COVID-19 vaccine uptake, conspiracy theories, and health literacy among Black individuals in Canada: Racial discrimination, confidence in health, and COVID-19 stress as mediators.

Factors influencing vaccine uptake in Black individuals remain insufficiently documented. Understanding the role of COVID-19 related stress, conspiracy theories, health literacy, racial discrimination experiences, and confidence in health authorities can inform programs to increase vaccination coverage. We sought to analyze these factors and vaccine uptake among Black individuals in Canada. A representative sample of 2002 Black individuals from Ontario, Quebec, Alberta, Nova Scotia, New Brunswick, British Columbia, and Manitoba, aged 14 years or older completed questionnaires assessing vaccine uptake, health literacy, conspiracy theories, racial discrimination experiences, COVID-19-related stress, and confidence in health authorities. Mediation analyses were conducted to assess (1) the effect of health literacy on COVID-19 vaccination uptake through confidence and need, COVID-19 related traumatic stress, and racial discrimination, and (2) the effect of conspiracy beliefs on COVID-19 vaccination uptake through the same factors. Overall, 69.57% (95% confidence interval, 67.55%-71.59%) of the participants were vaccinated and 83.48% of them received two or more doses. Those aged 55 years and older were less likely to be vaccinated, as well as those residing in British Columbia and Manitoba. Mediation models showed that the association between health literacy and COVID-19 vaccine uptake was mediated by confidence in health authorities (B = 0.02, p < 0.001), COVID-19-related stress (B = -0.02, p < 0.001), and racial discrimination (B = -0.01, p = 0.032), but both direct and total effects were nonsignificant. Lastly, conspiracy beliefs were found to have a partial mediation effect through the same mediators (B = 0.02, p < 0.001, B = -0.02, p < 0.001, B = -0.01, p = 0.011, respectively). These findings highlight the need for targeted interventions to address vaccine hesitancy and inform approaches to improve access to vaccinations among Black communities.

Socioeconomic inequalities in uptake of HIV testing during antenatal care: evidence from Sub-Saharan Africa.

BACKGROUND: Measuring socioeconomic inequalities in healthcare usage represents a critical step towards promoting health equity, in alignment with the principles of universal health coverage and the United Nations' Sustainable Development Goals. In this study, we assessed the socioeconomic inequalities in HIV testing during antenatal care (ANC) in sub-Saharan Africa. METHODS: Sub-Saharan Africa was the focus of this study. Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Mauritania, Mozambique, Rwanda, Sierra Leone, Uganda, Zambia, and Zimbabwe were the countries included in the study. This study used current Demographic and Health Surveys data spanning from 2015 to 2022. A total of 70,028 women who tested for HIV as part of antenatal contacts formed the sample for analysis. We utilized the standard concentration index and curve to understand the socioeconomic inequalities in HIV testing during antenatal care among women. Additionally, a decomposition analysis of the concentration index was ran to ascertain the contributions of each factor to the inequality. RESULTS: Overall, 73.9% of women in sub-Saharan Africa tested for HIV during ANC. The countries with the highest proportions were Malawi, Rwanda, Zambia, and Zimbabwe. Mali Benin, Guinea, Mali, and Mauritania were the countries with the lowest proportions of HIV testing. Being among the richer [AOR 1.10, 95% CI: 1.02,1.18] and richest [AOR 1.41, 95% CI:1.30, 1.54] wealth quintiles increased the odds of HIV testing during ANC. The concentration value of 0.03 and the curve show that HIV testing is more concentrated among women in the highest wealth quintile. Hence, wealthy women are advantaged in terms of HIV testing. As the model's residual value is negative (-0.057), the model overestimates the level of inequality in the outcome variable (HIV during ANC), which means that the model's explanatory factors can account for higher concentration than is the case. CONCLUSION: We found that there is substantial wealth index-related inequalities in HIV testing, with women of the poorest wealth index disadvantaged in relation to the HIV testing. This emphasizes the necessity for sub-Saharan Africa public health programs to think about concentrating their limited resources on focused initiatives to grasp women from these socioeconomic circumstances. To increase women's access to HIV testing, maternal and child health programs in sub-Saharan Africa should attempt to minimize female illiteracy and poverty. Consequently, health education may be required to provide women with comprehensive HIV knowledge and decrease the number of lost opportunities for women to get tested for HIV. Given the link between knowledge of HIV and HIV testing, it is important to focus on community education and sensitization about HIV and the need to know one's status.

Female genital mutilation/cutting among girls aged 0-14: evidence from the 2018 Mali Demographic and Health Survey data.

BACKGROUND: Female genital mutilation/cutting (FGM/C) is considered a social norm in many African societies, with varying prevalence among countries. Mali is one of the eight countries with very high prevalence of FGM/C in Africa. This study assessed the individual and contextual factors associated with female FGM/C among girls aged 0-14 years in Mali. METHODS: We obtained data from the 2018 Mali Demographic and Health Survey. The prevalence of FGM/C in girls was presented using percentages while a multilevel binary logistic regression analysis was conducted to assess the predictors of FGM/C and the results were presented using adjusted odds ratios with associated 95% confidence intervals (CIs). RESULTS: The results indicate that more than half (72.7%, 95% CI = 70.4-74.8) of women in Mali with daughters had at least one daughter who has gone through circumcision. The likelihood of circumcision of girls increased with age, with women aged 45-49 having the highest odds compared to those aged 15-19 (aOR = 17.68, CI = 7.91-31.79). A higher likelihood of FGM/C in daughters was observed among women who never read newspaper/magazine (aOR = 2.22, 95% CI = 1.27-3.89), compared to those who read newspaper/magazine at least once a week. Compared to women who are not circumcised, those who had been circumcised were more likely to have their daughters circumcised (aOR = 53.98, 95% CI = 24.91-117.00). CONCLUSION: The study revealed the age of mothers, frequency of reading newspaper/magazine, and circumcision status of mothers, as factors associated with circumcision of girls aged 0-14 in Mali. It is, therefore, imperative for existing interventions and new ones to focus on these factors in order to reduce FGM/C in Mali. This will help Mali to contribute to the global efforts of eliminating all harmful practices, such as child, early and forced marriage and female genital mutilation by 2030.

Association between sexual violence and multiple high-risk fertility behaviours among women of reproductive age in sub-Saharan Africa.

BACKGROUND: Intimate partner violence has adverse outcomes on the sexual and reproductive health of women. In this study, we examined the association between sexual violence and multiple high-risk fertility behaviours (MHRFB) among women in sub-Saharan Africa (SSA). METHODS: We conducted a cross-sectional analysis of data pooled from the most recent Demographic and Health Surveys of 20 countries in SSA. We included countries with most recent datasets conducted from 2015 to 2021 and had data on all variables included in the study. A weighted sample of 88,011 was included in the study. We used a multilevel binary logistic regression to examine the association between sexual violence and MHRFB, controlling for other covariates. The regression results were presented using adjusted odds ratio (aOR) with 95% confidence interval (CI). Statistical significance was set at p < 0.05. RESULTS: The overall prevalence of MHRFB was 22.53% (95% CI: 22.26-22.81), which ranged from 9.94% in South Africa to 30.38% in Chad. For sexual violence, the pooled prevalence was 7.02% (95% CI: 6.86-7.19). Burundi (20.58%) and the Gambia (2.88%) reported the highest and lowest proportions, respectively. Women who experienced sexual violence were more likely to engage in MHRFB compared to those who did not experience sexual violence [aOR = 1.11, 95% CI: 1.02, 1.21]. CONCLUSION: There is a positive association between sexual violence and the risk of MHRFB. Our findings underscore a need for sub-Saharan African countries to strengthen their efforts to reduce the occurrence of sexual violence in intimate partner relationships. To augment efforts and accelerate social change, sub-Saharan African countries can introduce pro-poor policies and interventions to improve the wealth status of women. Also, empowering women through the encouragement of attaining higher education would be a useful step in lowering the risk of MHRFB in SSA.

Association between the survey-based women's empowerment index (SWPER) and intimate partner violence in sub-Saharan Africa.

BACKGROUND: Intimate partner violence (IPV) is high among women of reproductive age in sub-Saharan Africa (SSA). However, empowering women enables them to confront and mitigate IPV. In this study, we examined the association between the survey-based women's empowerment index (SWPER) and IPV in SSA. METHODS: We used data from the Demographic and Health Surveys of 19 countries conducted from 2015 to 2021. Our study was restricted to a weighted sample of 82,203 women of reproductive age who were married or cohabiting. We used spatial maps to show the proportions of women who experienced past-year IPV. A five-modelled multilevel binary logistic regression analysis was adopted to examine the association between SWPER and IPV. The results were presented using the adjusted odds ratio (AOR) with their respective 95% confidence interval (CI). Statistical significance was set at p < 0.05. RESULTS: With physical and emotional violence, the country with the highest prevalence was Sierra Leone, with a prevalence of 39.00% and 38.97% respectively. Rwanda (10.34%), Zambia (11.09%), Malawi (15.00%), Uganda (16.88%), and Burundi (20.32%) were the hotspot countries for sexual violence. Angola (34.54%), Uganda (41.55%), Liberia (47.94%), and Sierra Leone (59.98%) were the hotspot countries for IPV. A high SWPER score in attitudes to violence significantly decreased the odds of IPV [AOR = 0.70; 95% CI = 0.66, 0.75]. Also, women with medium score in decision-making were less likely to experience IPV compared to those with lower scores [AOR = 0.89; 95% CI = 0.83, 0.95]. However, higher odds of experiencing IPV was found among women with medium score in autonomy compared to those with low scores [AOR = 1.07; 95% CI = 1.01, 1.14]. CONCLUSIONS: Our study has shown that the three dimensions of SWPER significantly predict IPV among women. Consequently, it is crucial that sub-Saharan African countries implement various initiatives, such as IPV advocacy programs and economic livelihood empowerment initiatives. These initiatives should not only aim to improve women's attitudes to domestic violence but also to enhance their social independence, autonomy, and decision-making capacity.

Where are the links? Using a causal loop diagram to assess interactions in healthcare coordination for youth experiencing homelessness in Toronto, Canada.

BACKGROUND: Youth experiencing homelessness (YEH) suffer from poorer physical and mental health outcomes than stably housed youth. Additionally, YEH are forced to navigate fragmented health and social service systems on their own, where they often get lost between systems when transitioning or post-discharge. Inevitably, YEH require support with health system navigation and healthcare coordination. The aim of this study is to understand interactions within and between the emergency youth shelter (EYS) and health systems that affect healthcare coordination for YEH in Toronto, Canada, and how these interactions can be targeted to improve healthcare coordination for YEH. METHODS: This study is part of a larger qualitative case study informed by the framework for transformative systems change. To understand interactions in healthcare coordination for YEH within and between the EYS and health systems, we developed a causal loop diagram (CLD) using in-depth interview data from 24 key informants at various levels of both systems. Open and focused codes developed during analysis using Charmaz's constructivist grounded theory methodology were re-analysed to identify key variables, and links between them to create the CLD. The CLD was then validated by six stakeholders through a stakeholder forum. RESULTS: The CLD illustrates six balancing and one reinforcing feedback loop in current healthcare coordination efforts within the EYS and health systems, respectively. Increasing EYS funding, building human resource capacity, strengthening inter and intra-systemic communication channels, and establishing strategic partnerships and formal referral pathways were identified among several other variables to be targeted to spiral positive change in healthcare coordination for YEH both within and between the EYS and health systems. CONCLUSIONS: The CLD provides a conceptual overview of the independent and integrated systems through which decision-makers can prioritize and guide interventions to strengthen healthcare coordination within and between the EYS and health systems. Overall, our research findings suggest that key variables such as streamlining communication and improving staff-youth relationships be prioritized, as each of these acts interdependently and influences YEH's access, quality and coordination of healthcare.

Where's the Disconnect? Exploring Pathways to Healthcare Coordinated for Youth Experiencing Homelessness in Toronto, Canada, Using Grounded Theory Methodology.

About 900 youth experiencing homelessness (YEH) reside at an emergency youth shelter (EYS) in Toronto on any given night. Several EYSs offer access to healthcare based on youths' needs, including access to primary care, and mental health and addictions support. However, youth also require healthcare from the broader health system, which is often challenging to navigate and access. Currently, little is known about healthcare coordination efforts between the EYS and health systems for YEH. Using grounded theory methodology, we interviewed 24 stakeholders and concurrently analyzed and compared data to explore pathways to healthcare coordinated for youth who reside at an EYS in Toronto. We also investigated fundamental parts (i.e., norms, resources, regulations, and operations) within the EYS and health systems that influence these pathways to healthcare using thematic analysis. A significant healthcare coordination gap was found between these two systems, typically when youth experience crises, often resulting in a recurring loop of transition and discharge between EYSs and hospitals. Several parts within each system act interdependently in hindering adequate healthcare coordination between the EYS and health systems. Incorporating training for system staff on how to effectively coordinate healthcare and work with homeless populations who have complex health needs, and rethinking information-sharing policies within circles of care are examples of how system parts can be targeted to improve healthcare coordination for YEH. Establishing multidisciplinary healthcare teams specialized to serve the complex needs of YEH may also improve healthcare coordination between systems, and access and quality of healthcare for this population.

Vaccine mistrust among Black individuals in Canada: The major role of health literacy, conspiracy theories, and racial discrimination in the healthcare system.

The COVID-19 pandemic disproportionately affected Black communities in Canada in terms of infection and mortality rates compared to the general population. Despite these facts, Black communities are among those with the highest level of COVID-19 vaccine mistrust (COVID-19 VM). We collected novel data to analyze the sociodemographic characteristics and factors associated with COVID-19 VM among Black communities in Canada. A survey was conducted among a representative sample of 2002 Black individuals (51.66% women) aged 14-94 years (M = 29.34; SD = 10.13) across Canada. Vaccine mistrust was assessed as the dependent variable and conspiracy theories, health literacy, major racial discrimination in healthcare settings, and sociodemographic characteristics of participants were assessed as independent variables. Those with a history of COVID-19 infection had higher COVID-19 VM score (M = 11.92, SD = 3.88) compared to those with no history of infection (M = 11.25, SD = 3.83), t (1999) = -3.85, p < 0.001. Participants who reported having experienced major racial discrimination in healthcare settings were more likely to report COVID-19 VM (M = 11.92, SD = 4.03) than those who were not (M = 11.36, SD = 3.77), t (1999) = -3.05, p = 0.002. Results also showed significant differences for age, education level, income, marital status, provinces, language, employment status, and religion. The final hierarchical linear regression showed that conspiracy beliefs (B = 0.69, p < 0.001) were positively associated with COVID-19 VM, while health literacy (B = -0.05, p = 0.002) was negatively associated with it. The mediated moderation model showed that conspiracy theories completely mediated the association between racial discrimination and vaccine mistrust (B = 1.71, p < 0.001). This association was also completely moderated by the interaction between racial discrimination and health literacy (B = 0.42, p = 0.008), indicating that despite having a high level of health literacy, those who experienced major racial discrimination in health services developed vaccine mistrust. This first study on COVID-19 VM exclusively among Black individuals in Canada provides data that can significantly impact the development of tools, trainings, strategies, and programs to make the health systems free of racism and increase their confidence in vaccination for COVID-19 and other infectious diseases.

Prevalence and factors related to COVID-19 vaccine hesitancy and unwillingness in Canada: A systematic review and meta-analysis.

This systematic review and meta-analysis examined the prevalence and factors associated with vaccine hesitancy and vaccine unwillingness in Canada. Eleven databases were searched in March 2022. The pooled prevalence of coronavirus disease 2019 (COVID-19) vaccine hesitancy and unwillingness was estimated. Subgroup analyses and meta-regressions were performed. Out of 667 studies screened, 86 full-text articles were reviewed, and 30 were included in the systematic review. Twenty-four articles were included in the meta-analysis; 12 for the pooled prevalence of vaccine hesitancy (42.3% [95% CI, 33.7%-51.0%]) and 12 for vaccine unwillingness (20.1% [95% CI, 15.2%-24.9%]). Vaccine hesitancy was higher in females (18.3% [95% CI, 12.4%-24.2%]) than males (13.9% [95% CI, 9.0%-18.8%]), and in rural (16.3% [95% CI, 12.9%-19.7%]) versus urban areas (14.1% [95%CI, 9.9%-18.3%]). Vaccine unwillingness was higher in females (19.9% [95% CI, 11.0%-24.8%]) compared with males (13.6% [95% CI, 8.0%-19.2%]), non-White individuals (21.7% [95% CI, 16.2%-27.3%]) than White individuals (14.8% [95% CI, 11.0%-18.5%]), and secondary or less (24.2% [95% CI, 18.8%-29.6%]) versus postsecondary education (15.9% [95% CI, 11.6%-20.2%]). Factors related to racial disparities, gender, education level, and age are discussed.

Malaria profile and socioeconomic predictors among under-five children: an analysis of 11 sub-Saharan African countries.

BACKGROUND: African region accounts for 95% of all malaria cases and 96% of malaria deaths with under-five children accounting for 80% of all deaths in the region. This study assessed the socioeconomic determinants of malaria prevalence and provide evidence on the socioeconomic profile of malaria infection among under-five children in 11 SSA countries. METHODS: This study used data from the 2010 to 2020 Demographic and Health Survey (DHS). The survey used a two-stage stratified-cluster sampling design based on the sampling frame of the population and housing census of countries included. Statistical analyses relied on Pearson's χ2, using the CHAID decision-tree algorithm and logistic regression implemented in R V.4.6. RESULTS: Of 8547 children considered, 24.2% (95% confidence interval CI 23.4-25.05%) had malaria infection. Also, the prevalence of malaria infection seems to increase with age. The following variables are statistically associated with the prevalence of malaria infection among under-five children: under-five child's age, maternal education, sex of household head, household wealth index, place of residence, and African region where mother-child pair lives. Children whose mothers have secondary education have about 56% lower risk (odds ratio = 0.44; 95% CI 0.40-0.48) of malaria infection and 73% lower (odds ratio = 0.37; 95% CI 0.32-0.43) among children living in the richest households, compared to children living in the poorest households. CONCLUSIONS: The findings of this study provide unique insights on how socioeconomic and demographic variables, especially maternal education level significantly predicts under-five malaria prevalence across the SSA region. Therefore, ensuring that malaria interventions are underpinned by a multisectoral approach that comprehensively tackles the interplay of maternal education and other socioeconomic variables will be critical in attaining malaria prevention and control targets in SSA.

Is intimate partner violence vertically transmitted among women in sub-Saharan Africa? Evidence from demographic health surveys between 2010 and 2019.

BACKGROUND: Violence against women is a major human rights violation, and the continuous occurrence of this can have many implications for women's social and health outcomes. The experience of violence from an intimate partner could be more intriguing, especially if such women experienced their mother's intimate partner violence (IPV) issues. Thus, this study examined the vertical transmission of IPV among women in sub-Saharan Africa (SSA). METHODS: A total of 97,542 eligible women were drawn from 27 countries in SSA using a retrospective secondary dataset from Demographic Health Surveys conducted between 2010 and 2019. Multivariable analysis was employed to determine the association between the vertical transmission of IPV from mother to daughter and the covariates associated with IPV in SSA at p < 0.05. RESULTS: The results showed that 40% of the respondents had experienced lifetime IPV, whilst 25% of those women reported that their mothers experienced it in childhood in SSA. Country-specific variations showed the highest prevalence of IPV experienced in Sierra Leone (60%) and the lowest in Comoros (9%). Results from model 1 showed that women who reported that their mothers experienced IPV were found to be significantly more than two times more likely to have experienced any form of IPV compared to those whose mothers did not (aOR = 2.66; 95% CI: 2.59-2.74), after adjusting for cofounders in Model 2, the result still showed that women who reported that their mothers experienced IPV were found to be significantly more than two times more likely to have experienced any form of IPV compared to those whose mothers did not (aOR = 2.56; 95% CI: 2.48-2.63). On the other hand, women with higher-educated partners, women in rural areas, and those from female-headed households were less likely to experience IPV. CONCLUSION: This study concluded that women whose mothers experienced IPV were more likely to have experienced IPV. Our study also identified that education, rural areas, and female-headed households were protective factors against experiencing IPV. To address the groups of women at higher risk for experiencing IPV, we recommend ensuring that girls complete their education to promote greater wealth and resources.

Early Sexual Debut and Its Associated Factors Among Young Women Aged 15-24 in Mali: A Multilevel Analysis.

Early sexual debut is associated with increased risk of several sexual and reproductive health problems, including unwanted pregnancies and sexually transmitted infections. Hence, determining factors that promote early sexual initiation is significant to guide policy and inform interventions aimed to promote the health of young people through to adulthood. This study examined the prevalence of early sexual debut and its associated factors among young women in Mali. Using cross-sectional nationally representative data from the 2018 Mali Demographic and Health Survey, a total of 4063 young women aged 15-24 were included in the study. Multilevel binary logistic regression analysis was done to determine the factors associated with early sexual debut. The results were presented using adjusted odds ratios (aOR) and 95% confidence intervals (CIs). The prevalence of early sexual debut in Mali was 17.8% (95% CI; 16-19.7%). Young women who attended higher school had lower odds of early sexual debut (aOR = 0.10, 95% CI; 0.01-0.82) compared to young women who had no formal education. Young women from richest households had lower odds of early sexual debut compared to those from the poorest households (aOR = 0.48, 95% CI; 0.27-0.82). Young women from households with large family size also had lower odds of experiencing early sexual debut compared to those in small family size (aOR = 0.81, 95% CI; 0.66-0.99). Furthermore, the odds of early sexual debut were lower among young women in Koulikoro (aOR = 0.59, 95% CI; 0.39-0.90), Sikasso (aOR = 0.35, 95% CI; 0.21-0.56), Segou (aOR = 0.40, 95% CI; 0.25-0.64), and Mopti (aOR = 0.44, 95% CI; 0.23-0.82) regions compared to young women in Kayes region. Higher odds of early sexual debut were found among currently employed compared to not currently employed young women (aOR = 1.74, 95% CI; 1.42-2.12) and currently married compared to not currently married young women (aOR = 4.64, 95% CI; 3.64-5.92). Young women from the Peulh ethnic groups compared to those from the Bambara ethnic groups were at a higher odds of early sexual debut (aOR = 1.43, 95% CI; 1.03-1.99). The findings suggest the need for interventions aimed at addressing early sexual debut among young women. These can include emphasizing the promotion and importance of female education, addressing the cultural practices that promote negative sexual norms/practices such as child marriages, and ensuring social change through efforts such as creating employment or economic opportunities for families.

Correlates of repeat pregnancies among adolescent girls and young women in sub-Saharan Africa.

BACKGROUND: Adolescent girls and young women are vulnerable populations who are at risk of several adverse sexual and reproductive health outcomes, including unintended pregnancies, sexually transmitted infections, unsafe abortions, and death from pregnancy-related complications. In this study, we examined the correlates of repeat pregnancies among adolescent girls and young women in sub-Saharan Africa (SSA). METHODS: We extracted data from the most recent Demographic and Health Surveys (DHS) of 31 countries in SSA. Countries whose surveys were conducted from 2010 to 2020 were included in the study. A total of 108,572 adolescent girls and young women (15-24 years) were included in the study. We used a multilevel mixed-effect binary logistic regression analysis to examine the correlates of repeat pregnancies among adolescent girls and young women in SSA. RESULTS: We found that adolescent girls and young women aged 20-24 [aOR = 2.36; 95%CI = 2.22, 2.51], those married [aOR = 7.52; 95%CI = 6.81, 8.30], living with a partner [aOR = 7.51; 95%CI = 6.87, 8.21], and those who had sexual intercourse before age 20 [aOR = 1.41; 95%CI = 1.33, 1.51] had higher odds of experiencing repeat pregnancies compared to those aged 15-19, those never in a union, those whose first sexual intercourse occurred at age 20 and above, respectively. Respondents exposed to listening to radio [aOR = 1.12; 95%CI = 1.06, 1.18] and those who justified intimate partner violence [aOR=1.13; 95%CI = 1.07, 1.19] had higher odds of experiencing repeat pregnancies compared to those who never listened to radio and those who did not justify intimate partner violence, respectively. Young women who had attained secondary or higher educational level [aOR = 0.83; 95%CI = 0.78, 0.90], those exposed to reading newspaper or magazine [aOR = 0.90; 95%CI = 0.82, 0.98], those residing in rural areas [aOR = 0.92; 95%CI = 0.86, 0.98], and those belonging to the richer [aOR = 0.87; 95%CI = 0.80, 0.95] and richest [aOR = 0.68; 95%CI = 0.61, 0.76] wealth quintile were less likely to experience repeat pregnancies. CONCLUSION: The correlates of repeat pregnancies include age, age at first sexual intercourse, marital status, exposure to media, justification of intimate partner violence, wealth index, educational attainment, and place of residence. The findings underscore the need for governments and policymakers in SSA to implement policies that target the most at-risk groups: those with no formal education, the poor, and adolescent girls. Our findings also highlight the need to strengthen advocacy against the justification of intimate partner violence and intensify girl-child education.

An assessment of Individual, community and state-level factors associated with inadequate iodised salt consumption among pregnant and lactating women in Nigeria.

BACKGROUND: Iodine deficiency is the most common cause of thyroid disease, and in its severe form can result in cretinism; the impairment of the brain development of a child. Pregnant and breastfeeding women's daily iodine requirement is elevated due to physiological changes in iodine metabolism, requiring up to double the iodine intake of other women. Although Nigeria was the first African country to be declared iodine sufficient in 2007, recent evidence has shown that only about seven in ten households consume salt with adequate iodine content (≥ 15 ppm), with variation across states. The study aimed to assess the Individual- and household-, community- and state-level factors associated with inadequate iodised salt consumption among pregnant women and breastfeeding mothers in Nigeria. METHODS: This study utilised the Multiple Indicator Cluster Survey to assess factors associated with inadequate iodised salt consumption among 4911 pregnant women and breastfeeding mothers in Nigeria. The descriptive analysis was presented using frequencies and percentages. The prevalence of adequate and inadequate iodised salt consumption with their 95% confidence interval were computed. Several multi-level mixed effect log-binomial logistic regressions were used to explore the factors associated with inadequate iodised salt consumption. The Loglikelihood, Akaike Information Criterion and Bayesian Information Criterion were used to assess the goodness of fit of the models. All analyses were adjusted for the complex survey design and analysed using Stata 15.0 at p < 0.05. RESULTS: The prevalence of inadequate iodised salt consumption among pregnant and breastfeeding mothers was 35.2% (95% CI: 33.1-37.5). Inadequate consumption of iodised salt was highest among pregnant and breastfeeding women aged 45-49 years (48.2%; 95%CI: 37.8-58.8), as well as those with non-formal education (52.7%; 95%CI: 47.7-57.6) and no education (34.6%; 95%CI: 31.3-38.1). Our findings revealed that pregnant and breastfeeding women living in the poorer, middle, richer and richest quintiles were 32%, 47%, 35% and 62% less likely to consume salt with inadequate iodine compared to those in the poorest households. Those with non-formal education were 1.8 times (95%CI: 1.36-2.42) more likely to consume salt with deficient iodine than those without education. Pregnant and breastfeeding mothers residing in moderately and most deprived communities were 3.5 (95%CI: 2.57-4.73) and 4.7 times (95%CI: 3.38-6.55) more likely to consume salt with inadequate iodine than those from least deprived communities. Women in the Northwestern region and those from the Southwestern region were 4.0 and 3.5 times, respectively, more likely to consume salt with inadequate iodine compared to pregnant and breastfeeding women residing in the North-Central region. CONCLUSIONS: The study has shown that inadequate consumption of iodised salt dominates among older pregnant and breastfeeding women. Also, women with non-formal education have higher prospects of consuming salt with lesser iodine. There is a need to enhance women's economic opportunities and empowerment as well as sensitisation on their nutritional requirements during pregnancy and breastfeeding. Both formal and non-formal educational initiatives on nutrition are extremely important and should be prioritised by the Nigerian government in its efforts to encourage the consumption of iodised salt among pregnant and lactating mothers. Additionally, health promotion interventions that seek to advocate iodised salt intake must be prioritised by the actors in the health sector.

High risk fertility behaviour and health facility delivery in West Africa.

BACKGROUND: Evidence suggests that women who give birth in a health facility have lower odds of experiencing pregnancy complications and significantly reduced risk of death from pregnancy-related causes compared to women who deliver at home. Establishing the association between high-risk fertility behaviour (HRFB) and health facility delivery is imperative to inform intervention to help reduce maternal mortality. This study examined the association between HRFB and health facility delivery in West Africa. METHODS: Data for the study were extracted from the most recent Demographic and Health Surveys of twelve countries in West Africa conducted from 2010 to 2020. A total of 69,479 women of reproductive age (15-49 years) were included in the study. Place of delivery was the outcome variable in this study. Three parameters were used as indicators of HRFB based on previous studies. These were age at first birth, short birth interval, and high parity. Multivariable binary logistic regression analysis was performed to examine the association between HRFB and place of delivery and the results were presented using crude odds ratio (cOR) and adjusted odds ratio (aOR), with their respective 95% confidence interval (CI). RESULTS: More than half (67.64%) of the women delivered in a health facility. Women who had their first birth after 34 years (aOR = 0.52; 95% CI = 0.46-0.59), those with short birth interval (aOR = 0.91; 95% CI = 0.87-0.96), and those with high parity (aOR = 0.58; 95% CI = 0.55-0.60) were less likely to deliver in a health compared to those whose age at first delivery was 18-34 years, those without short birth interval, and those with no history of high parity, respectively. The odds of health facility delivery was higher among women whose first birth occurred at an age less than 18 years compared to those whose age at first birth was 18-34 years (aOR = 1.17; 95% CI = 1.07-1.28). CONCLUSION: HRFB significantly predicts women's likelihood of delivering in a health facility in West Africa. Older age at first birth, shorter birth interval, and high parity lowered women's likelihood of delivering in a health facility. To promote health facility delivery among women in West Africa, it is imperative for policies and interventions on health facility delivery to target at risk sub-populations (i.e., multiparous women, those with shorter birth intervals and women whose first birth occurs at older maternal age). Contraceptive use and awareness creation on the importance of birth spacing should be encouraged among women of reproductive age in West Africa.

Texting for life: a mobile phone application to connect pregnant women with emergency transport and obstetric care in rural Nigeria.

BACKGROUND: Difficulty in transportation to access skilled providers has been cited repeatedly as a major barrier to utilization of emergency obstetric care in Nigeria. OBJECTIVE: The objective of this paper is to describe the design, implementation, and outcomes of a mobile phone technology aimed at rapidly reaching rural Nigerian women who experience pregnancy complications with emergency transportation and access to providers. METHOD: The project was implemented in 20 communities in two predominantly rural Local Government Areas (LGAs) of Edo State, in southern Nigeria, as part of a larger implementation project aimed at improving the access of rural women to skilled pregnancy care. The digital health innovation named Text4Life, allowed women to send a brief message from their mobile phone to a server linked to Primary Health Care (PHC) facilities and to access pre-registered transport owners. Pregnant women were registered and taught to text short messages to a server from their mobile phones or those of a friend or relative when they experience complications. RESULTS: Over 18 months, 56 women out of 1620 registered women (3.5%) texted the server requesting emergency transportation. Of this number, 51 were successfully transported to the PHC facilities, 46 were successfully treated at the PHC, and five were referred to higher-level care facilities. No maternal deaths occurred during the period, while four perinatal deaths were recorded. CONCLUSION: We conclude that a rapid short message sent from a mobile phone to a central server and connected to transport providers and health facility managers is effective in increasing the access of pregnant women to skilled emergency obstetric services in rural Nigeria.

Exposure to interparental violence and intimate partner violence among women in Papua New Guinea.

INTRODUCTION: Evidence suggests that childhood exposure to interparental violence increases the risk of intimate partner violence (IPV) experience or perpetration in adolescence or adulthood. However, it is unclear if exposure to interparental violence increases the risk of IPV among women in Papua New Guinea. This study, therefore, seeks to fill this gap in the literature by examining the association between childhood exposure to interparental violence and IPV among women in Papua New Guinea. METHODS: We used data from the most recent 2016-18 Papua New Guinea Demographic and Health Survey. We included 3,512 women in our analyses. Past-year experience of IPV was the outcome variable in this study. Exposure to interparental violence was the key explanatory variable. We used a multilevel binary logistic regression to examine the association between exposure to interparental violence and IPV. RESULTS: We found a higher probability of experiencing IPV among women exposed to interparental violence [aOR = 1.45, 95% CI = 1.13, 1.86] relative to women who were not exposed. Furthermore, we found that women living in rural areas had a lower likelihood of IPV experience [aOR = O.50, 95% CI = 0.32, 0.80] compared to those in urban settings. Finally, a greater odd of IPV experience was found among women staying in the Highlands Region [aOR = 1.44, 95% CI = 1.06, 1.96] compared to those staying in the Southern Region. CONCLUSION: Exposure to interparental violence was found to be significantly associated with IPV among women in Papua New Guinea. The findings of this study suggest the need for proven operational strategies to reduce IPV, such as improving anti-IPV laws in Papua New Guinea. We recommend the development and implementation of intercession strategies to reduce the experience and justification of violence among women exposed to interparental violence. In addition, health professionals should implement counseling and health education initiatives to tackle the consequences of IPV on women's well-being.

Gender differences in the acceptance of wife-beating: evidence from 30 countries in Sub-Saharan Africa.

BACKGROUND: The World Health Organization (WHO) has cited domestic violence as an urgent global maternal and child health priority. Gender differences in the acceptance of wife-beating have not been explored at the multi-country level in sub-Saharan Africa (SSA) where the occurrence of wife-beating (36%) is greater than the global average (30%). It is against this backdrop that we examine the gender differences in the acceptance of wife beating in SSA. METHODS: We used Demographic and Health Survey data from 30 SSA countries. Acceptance of wife beating among women and men was the principal outcome variable of interest. We employed Multiple correspondence analysis and logistic regression model as the primary estimation methods for this study. The descriptive statistics show that women had a higher acceptance rate (44%) of wife beating than men (25%). For the women sample, Mali, Democratic Republic of Congo, Chad, and Guinea had higher rates of acceptance of the wife beating (80.6%, 78.4%, 77.1% and 70.3% respectively) For the men, only Guinea had an acceptance rate above 50 percent. RESULTS: We found that all else equal, women's acceptance of wife beating is higher for male-headed households than for female-headed households. Women without formal education were 3.1 times more likely to accept wife beating than those with higher education. Men with no formal education were 2.3 times more likely to accept wife beating than men with higher education. We found that polygamous women were comparable to polygamous men. Polygamous women were 1.2 times more likely to accept wife beating than those in monogamous marriages. Women were 1.2 times more likely to accept wives beating if they had extramarital relationships. Contrarily, men who engaged in extramarital affairs were 1.5 times more likely to justify wife beating. We also found that women's acceptance of wife beating decreases as they age. Men who decide on major household purchases and spending decisions on their earnings are more likely to accept wife beating. Corollary, women with similar gender and employment roles also accept wife beating. Finally, exposure to mass media is significantly associated with lower acceptance of wife beating for women and men. CONCLUSION: We conclude that women have a higher acceptance rate of wife beating than men in SSA. Acceptance of wife beating differs significantly by country. Given the same level of education, women are more likely to accept wife beating than men. If women and men have similar levels of employment and gender roles, acceptance of wife beating is higher when men make major household purchasing decisions and and it is still higher even when the woman makes these decisions. Acceptance of wife beating is higher among young women and men, the uneducated, those in polygamous marriages, women, and men who engage in extra marital affairs, poor households and in rural areas. The findings indicate the need for policies and programs by SSA countries to truncate the high acceptance rate of wife beating, especially among women.

Socioeconomic inequalities in modern contraceptive use among women in Benin: a decomposition analysis.

BACKGROUND: Contraceptive use is crucial to achieving Sustainable Development Goal 3. Evidence of socioeconomic inequality in the use of modern contraceptives is essential to address the developing inequality in its utilisation given the low prevalence of contraceptive use among women in Benin. This study examined the socioeconomic inequalities in modern contraceptive use among women in Benin. METHODS: We performed a cross-sectional analysis of the 2017-18 Benin Demographic and Health Survey data. A weighted sample of 7,360 sexually active women of reproductive age was included in the study. We used a concentration curve to plot the cumulative proportion of women using modern contraception. Decomposition analysis was conducted to determine factors accounting for the socioeconomic disparities in modern contraceptive use. RESULTS: We noted that the richest women had higher odds of modern contraceptive use (adjusted odds ratio [aOR] = 1.67, CI = 1.22-2.30) compared to the poorest women. Other factors that showed significant associations with modern contraception use were age, marital status, religious affiliation, employment status, parity, women's educational level, and ethnicity. We found that modern contraceptive use is highly concentrated among the rich, with rich women having a higher propensity of using modern contraception relative to the poor. Also, the disadvantaged to modern contraceptive use included the poor, those aged 45-49, married women, those working, those with four or more live births, rural residents, and women of Bariba and related ethnicity. Conversely, favourable concentration in modern contraceptive use was found among the rich, women aged 20-24, the divorced, women with two live births, the highly educated, those with media exposure, and women of Yoruba and related ethnicity. CONCLUSION: The study has shown that wealthy women are more likely to utilize contraceptives than the poor. This is because wealthy women could afford both the service itself and the travel costs to the health facility, hence overcoming any economic barriers to using modern contraception. Other factors such as age, marital status, religion, employment status, parity, mother's educational level, and ethnicity were associated with contraceptive use in Benin. The Benin government and other stakeholders should develop family planning intercession techniques that address both the supply and demand sides of the equation, with a focus on reaching the illiterate and under-resourced population without admittance to modern contraception.

Exposure to interparental violence and justification of intimate partner violence among women in Papua New Guinea.

BACKGROUND: Previous studies have demonstrated that exposure to interparental violence is associated with intimate partner violence justification in a variety of contexts. In this study, we examined the association between exposure to interparental violence and justification of intimate partner violence among women in Papua New Guinea. METHODS: We used data from the 2016-18 Papua New Guinea Demographic and Health Survey. We included 2839 women of reproductive age (15-49 years) in a sexual union (married and cohabiting) in the study. We used a multivariable binary multilevel regression analysis to examine the association between interparental violence and justification of intimate partner violence. We presented the results of the regression analysis using crude odds ratio (cOR) and adjusted odds ratios (aORs), with their 95% confidence intervals (CIs). RESULTS: Women exposed to interparental violence were 1.26 (95%CI = 1.05, 1.53) times more likely to justify intimate partner violence than those who were not exposed. Women who resided in the Highlands (aOR = 2.50, 95%CI = 1.78, 3.51), Momase (aOR = 1.96, 95%CI = 1.40, 2.75), and Islands (aOR = 1.42, 95%CI = 1.01, 1.99) were more likely to justify intimate partner violence compared to those in the Southern region. Women who were exposed to one (aOR = 1.38, 95%CI = 1.06, 1.82) mass media were more likely to justify intimate partner violence compared to those who had no exposure to mass media. On the other hand, women aged 25-34 years (aOR = 0.66, 95%CI = 0.48, 0.91) and 35-49 years (aOR = 0.66, 95%CI = 0.44, 0.97) were less likely to justify intimate partner violence compared to those aged 15-24 years. CONCLUSIONS: Our study has shown that exposure to interparental violence is a predictor of intimate partner violence justification. This study suggests the need for conscious and continuous efforts to identify and assist women who have been exposed to interparental violence to help prevent its transition to later life. Policies and interventions should be developed and implemented to curtail children's exposure to domestic violence in their households. Also, laws and policies need to condemn any violence and demystify community justification and acceptance of intimate partner violence, taking into consideration the significant sociodemographic characteristics of the women highlighted in the study.