Steve Clements

Contextual influences on the use of health facilities for childbirth in Africa.

OBJECTIVES Previous studies of maternal health-seeking behavior focused on individual- and household-level factors. We examined community-level influences on the decision to deliver a child in a health facility across 6 African countries. METHODS Demographic and Health Survey data were linked with contextual data, and multilevel models were fitted to identify the determinants of childbirth in a health facility in the 6 countries. RESULTS We found strong community-level influences on a womans decision to deliver her child in a health facility. Several pathways of influence between the community and individual were identified. CONCLUSIONS Community economic development, the climate of female autonomy, service provision, and fertility preferences all exert an influence on a womans decision to seek care during labor, but significant community variation remains unexplained.

Contextual Influences on Modern Contraceptive Use in Sub-Saharan Africa

OBJECTIVES We examined the role of community-level factors in explaining geographic variations in modern contraceptive use in 6 African countries. METHODS We analyzed Demographic and Health Survey and contextual data sources with multilevel modeling techniques to identify factors contributing to geographic variations in womens use of modern contraceptives. RESULTS We found significant associations between several community-level factors and reported use of modern contraceptive methods. We also identified several pathways of influence between the community and the individual. CONCLUSIONS Aspects of a communitys sociocultural and economic environment appear to influence a womans use of modern contraceptive methods.

What Determines Geographical Variation in Rates of Acceptance onto Renal Replacement Therapy in England

Objective: To determine the independent effects of need and supply factors on the known geographical variation in acceptance rates onto renal replacement therapy (RRT) in England. Methods: Data were obtained from all renal units in England on the characteristics of all cases aged 16 years and over, resident in England, who were accepted onto RRT in 1991 and 1992. Of these, 5715 (94.5%) had a valid postcode that could be matched to a census ward. Multilevel modelling using Poisson regression was used. The number of acceptances in each census ward within age bands 16–34, 35–64 and 65+ was the dependent variable. Independent effects modelled were: (1) individual factors (age, sex); (2) census ward need factors — ethnicity (expressed as the percentage of the ward population that was Asian or African-Caribbean), socio-economic deprivation — and supply factors — ‘access’ to the nearest renal unit using crowfly and road travel time and distance, and services available to each ward expressed as number of haemodialysis stations per 100 000 catchment population of the nearest renal unit; (3) district health authority level effects. Results: Age was a major determinant of acceptance, with a 7-fold higher rate in males aged over 64 years compared with younger men. Acceptance rates were lower in females, with a negative age-sex interaction in females aged over 64 years. The percentage of both Asian and African-Caribbean populations per ward was a highly significant positive determinant. Deprivation was also a significant determinant, best represented by a customised index. There was an inverse relation of acceptance with distance, especially road travel time. Other supply side variables had a significant effect though there was no independent district effect. There was some variation in the strength of these relationships by type of area (Greater London, urban and non-urban). Conclusions: Need and supply factors influence service use as expressed as acceptance onto RRT. Pressure to expand RRT services needs to be aimed at areas with large minority ethnic populations and those living far from existing units.

Spatial variation in teenage conceptions in south and west England

Multilevel Poisson models are used to identify factors influencing variation in census ward level teenage conception rates. Multilevel logistic models are also employed to examine the outcome of these conceptions. Demographic and socioeconomic characteristics are accounted for as well as access to family planning services. The paper emphasizes the importance of customized deprivation indices that are specific to the health outcome in urban and rural areas.

Who is being served least by family planning providers? A study of modern contraceptive use in Ghana, Tanzania And Zimbabwe.

This study was conducted to identify the poorest and other vulnerable sub-groups being served least by family planning providers. The study was set in three countries in sub-Saharan Africa, namely, Ghana, Tanzania and Zimbabwe. This region generally has a low but increasing uptake of modern contraceptive methods. As the use of family planning providers increases, there is a need to understand who is not being served and why. Logistic regression analyses of demographic and health survey data were conducted to identify the characteristics and geographical areas of women who are not using modern contraceptive methods. The results show some similarities among the countries in those using modern methods the least. However, a number of groups were country specific. Identifying the poorest women with the lowest use of modern methods is best done by assessing their household amenities or their partners status rather than theirs.