Joseph Kangmennaang

Investigating the disparities in cervical cancer screening among Namibian women

OBJECTIVES We examined the influence of knowledge and information, health care access and different socio-economic variables on womens decision to screen for cervical cancer using a nationally representative dataset. METHODS We use hierarchical binary logit regression models to explore the determinants of screening for cervical cancer among women who reported hearing about cervical cancer. This enabled us to include the effect of unobserved heterogeneity at the cluster level that may affect screening behaviors. RESULTS Among women who have heard about cervical cancer (N=6542), only 39% of them did undergo screening with a mean age of 33 years. The univariate results reveal that women who are educated, insured, can afford money needed for treatment and reported distance not a barrier to accessing healthcare were more likely to screen. Our multivariate results indicate that insured women (OR=1.89, p=0.001) and women who had access to information through education and contact with a health worker (OR=1.41, p=0.001) were more likely to undertake screening compared to uninsured women and those with no contact with a health personnel, after controlling for relevant variables. CONCLUSIONS The adoption of a universal health insurance scheme that ensures equity in access to health care and extension of public health information targeting women in rural communities especially within the Caprivi region may be needed for a large scale increase in cervical cancer screening in Namibia.

Agroecology and healthy food systems in semi-humid tropical Africa: Participatory research with vulnerable farming households in Malawi

This paper assesses the relationship between agroecology, food security, and human health. Specifically, we ask if agroecology can lead to improved food security and human health among vulnerable smallholder farmers in semi-humid tropical Africa. The empirical evidence comes from a cross-sectional household survey (n=1000) in two districts in Malawi, a small country in semi-humid, tropical Africa. The survey consisted of 571 agroecology-adoption and 429 non-agroecology-adoption households. Ordered logistics regression and average treatment effects models were used to determine the effect of agroecology adoption on self-reported health. Our results show that agroecology-adoption households (OR=1.37, p=0.05) were more likely to report optimal health status, and the average treatment effect shows that adopters were 12% more likely to be in optimal health. Furthermore, being moderately food insecure (OR=0.59, p=0.05) and severely food insecure (OR=0.89, p=0.10) were associated with less likelihood of reporting optimal health status. The paper concludes that with the adoption of agroecology in the semi-humid tropics, it is possible for households to diversify their crops and diets, a condition that has strong implications for improved food security, good nutrition and human health.

The Influences of Health Insurance and Access to Information on Prostate Cancer Screening among Men in Dominican Republic

Objectives. Although research demonstrates the public health burden of prostate cancer among men in the Caribbean, relatively little is known about the factors that underlie the low levels of testing for the disease among this population. Study Design. A cross-sectional study of prostate cancer testing behaviours among men aged 40–60 years in Dominican Republic using the Demographic and Health Survey (2013). Methods. We use hierarchical binary logit regression models and average treatment effects combined with propensity score matching to explore the determinants of prostate screening as well as the average effect of health insurance coverage on screening. The use of hierarchical binary logit regression enabled us to control for the effect of unobserved heterogeneity at the cluster level that may affect prostate cancer testing behaviours. Results. Screening varied significantly with health insurance coverage, knowledge of cholesterol level, education, and wealth. Insured men were more likely to test for prostate cancer (OR = 1.65, p = 0.01) compared to the uninsured. Conclusions. The expansion and restructuring of Dominican Republic universal health insurance scheme to ensure equity in access may improve health access that would potentially impact positively on prostate cancer screening among men.

Impact of migration and remittances on household welfare among rural households in Northern and Central Malawi

Rural households employ migration as a major investment and livelihood strategy to mitigate the effects of adverse economic conditions, climate variability and food insecurity. While this is the case in most developing countries, the linkages between migration, remittances, and household welfare have not been adequately studied. This paper examines the effect of migration and remittances on the food security and asset wealth levels in rural communities in Northern and Central Malawi. Data is from a sample of 1000 rural households, collected using face-to-face structured surveys. The Household Food Insecurity Access Scale was used to evaluate the food security status of households. Results indicate that households with migrant members were (β = −0.157, p = 0.01) less likely to be food insecure and has an average treatment effect of (β = 0.151, p = 0.01) on household asset levels, indicating a positive effect on household asset accumulation. Remittance receipt had similar effects on household welfare. However, the effects of migration and remittance receipt on food security were greater than their effects on wealth. The study concludes by making relevant policy recommendations.

Utilisation of skilled birth attendants over time in Nigeria and Malawi

Nutrition is a direct contributor and target to Sustainable Development Goal 2 (“End hunger achieve food security and improved nutrition and promote sustainable agriculture”) a foundation and pre-requisite to Sustainable Development Goal 3 (“Ensure healthy lives and promote well-being for all at all ages”) and a decisive enabler to the remaining goals of the Sustainable Development Agenda 2030. The World Health Organization (WHO) supports all Member States to achieve “a world free of all forms of malnutrition where all people achieve health and well-being” a vision supported by our work with Member States and their partners to ensure universal access to effective nutrition actions and to healthy and sustainable diets1 in the context of the overall effort to ensure universal health coverage2. To do this WHO uses its convening power to help facilitate and align priority setting to mainstream nutrition in the health and development agenda; develop evidence-informed guidance supported by the highest quality science and ethical frameworks; support the adoption of guidance its implementation and the integration of effective actions into existing or new delivery platforms in the health systems. WHO guidelines are documents developed by WHO containing recommendations for clinical practice or public health policy and programmes. A recommendation tells the intended end-user of the guideline what he or she can or should do in specific situations to achieve the best health and nutrition outcomes possible individually or at the population level. It offers a choice among different interventions or measures having an anticipated positive impact on health and nutrition and implications for the use of resources.3 The WHO Department of Nutrition for Health and Development (NHD) develops guidelines in accordance with the procedures established in the WHO Handbook for Guideline Development.2 The WHO guideline development process ensures that WHO guidelines are of high methodological quality and are developed through an independent transparent evidence-informed consensual decision-making process. Though the process with which WHO develops guidelines is highly structured systematic and transparent the process for priority setting (i.e. prioritizing topics4 for guideline development) has been a dynamic one in order to accommodate new and renewed high-level commitments from the WHO Secretariat as well as emerging issues arising from discussions among Member States in the Governing Body fora such as the World Health Assembly (WHA). The priority issues are determined by their importance (i.e. magnitude prevalence and distribution of disease or nutrition problems) or the existence of preventable or modifiable biological behavioural and contextual determinants (risk factors). Updating guidelines is challenging if evidence has to be retrieved to support an increasing number of recommendations. In this situation it is important to give priority to assuring the principle of “primum non nocere” (first do no harm) to address controversial areas and to set a position on areas in which new evidence has emerged and requires prompt action. Ensuring a well-understood and efficiently communicated prioritization process is therefore crucial as external partners and stakeholders play an important role in the WHO guideline implementation process. Independence and transparency of the prioritization process gives the Organization a means of providing assurance that the process is free of any undue influence that may affect the reputation and objectivity of WHO. Therefore in an effort to maintain transparency in the normative work of WHO and to enhance the understanding of the process used to prioritize topics for guideline development among Member States and stakeholders the Department of Nutrition for Health and Development (NHD) is leading the work on making the prioritization process more accessible and has developed an online tool to further facilitate the participation of Member States and their stakeholders in the guideline prioritization process. This process aims to complement the decisions of the World Health Assembly (WHA) the decision-making body of WHO. (ExcerptsABSTRACT Despite recent modest progress in reducing maternal and infant mortality rates in sub-Saharan Africa, Nigeria and Malawi were still in the top 20 countries with highest rates of mortalities globally in 2015. Utilisation of professional services at delivery – one of the indictors of MDG 5 – has been suggested to reduce maternal mortality by 50%. Yet, contextual, socio-cultural and economic factors have served as barriers to uptake of such critical service. In this paper, we examined the impact of residential wealth index on utilisation of Skilled Birth Attendant in Nigeria (2003, 2008 and 2013), and Malawi (2000, 2004 and 2010) using Demographic and Health Survey data sets. The findings from multivariate logistic regressions show that women in Nigeria were 23% less likely to utilise skilled delivery services in 2013 compared to 2003. In Malawi, women were 75% more likely to utilise skilled delivery services in 2010 than in 2000. Residential wealth index was a significant predictor of utilisation of skilled delivery services over time in both Nigeria and Malawi. These findings illuminate progress made - based on which we make recommendations for achievement of SDG-3: ensure healthy lives and promote well-being for all at all ages in Nigeria and Malawi, and similar context.

Timing and utilisation of antenatal care service in Nigeria and Malawi

ABSTRACT As the world draws curtains on the implementation of Millennium Development Goals (MDGs), there is increasing interest in evaluating the performance of countries on the goals and assessing related challenges and opportunities to inform the upcoming Sustainable Development Goals (SDGs). This study examined changes in the timing and utilisation of maternal health care services in Nigeria and Malawi; using multivariate negative log–log and logistic regression models fitted to demographic and health survey data sets. Predicted probabilities were also computed to observe the net differences in the likelihood of both the first and the required number of antenatal care (ANC) visits for each of the three analysis years. Women in Nigeria were 7% less likely in 2008 compared to 2003, and in Malawi, 32% more likely in 2013 compared to 2000, to utilise ANC in the first trimester of pregnancy. Timing of first ANC visit was strongly influenced by wealth in Nigeria but not in Malawi. The findings in our case studies show how various contextual factors may enable or inhibit policy performance. Maternal and child health, SDGs should incorporate both wealth and degrees of urbanicity into country level implementation strategies.

Breast cancer screening among women in Namibia: explaining the effect of health insurance coverage and access to information on screening behaviours

Objectives: Breast cancer contributes substantially to morbidity and mortality in Namibia as is the case in most countries in Sub-Saharan Africa (SSA). However, there is a dearth of nationally representative studies that examine the odds of screening for breast cancer in Namibia and SSA at large. This paper aims to fill this gap by examining the determinants of breast cancer screening guided by the Health Belief Model. Methods: We applied hierarchical binary logit regression models to explore the determinants of breast cancer screening using the 2013 Namibia Demography and Health Survey (NDHS). We accounted for the effect of unobserved heterogeneity that may affect breast cancer, testing behaviours among women cluster level. The NDHS is a nationally representative dataset that has recently started to collect information on cancer screening. Results: The results show that women who have health insurance coverage (odds ratio (OR) = 1.62, p ≤ 0.01), maintain contact with health professionals (OR = 1.47, p = 0.01), and who have secondary (OR = 1.38, p = 0.01) and higher (OR = 1.77, p ≤ 0.01) education were more likely to be screened for breast cancer. Factors that influence women’s perception of their susceptibility to breast cancer such as birthing experience, age, region and place of residence were associated with screening in this context. Conclusions: Overall, the health belief model predicted women’s testing behaviours and also revealed the absence of relevant risk factors in the NDHS data that might influence screening. Overall, our results show that strategies for early diagnosis of breast cancer should be given major priority by cancer control boards as well as ministries of health in SSA. These strategies should centre on early screening and may involve reducing or eliminating barriers to health care, access to relevant health information and encouraging breast self-examination.

What Prevents Men Aged 40–64 Years from Prostate Cancer Screening in Namibia?

Objectives. Although a growing body of evidence demonstrates the public health burden of prostate cancer in SSA, relatively little is known about the underlying factors surrounding the low levels of testing for the disease in the context of this region. Using Namibia Demographic Health Survey dataset (NDHS, 2013), we examined the factors that influence mens decision to screen for prostate cancer in Namibia. Methods. We use complementary log-log regression models to explore the determinants of screening for prostate cancer. We also corrected for the effect of unobserved heterogeneity that may affect screening behaviours at the cluster level. Results. The results show that health insurance coverage (OR = 2.95, p = 0.01) is an important predictor of screening for prostate cancer in Namibia. In addition, higher education and discussing reproductive issues with a health worker (OR = 2.02, p = 0.05) were more likely to screening for prostate cancer. Conclusions. A universal health insurance scheme may be necessary to increase uptake of prostate cancer screening. However it needs to be acknowledged that expanded screening can have negative consequences and any allocation of scarce resources towards screening must be guided by evidence obtained from the local context about the costs and benefits of screening.

Gestational age at first antenatal visit in Namibia

ObjectivesTo examine the relationship between pregnancy intention and gestational age at first antenatal visit in Namibia.MethodsThis study uses secondary data from the 2013 Namibia Demographic and Health Survey (NDHS). Log-normal survival models are used to examine the independent effect of pregnancy intention on gestational age at first antenatal visit while controlling for relevant sociodemographic and socioeconomic covariates.ResultsThis study finds that those who indicated unwanted pregnancies were significantly more likely to delay initiating antenatal care (ANC). Other variables also associated with gestational age at first antenatal visit include contact with a health worker, health insurance, media exposure to safe motherhood messages, birth order, relationship with head of household, maternal education, and urban residence.ConclusionsTimely ANC is necessary to identify and mitigate risk factors in pregnancy but many mothers in Namibia do not receive such care. Reducing unwanted pregnancies through family planning may limit ANC delays. After unwanted pregnancies occur, women may benefit from further education and resources that empower them to pursue ANC promptly.

Circumcision Status and Time to Sexual Debut Among Youth in Sub-Saharan Africa: Evidence from Six Demographic and Health Surveys

This paper examines the relationship between circumcision status and timing of sexual debut among unmarried youth in Sub-Saharan Africa using Demographic and Health Surveys. Results from survival analysis indicate that the association between circumcision and timing of first sex is place and context specific. Compared to uncircumcised, circumcised men in Rwanda, Uganda and Namibia hasten sexual initiation, whilst circumcised youth in Ethiopia and Mali delayed sex initiation. In Togo however, we found parity in timing to sexual debut. Our multivariate results reveal that, knowledge of HIV/AIDS risk and educational level also feed into the association between circumcision and timing of sex initiation- implying that efforts to prevent new HIV infection through circumcision could benefit from a proper understanding of how diverse set of factors interact in specific contexts to shape youth’s decisions to initiate early sex.ResumenEste artículo examina la relación entre el estado de la circuncisión y el momento de la iniciación sexual entre los jóvenes solteros en África subsahariana usando encuestas demográficas y salud. Resultados de los modelos de supervivencia indican que la asociación entre la circuncisión y el momento de la primera relación sexual es lugar y contexto específico. En comparación con los hombres incircuncisos, circuncidados en Ruanda, Uganda y Namibia aceleran la iniciación sexual mientras jóvenes circuncidados en Etiopía y Malí retrasa iniciación sexual. En Togo sin embargo, encontramos la paridad en el momento de la iniciación sexual. Nuestros resultados multivariantes revelan que, conocimiento de riesgo de VIH/SIDA y el nivel educativo también alimenta la asociación entre la circuncisión y el momento de iniciación de sexo-lo que implica que los esfuerzos para prevenir la nueva infección por el VIH podrían beneficiarse de una adecuada comprensión de conjunto la diversidad de factores que interactúan en contexto específico para moldear las decisiones de los jóvenes a iniciar relaciones sexuales tempranas.