Do dietary practices and household environmental quality mediate socio-economic inequalities in child undernutrition risk in West Africa?

OBJECTIVE: We investigated the relationship between socio-economic status and child undernutrition in West Africa (WA), and further examined the mediating role of dietary practices (measured as minimum dietary diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD)) and household environmental quality (HEQ) in the observed relationship. DESIGN: Thirteen countries were included in the study. We leveraged the most recent Demographic and Health Surveys datasets ranging from 2010 to 2019. Poisson regression model with robust standard errors was used to estimate prevalence ratios and their corresponding 95 % CI. Structural equation modelling was used to conduct the mediation analysis. SETTING: West Africa. PARTICIPANTS: 132 448 under-five children born within 5 years preceding the survey were included. RESULTS: Overall, 32·5 %, 8·2 %, 20·1 % and 71·7 % of WA children were stunted, wasted, underweight and anaemic, respectively. Prevalence of undernutrition decreased with increasing maternal education and household wealth (Trend P-values < 0·001). Secondary or higher maternal education and residence in rich households were associated with statistically significant decrease in the prevalence of stunting, wasting, underweight and anaemia among children in WA. MAD was found to mediate the association of low maternal education and poor household wealth with childhood stunting and underweight by 35·9 % to 44·5 %. MDD, MMF and HEQ did not mediate the observed relationship. CONCLUSIONS: The study findings enables an evaluation and improvement of existing intervention strategies through a socio-economic lens to help address the high burden of child undernutrition in WA and other developing regions.

Secular trends in low birth weight and child undernutrition in West Africa: evidence from complex nationwide surveys, 1985-2019.

OBJECTIVE: We present prevalence estimates and secular trends of stunting, wasting, underweight, and anaemia among children under 5 years of age and low birth weight (LBW) over the period 1985-2019 in West Africa (WA). DESIGN: Analysis of Demographic and Health Survey (DHS) and World Bank data. DerSimonian-Laird random effect model with the Knapp-Hartung adjustment to the standard error was used to derive overall prevalence estimates. We used fixed effect ordinary least square regression models with cluster robust standard error to conduct time trends analyses. SETTING: West Africa. PARTICIPANTS: Children aged 0 to 59 months. RESULTS: Three distinct periods (1986-1990, 1993-1996 and 1997-2000) of sharp increases in prevalence of all outcomes was observed. After the year 2000, prevalence of all outcomes except LBW started to decline with some fluctuations. LBW prevalence showed a steady increase after 2000. We observed a decline in prevalence of stunting (ß = -0·20 %; 95 % CI -0·43 %, 0·03 %), log-wasting (ß = -0·02 %; 95 % CI -0·02 %, -0·01 %), log-underweight (ß = -0·02 %; 95 % CI -0·03 %, -0·01 %) anaemia (ß = -0·44; 95 % CI -0·55 %, -0·34 %), and an increase in LBW (ß = 0·06 %; 95 % CI -0·10 %, 0·22 %) in WA over the period. Pooled prevalence of stunting, wasting, underweight, anaemia and LBW in WA for the period 1985-2019 was 26·1 %, 16·4 %, 22·7 %, 76·2 % and 11·3 %, respectively. CONCLUSIONS: Child undernutrition prevalence varied greatly between countries and the year cohorts. We observed marginal reductions in prevalence of all outcomes except anaemia where the reductions were quite striking and LBW where an increase was noted. There is the need for more rigorous and sustained targeted interventions in WA.

Spatial heterogeneity in drinking water sources in the Greater Accra Metropolitan Area (GAMA), Ghana.

Universal access to safe drinking water is essential to population health and well-being, as recognized in the Sustainable Development Goals (SDG). To develop targeted policies which improve urban access to improved water and ensure equity, there is the need to understand the spatial heterogeneity in drinking water sources and the factors underlying these patterns. Using the Shannon Entropy Index and the Index of Concentration at the Extremes at the enumeration area level, we analyzed census data to examine the spatial heterogeneity in drinking water sources and neighborhood income in the Greater Accra Metropolitan Area (GAMA), the largest urban agglomeration in Ghana. GAMA has been a laboratory for studying urban growth, economic security, and other concomitant socio-environmental and demographic issues in the recent past. The current study adds to this literature by telling a different story about the spatial heterogeneity of GAMA's water landscape at the enumeration area level. The findings of the study reveal considerable geographical heterogeneity and inequality in drinking water sources not evidenced in previous studies. We conclude that heterogeneity is neither good nor bad in GAMA judging by the dominance of both piped water sources and sachet water (machine-sealed 500-ml plastic bag of drinking water). The lessons from this study can be used to inform the planning of appropriate localized solutions targeted at providing piped water sources in neighborhoods lacking these services and to monitor progress in achieving universal access to improved drinking water as recognized in the SDG 6 and improving population health and well-being.

Socioeconomic determinants of birth registration in Ghana.

BACKGROUND: Identity registration is not only a matter of human rights but it also serves as an important instrument for planning about health, education and overall development. This paper examines the chances of a child born in Ghana between 2001 and 2006 obtaining legal status of identity. METHODS: Data for this paper were extracted from the 2006 Ghana Multiple Indicator Cluster Survey (MICS). We used discrete choice modelling in estimating the likelihood of child registration in Ghana. RESULTS: Mother's education and household wealth are identified to be positively associated with the likelihood of a child being registered. In the context of structural factors, being a resident in the Eastern region of Ghana and rural areas were found to be risk factors for children not being registered. Besides, children who were resident in households where the head is affiliated to Traditional Religion were found to be at significant risk of being unregistered. CONCLUSION: Overall, our findings give an impression of birth registration being a privilege for children whose parents are educated, wealthy and resident in urban communities. Policies meant to increase uptake have to be broad-based, targeting the less privileged particularly with practical interventions such as transport vouchers to registration centres. This may help appropriate meaning to international protocols on birth registration as a human right issue to which Ghana affirms.

HOUSEHOLD NUCLEATION, DEPENDENCY AND CHILD HEALTH OUTCOMES IN GHANA.

This study uses three key anthropometric measures of nutritional status among children (stunting, wasting and underweight) to explore the dual effects of household composition and dependency on nutritional outcomes of under-five children in Ghana. The objective is to examine changes in household living arrangements of under-five children to explore the interaction of dependency and nucleation on child health outcomes. The concept of nucleation refers to the changing structure and composition of household living arrangements, from highly extended with its associated socioeconomic system of production and reproduction, social behaviour and values, towards single-family households - especially the nuclear family, containing a husband and wife and their children alone. A negative relationship between levels of dependency, as measured by the number of children in the household, and child health outcomes is premised on the grounds that high dependency depletes resources, both tangible and intangible, to the disadvantage of young children. Data were drawn from the last four rounds of the Ghana Demographic and Health Surveys (GDHSs), from 1993 to 2008, for the first objective - to explore changes in household composition. For the second objective, the study used data from the 2008 GDHS. The results show that, over time, households in Ghana have been changing towards nucleation. The main finding is that in households with the same number of dependent children, in nucleated households children under age 5 have better health outcomes compared with children under age 5 in non-nucleated households. The results also indicate that the effect of dependency on child health outcomes is mediated by household nucleation and wealth status and that, as such, high levels of dependency do not necessarily translate into negative health outcomes for children under age 5, based on anthropometric measures.

Neighbourhood mothers' education and its differential impact on stunting: Evidence from 30 Sub-Saharan African countries.

The study used data from Demographic and Health Surveys for 30 Sub-Saharan African countries to investigate differences in the residential effects of mothers' education on stunting. Multilevel logistic regressions were employed to examine the neighbourhood effects of mothers' education on stunting. The study found that although a higher proportion of mothers with secondary education in a neighbourhood, irrespective of the residence type (rural or urban), reduces a child's probability of being stunted, this effect is stronger for children residing in rural areas than those in the urban. Achieving a target of at least 75 per cent of mothers obtaining secondary education and higher will bridge the rural-urban gap in stunting in Sub-Saharan Africa.

Birth weight mediates the association of maternal undernutrition with child undernutrition prevalence in West Africa.

BACKGROUND: Maternal nutritional status before and during pregnancy is an important determinant of foetal health. In West Africa, maternal and child undernutrition remains a major public health problem and it is important to establish the mechanistic pathway linking the two disorders to help address the problem. We therefore assessed the mediating role of low birth weight (LBW) in the relationship of maternal undernutrition with child undernutrition in West Africa. METHODS: We included recent (2010-2019) DHS data from thirteen West African countries. Poisson regression model with robust standard errors was used to assess the relationship between maternal undernutrition (body mass index and anaemia) and child undernutrition (stunting, wasting, underweight, and anaemia). Structural equation modelling was used to conduct the mediation analysis. RESULTS: Prevalence of stunting, wasting, underweight, and anaemia among under-five children in West Africa was found to be 32.4%, 8.1%, 20.1%, and 71.5%, respectively. We found children of underweight mothers to be more likely to be undernourished (stunted, wasted, and underweight) and anaemic compared to children of normal-weight mothers. Also, children of anaemic mothers were more likely to be stunted and anaemic but not wasted compared with children of non-anaemic mothers. LBW mediated the observed relationships between maternal BMI and childhood stunting (22.6%), and maternal anaemia and childhood stunting (24.9%), wasting (11.7), and anaemia (6.6%). CONCLUSION: We found maternal undernutrition to be associated with child undernutrition in West Africa with LBW noted to be a mediator of the observed relationship. We recommend that, to address the child undernutrition problem in West Africa, governments and policymakers must integrate measures to address the burden of LBW.

Socio-demographic and neighbourhood factors influencing urban green space use and development at home: A population-based survey in Accra, Ghana.

In Sub-Saharan Africa and other developing regions, there has been very little systematic attempt to document the uses and perceived health benefits of urban green spaces in cities and the factors influencing usage. We therefore sought to establish the availability, accessibility and use of urban green spaces, and the perceived health benefits in an African population. We also ascertained the factors influencing use and development of green spaces at home. A population-based survey was conducted in Accra, the capital city of Ghana, spanning 11 Municipal and 3 Sub-Metropolitan areas. Multivariable binary logistic regression adjusting for potential confounders was used to establish the association between green space use and development at home, and socio-demographic, neighbourhood and health factors. Odds ratios and their corresponding 95% confidence intervals were estimated from the models. Several socio-demographic (gender, age, marital status, occupation, ethnicity, religion) and district-level (population density, income level, neighbourhood greenness) factors were associated with use of green spaces and development of green spaces at home in Accra. Residents who were worried about depletion of green spaces in their community were more likely to develop green spaces at home. In neighbourhoods with moderate and high level of greenness, residents were less likely to develop green spaces at home. Five-percent and 47% of green space users in Accra reported witnessing an improvement in their physical and mental health, respectively, from use of green spaces. The study findings can inform policy action for promoting use and development of green spaces in African cities and for mitigating depletion and degradation of the limited urban greenery.

Quantifying within-city inequalities in child mortality across neighbourhoods in Accra, Ghana: a Bayesian spatial analysis.

OBJECTIVE: Countries in sub-Saharan Africa suffer the highest rates of child mortality worldwide. Urban areas tend to have lower mortality than rural areas, but these comparisons likely mask large within-city inequalities. We aimed to estimate rates of under-five mortality (U5M) at the neighbourhood level for Ghana's Greater Accra Metropolitan Area (GAMA) and measure the extent of intraurban inequalities. METHODS: We accessed data on >700 000 women aged 25-49 years living in GAMA using the most recent Ghana census (2010). We summarised counts of child births and deaths by five-year age group of women and neighbourhood (n=406) and applied indirect demographic methods to convert the summaries to yearly probabilities of death before age five years. We fitted a Bayesian spatiotemporal model to the neighbourhood U5M probabilities to obtain estimates for the year 2010 and examined their correlations with indicators of neighbourhood living and socioeconomic conditions. RESULTS: U5M varied almost five-fold across neighbourhoods in GAMA in 2010, ranging from 28 (95% credible interval (CrI) 8 to 63) to 138 (95% CrI 111 to 167) deaths per 1000 live births. U5M was highest in neighbourhoods of the central urban core and industrial areas, with an average of 95 deaths per 1000 live births across these neighbourhoods. Peri-urban neighbourhoods performed better, on average, but rates varied more across neighbourhoods compared with neighbourhoods in the central urban areas. U5M was negatively correlated with multiple indicators of improved living and socioeconomic conditions among peri-urban neighbourhoods. Among urban neighbourhoods, correlations with these factors were weaker or, in some cases, reversed, including with median household consumption and women's schooling. CONCLUSION: Reducing child mortality in high-burden urban neighbourhoods in GAMA, where a substantial portion of the urban population resides, should be prioritised as part of continued efforts to meet the Sustainable Development Goal national target of less than 25 deaths per 1000 live births.

Wealth status and risky sexual behaviour in Ghana and Kenya.

BACKGROUND: Emerging evidence seems to suggest that there is some association between individual socioeconomic status and sexual risk-taking behaviour in sub-Saharan Africa. A number of broad associations have emerged, among them, positive, neutral and negative relationships between wealth status and sexual risk-taking behaviour. Reduction in the number of sex partners as a behavioural change has been advocated as an important tool in HIV prevention, and affecting such a change requires an understanding of some of the factors that can influence social behaviour, interactions and activities of subpopulations. OBJECTIVES: To further explore the determinants of sexual risk-taking behaviour (individuals having multiple sex partners), especially the effects that variations in household wealth status, gender and different subpopulation groups have on this behaviour. METHODS: The relationship between wealth status and sexual risk-taking behaviour in the context of HIV/AIDS infection in Ghana and Kenya was assessed using raw data from the 2003 Demographic and Health Surveys of each country. Wealth quintiles were used as a proxy for economic status, while non-marital and non-cohabiting sexual partnerships were considered indicators for risky sexual behaviour. RESULTS: For females, there appears to be an increasing probability of sexual risk taking by wealth status in Kenya, while, in Ghana, an inverted J-shaped relationship is shown between wealth status and sexual risk taking. When controlled for other variables, the relationship between wealth status and sexual risk-taking behaviour disappears for females in the two countries. For males, there is no clearly discernable pattern between wealth status and sexual risk-taking behaviour in Ghana, while there is a general trend towards increasing sexual risk-taking behaviour by wealth status in Kenya. For Ghana, the highest probabilities are among the highest and the middle wealth quintiles; in Kenya, high probabilities were found for the two highest wealth quintiles. Controlling for the effects of other factors, the pattern for Ghana is further blurred (not statistically significant), but the relationship continues to show in the case of Kenya, and is significant for the highest quintile. In general, for both Ghana and Kenya, men in the highest wealth quintile were found to be more likely to have multiple sexual partners than the other groups. CONCLUSION: The changing phases of HIV infection indicate that it is no longer poverty that drives the epidemic. Rather, it is wealth and a number of other sociodemographic factors that explain sexual risk-taking behaviour that puts people at risk. Understanding local specific factors that predispose individuals towards sexual risk taking could help to expand the range of information and services needed to combat the HIV pandemic.

Reproducibility of statistical data, academic publications and policy implications: Evidence from Ghana.

This paper examines the accuracy, validity and presentation of statistical evidence and also assesses the implications of irreproducibility associated with variations in sample size for academic research work and policy-making. The 2012/13 Ghana Living Standards Survey (GLSS), 10 academic publications and the Free Senior High School policy in Ghana are used to address the objectives of the paper. The data show that about 20 per cent of the tables in the Main Report of the GLSS Six is irreproducible, 10 per cent of the tables have outcomes worth re-examining, and in terms of completeness in the presentation of statistical evidence, only 3 out of the 27 sampled tables report the sample size that was used. Again, nine out of the 10 academic publications use half of the original sample size, two-fifths of the publications do not report the sample size for the descriptive statistics, a couple of the papers show varying sample size between the descriptive statistics and the regression analysis.

Dietary diversity and child malnutrition in Ghana.

The health of children in Ghana has improved in recent years. However, the current prevalence rates of malnutrition remain above internationally acceptable levels. This study, therefore, revisits the determinants of child health by using Ghana's Multiple Indicator Cluster Survey to investigate the effect of infant feeding practices on child health. We used the World Health Organization's Infant and Young Children Feeding guidelines to measure dietary quality. The econometric analyses show that dietary diversity may cause improvement in children's health in Ghana. This suggests that educational campaigns on proper infant feeding and complementary dieting could be an effective means of improving the health of children in Ghana.