Victor Adekanmbi

Individual and contextual factors associated with childhood stunting in Nigeria: a multilevel analysis

Stunting, a form of undernutrition, is the best measure of child health inequalities as it captures multiple dimensions of childrens health, development and the environment where they live. The aim of this study was to quantify the predictors of childhood stunting in Nigeria. This study used data obtained from the 2008 Nigeria Demographic and Health Survey (NDHS). A total of 28 647 children aged 0-59 months included in NDHS in 2008 were analysed in this study. We applied multilevel multivariate logistic regression analysis in which individual-level factors were at the first level and community-level factors at the second level. The percentage change in variance of the full model accounted for about 46% in odds of stunting across the communities. The present study found that the following predictors increased the odds of childhood stunting: male gender, age above 11 months, multiple birth, low birthweight, low maternal education, low maternal body mass index, poor maternal health-seeking behaviour, poor household wealth and short birth interval. The community-level predictors found to have significant association with childhood stunting were: child residing in community with high illiteracy rate and North West and North East regions of the country. In conclusion, this study revealed that both individual- and community-level factors are significant determinants of childhood stunting in Nigeria.

Risk factors and a predictive model for under-five mortality in Nigeria: evidence from Nigeria demographic and health survey

BackgroundUnder-5 mortality is a major public health challenge in developing countries. It is essential to identify determinants of under-five mortality (U5M) childhood mortality because these will assist in formulating appropriate health programmes and policies in order to meet the United Nations MDG goal. The objective of this study was to develop a predictive model and identify maternal, child, family and other risk factors associated U5M in Nigeria.MethodsPopulation-based cross-sectional study which explored 2008 demographic and health survey of Nigeria (NDHS) with multivariable logistic regression. Likelihood Ratio Test, Hosmer-Lemeshow Goodness-of-Fit and Variance Inflation Factor were used to check the fit of the model and the predictive power of the model was assessed with Receiver Operating Curve (ROC curve).ResultsThis study yielded an excellent predictive model which revealed that the likelihood of U5M among the children of mothers that had their first marriage at age 20-24 years and ≥ 25 years declined by 20% and 30% respectively compared to children of those that married before the age of 15 years. Also, the following factors reduced odds of U5M: health seeking behaviour, breastfeeding children for > 18 months, use of contraception, small family size, having one wife, low birth order, normal birth weight, child spacing, living in urban areas, and good sanitation.ConclusionsThis study has revealed that maternal, child, family and other factors were important risk factors of U5M in Nigeria. This study has identified important risk factors that will assist in formulating policies that will improve child survival.

Exploring variations in childhood stunting in Nigeria using league table, control chart and spatial analysis

BackgroundStunting, linear growth retardation is the best measure of child health inequalities as it captures multiple dimensions of children’s health, development and environment where they live. The developmental priorities and socially acceptable health norms and practices in various regions and states within Nigeria remains disaggregated and with this, comes the challenge of being able to ascertain which of the regions and states identifies with either high or low childhood stunting to further investigate the risk factors and make recommendations for action oriented policy decisions.MethodsWe used data from the birth histories included in the 2008 Nigeria Demographic and Health Survey (DHS) to estimate childhood stunting. Stunting was defined as height for age below minus two standard deviations from the median height for age of the standard World Health Organization reference population. We plotted control charts of the proportion of childhood stunting for the 37 states (including federal capital, Abuja) in Nigeria. The Local Indicators of Spatial Association (LISA) were used as a measure of the overall clustering and is assessed by a test of a null hypothesis.ResultsChildhood stunting is high in Nigeria with an average of about 39%. The percentage of children with stunting ranged from 11.5% in Anambra state to as high as 60% in Kebbi State. Ranking of states with respect to childhood stunting is as follows: Anambra and Lagos states had the least numbers with 11.5% and 16.8% respectively while Yobe, Zamfara, Katsina, Plateau and Kebbi had the highest (with more than 50% of their under-fives having stunted growth).ConclusionsChildhood stunting is high in Nigeria and varied significantly across the states. The northern states have a higher proportion than the southern states. There is an urgent need for studies to explore factors that may be responsible for these special cause variations in childhood stunting in Nigeria.

Incomplete childhood immunization in Nigeria: a multilevel analysis of individual and contextual factors

BackgroundUnder-five mortality remains high in sub-Saharan Africa despite global decline. One quarter of these deaths are preventable through interventions such as immunization. The aim of this study was to examine the independent effects of individual-, community- and state-level factors on incomplete childhood immunization in Nigeria, which is one of the 10 countries where most of the incompletely immunised children in the world live.MethodsThe study was based on secondary analyses of cross-sectional data from the 2013 Nigeria Demographic and Health Survey (DHS). Multilevel multivariable logistic regression models were applied to the data on 5,754 children aged 12–23 months who were fully immunized or not (level 1), nested within 896 communities (level 2) from 37 states (level 3).ResultsMore than three-quarter of the children (76.3%) were not completely immunized. About 83% of children of young mothers (15–24 years) and 94% of those whose mothers are illiterate did not receive full immunization. In the fully adjusted model, the chances of not being fully immunized reduced for children whose mothers attended antenatal clinic (adjusted odds ratio [aOR] = 0.49; 95% credible interval [CrI] = 0.39–0.60), delivered in health facility (aOR = 0.62; 95% CrI = 0.51–0.74) and lived in urban area (aOR = 0.66; 95% CrI = 0.50–0.82). Children whose mothers had difficulty getting to health facility (aOR = 1.28; 95% CrI = 1.02–1.57) and lived in socioeconomically disadvantaged communities (aOR = 2.93; 95% CrI = 1.60–4.71) and states (aOR = 2.69; 955 CrI =1.37–4.73) were more likely to be incompletely immunized.ConclusionsThis study has revealed that the risk of children being incompletely immunized in Nigeria was influenced by not only individual factors but also community- and state-level factors. Interventions to improve child immunization uptake should take into consideration these contextual characteristics.

Effect of Using the Same vs Different Order for Second Readings of Screening Mammograms on Rates of Breast Cancer Detection: A Randomized Clinical Trial

IMPORTANCE Interpreting screening mammograms is a difficult repetitive task that can result in missed cancers and false-positive recalls. In the United Kingdom, 2 film readers independently evaluate each mammogram to search for signs of cancer and examine digital mammograms in batches. However, a vigilance decrement (reduced detection rate with time on task) has been observed in similar settings. OBJECTIVE To determine the effect of changing the order for the second film reader of batches of screening mammograms on rates of breast cancer detection. DESIGN, SETTING, AND PARTICIPANTS A multicenter, double-blind, cluster randomized clinical trial conducted at 46 specialized breast screening centers from the National Health Service Breast Screening Program in England for 1 year (all between December 20, 2012, and November 3, 2014). Three hundred sixty readers participated (mean, 7.8 readers per center)-186 radiologists, 143 radiography advanced practitioners, and 31 breast clinicians, all fully qualified to report mammograms in the NHS breast screening program. INTERVENTIONS The 2 readers examined each batch of digital mammograms in the same order in the control group and in the opposite order to one another in the intervention group. MAIN OUTCOMES AND MEASURES The primary outcome was cancer detection rate; secondary outcomes were rates of recall and disagreements between readers. RESULTS Among 1,194,147 women (mean age, 59.3; SD, 7.49) who had screening mammograms (596,642 in the intervention group; 597,505 in the control group), the images were interpreted in 37,688 batches (median batch size, 35; interquartile range [IQR]; 16-46), with each reader interpreting a median of 176 batches (IQR, 96-278). After completion of all subsequent diagnostic tests, a total of 10,484 cases (0.88%) of breast cancer were detected. There was no significant difference in cancer detection rate with 5272 cancers (0.88%) detected in the intervention group vs 5212 cancers (0.87%) detected in the control group (difference, 0.01% points; 95% CI, -0.02% to 0.04% points; recall rate, 24,681 [4.14%] vs 24,894 [4.17%]; difference, -0.03% points; 95% CI, -0.10% to 0.04% points; or rate of reader disagreements, 20,471 [3.43%] vs 20,793 [3.48%]; difference, -0.05% points; 95% CI, -0.11% to 0.02% points). CONCLUSIONS AND RELEVANCE Interpretation of batches of mammograms by qualified screening mammography readers using a different order vs the same order for the second reading resulted in no significant difference in rates of detection of breast cancer. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN46603370.

Contextual socioeconomic factors associated with childhood mortality in Nigeria: a multilevel analysis

Background Childhood mortality is a well-known public health issue, particularly in the low and middle income countries. The overarching aim of this study was to examine whether neighbourhood socioeconomic disadvantage is associated with childhood mortality beyond individual-level measures of socioeconomic status in Nigeria. Methods Multilevel logistic regression models were applied to data on 31 482 under-five children whether alive or dead (level 1) nested within 896 neighbourhoods (level 2) from the 37 states in Nigeria (level 3) using the most recent 2013 Nigeria Demographic and Health Survey (DHS). Results More than 1 of every 10 children studied had died before reaching the age of 5 years (130/1000 live births). The following factors independently increased the odds of childhood mortality: male sex, mothers age at 15–24 years, uneducated mother or low maternal education attainment, decreasing household wealth index at individual level (level 1), residing in rural area and neighbourhoods with high poverty rate at level 2. There were significant neighbourhoods and states clustering in childhood mortality in Nigeria. Conclusions The study provides evidence that individual-level and neighbourhood-level socioeconomic conditions are important correlates of childhood mortality in Nigeria. The findings of this study also highlight the need to implement public health prevention strategies at the individual level, as well as at the area/neighbourhood level. These strategies include the establishment of an effective publicly funded healthcare system, as well as health education and poverty alleviation programmes.

Contextual factors associated with health care service utilization for children with acute childhood illnesses in Nigeria

Objective To examine the independent contribution of individual, community and state-level factors to health care service utilization for children with acute childhood illnesses in Nigeria. Materials and methods The study was based on secondary analyses of cross-sectional population-based data from the 2013 Nigeria Demographic and Health Survey (DHS). Multilevel logistic regression models were applied to the data on 6,427 under-five children who used or did not use health care service when they were sick (level 1), nested within 896 communities (level 2) from 37 states (level 3). Results About one-quarter of the mothers were between 15 and 24 years old and almost half of them did not have formal education (47%). While only 30% of the children utilized health service when they were sick, close to 67% lived in the rural area. In the fully adjusted model, mothers with higher education attainment (Adjusted odds ratio [aOR] = 1.63; 95% credible interval [CrI] = 1.31–2.03), from rich households (aOR = 1.76; 95% CrI = 1.35–2.25), with access to media (radio, television or magazine) (aOR = 1.18; 95% CrI = 1.08–1.29), and engaging in employment (aOR = 1.18; 95% CrI = 1.02–1.37) were significantly more likely to have used healthcare services for acute childhood illnesses. On the other hand, women who experienced difficulty getting to health facilities (aOR = 0.87; 95% CrI = 0.75–0.99) were less likely to have used health service for their children. Conclusions Our findings highlight that utilization of healthcare service for acute childhood illnesses was influenced by not only maternal factors but also community-level factors, suggesting that public health strategies should recognise this complex web of individual composition and contextual composition factors to guide provision of healthcare services. Such interventions could include: increase in female school enrolment, provision of interest-free loans for small and medium scale enterprises, introduction of mobile clinics and establishment of more primary health care centres.

Factors That Predict Differences in Childhood Mortality in Nigerian Communities: A Prognostic Model.

OBJECTIVE To identify predictors of variations of childhood mortality between Nigerian communities and to identify high-risk communities where childhood mortality was higher than expected. STUDY DESIGN Secondary analysis of the 2013 Nigeria Demographic and Health Survey data using prognostic univariable and multivariable mixed Poisson regression models. Likelihood ratio test, Hosmer-Lemeshow goodness-of-fit, and variance inflation factor were used to evaluate the fitness of the final model. RESULTS The final adjusted model revealed that communities with high rating of multiple childhood deprivation (relative risk 1.14, 95% CI 1.09-1.19) and maternal socioeconomic deprivation (relative risk 1.22, 95% CI 1.14-1.29) were associated significantly with the risk of childhood mortality. Communities with enhanced maternal hospital-based health-seeking behaviors and more advantageous environmental conditions had reduced risks of childhood mortality. Similarly, children living in communities with high ethnic diversity were significantly less likely to die before their fifth birthday (relative risk 0.96, 95% CI 0.94-0.97). About 64% of the observed heterogeneity in childhood mortality in these communities was explained by the final model. Eleven of the 896 communities had higher than expected childhood mortality rates during the study period. CONCLUSIONS Of the 31 482 children included in this survey, 2886 had died before their fifth birthday (128 deaths per 1000 live births). There are variations in childhood mortality across Nigerian communities that are not determined only by health system functions but also by factors beyond the scope of health authorities and healthcare delivery systems.

Pattern of utilisation of dental health care among HIV-positive adult Nigerians

PURPOSE To determine the pattern of dental care utilisation of people living with HIV (PLHIV). MATERIALS AND METHODS A cross-sectional questionnaire survey of 239 PLHIV patients in three care centres was done. Information on sociodemographics, dental visit, risk groups, living arrangement, medical insurance and need of dental care was recorded. The EC Clearinghouse and WHO clinical staging was used to determine the stage of HIV/AIDS infection following routine oral examinations under natural daylight. Multivariate logistic regression models were created after adjusting for all the covariates that were statistically significant at univariate/bivariate levels. RESULTS The majority of subjects were younger than 50 years, about 93% had not seen a dentist before being diagnosed HIV positive and 92% reported no dental visit after contracting HIV. Among nonusers of dental care, 14.3% reported that they wanted care but were afraid to seek it. Other reasons included poor awareness, lack of money and stigmatisation. Multivariate analysis showed that lack of dental care was associated with employment status, living arrangements, educational status, income per annum and presenting with oral symptoms. The area under the receiver operating curve was 84% for multivariate logistic regression model 1, 70% for model 2, 67% for model 3 and 71% for model 4, which means that the predictive power of the models were good. CONCLUSION Contrary to our expectations, dental utilisation among PLHIV was generally poor among this group of patients. There is serious and immediate need to improve the awareness of PLHIVs in African settings and barriers to dental care utilisation should also be removed or reduced.

Integrating community pharmacy into community based anti-retroviral therapy program: A pilot implementation in Abuja, Nigeria

Background The landscape of Human Immunodeficiency Virus (HIV) epidemic control is shifting with the United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 benchmarks for epidemic control. Community-based Antiretroviral Therapy (CART) models have improved treatment uptake and demonstrated good clinical outcomes. We assessed the feasibility of integrating community pharmacy as a task shift structure for differentiated community ART in Abuja-Nigeria. Methods Stable patients on first line ART regimens from public health facilities were referred to community pharmacies in different locations within the Federal Capital Territory, Abuja for prescription refills and treatment maintenance. Bio-demographic and clinical data were collected from February 25, 2016 to May 31st, 2017 and descriptive statistics analysis applied. The outcomes of measure were prescription refill and patient retention in care at the community pharmacy. Results Almost 10% of stable patients on treatment were successfully devolved from eight health facilities to ten community pharmacies. Median age of the participants was 35 years [interquartile range (IQR); 30, 41] with married women in the majority. Prescription refill was 100% and almost all the participants (99.3%) were retained in care after they were devolved to the community pharmacies. Only one participant was lost-to-follow-up as a result of death. Conclusion Excellent prescription refill and high retention in care with very low loss-to-follow-up were associated with the community pharmacy model. The use of community pharmacy for community ART is feasible in Nigeria. We recommend the scale up of the model in all the 36 states of Nigeria.