 enumeration areas in each state. They administered a questionnaire to women 14-49 years old which included questions about birth registration of their children 0-47 months old and about socio-economic and other factors potentially related to birth registration, including education of the parents, poverty (food sufficiency), marital status of the mother, maternal antenatal care and place of delivery of the last pregnancy. Bivariate then multivariate analysis examined associations with birth registration. Facilitators later conducted separate male and female focus group discussions in the same 90 communities in each state, discussing the reasons for the findings about levels of birth registration.
Nearly half (45%) of 8602 children in Cross River State and only a fifth (19%) of 9837 in Bauchi State had birth certificates (seen or unseen). In both states, children whose mothers attended antenatal care and who delivered in a government health facility in their last pregnancy were more likely to have a birth certificate, as were children of more educated parents, from less poor households, and from urban communities. Focus group discussions revealed that many people did not know about birth certificates or where to get them, and parents were discouraged from getting birth certificates because of the unofficial payments involved.
There are low levels of birth registration in Bauchi and Cross River states, particularly among disadvantaged households. As a result of this study, both states have planned interventions to increase birth registration, including closer collaboration between the National Population Commissions and state health services.
BMC Research Notes 12/2015; 8(1):1026. DOI:10.1186/s13104-015-1026-y
[Show abstract][Hide abstract] ABSTRACT: Migration can be a major risk factor for gender violence due to cultural differences, stereotypes, unemployment, and lack of knowledge about services and immigration laws. Even though it is possible to get evidence about many of these issues, there is a lack of evidence-informed interventions designed to reduce gender violence among Arab immigrants in Canada. The hierarchical structure within many Arab families in western societies can challenge prescribed gender roles, which might be perceived as a threat to the continuity of the culture and a reason for abuse. This literature review addresses issues for interventions that seek to reduce gender violence while recognizing resilience, family hierarchy, and the value of maintaining a family as potentially protective factors in prevention programming.
Journal of Family Violence 05/2015; DOI:10.1007/s10896-015-9718-6 · 1.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Malnutrition remains an important cause of childhood morbidity and mortality; the levels of childhood malnutrition in Nigeria are among the highest in the world. The literature supports many direct and indirect causes of malnutrition, but few studies have examined the link between maternal care during pregnancy and childbirth and childhood malnutrition. This study examines this potential link in Bauchi and Cross River states in Nigeria.
In 2011, a household survey collected information about children under four years old and their mothers' last pregnancy. Trained fieldworkers measured mid-upper arm circumference (MUAC) of children aged 6-47 months. We examined associations with childhood malnutrition in bivariate and multivariate analysis.
Some 4.4% of 3643 children in Cross River, and 14.7% of 2706 in Bauchi were malnourished (MUAC z-score). In both states, a child whose mother had fewer than four government antenatal care visits was more likely to be malnourished (Cross River: OR 1.85, 95%CIca 1.33-2.55; Bauchi: OR 1.29, 95%CIca 1.02-1.63). In Bauchi, a child whose mother who rarely or never discussed pregnancy and childbirth with her husband (OR 1.34, 95%CIca 1.07-1.68), and who did not have her last delivery attended by a skilled health worker was more likely to be malnourished (OR 1.50, 95%CIca 1.09-2.07).
These findings, if confirmed in other studies, suggest that poor care of women in pregnancy and childbirth could pose a longer term risk to the health of the child, as well as increasing immediate risks for both mother and child. Significance for public healthChildhood malnutrition is a public health priority, accounting for almost 1/5 of global disease burden among children under five years old. Many studies have examined risk factors for childhood malnutrition, but few have examined the link between maternal care during pregnancy and childbirth and childhood malnutrition. This study, albeit a cross-sectional design, provides evidence of a link between poor care during pregnancy and childbirth and childhood malnutrition in two states of Nigeria. This is important for public health because it suggests another benefit of caring for women during pregnancy and childbirth. This could not only reduce maternal and child perinatal mortality, but also have benefits for the longer-term health and development of children. This finding could be useful for paternal advocacy; it may motivate men to support their wives during pregnancy and childbirth since through this support, fathers can also protect the future development of their children.
[Show abstract][Hide abstract] ABSTRACT: Poor children have a higher risk of contracting malaria and may be less likely to receive effective treatment. Malaria is an important cause of morbidity and mortality in Nigerian children and many cases of childhood fever are due to malaria. This study examined socioeconomic factors related to taking children with fever for treatment in formal health facilities.
A household survey conducted in Bauchi and Cross River states of Nigeria asked parents where they sought treatment for their children aged 0-47 months with severe fever in the last month and collected information about household socio-economic status. Fieldworkers also recorded whether there was a health facility in the community. We used treatment of severe fever in a health facility to indicate likely effective treatment for malaria. Multivariate analysis in each state examined associations with treatment of childhood fever in a health facility.
43% weighted (%wt) of 10,862 children had severe fever in the last month in Cross River, and 45%wt of 11,053 children in Bauchi. Of these, less than half (31%wt Cross River, 44%wt Bauchi) were taken to a formal health facility for treatment. Children were more likely to be taken to a health facility if there was one in the community (OR 2.31 [95% CI 1.57-3.39] in Cross River, OR 1.33 [95% CI 1.0-1.7] in Bauchi). Children with fever lasting less than five days were less likely to be taken for treatment than those with more prolonged fever, regardless of whether there was such a facility in their community. Educated mothers were more likely to take children with fever to a formal health facility. In communities with a health facility in Cross River, children from less-poor households were more likely to go to the facility (OR 1.30; 95% CI 1.07-1.58).
There is inequity of access to effective malaria treatment for children with fever in the two states, even when there is a formal health facility in the community. Understanding the details of inequity of access in the two states could help the state governments to plan interventions to increase access equitably. Increasing geographic access to health facilities is needed but will not be enough.
[Show abstract][Hide abstract] ABSTRACT: Childhood vaccination rates in Nigeria are among the lowest in the world and this affects morbidity and mortality rates. A 2011 mixed methods study in two states in Nigeria examined coverage of measles vaccination and reasons for not vaccinating children.
A household survey covered a stratified random cluster sample of 180 enumeration areas in Bauchi and Cross River States. Cluster-adjusted bivariate and then multivariate analysis examined associations between measles vaccination and potential determinants among children aged 12-23 months, including household socio-economic status, parental knowledge and attitudes about vaccination, and access to vaccination services. Focus groups of parents in the same sites subsequently discussed the survey findings and gave reasons for non-vaccination. A knowledge to action strategy shared findings with stakeholders, including state government, local governments and communities, to stimulate evidence-based actions to increase vaccination rates.
Interviewers collected data on 2,836 children aged 12-23 months in Cross River and 2,421 children in Bauchi. Mothers reported 81.8% of children in Cross River and 42.0% in Bauchi had received measles vaccine. In both states, children were more likely to receive measles vaccine if their mothers thought immunisation worthwhile, if immunisation was discussed in the home, if their mothers had more education, and if they had a birth certificate. In Bauchi, maternal awareness about immunization, mothers' involvement in deciding about immunization, and fathers' education increased the chances of vaccination. In Cross River, children from communities with a government immunisation facility were more likely to have received measles vaccine. Focus groups revealed lack of knowledge and negative attitudes about vaccination, and complaints about having to pay for vaccination. Health planners in both states used the findings to support efforts to increase vaccination rates.
Measles vaccination remains sub-optimal, particularly in Bauchi. Efforts to counter negative perceptions about vaccination and to ensure vaccinations are actually provided free may help to increase vaccination rates. Parents need to be made aware that vaccination should be free, including for children without a birth certificate, and vaccination could be an opportunity for issuing birth certificates. The study provides pointers for state level planning to increase vaccination rates.
[Show abstract][Hide abstract] ABSTRACT: Background
Antenatal care (ANC) attendance is a strong predictor of maternal outcomes. In Nigeria, government health planners at state level and below have limited access to population-based estimates of ANC coverage and factors associated with its use. A mixed methods study examined factors associated with the use of government ANC services in two states of Nigeria, and shared the findings with stakeholders.MethodsA quantitative household survey in Bauchi and Cross River states of Nigeria collected data from women aged 15¿49 years on ANC use during their last completed pregnancy and potentially associated factors including socio-economic conditions, exposure to domestic violence and local availability of services. Bivariate and multivariate analysis examined associations with having at least four government ANC visits. We collected qualitative data from 180 focus groups of women who discussed the survey findings and recommended solutions. We shared the findings with state, Local Government Authority, and community stakeholders to support evidence-based planning.Results40% of 7870 women in Bauchi and 46% of 7759 in Cross River had at least four government ANC visits. Women's education, urban residence, information from heath workers, help from family members, and household owning motorized transport were associated with ANC use in both states. Additional factors for women in Cross River included age above 18 years, being married or cohabiting, being less poor (having enough food during the last week), not experiencing intimate partner violence during the last year, and education of the household head. Factors for women in Bauchi were presence of government ANC services within their community and more than two previous pregnancies. Focus groups cited costly, poor quality, and inaccessible government services, and uncooperative partners as reasons for not attending ANC. Government and other stakeholders planned evidence-based interventions to increase ANC uptake.Conclusion
Use of ANC services remains low in both states. The factors related to use of ANC services are consistent with those reported previously. Efforts to increase uptake of ANC should focus particularly on poor and uneducated women. Local solutions generated by discussion of the evidence with stakeholders could be more effective and sustainable than externally driven interventions.
[Show abstract][Hide abstract] ABSTRACT: Background:
Vaccination is a key current prophylactic measure for occupational risk of hepatitis B virus (HBV) infection. This study measures HBV vaccination coverage among health personnel in a Mexican hospital, and identifies factors associated with completion of the vaccination schedule.
A cross-sectional study in workers of the Acapulco General Hospital, Mexico. Interviews documented vaccination history against HBV, number of doses received, and date of vaccination. Health workers with complete vaccination were considered those with at least three doses of vaccine received at intervals of two months between first and second doses, and six months to a year in the third dose.
Some 52% of workers (436/834) reported at least one vaccination during their professional life and only 5.5% (46/834) completed the HBV vaccination schedule. Factors associated with completion were academic degree, perception of infection risk at work, and knowledge of vaccine efficacy and the need for a complete schedule.
In line with hospitals in other studies, few hospital workers were fully vaccinated. Evidence from this study can inform efforts to increase HBV vaccination coverage.
Gaceta medica de Mexico 09/2014; 150(5):395-402. · 0.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Poor people bear a disproportionate burden of malaria and prevention measures may not reach them well. A study carried out to examine the socio-economic factors associated with ownership and use of treated bed nets in Cross River and Bauchi States of Nigeria took place soon after campaigns to distribute treated bed nets.
A cross-sectional household survey about childhood illnesses among mothers of children less than four years of age and focus group discussions in 90 communities in each of the two states asked about household ownership of treated bed nets and their use for children under four years old. Bivariate and multivariate analyses examined associations between socio-economic and other variables and these outcomes in each state.
Some 72% of 7,685 households in Cross River and 87% of 5,535 households in Bauchi State had at least one treated bed net. In Cross River, urban households were more likely to possess bed nets, as were less-poor households (enough food in the last week), those with a male head, and those from communities with a formal health facility. In Bauchi, less-poor households and those with a more educated head were more likely to possess nets. In households with nets, only about half of children under four years old always slept under a net: 54% of 11,267 in Cross River and 57% of 11,277 in Bauchi. Factors associated with use of nets for young children in Cross River were less-poor households, fewer young children in the household, more education of the father, antenatal care of the mother, and younger age of the child, while in Bauchi the factors were a mother with more education and antenatal care, and younger age of the child. Some focus groups complained of distribution difficulties, and many described misconceptions about adverse effects of nets as an important reason for not using them.
Despite a recent campaign to distribute treated bed nets, disadvantaged households were less likely to possess them and to use them for young children. Efforts are needed to reach these households and to dispel fears about dangers of using treated nets.
[Show abstract][Hide abstract] ABSTRACT: Elected national representatives make decisions to fund health programmes, but may lack skills to interpret evidence on health-related topics. In 2011, we surveyed the 61 members of Botswana's Parliament about their use of epidemiological evidence, then provided two half-days of training about using evidence. We included the importance of counter-factual evidence, the number needed to treat, and unit costs of interventions. A further session in 2012 covered evidence about the HIV epidemic in Botswana and planning the best mix of interventions to reduce new HIV infections. The 27 respondents reported they lacked good quality, timely evidence, and had difficulty interpreting and using evidence. Thirty-six, including seven ministers, attended one or both trainings. They participated actively and their evaluation was positive. Our experience in Botswana could potentially be extended to other countries in the region to support evidence-based efforts to tackle the HIV epidemic.Journal of Public Health Policy advance online publication, 10 July 2014; doi:10.1057/jphp.2014.30.
Journal of Public Health Policy 07/2014; 35(4). DOI:10.1057/jphp.2014.30 · 1.78 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This paper describes implementation research of an intervention in a complex HIV prevention randomised trial in southern Africa. Researchers collected stories of change attributed by 106 community members to an audio-drama edutainment intervention in 41 sites in Botswana, Namibia and Swaziland. The team analysed themes in the stories following a behaviour change model of conscious knowledge, attitudes, subjective norms, intention to change, agency, discussion and action (CASCADA). Storytellers attributed positive changes to the intervention in the areas of gender violence, multiple sexual partners, transactional and intergenerational sex and condom use. Their stories illustrate each of the steps in the CASCADA behaviour change model. As well as supporting an enabling environment for other interventions in the trial, the audio-drama also helped some participants to make personal changes. Collecting and discussing the stories were encouraging for the trial fieldworkers. Documenting the experiences of participants and framing the analysis of stories in an explicit behaviour change model allowed us to reflect on potential mechanisms and pathways through which the intervention impacts on individuals and communities. It helped in the design of the quantitative instruments to measure intermediate outcomes of the trial.
AIDS Care 07/2014; 26(12):1-7. DOI:10.1080/09540121.2014.931560 · 1.60 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Most HIV prevention strategies assume beneficiaries can act on their prevention decisions. But some people are unable to do so. They are ‘choice-disabled’. Economic and educational interventions can reduce sexual violence, but there is less evidence that they can reduce HIV. There is little research on complex interventions in HIV prevention, yet all countries in southern Africa implement combination prevention programmes.
The primary objective is to reduce HIV infections among women aged 15 to 29 years. Secondary objectives are reduction in gender violence and improvement in HIV-related knowledge, attitudes and practices among youth aged 15 to 29 years.
A random sample of 77 census enumeration areas in three countries (Botswana, Namibia and Swaziland) was allocated randomly to three interventions, alone or in combination, in a factorial design stratified by country, HIV rates (above or below average for country), and urban/rural location. A baseline survey of youth aged 15 to 29 years provided cluster specific rates of HIV. All clusters continue existing prevention efforts and have a baseline and follow-up survey. Cluster is the unit of allocation, intervention and analysis, using generalised estimating equations, on an intention-to-treat basis.
One intervention discusses evidence about choice disability with local HIV prevention services, to help them to serve the choice-disabled. Another discusses an eight-episode audio-docudrama with community groups, of all ages and both sexes, to generate endogenous strategies to reduce gender violence and develop an enabling environment. A third supports groups of women aged 18 to 25 years to build self-esteem and life skills and to set up small enterprises to generate income.
A survey in all clusters after 3 years will measure outcomes, with interviewers unaware of group assignment of the clusters. The primary outcome is HIV infection in women aged 15 to 29 years. Secondary outcomes in youth aged 15 to 29 years are gender violence and protective knowledge, attitudes, subjective norms, intention to change, agency, discussion of prevention and practices related to HIV and gender violence.
Trial registration number: ISRCTN28557578
[Show abstract][Hide abstract] ABSTRACT: Objectives To study prevalence at two time points and risk factors for experience of forced or coerced sex among school-going youth in 10 southern African countries.
Design Cross-sectional surveys, by facilitated self-administered questionnaire, of in-school youth in 2003 and 2007.
Setting Schools serving representative communities in eight countries (Botswana, Lesotho, Malawi, Mozambique, Namibia, Swaziland, Zambia and Zimbabwe) in 2003 and with Tanzania and South Africa added in 2007.
Participants Students aged 11–16 years present in the school classes.
Main outcome measures Experience of forced or coerced sex, perpetration of forced sex.
Results In 2007, 19.6% (4432/25 840) of female students and 21.1% (4080/21 613) of male students aged 11–16 years reported they had experienced forced or coerced sex. Rates among 16-year-olds were 28.8% in females and 25.4% in males. Comparing the same schools in eight countries, in an analysis age standardised on the 2007 Botswana male sample, there was no significant decrease between 2003 and 2007 among females in any country and inconsistent changes among males. In multilevel analysis using generalised linear mixed model, individual-level risk factors for forced sex among female students were age over 13 years and insufficient food in the household; school-level factors were a lower proportion of students knowing about child rights and higher proportions experiencing or perpetrating forced sex; and community-level factors were a higher proportion of adults in favour of transactional sex and a higher rate of intimate partner violence. Male risk factors were similar. Some 4.7% of female students and 11.7% of male students reported they had perpetrated forced sex. Experience of forced sex was strongly associated with perpetration and other risk factors for perpetration were similar to those for victimisation.
Conclusions Forced or coerced sex remained common among female and male youth in 2007. Experience of sexual abuse in childhood is recognised to increase the risk of HIV infection. The association the authors found between forced sex and school-level factors suggests preventive interventions in schools could help to tackle the HIV epidemic in southern Africa.
BMJ Open 03/2012; 2(2):e000754. DOI:10.1136/bmjopen-2011-000754 · 2.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The Maldives faces challenges in the provision of health services to its population scattered across many small islands. The government commissioned two separate reproductive health surveys, in 1999 and 2004, to inform their efforts to improve reproductive and sexual health services.
A stratified random sample of islands provided the study base for a cluster survey in 1999 and a follow-up of the same clusters in 2004. In 1999 the household survey enquired about relevant knowledge, attitudes and practices and views and experience of available reproductive health services, with a focus on women aged 15-49 years. The 2004 household survey included some of the same questions as in 1999, and also sought views of men aged 15-64 years. A separate survey about sexual and reproductive health covered 1141 unmarried youth aged 15-24 years.
There were 4087 household respondents in 1999 and 4102 in 2004. The contraceptive prevalence rate (CPR) for modern methods was 33% in 1999 and 34% in 2004. Antenatal care improved: more women in 2004 than in 1999 had at least four antenatal care visits (90.0% v 65.1%) and took iron supplements (86.7% v 49.6%) during their last pregnancy. The response rate for the youth survey was only 42% (varying from 100% in some islands to 12% in sites in the capital). The youth respondents had some knowledge gaps (one third did not know if people with HIV could look healthy and less than half thought condoms could protect against HIV), and some unhelpful attitudes about gender and reproductive health.
The two household surveys were commissioned as separate entities, with different priorities and data capture methods, rather than being undertaken as a specific research study. The direct comparisons we could make indicated an unchanged CPR and improvements in antenatal care, with the Maldives ahead of the South Asia region for antenatal care. The low response rate in the youth survey limited interpretation of the findings. But the survey highlighted areas requiring attention. Surveys not undertaken primarily for research purposes have important limitations but can provide useful information.
BMC Health Services Research 12/2011; 11 Suppl 2(Suppl 2):S6. DOI:10.1186/1472-6963-11-S2-S6 · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Unofficial payments in health services around the world are widespread and as varied as the health systems in which they occur. We reviewed the main lessons from social audits of petty corruption in health services in South Asia (Bangladesh, Pakistan), Africa (Uganda and South Africa) and Europe (Baltic States).
The social audits varied in purpose and scope. All covered representative sample communities and involved household interviews, focus group discussions, institutional reviews of health facilities, interviews with service providers and discussions with health authorities. Most audits questioned households about views on health services, perceived corruption in the services, and use of government and other health services. Questions to service users asked about making official and unofficial payments, amounts paid, service delivery indicators, and satisfaction with the service.
Contextual differences between the countries affected the forms of petty corruption and factors related to it. Most households in all countries held negative views about government health services and many perceived these services as corrupt. There was little evidence that better off service users were more likely to make an unofficial payment, or that making such a payment was associated with better or quicker service; those who paid unofficially to health care workers were not more satisfied with the service. In South Asia, where we conducted repeated social audits, only a minority of households chose to use government health services and their use declined over time in favour of other providers. Focus groups indicated that reasons for avoiding government health services included the need to pay for supposedly free services and the non-availability of medicines in facilities, often perceived as due to diversion of the supplied medicines.
Unofficial expenses for medical care represent a disproportionate cost for vulnerable families; the very people who need to make use of supposedly free government services, and are a barrier to the use of these services. Patient dissatisfaction due to petty corruption may contribute to abandonment of government health services. The social audits informed plans for tackling corruption in health services.
BMC Health Services Research 12/2011; 11 Suppl 2(Suppl 2):S12. DOI:10.1186/1472-6963-11-S2-S12 · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Since 2005, the Tłįcho Community Services Agency (TCSA) in Canada's Northwest Territories (NT) has addressed rising rates of sexually transmitted infections (STI). In 2009, STI rates in the NT were ten times higher than the national rate and Tłįcho regional rates were nearly four times that of the NT--91 cases per 1000 people. We describe a social audit process that assessed the impact of an evidence-based community-led intervention.
A baseline survey of sexual health knowledge, attitudes and behaviours in 2006/07 provided evidence for a Community Action Research Team (CART) to develop and to put in place culturally appropriate interventions in the Tłįcho region. A follow-up study in 2010 sought to assess the impact of CART activities on condom use and underlying conscious knowledge, attitudes, subjective norms, intention to change, sense of agency and discussions related to condom use and STI risks. We report the contrasts using Odds Ratios (OR) and 95% confidence intervals (CI).
One in every three follow-up respondents (315/808) participated in at least one CART activity. Participation in highly ranked interventions was associated with increased condom use during the last sexual encounter (OR 1.45, 95%CI 1.07-1.98). Those exposed to three or more activities were more likely to talk openly about condoms (OR 2.08, 95%CI 1.41-3.28), but were also less likely to be monogamous (OR 0.49, 95%CI 0.29-0.90).
The measurable impact on condom use indicates a strong beginning for the Tłįcho community intervention programmes. The interventions also seem to generate increased discussion, often a precursor to action. The Tłįcho can use the evidence to improve and refocus their programming, increase knowledge and continue to improve safe condom use practices.
BMC Health Services Research 12/2011; 11 Suppl 2(Suppl 2):S9. DOI:10.1186/1472-6963-11-S2-S9 · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: After election in 1994, the South African government implemented national and regional programmes, such as the Wild Coast Spatial Development Initiative (SDI), to provoke economic growth and to decrease inequities. CIET measured development in the Wild Coast region across four linked cross-sectional surveys (1997-2007). The 2007 survey was an opportunity to look at inequities since the original 1997 baseline, and how such inequities affect access to health care.
The 2000, 2004 and 2007 follow-up surveys revisited the communities of the 1997 baseline. Household-level multivariate analysis looked at development indicators and access to health in the context of inequities such as household crowding, access to protected sources of water, house roof construction, main food item purchased, and perception of community empowerment. Individual multivariate models accounted for age, sex, education and income earning opportunities.
Overall access to protected sources of water increased since the baseline (from 20% in 1997 to 50% in 2007), yet households made of mud and grass, and households who bought basics as their main food item were still less likely to have protected sources of water. The most vulnerable, such as those with less education and less water and food security, were also less likely to have worked for wages leaving them with little chance of improving their standard of living (less education OR 0.59, 95%CI 0.37-0.94; less water security OR 0.67, 95%CI 0.48-0.93; less food security OR 0.43, 95%CI 0.29-0.64). People with less income were more likely to visit government services (among men OR 0.28, 95%CI 0.13-0.59; among women OR 0.33, 95%CI 0.20-0.54), reporting decision factors of cost and distance; users of private clinics sought out better service and medication. Lower food security and poorer house construction was also associated with women visiting government rather than private health services. Women with some formal education were nearly eight times more likely than women with no education to access health services for prevention rather than curative reasons (OR 7.65, 95%CI 4.10-14.25).
While there have been some improvements, the Wild Coast region still falls well below provincial and national standards in key areas such as access to clean water and employment despite years of government-led investment. Inequities remain prominent, particularly around access to health services.
BMC Health Services Research 12/2011; 11 Suppl 2(Suppl 2):S5. DOI:10.1186/1472-6963-11-S2-S5 · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Nigeria continues to have high rates of maternal morbidity and mortality. This is partly associated with lack of adequate obstetric care, partly with high risks in pregnancy, including heavy work. We examined actionable risk factors and underlying determinants at community level in Bauchi and Cross River States of Nigeria, including several related to male responsibility in pregnancy.
In 2009, field teams visited a stratified (urban/rural) last stage random sample of 180 enumeration areas drawn from the most recent censuses in each of Bauchi and Cross River states. A structured questionnaire administered in face-to-face interviews with women aged 15-49 years documented education, income, recent birth history, knowledge and attitudes related to safe birth, and deliveries in the last three years. Closed questions covered female genital mutilation, intimate partner violence (IPV) in the last year, IPV during the last pregnancy, work during the last pregnancy, and support during pregnancy. The outcome was complications in pregnancy and delivery (eclampsia, sepsis, bleeding) among survivors of childbirth in the last three years. We adjusted bivariate and multivariate analysis for clustering.
The most consistent and prominent of 28 candidate risk factors and underlying determinants for non-fatal maternal morbidity was intimate partner violence (IPV) during pregnancy (ORa 2.15, 95%CIca 1.43-3.24 in Bauchi and ORa 1.5, 95%CI 1.20-2.03 in Cross River). Other spouse-related factors in the multivariate model included not discussing pregnancy with the spouse and, independently, IPV in the last year. Shortage of food in the last week was a factor in both Bauchi (ORa 1.66, 95%CIca 1.22-2.26) and Cross River (ORa 1.32, 95%CIca 1.15-1.53). Female genital mutilation was a factor among less well to do Bauchi women (ORa 2.1, 95%CIca 1.39-3.17) and all Cross River women (ORa 1.23, 95%CIca 1.1-1.5).
Enhancing clinical protocols and skills can only benefit women in Nigeria and elsewhere. But the violence women experience throughout their lives--genital mutilation, domestic violence, and steep power gradients--is accentuated through pregnancy and childbirth, when women are most vulnerable. IPV especially in pregnancy, women's fear of husbands or partners and not discussing pregnancy are all within men's capacity to change.
BMC Health Services Research 12/2011; 11 Suppl 2(Suppl 2):S7. DOI:10.1186/1472-6963-11-S2-S7 · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Health planners and managers make decisions based on their appreciation of causality. Social audits question the assumptions behind this and try to improve quality of available evidence. The method has its origin in the follow-up of Bhopal survivors in the 1980s, where “cluster cohorts” tracked health events over time. In social audit, a representative panel of sentinel sites are the framework to follow the impact of health programmes or reforms. The epidemiological backbone of social audit tackles causality in a calculated way, balancing computational aspects with appreciation of the limits of the science.
Social audits share findings with planners at policy level, health services providers, and users in the household, where final decisions about use of public services rest. Sharing survey results with sample communities and service workers generates a second order of results through structured discussions. Aggregation of these evidence-based community-led solutions across a representative sample provides a rich substrate for decisions. This socialising of evidence for participatory action (SEPA) involves a different skill set but quality control and rigour are still important.
Early social audits addressed settings without accepted sample frames, the fundamentals of reproducible questionnaires, and the logistics of data turnaround. Feedback of results to stakeholders was at CIET insistence – and at CIET expense. Later social audits included strong SEPA components. Recent and current social audits are institutionalising high level research methods in planning, incorporating randomisation and experimental designs in a rigorous approach to causality.
The 25 years have provided a number of lessons. Social audit reduces the arbitrariness of planning decisions, and reduces the wastage of simply allocating resources the way they were in past years. But too much evidence easily exceeds the uptake capacity of decision takers. Political will of governments often did not match those of donors with interest conditioned by political cycles. Some reforms have a longer turnaround than the political cycle; short turnaround interventions can develop momentum. Experience and specialisation made social audit seem more simple than it is. The core of social audit, its mystique, is not easily taught or transferred. Yet teams in Mexico, Nicaragua, Canada, southern Africa, and Pakistan all have more than a decade of experience in social audit, their in-service training supported by a customised Masters programme.
BMC Health Services Research 12/2011; 11 Suppl 2(Suppl 2):S1. DOI:10.1186/1472-6963-11-S2-S1 · 1.71 Impact Factor