Mothers' dietary practices in the Amoron'i Mania region Madagascar.

INTRODUCTION: Madagascar has one of the highest prevalence's of malnutrition worldwide. Dietary practice is an important element to consider in the fight against malnutrition. This study aims to describe mothers' dietary patterns and dietary diversity and to identify characteristics associated with this dietary diversity. METHODS: A cross sectional study was carried-out among 670 non-pregnant mothers aged 18 to 45, who had delivered more than 6 months earlier and were living in the Amoron'i Mania region of Madagascar. The study was conducted during the post-harvest period. A food frequency questionnaire were used to assess the dietary pattern and the women's dietary diversity score was established from the 24-hour recall data. RESULTS: Almost all (99%) of mothers ate rice every day and 59% ate green leaves. Fifty three percent of mothers had consumed fruit less than once per week, 55% for legumes, 67% for vegetables and 91% for meat. Dietary diversity score ranged from 1 to 7 and 88% of mothers had a low dietary diversity score (<5). On multivariate analysis, factors significantly associated with low dietary diversity were: low education level (AOR=3.80 [1.58-9.02], p=0.003), parity higher than 3 (AOR=2.09 [1.22-3.56], p=0.007), birth interval ≥ 24 months (AOR=4.01 [2.08-7.74], p<0.001), rice production availability ≤ 6 months (AOR=2.33 [1.30-4.17], p=0.013), low attendance at market (AOR=4.20 [1.63-10.83], p<0.001) and low movable property possession score (AOR=4.87 [2.15-11.04], p<0.001). CONCLUSION: Mother's experience poor diet diversity. Unfavorable socioeconomic conditions are associated with this poor food diversification.

[Funding of the management of severe malaria in children by Kinshasa households (Democratic Republic of Congo)]. / Financement de la prise en charge du paludisme grave de l’'enfant par les ménages à Kinshasa, République Démocratique du Congo.

INTRODUCTION: The objective of this study was to determine the source of health care funding for heads of households related to the management of severe malaria in children admitted to a Kinshasa reference hospital. METHODS: This cross-sectional study was conducted on 1,350 hospitalised children under the age of 15 years treated for severe malaria in Kinshasa reference hospitals from January to November 2011 and the heads of households of these children. RESULTS: Only 46% of heads of households reported having sufficient funds directly available in the household budget. The remaining 54% had to call upon external sources of funding (sale of assets, loans, pawning goods). The use of a loan tended to increase significantly mainly for households with a low (adjusted odds ratio = 6.2), and intermediate socioeconomic status (adjusted odds ratio = 3.8) and for households working in the informal sector (adjusted odds ratio = 2.5). Similarly, the sale of assets was more frequently reported for households working in the informal sector (adjusted odds ratio = 2.4) and for female heads of households (adjusted odds ratio = 3.9). CONCLUSION: The management of severe malaria is a burden on household income. The majority of heads of households concerned needs to use external funding sources. A State subsidy for this management would help to reduce the risk of debt and sale of assets, especially for the poorest households.

Incidence of catastrophic health expenditures for households: an example of medical attention for the treatment of severe childhood malaria in Kinshasa reference hospitals, Democratic Republic of Congo.

This study aimed to estimate the incidence of catastrophic health expenditures faced by households in Kinshasa with children affected by severe malaria. A total of 1350 children below the age of 15 year who were hospitalized due to severe malaria were included in the study. We analyzed the incidence of households facing catastrophic expenditures according to two thresholds: 40% of the household's capacity to pay and 10% of the household's total consumption. Based on the '40% of the capacity to pay' threshold, the incidence of catastrophic health expenditures reached 81.1%, and this estimate reached 46.4% for the '10% above total consumption' threshold. Regarding the ≥ 40% capacity to pay threshold, the incidences of catastrophic expenditures was higher among households with children who were admitted to state hospitals (adjusted odds ratio [aOR] 3.7) and private hospitals (aOR 59.1), for poor households (aOR 13), for households with medium socioeconomic statuses (aOR 3.2), for female-headed households (aOR 2.9), for households with children affected by the neurological form (aOR 4.8) and respiratory distress (aOR 3.6), and for households who opted for a pre-hospital resort (aOR 2.7). Similar results were obtained when the 10% above the total consumption threshold was applied. Greater government financing of medical attention would lead to a reduction in the catastrophic health expenditures faced by the poorest households.

Costs of treatment of children affected by severe malaria in reference hospitals of Kinshasa, Democratic Republic of Congo.

INTRODUCTION: Malaria remains a real problem of public health. Its hospital care generates important expenditures for affected households. The present study aimed to estimate direct and indirect costs of severe child malaria in reference hospitals in Kinshasa. METHODOLOGY: This prospective study included 1,350 children under 15 years of age suffering from severe malaria. The study was performed between 1 January and 30 November, 2011. Data were collected in nine reference hospitals. The studied parameters were direct pre-hospital costs, direct hospital costs, and indirect costs. Costs were assessed from the household point of view. RESULTS: Median costs associated with the disease ranged from 114 USD in confessional hospitals to 173 USD in state hospitals and 308 USD in private hospitals. Direct pre-hospital median costs ranged between 3 and 11 USD. Direct hospital costs reached 72 USD in confessional hospitals, 139 USD in state hospitals, and 254 USD in private hospitals. Indirect costs ranged from 22 USD in state hospitals to 30 USD in confessional hospitals and 46 USD in private hospitals, regardless of the status of the accompanying parent or guardian. Factors explaining the variability of costs were the neurological form of malaria, indirect recourse to hospital, socioeconomic level, type of prescribing person, child's status upon leaving the hospital, and child's transfusion status. CONCLUSIONS: The care of severe child malaria appeared to be expensive in private and state hospitals. A state subsidy of health care and regulation of the private sector would contribute to the reduction of malaria's financial impact.

Effect of adopting host-country nationality on perinatal mortality rates and causes among immigrants in Brussels.

OBJECTIVES: Perinatal mortality rates vary between ethnic groups but the relation with immigrant status is unclear. Previous research suggested that birth outcomes may either improve or deteriorate with duration of residence, depending on the migrant group. The objectives of this study are to describe and measure inequalities in pregnancy outcomes, perinatal mortality and causes of perinatal deaths according to current citizenship versus national origin of the mother, in Brussels. STUDY DESIGN: This is a population-based cohort study using data from linked birth and death certificates from the Belgian civil registration system. The data relate to all babies born between 1998 and 2008, whose mothers were living in Brussels, irrespective of the place of delivery. We used a logistic regression to estimate the odds ratios (ORs) for the association between mortality, causes of deaths and nationality. RESULTS: Women from Morocco, sub-Saharan Africa and Turkey experience an 80% excess in perinatal mortality (p<0.0001) compared to Belgians, but this excess of perinatal mortality is not observed for mothers with Belgian citizenship at delivery. For sub-Saharan African women, this excess is caused mainly by immaturity-related conditions and reflects a high rate of preterm deliveries, low birth weight and a low socio-economic level. Moroccan and Turkish mothers have favourable pregnancy outcomes that persist after adopting Belgian nationality, but they experience a strong excess of perinatal mortality, mainly due to congenital anomalies and asphyxia or unexplained deaths prior to the onset of labour. CONCLUSION: In Brussels, perinatal mortality varies according to nationality but those differences do not persist after adopting Belgian nationality. The explanation of this positive effect is probably due to a mix of determinants such as acculturation, use of health services or cultural contexts. Further analysis should help to better understand the results observed.

Belgian global implementation of cardiovascular and stroke risk assessment study: methods and baseline data of the BELGICA-STROKE STUDY.

OBJECTIVES: BELGICA-STROKE is a longitudinal study to enhance the use of online cardiovascular risk prediction scores based on the SCORE 10-year risk estimates for fatal cardiovascular disease (adapted for Belgium) and the Framingham 10-year stroke risk and to evaluate their impact on the cardiovascular risk profile of hypertensive patients. Methods and baseline characteristics are described here. DESIGN: Prospective, multicenter study in primary care. METHODS: General practitioners (N = 810) recruited consecutive hypertensive patients aged >40 years who were not at blood pressure goal and assessed them every 4 months. The estimated 10-year risks for fatal cardiovascular disease and stroke were available on a secured, specially designed study website. The calculated risk profile of a patient was modifiable by adding treatment goals in order to increase awareness and motivation of both physician and patient. An automated feedback on goal-level attainment and both cardiovascular risk scores was provided. RESULTS: Mean age of the 15,744 patients was 66.3 years: 51.9% were men, 77.8% had excess weight, 19.4% were smokers, and 25.9% had diabetes. Left ventricle hypertrophy was present in 20.0%, atrial fibrillation in 5.8%. Mean blood pressure was 153.8/88.2 mmHg, mean cholesterol 211.5 mg/dl. Most patients (89.2%) received antihypertensive medication, of which 36.9% was monotherapy. Mean estimated 10-year stroke risk was 19.1%, and mean estimated 10-year fatal cardiovascular disease risk 5.9%. CONCLUSIONS: The 10-year estimated stroke and fatal cardiovascular disease risks were moderate to high in hypertensive patients not at goal blood pressure, emphasizing the importance of global cardiovascular risk factor assessment.

High perinatal mortality rate among immigrants in Brussels.

BACKGROUND: The relation between immigration status and perinatal mortality is unclear. The objective of this study is to describe and measure inequalities in perinatal mortality and causes of perinatal deaths according to maternal nationality and socioeconomic status. METHODS: A population-based cohort study related to all babies born during the period of 1998-2006 whose mothers were living in Brussels, irrespective of the place of delivery. Perinatal and post-perinatal mortality were analysed according to the nationality and sociodemographic characteristics of the mothers at birth. We used logistic regression to estimate the odds ratios (ORs) for the association between mortality and nationality. RESULTS: The women of sub-Saharan Africa experience a 50% excess in perinatal mortality, which primarily reflects a high rate of preterm deliveries and low birth weight, as well as a low socioeconomic level. Paradoxically, despite their favourable rates of preterm and low-birth-weight births, Maghrebian and Turkish women experience a strong excess (50-70%) of perinatal mortality caused primarily by congenital anomalies. Differences in age, parity distributions and multiple births play no significant role, and the excess does not reflect low socioeconomic levels. This excess of perinatal mortality contrasts with the absence of an excess of post-perinatal mortality. CONCLUSION: In Brussels, patterns of inequalities in perinatal mortality and causes of perinatal deaths vary according to nationality; perinatal mortality is increased in particular ethnic groups independently of socioeconomic status and maternal characteristics.

[Intra-hospital mortality of children in central Africa: looking at the impact of a training programme and increased supervision]. / Impact d'un programme de formation et de supervision de la qualité des soins sur la mortalité intra-hospitalière des enfants en Afrique centrale.

The study's aim was to evaluate the impact of an in-service training course and supervision of physicians and nurses in terms of quality of care on intra-hospital mortality. The study included 2 cohorts of children. Cohort 1 included 414 children from 0 to 15-years-old who were followed in the paediatric wards of the provincial hospital of Goma (HPG) between April 1, 2003 and March 31, 2004. Cohort 2 included 996 children from 0 to 15-years-old where were treated and followed in the same service between January 1, 2005 and December 31, 2005. General and specific mortalities occurring before and after an intervention were compared, as were the ratios of the observed deaths to the predicted deaths through the application of the Goma1 model to cohort 2. Overall mortality decreased by 15,9% (before the intervention) to 4,6% (after the intervention), translating to a total reduction of 71,1%. The ratios between the observed deaths and the predicted deaths were lower than 1, globally and when stratified. The risk of death in the cohort 1 (before the intervention) is 6,8 times higher than in cohort 2 (after the intervention). This shows an improvement of child survival after the intervention.

Prospective casemix-based funding, analysis and financial impact of cost outliers in all-patient refined diagnosis related groups in three Belgian general hospitals.

This study examined the impact of cost outliers in term of hospital resources consumption, the financial impact of the outliers under the Belgium casemix-based system, and the validity of two "proxies" for costs: length of stay and charges. The cost of all hospital stays at three Belgian general hospitals were calculated for the year 2001. High resource use outliers were selected according to the following rule: 75th percentile +1.5 xinter-quartile range. The frequency of cost outliers varied from 7% to 8% across hospitals. Explanatory factors were: major or extreme severity of illness, longer length of stay, and intensive care unit stay. Cost outliers account for 22-30% of hospital costs. One-third of length-of-stay outliers are not cost outliers, and nearly one-quarter of charges outliers are not cost outliers. The current funding system in Belgium does not penalize hospitals having a high percentage of outliers. The billing generated by these patients largely compensates for costs generated. Length of stay and charges are not a good approximation to select cost outliers.

Analysis of cost outliers within APR-DRGs in a Belgian general hospital: two complementary approaches.

CONTEXT AND OBJECTIVES: The objective of this study was to find factors that could explain high and low resource use outliers, by associating an explanatory analysis with a statistical analysis. METHOD: High resource use outliers were selected according to the following rule: 75th percentile + 1.5* inter-quartile range. Low resource use outliers were selected according to: 25th percentile - 1.5* inter-quartile range. The statistical approach was based on a multivariate analysis using logistic regression. A decision tree approach using predictors from this analysis (intensive care unit (ICU) stay, high severity of illness and social factors associated with longer length of stay) was also tested as a more intuitive tool for use by hospitals in focussing review efforts on "not explained" cost outliers. RESULTS: High resource use outliers accounted for 6.31% of the hospital stays versus 1.07% for low resource use outliers. The probability of a patient being a high resource use outlier was higher with an increase in the length of stay (odds ratios (OR) = 1.08), when the patient was treated in an intensive care unit (OR = 3.02), with a major or extreme severity of illness (OR=1.46), and with the presence of social factors (OR = 1.44). The probability of being a low outlier is lower for older patients (OR = 0.98). The probability of being a low outlier is also lower without readmission within the year (OR = 0.55). The more intuitive decision tree method identified 92.26% of the cases identified through residuals of the regression model. One quarter of the high cost outliers were flagged for additional review ("not justified" on the basis of the model), with nearly three-quarters "justified" by clinical and social factors. CONCLUSION: The analysis of cost outliers can meet different aims (financing of justifiable outliers, improvement of the care process for the outliers not justifiable on medical or social grounds). The two methods are complementary, by proposing a statistical and a didactic approach to achieve the goal of high quality care using fewer resources.

[Profile of members and non members of mutual health insurance system in Rwanda: the case of the health district of Kabutare]. / Le profil des membres et des non membres des mutuelles de santé au Rwanda: le cas du district sanitaire de Kabutare.

The establishment of mutual health insurance systems is one of the priorities of the Rwandan government. Pilot studies have been conducted in three districts of the country. Nonetheless, after 4 years of implementation (1999-2003), the population coverage by these insurance systems remains relatively low. A cross-sectional study of 1042 households in the Kabutare health district allowed for a comparison of socio-economic and demographic variables, and the medical, surgical, gynaecological, and obstetrical history of health insurance scheme members and non-members. The results of the study demonstrate that the distribution of members and non-members is similar in terms of sex, marital status, professional status and medical history. However, larger households (more than five members) and those having a relatively higher income (more than USD 230 per annum) are more likely to be insured than other households. Members of the mutual health insurance use more the health services than non-members, spend less on health care and increasingly maintain membership. The study emphasizes the relevance to further promote mutual health insurance, but also points to the need for mechanisms to ensure financial access for the poor rural population.

[Healthcare access in Benin: poverty and community aid networks]. / Accès aux soins de santé au Bénin: indigence et réseaux d'aide communautaire.

The objective of this study was to evaluate the capacity of poor and non-poor households to pay for health care and to show how existing community assistance (or solidarity) networks (CAN) may compensate for this inability. Sixteen (16) study sites were randomly selected after stratification of Benin into four groups. All 1,312 households in our sample (668 poor and 664 non-poor) were interviewed, and 48 focus group were held with opinion leaders, women, healthcare workers, social workers, and persons responsible for these networks. The survey showed that only 27% of the heads of households have permanent financial access to health care and health services. This financial access is lower for the poor (9%) than for others (46%). However, the capacity of heads of households to pay reached 84% (87% for the non-poor and 81% for the poor, with P<0.01). Capacity to pay differs between strata (P<0.001) and is higher in the urban strata. For 25% of the families, intervention of the CAN made payment possible, preferentially for the poor. In 90% of cases, this community support came from the family network. Health centre management committees contributed in only 0.8% of cases. In general, help covered only a small percentage of those in need. The health policy of African countries must ensure that health care is accessible to the population, especially the poor.