Rathavuth Hong

HIV infection does not disproportionately affect the poorer in sub-Saharan Africa.

Background:Wealthier populations do better than poorer ones on most measures of health status, including nutrition, morbidity and mortality, and healthcare utilization. Objectives:This study examines the association between household wealth status and HIV serostatus to identify what characteristics and behaviours are associated with HIV infection, and the role of confounding factors such as place of residence and other risk factors. Methods:Data are from eight national surveys in sub-Saharan Africa (Kenya, Ghana, Burkina Faso, Cameroon, Tanzania, Lesotho, Malawi, and Uganda) conducted during 2003–2005. Dried blood spot samples were collected and tested for HIV, following internationally accepted ethical standards and laboratory procedures. The association between household wealth (measured by an index based on household ownership of durable assets and other amenities) and HIV serostatus is examined using both descriptive and multivariate statistical methods. Results:In all eight countries, adults in the wealthiest quintiles have a higher prevalence of HIV than those in the poorer quintiles. Prevalence increases monotonically with wealth in most cases. Similarly for cohabiting couples, the likelihood that one or both partners is HIV infected increases with wealth. The positive association between wealth and HIV prevalence is only partly explained by an association of wealth with other underlying factors, such as place of residence and education, and by differences in sexual behaviour, such as multiple sex partners, condom use, and male circumcision. Conclusion:In sub-Saharan Africa, HIV prevalence does not exhibit the same pattern of association with poverty as most other diseases. HIV programmes should also focus on the wealthier segments of the population.

Relationship between household wealth inequality and chronic childhood under-nutrition in Bangladesh

BackgroundHousehold food insecurity and under-nutrition remain critically important in developing countries struggling to emerge from the scourge of poverty, where historically, improvements in economic conditions have benefited only certain privileged groups, causing growing inequality in health and healthcare among the population.MethodsUtilizing information from 5,977 children aged 0-59 months included in the 2004 Bangladesh Demographic and Health Survey , this study examined the relationship between household wealth inequality and chronic childhood under-nutrition. A child is defined as being chronically undernourished or whose growth rate is adversely stunted, if his or her z-score of height-for-age is more than two standard deviations below the median of international reference. Household wealth status is measured by an established index based on household ownership of durable assets. This study utilized multivariate logistic regressions to estimate the effect of household wealth status on adverse childhood growth rate.ResultsThe results indicate that children in the poorest 20% of households are more than three time as likely to suffer from adverse growth rate stunting as children from the wealthiest 20% of households (OR=3.6; 95% CI: 3.0, 4.3). The effect of household wealth status remain significantly large when the analysis was adjusted for a childs multiple birth status, age, gender, antenatal care, delivery assistance, birth order, and duration that the child was breastfed; mothers age at childbirth, nutritional status, education; household access to safe drinking water, arsenic in drinking water, access to a hygienic toilet facility, cooking fuel cleanliness, residence, and geographic location (OR=2.4; 95% CI: 1.8, 3.2).ConclusionThis study concludes that household wealth inequality is strongly associated with childhood adverse growth rate stunting. Reducing poverty and making services more available and accessible to the poor are essential to improving overall childhood health and nutritional status in Bangladesh.

Evaluation of bias in HIV seroprevalence estimates from national household surveys

Objectives: To evaluate HIV seroprevalence estimates from demographic and health surveys (DHS) and AIDS indicator surveys (AIS) for potential bias because of non-response and exclusion of non-household population groups. Methods: Data are from 14 DHS/AIS surveys with HIV testing, conducted during 2003–6. Blood samples were collected and analysed for HIV using standard laboratory and quality control procedures. HIV prevalence among non-tested adults was predicted based on multivariate statistical models of HIV for those who were interviewed and tested, using a common set of predictor variables. Estimates of the size of non-household populations in national censuses were used to assess potential bias because of their exclusion in the household surveys under different assumptions about proportion of adults and HIV prevalence in non-household populations. Results: Non-tested men had significantly higher predicted HIV prevalence than those tested in eight of the 14 countries, while non-tested women had significantly higher predicted prevalence than those tested in seven of the 14 countries. Effects of non-response were somewhat stronger in lower-prevalence countries. The overall effect of non-response on observed national HIV estimates was small and insignificant in all countries. Estimated effects of exclusion of non-household population groups were generally small, even in concentrated epidemics in India and Cambodia under the scenario that 75% of the non-household population was adults having 20 times greater HIV prevalence than adults in household surveys. Conclusions: Non-response and the exclusion of non-household population groups tend to have small, insignificant effects on national HIV seroprevalence estimates obtained from household surveys.

Comparison of HIV prevalence estimates from antenatal care surveillance and population-based surveys in sub-Saharan Africa

Objective: To compare HIV seroprevalence estimates obtained from antenatal care (ANC) sentinel surveillance surveys in Ethiopia, Kenya, Malawi, Tanzania and Uganda with those from population-based demographic and health surveys (DHS) and AIDS indicator surveys (AIS). Methods: Geographical information system methods were used to map ANC surveillance sites and DHS/AIS survey clusters within a 15-km radius of the ANC sites. National DHS/AIS HIV prevalence estimates for women and men were compared with national prevalence estimates from ANC surveillance. DHS/AIS HIV prevalence estimates for women and men residing within 15 km of ANC sites were compared with those from ANC surveillance. For women, these comparisons were also stratified by current pregnancy status, experience of recent childbirth and receiving ANC for the last birth. Results: In four of the five countries, national DHS/AIS estimates of HIV prevalence were lower than the ANC surveillance estimates. Comparing women and men in the catchment areas of the ANC sites, the DHS/AIS estimates were similar to ANC surveillance estimates. DHS/AIS estimates for men residing in the catchment areas of ANC sites were much lower than ANC surveillance estimates for women in all cases. ANC estimates were higher for younger women than DHS/AIS estimates for women in ANC catchment areas, but lower at older ages. In all cases, urban prevalence was higher than rural prevalence but there were no consistent patterns by education. Conclusions: ANC surveillance surveys tend to overestimate HIV prevalence compared to prevalence among women in the general population in DHS/AIS surveys. However, the ANC and DHS/AIS estimates are similar when restricted to women and men, or to women only, residing in catchment areas of ANC sites. Patterns by age and urban/rural residence suggest possible bias in the ANC estimates.

Family planning services quality as a determinant of use of IUD in Egypt

BackgroundBoth availability and quality of family planning services are believed to have contributed to increasing contraceptive use and declining fertility rates in developing countries. Yet, there is limited empirical evidence to show the relationship between the quality of family planning services and the population based prevalence of contraceptive methods. This study examined the relationship between quality of family planning services and use of intrauterine devices (IUD) in Egypt.MethodsThe analysis used data from the 2003 Egypt Interim Demographic and Health Survey (EIDHS) that included 8,445 married women aged 15–49, and the 2002 Egypt Service Provision Assessment (ESPA) survey that included 602 facilities offering family planning services. The EIDHS collected latitude and longitude coordinates of all sampled clusters, and the ESPA collected these coordinates for all sampled facilities. Using Geographic Information System (GIS) methods, individual women were linked to a facility located within 10 km of their community. A facility-level index was constructed to reflect the quality of family planning services. Four dimensions of quality of care were examined: counseling, examination room, supply of contraceptive methods, and management. Effects of quality of family planning services on the use of IUD and other contraceptive methods were estimated using multinomial logistic regression. Results are presented as relative risk ratios (RRR) with significance levels (p-values).ResultsIUD use among women who obtained their method from public sources was significantly positively associated with quality of family planning services (RRR = 1.36, p < 0.01), independent of distance to the facility, facility type, age, number of living children, education level, household wealth status, and residence. Quality of services related to counseling and examination room had strong positive effects on use of IUD (RRR = 1.61 for counseling and RRR = 1.46 for examination room). Obtaining IUD from a private source or using other contraceptive methods was not associated with quality of services.ConclusionThis study is one among the few that used geographic information to link data from a population-based survey with an independently sampled health facility survey. The findings demonstrate that service quality is an important determinant of use of clinical contraceptive methods in Egypt. Improving quality of family planning services may help further increase use of clinical contraceptive methods and reduce fertility.

Impact of Prenatal Care on Infant Survival in Bangladesh

Despite improvements in public health in recent decades, levels of infant and child mortality remain unacceptably high, particularly in developing countries where primary healthcare services including prenatal care services are not universally available. Using information on 7,001 childbirths in five years preceding the 2004 Bangladesh Demographic and Health Survey, this study examined the relationship between receiving prenatal care during pregnancy and infant mortality using multivariate survival analysis. The results are presented in hazard ratios (HR) with 95% confidence intervals (95% CI). Results indicate that children of mothers who did not receive prenatal care during pregnancy were more than twice as likely to die during infancy as children whose mothers received prenatal care during pregnancy (HR=2.40, 95% CI: 1.74, 3.31) independent of childs sex, delivery assistance, birth order; mothers age at child birth, nutritional status, education level; household living conditions, and other factors. Children born to older mothers living in households without safe drinking water were at an increased risk. The study concludes that prenatal care is strongly negatively associated with infant mortality in Bangladesh independent of other risk factors. The results suggest that improving prenatal care services at the community level is key to improving child survival in Bangladesh.

Being Insured Improves Safe Delivery Practices in Rwanda

Rwanda still faces major hurdles in its effort to achieve universal access to health care for all. Even though there is an improvement in overall population health status and community-based funding of insurance coverage, a large percentage of women still deliver their babies at home assisted by unskilled birth attendants or unassisted. This paper examines the relationship between being insured and delivery at home and delivery by an unskilled attendant/unassisted. It is evident that uninsured women are significantly more likely to deliver their babies at home by an unskilled birth attendant/unassisted. Moreover, taking other factors into consideration, women who delivered at home are more likely to have no formal education, reside in a rural area, work in the agricultural sector, and are in the poorest household quintile. Findings from this study suggest that being insured may lift financial barriers and encourage women to deliver their babies in a health facility by a skilled birth attendant. Nonetheless, when health insurance status is controlled in multivariate models, certain socioeconomic inequalities do exist for women giving birth in a health facility and by a skilled birth attendant. These inequalities should decline when the insured population increases.

Trends in HIV-related behaviors and knowledge in Uganda 1989-2005: evidence of a shift toward more risk-taking behaviors.

Objective(s):To describe recent trends in HIV-related behaviors and knowledge in Uganda between 1989 and 2005. Design:Population-based, cross-sectional national surveys of adult women and men. Methods:Trend analysis of selected HIV-related behavior and knowledge indicators, using data from the 2004-2005 Uganda HIV/AIDS Sero-Behavioral Survey and the 2000-2001, 1995, and 1988-1989 Uganda Demographic and Health Surveys. Responses to similar questions across the different surveys were compared to determine trends in indicators. Results:HIV/AIDS knowledge increased to a high level by 2001 and remained stable thereafter. Some self-reported risk behaviors improved, whereas others deteriorated. Among 15- to 24-year-old women and men, primary abstinence increased, from 23% in 1989 to 32% in 2005 and from 32% in 1995 to 42% in 2005, respectively. In men, there were increases in sex with multiple partners and sex with nonspousal partners, although reported condom use during nonspousal sex declined. Of men aged 15-49 years, self-reported multiple sex partnership increased from 24% in 2001 to 29% in 2005 and nonspousal sex increased from 28% in 2001 to 37% in 2005. Between 2001 and 2005, condom use during last nonspousal sex declined from 65% to 55% in men aged 15-24 years. Conclusions:Although substantial improvements in HIV-related risk behaviors and knowledge occurred since 1989, recent increases in some HIV-related risk behaviors were observed, indicating a shift toward more risk-taking behaviors. Prevention efforts should be reinvigorated to address this, otherwise the past success in the HIV fight will be reversed. Monitoring of HIV-related indicators should be continued.

Effect of multiple birth on infant mortality in Bangladesh.

Aim:  Levels of infant and child mortality in many developing countries remain unacceptably high, and they are disproportionably higher among high‐risk groups such as newborn and infant of multiple births, particularly in countries where advanced medical cares are available only at regional referral levels with limited access by the poor rural women and children. This study examined the relationship between high‐risk infant of multiple birth and infant mortality in Bangladesh.

Association of maternal HIV infection with increase of infant mortality in Malawi.

Aim:  To determine the association between maternal HIV infection and infant mortality in Malawi.