Identifying determinants of under-five child mortality in northern Togo.

Background: Although global rates of under-five mortality have declined, many low- and middle-income countries (LMICs), including Togo, have not achieved sufficient progress. We aimed to identify the structural and intermediary determinants associated with under-five mortality in northern Togo. Methods: We collected population-representative cross-sectional household surveys adapted from the Demographic Household Survey (DHS) and Multiple Indicator Cluster Survey from women of reproductive age in northern Togo in 2018. The primary outcome was under-five mortality for children born to respondents in the 10-year period prior to the survey. We selected structural and intermediary determinants of health from the World Health Organization Conceptual Framework for Action on the Social Determinants of Health. We estimated associations between determinants and under-five mortality for births in the last 10 years (model 1 and 2) and two years (model 3) using Cox proportional hazards models. Results: Of the 20 121 live births in the last 10 years, 982 (4.80%) children died prior to five years of age. Prior death of a sibling (adjusted hazard ratio (aHR) = 5.02; 95% confidence interval (CI) = 4.23-5.97), maternal ethnicity (i.e. Konkomba, Temberma, Lamba, Losso, or Peul), multiple birth status (aHR = 2.27; 95% CI = 1.78-2.90), maternal age under 25 years (women <19 years: aHR = 2.05; 95% CI = 1.75-2.39; women 20-24 years: aHR = 1.48; 95% CI = 1.29-1.68), lower birth interval (aHR = 1.51; 95% CI = 1.31-1.74), and higher birth order (second or third born: aHR = 1.45; 95% CI = 1.32-1.60; third or later born: aHR = 2.14; 95% CI = 1.74-2.63) were associated with higher hazard of under-five mortality. Female children had lower hazards of under-five mortality (aHR = 0.80; 95% CI = 0.73-0.89). Under-five mortality was also lower for children born in the last two years (n = 4852) whose mothers received any (aHR = 0.48; 95% CI = 0.30-0.78) or high quality (aHR = 0.51; 95% CI = 0.29-0.88) prenatal care. Conclusion: Compared to previous DHS estimates, under-five mortality has decreased in Togo, but remains higher than other LMICs. Prior death of a sibling and several intermediary determinants were associated with a higher risk of mortality, while receipt of prenatal care reduced that risk. These findings have significant implications on reducing disparities related to mortality through strengthening maternal and child health care delivery.

Impact of the Affordable Health Care Act (ACA) on Racial/Ethnic Inequities in Access to and Utilization of Healthcare in New York City.

The Affordable Care Act (ACA) expanded health insurance coverage in the USA, but whether it increased healthcare utilization or reduced racial/ethnic inequities in access to and utilization of care is unclear. We evaluated the ACA impact on health insurance coverage, unmet medical need, and having a personal doctor and whether this impact was modified by racial/ethnic identity among New York City (NYC) residents. We used data from multiple years of the Community Health Survey (2009-2017) and used logistic regression to assess whether having health insurance, unmet medical need, or a personal doctor varied pre- (2009-2012) versus post-ACA (2013-2017), adjusting for age, sex, nativity status, and general health. We assessed effect measure modification by race/ethnicity and stratified if we found significant interaction. We found that health insurance coverage and having a personal doctor increased post-ACA (aOR = 1.44, p < 0.001 and aOR = 1.09, p = 0.024, respectively) while having unmet medical need decreased (aOR = 0.90, p = 0.004). There was little indication of interaction between ACA and race/ethnicity; in stratified models, the ACA had a stronger impact on health insurance coverage for those of other race than all other groups (aOR = 2.16, p = 0.002 versus aOR 1.22-1.54 for white, Black, and Hispanic adults) and a stronger impact on having a personal doctor for Hispanic adults (aOR 1.27, p < 0.001 versus weaker non-significant associations for other groups), with no effect modification for unmet medical need. Thus, it appears that ACA improved healthcare access and utilization but did not have a major impact on reducing racial/ethnic inequities in these outcomes in NYC.

The application of intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) to examine birthweight inequities in New York City.

Exploring the intersection of dimensions of social identity is critical for understanding drivers of health inequities. We used multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) to examine the intersection of age, race/ethnicity, education, and nativity status on infant birthweight among singleton births in New York City from 2012 to 2018 (N = 725,875). We found evidence of intersectional effects of various systems of oppression on birthweight inequities and identified U.S.-born Black women as having infants of lower-than-expected birthweights. The MAIHDA approach should be used to identify intersectional causes of health inequities and individuals affected most to develop policies and interventions redressing inequities.

The Impact of the COVID-19 Pandemic on College Students' Health and Financial Stability in New York City: Findings from a Population-Based Sample of City University of New York (CUNY) Students.

Understanding the effect of the coronavirus disease 2019 (COVID-19) pandemic on students' health and financial stability is important to establish effective interventions to mitigate these effects, which may have long-term consequences on their health and well-being. Public universities in urban centers represent a substantial proportion of college students in the USA. We implemented a cross-sectional population-based online survey of 2282 students in a large, public university in New York City in April 2020. We created weights to account for non-response and used Poisson regression with robust standard errors to estimate adjusted prevalence ratios (aPR) for factors associated with mental health outcomes. Students experienced high rates of anxiety/depression and financial instability due to the pandemic. Half of the students reported anxiety/depression (54.5%) and an increased need for mental health services (49.0%) as a result of the COVID-19 pandemic. The majority (81.1%) reported loss of household income, and half (49.8%) reported worries about losing housing. High levels of food (aPR  = 1.4, 95% CI 1.2, 1.6) and housing (aPR = 1.3, 95% CI 1.2, 1.4) insecurity were the strongest predictors of anxiety/depression. Household and personal experiences with possible COVID-19 symptoms were also associated with anxiety/depression or the need for increased mental health services. Addressing student needs at public urban universities requires an integrated holistic approach that targets urgent mental health and economic needs related to the impact of COVID-19. Students who become infected need mental health services as well as health monitoring.

Sexual Relationship Power and Socio-demographic Factors Predicting Contraceptive Use, Antenatal Visits and Sick Child Health Service Use in Northern Togo.

INTRODUCTION: Implementation of community-based healthcare services offering effective contraception, antenatal care (ANC), and treatment for symptomatic children under five has reduced maternal and child mortality in Togo. However, understanding if women are utilizing these services differentially based on social or demographic factors is important. This study identifies whether sexual relationship and socio-demographic factors are associated with healthcare utilization in four health facility catchment areas. METHODS: We conducted a cross-sectional household survey of women aged 15-49 in four health facility catchment areas in 2016 (three rural sites, one urban site). We used multivariable Poisson regression to test whether socio-demographic factors and a validated sexual relationship power scale were associated with contraceptive use, ANC visits, and seeking treatment for symptomatic children under five. RESULTS: Among women not pregnant or desiring pregnancy, older age, lower education, and single relationship status were associated with lower use of effective contraception. Among women who gave birth in two years preceding survey, low relationship power and low wealth quintile were associated with being less likely to attend at least four ANC visits. Women in rural sites were slightly more likely than women in the urban site to report seeking treatment for child under five with malaria, pneumonia, and/or diarrhea symptoms in last 2 weeks. DISCUSSION: Interventions in low-resource settings should explore ways to reach women with low health-service utilization to improve contraceptive use, ANC visits, and treatment for sick children. Furthermore, age, education, marital status, wealth status and sexual relationship power must be considered when targeting maternal health behaviors. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03773913; Date of registration: 12 Dec. 2018.

Primary care patients' preferences for reproductive health service needs assessment and service availability in New York Federally Qualified Health Centers.

OBJECTIVES: Expanding reproductive health services in primary care could increase access to preconception and contraceptive services. We assessed patients' preferences around wording, frequency and staffing for reproductive health service needs assessment and availability of a range of reproductive health services in primary care. STUDY DESIGN: We implemented a cross-sectional anonymous survey of adults in the waiting rooms of four Federally Qualified Health Centers (FQHCs) in New York State in 2017. We present descriptive findings on preferences, including preferences among four questions on reproductive health needs assessment, and differences by socio-demographic characteristics. RESULTS: We had an 89.4% response rate. Of 1,071 respondents, 68.8% self-reported gender as female, 26.5% male and 4.1% transgender/other, while 40.8% self-identified as black non-Hispanic, 32.2% white non-Hispanic, 17.6% Hispanic and 9.4% other. A third had no preferred reproductive health needs assessment question (34.5%), while another third preferred, "Can I help you with any reproductive health services today such as birth control or planning a healthy pregnancy?" (31.5%). Respondents wanted to be asked by a doctor (43.9%) or nurse/medical assistant (21.1%). Females wanted to be asked at every visit (52.9%) more than males (43.9%) and transgender/other individuals (34.1%, p < 0.01). The majority would like to be able to access contraception (59.0%) and sexually transmitted infection (STI) testing (55.4%) at their FQHC. CONCLUSIONS: Most patients supported inclusion of reproductive health discussions and contraception and STI services at these FQHCs. Among those with a preference, patients preferred to be asked about reproductive health service needs rather than pregnancy intentions or desires. IMPLICATIONS: Primary care settings should consider routine inclusion of reproductive health needs assessments over screening for pregnancy intentions or desires. Primary care settings which do not currently provide contraception and sexually transmitted infection testing should consider making these services available.

Assessing the Integrated Community-Based Health Systems Strengthening initiative in northern Togo: a pragmatic effectiveness-implementation study protocol.

BACKGROUND: Over the past decade, prevalence of maternal and child morbidity and mortality in Togo, particularly in the northern regions, has remained high despite global progress. The causes of under-five child mortality in Togo are diseases with effective and low-cost prevention and/or treatment strategies, including malaria, acute lower respiratory infections, and diarrheal diseases. While Togo has a national strategy for implementing the integrated management of childhood illness (IMCI) guidelines, including a policy on integrated community case management (iCCM), challenges in implementation and low public sector health service utilization persist. There are critical gaps to access and quality of community health systems throughout the country. An integrated facility- and community-based initiative, the Integrated Community-Based Health Systems Strengthening (ICBHSS) initiative, seeks to address these gaps while strengthening the public sector health system in northern Togo. This study aims to evaluate the effect and implementation strategy of the ICBHSS initiative over 48 months in the catchment areas of 21 public sector health facilities. METHODS: The ICBHSS model comprises a bundle of evidence-based interventions targeting children under five, women of reproductive age, and people living with HIV through (1) community engagement and feedback; (2) elimination of point-of-care costs; (3) proactive community-based IMCI using community health workers (CHWs) with additional services including family planning, HIV testing, and referrals; (4) clinical mentoring and enhanced supervision; and (5) improved supply chain management and facility structures. Using a pragmatic type II hybrid effectiveness-implementation study, we will evaluate the ICBHSS initiative with two primary aims: (1) determine effectiveness through changes in under-five mortality rates and (2) assess the implementation strategy through measures of reach, adoption, implementation, and maintenance. We will conduct a mixed-methods assessment using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework. This assessment consists of four components: (1) a stepped-wedge cluster randomized control trial using a community-based household survey, (2) annual health facility assessments, (3) key informant interviews, and (4) costing and return-on-investment assessments for each randomized cluster. DISCUSSION: Our research is expected to contribute to continuous quality improvement initiatives, optimize implementation factors, provide knowledge regarding health service delivery, and accelerate health systems improvements in Togo and more broadly. TRIAL REGISTRATION: ClinicalTrials.gov , NCT03694366 , registered 3 October 2018.

Sociodemographic variation in the oral microbiome.

PURPOSE: Variations in the oral microbiome are potentially implicated in social inequalities in oral disease, cancers, and metabolic disease. We describe sociodemographic variation of oral microbiomes in a diverse sample. METHODS: We performed 16S rRNA sequencing on mouthwash specimens in a subsample (n = 282) of the 2013-2014 population-based New York City Health and Nutrition Examination Study. We examined differential abundance of 216 operational taxonomic units, and alpha and beta diversity by age, sex, income, education, nativity, and race/ethnicity. For comparison, we examined differential abundance by diet, smoking status, and oral health behaviors. RESULTS: Sixty-nine operational taxonomic units were differentially abundant by any sociodemographic variable (false discovery rate < 0.01), including 27 by race/ethnicity, 21 by family income, 19 by education, 3 by sex. We found 49 differentially abundant by smoking status, 23 by diet, 12 by oral health behaviors. Genera differing for multiple sociodemographic characteristics included Lactobacillus, Prevotella, Porphyromonas, Fusobacterium. CONCLUSIONS: We identified oral microbiome variation consistent with health inequalities, more taxa differing by race/ethnicity than diet, and more by SES variables than oral health behaviors. Investigation is warranted into possible mediating effects of the oral microbiome in social disparities in oral and metabolic diseases and cancers.

A newly developed tool for measuring the availability of human resources for emergency obstetric and newborn care services: prospective analytic study in two district-level public facilities in Bangladesh.

BACKGROUND: In Bangladesh, while the infrastructure of public health facilities to provide maternal and newborn care services is adequate, services are not always available due to insufficient staffing. A human resource availability index for health facilities is needed for monitoring and advocacy. This study aimed to develop indices for measuring the availability of different types of human resources to provide round-the-clock emergency obstetric and newborn care (EmONC) service at district-level public facilities. METHODS: As part of a larger intervention study, 30 days of prospective observation of providers was done at a district hospital (DH) and a mother and child welfare centre (MCWC) in one district of Bangladesh using checklists. A scoring system was developed to create an index to quantify the availability of providers for maternal and newborn care. RESULTS: Based on the newly developed index, medical doctors in the emergency department of the DH were 100% available, but ranged from 27 to 41% availability in the obstetrics/gynecology (ob/gyn) and pediatric wards. In MCWC, the corresponding indices ranged from 32 to 36%. In the DH, the availability of nurses in the ob/gyn ward (96%) was relatively better than in the pediatric ward (65%) but that in operation theatre was only 31%. In the MCWC, the index for the presence of a paramedic or nursing aid was 82% in the ob/gyn ward and 63% in the operation theatre. However, the availability scores of facility support staff for maintenance and security were generally high (over 90%) in both facilities. CONCLUSIONS: Our newly developed index on availability of providers demonstrated huge gaps in availability of providers in evening and night shifts in most of the disciplines in the study facilities. This provider availability index is easy to create and can be used as a meaningful tool to quantify gaps in human resources by type in various types of district-level health facilities. Further studies are needed for adaptation of this tool in different types of health facilities and to assess its implication as an advocacy tool.

Identifying inequities in maternal and child health through risk stratification to inform health systems strengthening in Northern Togo.

OBJECTIVE: In Togo, substantial progress in maternal and child health is needed to reach global development goals. To better inform clinic and community-based health services, this study identifies factors associated with maternal and child health care utilization in the Kara region of Northern Togo. METHODS: We conducted a population-representative household survey of four health clinic catchment areas of 1,075 women of reproductive age in 2015. Multivariable logistic regression was used to model individual and structural factors associated with utilization of four maternal and child health services. Key outcomes were: facility-based delivery, maternal postnatal health check by a health professional within the first six weeks of birth, childhood vaccination, and receipt of malaria medication for febrile children under age five within 72 hours of symptom onset. RESULTS: 83 percent of women who gave birth in the last 2 years delivered at a health facility. In adjusted models, the strongest predictor of facility delivery in the rural catchment areas was proximity to a health center, with women living under three kilometers having 3.7 (95% CI 1.7, 7.9) times the odds of a facility birth. Only 11 percent of women received a health check by a health provider at any time in the postnatal period. Postnatal health checks were less likely for women in the poorest households and for women who resided in rural areas. Children of polygamous mothers had half the odds of receiving malaria medication for fever within 72 hours of symptom onset, while children with increased household wealth status had increased odds of childhood vaccination and receiving treatment for malaria. CONCLUSION: Our analysis highlights the importance of risk stratification analysis to inform the delivery and scope of maternal and child health programs needed to reach those with the least access to care.

Abortion health services in Canada: Results of a 2012 national survey.

OBJECTIVE: To determine the location of Canadian abortion services relative to where reproductive-age women reside, and the characteristics of abortion facilities and providers. DESIGN: An international survey was adapted for Canadian relevance. Public sources and professional networks were used to identify facilities. The bilingual survey was distributed by mail and e-mail from July to November 2013. SETTING: Canada. PARTICIPANTS: A total of 94 abortion facilities were identified. MAIN OUTCOME MEASURES: The number and location of services were compared with the distribution of reproductive-age women by location of residence. RESULTS: We identified 94 Canadian facilities providing abortion in 2012, with 48.9% in Quebec. The response rate was 83.0% (78 of 94). Facilities in every jurisdiction with services responded. In Quebec and British Columbia abortion services are nearly equally present in large urban centres and rural locations throughout the provinces; in other Canadian provinces services are chiefly located in large urban areas. No abortion services were identified in Prince Edward Island. Respondents reported provision of 75 650 abortions in 2012 (including 4.0% by medical abortion). Canadian facilities reported minimal or no harassment, in stark contrast to American facilities that responded to the same survey. CONCLUSION: Access to abortion services varies by region across Canada. Services are not equitably distributed in relation to the regions where reproductive-age women reside. British Columbia and Quebec have demonstrated effective strategies to address disparities. Health policy and service improvements have the potential to address current abortion access inequity in Canada. These measures include improved access to mifepristone for medical abortion; provincial policies to support abortion services; routine abortion training within family medicine residency programs; and increasing the scope of practice for nurses and midwives to include abortion provision.

Lifecourse infectious origins of sexual inequalities in central adiposity.

BACKGROUND: Social disparities in obesity are often more marked among women than men, possibly due to social factors. Taking a life-history perspective, we hypothesized that childhood infections could be relevant via sex-specific effects of immune system activation on sexual development and, hence, body shape. METHODS: We used multivariable linear regression to assess the sex-specific, adjusted associations of 'childhood' pathogens [0 (n = 1002), 1 (n = 2199), 2 (n = 3442) or 3 (n = 4833) of HSV1, CMV and hepatitis A antibodies] and 'adult' pathogens [0 (n = 5836), 1 (n = 3018) or ≥ 2 (n = 720) of HSV2, HHV8 and hepatitis B or C) with waist-hip ratio (WHR) and body mass index (BMI) standard deviations (SDs) using NHANES III (1988-94). As validation, we assessed associations with height. RESULTS: 'Childhood' pathogens were positively associated with WHR among women [0.18 SD, 95% confidence interval (95% CI) 0.04-0.32 for 3, compared with 0], but not men (-0.04 SD, 95% CI -0.15 to 0.08), adjusted for age, education, race/ethnicity, smoking and alcohol. Further adjustments for leg length barely changed the estimates. There were no such sex-specific associations for BMI or for adult pathogens. 'Childhood', but not 'adult', pathogens were negatively associated with height, adjusted for age, sex, education and race/ethnicity. CONCLUSIONS: These observations are consistent with the lifecourse hypothesis that early exposure to infections makes women vulnerable to central obesity. This hypothesis potentially sheds new light on the developmental origins of obesity, and is consistent with the generally higher levels of central obesity among women than men in developing populations.