Tiziana Leone

Impact and Determinants of Sex Preference in Nepal

CONTEXT Gender discrimination and son preference are key demographic features of South Asia and are well documented for India. However, gender bias and sex preference in Nepal have received little attention. METHODS 1996 Nepal Demographic and Health Survey data on ever-married women aged 15-49 who did not desire any more children were used to investigate levels of gender bias and sex preference. The level of contraceptive use and the total fertility rate in the absence of sex preference were estimated, and logistic regression was performed to analyze the association between socioeconomic and demographic variables and stopping childbearing after the birth of a son. RESULTS Commonly used indicators of gender bias, such as sex ratio at birth and sex-specific immunization rates, do not suggest a high level of gender discrimination in Nepal. However, sex preference decreases contraceptive use by 24% and increases the total fertility rate by more than 6%. Womens contraceptive use, exposure to the media, parity, last birth interval, educational level and religion are linked to stopping childbearing after the birth of a boy, as is the ethnic makeup of the local area. CONCLUSIONS The level of sex preference in Nepal is substantial. Sex preference is an important barrier to the increase of contraceptive use and decline of fertility in the country; its impact will be greater as desired family size declines.

Have health trends worsened in Greece as a result of the financial crisis? A quasi-experimental approach.

BACKGROUND Health in Greece deteriorated after the recent financial crisis, but whether this decline was caused by the recent financial crisis has not been established. This article uses a quasi-experimental approach to examine the impact of the recent financial crisis on health in Greece. METHODS Data came from the European Union Statistics on Income and Living Conditions survey for the years 2006-09. We applied a difference-in-differences approach that compares health trends before and after the financial crisis in Greece with trends in a control population (Poland) that did not experience a recession and had health trends comparable with Greece before the crisis. We used logistic regression to model the impact of the financial crisis on poor self-rated health, controlling for demographic confounders. RESULTS Results provide strong evidence of a statistically significant negative effect of the financial crisis on health trends. Relative to the control population, Greece experienced a significantly larger increase in the odds of reporting poor health after the crisis (odds ratio, 1.16; 95% confidence interval, 1.04-1.29). There was no difference in health trends between Poland and Greece before the financial crisis, supporting a causal interpretation of health declines in Greece as a result of the financial crisis. CONCLUSION Results provide evidence that trends in self-rated health in Greece worsened as a result of the recent financial crisis. Findings stress the need for urgent health policy responses to the recent economic collapse in Greece as the full impact of austerity measures unfolds in the coming years.

Community factors affecting rising caesarean section rates in developing countries: an analysis of six countries.

Caesarean section rates have risen dramatically in several developing countries, especially in Latin America and South Asia. This raises a range of concerns about the use of caesarean section for non-emergency cases, not least the progressive shift of resources to non-essential medical interventions in resource-poor settings and additional health risks to mothers and newborns following a caesarean section. There are only a few studies that have systematically examined the factors influencing the recent increase in caesarean rates. In particular, it is not clear whether high elective caesarean rates are driven by medical, institutional or individual and family decisions. Where a womans decisions predominate her interaction with peers and significant others have an impact on her caesarean section choices. Using random intercept logistic regression analyses, this paper analyses the institutional, socio-economic and community factors that influence caesarean section in six countries: Bangladesh, Colombia, Dominican Republic, Egypt, Morocco and Vietnam. The analyses, based on data from over 20,000 births, show that women of higher socio-economic background, who had better access to antenatal services are the most likely to undergo a caesarean section. Women who exchange reproductive health information with friends and family are less likely to experience a caesarean section than their counterparts. The study concludes that there is a need to pursue community-based approaches for curbing rising caesarean section rates in resource-poor settings.

Cultural constructions of the concept of household in sample surveys

We analyse the use of the concept of household in sample surveys, with evidence drawn from a review of survey definitions, a series of in-depth interviews with data producers and users, and a systematic study of recent literature. We consider the place of the concept within the discipline of demography, and demonstrate how its definition and use interact with cultural values and core concepts integral to the discipline. Focusing on Tanzania as a case study, we examine the diversity of factors that influence the construction of household-level data from cross-sectional household surveys. Throughout the survey process, contrasting interpretations of the meaning of household and different motivations for using specific definitions of the term interact. This generates data and outputs with potential for undercounting, bias, and misrepresentations, with adverse effects on the quality of data used for monitoring development indicators. Some ways of improving data collection on households are proposed.

Suicide and poverty in low-income and middle-income countries: a systematic review

Suicide is the 15th leading cause of death worldwide, with over 75% of suicides occurring in low-income and middle-income countries. Nonetheless, evidence on the association between suicide and poverty in low-income and middle-income countries is scarce. We did a systematic review to understand the association between suicidal ideations and behaviours and economic poverty in low-income and middle-income countries. We included studies testing the association between suicidal ideations and behaviours and economic poverty in low-income and middle-income countries using bivariate or multivariate analysis and published in English between January, 2004, and April, 2014. We identified 37 studies meeting these inclusion criteria. In 18 studies reporting the association between completed suicide and poverty, 31 associations were explored. The majority reported a positive association. Of the 20 studies reporting on the relationship between non-fatal suicidal ideations and behaviours and poverty, 36 associations were explored. Again, almost all studies reported a positive association. However, when considering each poverty dimension separately, we found substantial variations. These findings show a consistent trend at the individual level indicating that poverty, particularly in the form of worse economic status, diminished wealth, and unemployment is associated with suicidal ideations and behaviours. At the country level, there are insufficient data to draw clear conclusions. Available data show a potential benefit in addressing economic poverty within suicide prevention strategies, with particular attention to both chronic poverty and acute economic events.

Increasing the use of skilled health personnel where traditional birth attendants were providers of childbirth care: a systematic review.

Background Improved access to skilled health personnel for childbirth is a priority strategy to improve maternal health. This study investigates interventions to achieve this where traditional birth attendants were providers of childbirth care and asks what has been done and what has worked? Methods and Findings We systematically reviewed published and unpublished literature, searching 26 databases and contacting experts to find relevant studies. We included references from all time periods and locations. 132 items from 41 countries met our inclusion criteria and are included in an inventory; six were intervention evaluations of high or moderate quality which we further analysed. Four studies report on interventions to deploy midwives closer to communities: two studies in Indonesia reported an increase in use of skilled health personnel; another Indonesian study showed increased uptake of caesarean sections as midwives per population increased; one study in Bangladesh reported decreased risk of maternal death. Two studies report on interventions to address financial barriers: one in Bangladesh reported an increase in use of skilled health personnel where financial barriers for users were addressed and incentives were given to skilled care providers; another in Peru reported that use of emergency obstetric care increased by subsidies for preventive and maternity care, but not by improved quality of care. Conclusions The interventions had positive outcomes for relevant maternal health indicators. However, three of the studies evaluate the village midwife programme in Indonesia, which limits the generalizability of conclusions. Most studies report on a main intervention, despite other activities, such as community mobilization or partnerships with traditional birth attendants. Many authors note that multiple factors including distance, transport, family preferences/support also need to be addressed. Case studies of interventions in the inventory illustrate how different countries attempted to address these complexities. Few high quality studies that measure effectiveness of interventions exist.

Poverty and postnatal depression: a systematic mapping of the evidence from low and lower middle income countries

This study systematically maps, assesses and aggregates research relating to postnatal depression (PND) and poverty in low and lower middle income countries (LLMICs). Our search of 12 databases yielded 2202 articles, of which 47 items from 17 countries were included in our mapping. We highlight mechanisms for the relationships between poverty and PND in LLMICs. The research base on the relationships between poverty and PND in LLMIC is limited, but has recently expanded. It is dominated by studies that consider whether poverty is a risk factor for PND. Income, socio-economic status and education are all inconsistent risk factors for PND. Clues to better ways of framing and capturing economic stress in PND research is found in the qualitative studies included in our mapping. Evidence focuses overwhelmingly on individual-level analyses. To understand the scale and implications of PND in LLMICs, research has to take account of neighbourhoods, communities, and localities.

Financial accessibility and user fee reforms for maternal healthcare in five sub-Saharan countries: a quasi-experimental analysis.

Objectives Evidence on whether removing fees benefits the poorest is patchy and weak. The aim of this paper is to measure the impact of user fee reforms on the probability of giving birth in an institution or undergoing a caesarean section (CS) in Ghana, Burkina Faso, Zambia, Cameroon and Nigeria for the poorest strata of the population. Setting Womens experience of user fees in 5 African countries. Primary and secondary outcome measures Using quasi-experimental regression analysis we tested the impact of user fee reforms on facilities’ births and CS differentiated by wealth, education and residence in Burkina Faso and Ghana. Mapping of the literature followed by key informant interviews are used to verify details of reform implementation and to confirm and support our countries’ choice. Participants We analysed data from consecutive surveys in 5 countries: 2 case countries that experienced reforms (Ghana and Burkina Faso) by contrast with 3 that did not experience reforms (Zambia, Cameroon, Nigeria). Results User fee reforms are associated with a significant percentage of the increase in access to facility births (27 percentage points) and to a much lesser extent to CS (0.7 percentage points). Poor (but not the poorest), and non-educated women, and those in rural areas benefitted the most from the reforms. User fees reforms have had a higher impact in Burkina Faso compared with Ghana. Conclusions Findings show a clear positive impact on access when user fees are removed, but limited evidence for improved availability of CS for those most in need. More women from rural areas and from lower socioeconomic backgrounds give birth in health facilities after fee reform. Speed and quality of implementation might be the key reason behind the differences between the 2 case countries. This calls for more research into the impact of reforms on quality of care.

The effect of social participation on the subjective and objective health status of the over-fifties: evidence from SHARE

ABSTRACT Increasing social participation among older individuals to increase health and wellbeing has become a distinct policy goal of many national governments and the European Commission. However, to date the evidence on how social participation affects health, both subjective and objective, remains limited, especially since most studies do not account for the reciprocal relationship. The aim of this study is to analyse how changes in social participation affect both the subjective and objective health of older Europeans as well as how changes in health status affect social participation. Using longitudinal data from the Survey of Health, Ageing and Retirement in Europe (SHARE), the results suggest that both the uptake as well as the continuation of social activities increase the chances of improvements in subjective as well as objective health. Furthermore, improvements in self-rated health as well as grip strength significantly increase the chances of taking up new activities as well as continuing with existing ones. Country effect is not as strong as expected and the benefits could be homogeneous across different cultures once we control for socio-economic status. Overall, the results stress the need for taking into account the reciprocal relationship between social participation and health. The paper highlights the importance of focusing on both uptake and continuation of social participation when devising policy aimed at improving healthy ageing.

Inpatient care of the elderly in Brazil and India: Assessing social inequalities

The rapidly growing older adult populations in Brazil and India present major challenges for health systems in these countries, especially with regard to the equitable provision of inpatient care. The objective of this study was to contrast inequalities in both the receipt of inpatient care and the length of time that care was received among adults aged over 60 in two large countries with different modes of health service delivery. Using the Brazilian National Household Survey from 2003 and the Indian National Sample Survey Organisation survey from 2004 inequalities by wealth (measured by income in Brazil and consumption in India) were assessed using concentration curves and indices. Inequalities were also examined through the use of zero-truncated negative binomial models, studying differences in receipt of care and length of stay by region, health insurance, education and reported health status. Results indicated that there was no evidence of inequality in Brazil for both receipt and length of stay by income per capita. However, in India there was a pro-rich bias in the receipt of care, although once care was received there was no difference by consumption per capita for the length of stay. In both countries the higher educated and those with health insurance were more likely to receive care, while the higher educated had longer stays in hospital in Brazil. The health system reforms that have been undertaken in Brazil could be credited as a driver for reducing healthcare inequalities amongst the elderly, while the significant differences by wealth in India shows that reform is still needed to ensure the poor have access to inpatient care. Health reforms that move towards a more public funding model of service delivery in India may reduce inequality in elderly inpatient care in the country.