Adverse childhood experiences and bullying behaviours at work among workers in Japan.

OBJECTIVES: To examine the relationship between adverse childhood experiences (ACEs), workplace bullying victimisation and bullying behaviours to subordinates among Japanese workers. METHODS: We conducted an internet-based cross-sectional survey among workers who had enacted 0, 1 and ≥2 types of bullying behaviours that had been directed towards subordinates in the past 3 years (n=309 for each group, total N=927). We assessed ACEs with questionnaires about adverse experiences at home and bullying victimisation at school. The total and controlled direct effects of ACEs on the number of bullying behaviours to subordinates were estimated from a baseline-adjusted and a direct-effect marginal structural ordinal logistic model, respectively. RESULTS: There was a positive dose-response association between the level of ACEs and the frequency of workplace bullying victimisation, as well as the number of bullying behaviours enacted at work after adjustment for sex, age and childhood socioeconomic status (both p<0.001). Workers in the highest tertile of ACEs compared with the lowest tertile had 3.15 (95% CI 2.20 to 4.50) times higher odds of having perpetrated more bullying behaviours at work. The magnitude of the effect was 2.57 (95% CI 1.70 to 3.90) via pathways not mediated by workplace bullying victimisation in a direct-effect marginal structural model. CONCLUSIONS: People who had ACEs were at increased risk later in life of enacting bullying behaviours at work. Current findings may be useful to prevent bullying behaviours at work.

Cost of shifting from healthcare to long-term care in later life across major diseases: analysis of end-of-life care during the last 24 months of life.

Aim: To evaluate the costs associated with healthcare and long-term care during the last 24 months before death according to major disease groups. Methods: Individual data regarding healthcare and long-term care costs according to public insurance schemes during the last 24 months before death among all decedents older than 75 years reported in a city in Japan between April 1, 2010 and March 31, 2014 were identified; the data for nine major diseases were then analyzed. Results: For the 2149 decedents studied, the average healthcare costs per capita in the last 24 months of life for moderately-old (75 to 84 years) and extremely-old (85 years and older) decedents was 4,135,467 JPY and 2,493,001 JPY, respectively, while the average long-term care costs per capita for 24 months was 1,300,710 JPY and 2,723,239 JPY, respectively. The total costs (healthcare and long-term care combined) ranged from 9,169,547 JPY for chronic kidney disease to 5,023,762 JPY for ischemic heart disease. In all the diseases studied, the moderately-old decedents incurred higher healthcare costs while the extremely-old decedents incurred higher long-term care costs. However, for the care costs of chronic lower respiratory diseases, this pattern was not observed. Conclusion: A shift in expenditure from healthcare to long-term care as the decedents' age increased was observed in major diseases, with some exceptions.

Hidden burden of non-medical spending associated with inpatient care among the poor in Afghanistan.

OBJECTIVES: To elucidate the household payments required for medical and non-medical spending for inpatient health care and examine the pattern of household payments according to household economic status and the degree of remoteness of the area of residence. METHODS: The subjects were 5490 individuals included in a nationally representative survey in 2010. Their medical (diagnosis and medicine) and non-medical (accommodation and transportation) expenses for their most recent hospitalization were analyzed. RESULTS: Compared with the richest group, the poorest group paid less for diagnosis and medicine (AOR = 0.37, P < 0.001; AOR = 0.78, P = 0.009, respectively), paid similar amounts for accommodation (AOR = 1.19, P = 0.164), and more for transportation (AOR = 2.09, P < 0.001). Residents in urban areas paid less than residents in rural areas for accommodation and transportation (AOR = 0.73, P < 0.001; AOR = 0.58, P < 0.001, respectively). CONCLUSIONS: Poor households paid less for diagnosis and medicine, but more for transportation related to inpatient care. Non-medical spending for inpatient care among the poor should be considered for affordable and accessible health-care utilization.

Trends in inequalities in utilization of reproductive health services from 2000 to 2011 in Vietnam.

OBJECTIVE: This study aimed to examine changes in utilization of reproductive health services by wealth status from 2000 to 2011 in Vietnam. METHODS: Data from the Vietnam Multiple Indicator Cluster Surveys in 2000, 2006, and 2011 were used. The subjects were 550, 1023, and 1363 women, respectively, aged between 15 and 49 years who had given birth in the previous one or two years. The wealth index, a composite measure of a household's ownership of selected assets, materials used for housing construction, and types of water access and sanitation facilities, was used as a measure of wealth status. Main utilization indicators were utilization of antenatal care services, receipt of a tetanus vaccine, receipt of blood pressure measurement, blood examination and urine examination during antenatal care, receipt of HIV testing, skilled birth attendance at delivery, health-facility-based delivery, and cesarean section delivery. Inequalities by wealth index were measured by prevalence ratios, concentration indices, and multivariable adjusted regression coefficients. RESULTS: Significant increase in overall utilization was observed in all indicators (all p < 0.001). The concentration indices were 0.19 in 2000 and 0.06 in 2011 for antenatal care, 0.10 in 2000 and 0.06 in 2011 for tetanus vaccination, 0.23 in 2000 and 0.08 in 2011 for skilled birth attendance, 0.29 in 2006 and 0.12 in 2011 for blood examination, and 0.18 in 2006 and 0.09 in 2011 for health-facility-based delivery. The multivariable adjusted regression coefficients of reproductive health service utilization by wealth category were 0.06 in 2000 and 0.04 in 2011 for antenatal care, 0.07 in 2000 and 0.05 in 2011 for skilled birth attendance, and 0.07 in 2006 and 0.05 in 2011 for health-facility-based delivery. CONCLUSIONS: More women utilized reproductive health services in 2011 than in 2000. Inequality by wealth status in utilization of antenatal care, skilled birth attendance, and health-facility-based delivery had been reduced.

Unsafe sexual behaviour in domestic and foreign migrant male workers in multinational workplaces in Jordan: occupational-based and behavioural assessment survey.

OBJECTIVES: To examine the prevalence of unsafe sexual behaviour, sexually transmitted infection (STI)-related knowledge, health and work-related conditions, and correlates of practising unsafe sex among domestic and foreign male workers in multinational workplaces in Jordan. DESIGN: Cross-sectional behavioural assessment survey. SETTING: Multinational workplaces in Jordan. PARTICIPANTS: 230 Jordanian and 480 foreign male workers aged ≥ 18 years who had worked in a Qualified Industrial Zone (QIZ) for 12 months or more. OUTCOMES: The primary outcome was the prevalence of practising unsafe sex. 'Unsafe sex' was defined as sex with a non-regular sexual partner with inconsistent condom usage. RESULTS: Overall, 74.3% of workers reported lifetime sexual experience. The proportion of lifetime unsafe sex was similar among domestic (31.8%) and foreign (35.6%) workers. Of those, 59.2% of domestic and 68.1% of foreign workers started practising unsafe sex after joining the QIZ. Rates of lifetime unsafe sex were significantly higher among those who had their sexual debut after joining the QIZ in domestic (aOR, 2.2, 95% CI 1.1 to 4.4) and foreign workers (aOR, 2.4, 95% CI 1.4 to 4.1). Among the domestic workers, being 18-24 years old (aOR, 4.9), unmarried (aOR, 4.8), working in the QIZ for 5-8 years (aOR, 5.0), sometimes/frequently shopped with foreign workers (aOR, 2.1) or were current/ex-alcohol drinkers (aORs, 3.4) were independently significantly associated with higher odds of practising unsafe sex. CONCLUSIONS: A significant proportion of domestic and foreign male workers had been practising unsafe sex. The findings indicated that not only foreigners but also domestic male workers associating with foreign workers are at high risk of unsafe sex. Tailored interventions to promote safer sex in multinational workplaces in Jordan are needed.

Impact of the 2011 Great East Japan Earthquake on community health: ecological time series on transient increase in indirect mortality and recovery of health and long-term-care system.

BACKGROUND: The objectives were to clarify the trend in the cause-specific mortality rate and changes in health and long-term-care use after the Great East Japan Earthquake in 2011. METHODS: We obtained the following data from national sources: the number of deaths by cause, age and month; the amount of healthcare insurance expenditures by type of services, age and month; the amount of long-term-care insurance expenditures by type of services, age, care need and month. We estimated increase in standardised mortality rate postearthquake compared with pre-earthquake, and change in the standardised amount of health and long-term-care insurance expenditures post-earthquake compared with pre-earthquake in three severely affected prefectures, Iwate, Miyagi and Fukushima, by the adjustment for trends in the other prefectures. RESULTS: The risk of indirect mortality increased in the month of the earthquake (relative risk (RR) with 95% CI 1.20 (1.13 to 1.28) for those 60-69 years of age, 1.25 (1.17 to 1.32) for 70-79 years, and 1.33 (1.27 to 1.38) for 80 years and older). The amount of health and long-term-care insurance expenditures decreased among elderly persons in the month of the earthquake, and recovered to 95% of usual level within 1-5 months. Among cities and towns hit by tsunami, higher percentage of households flooded was associated with higher risk of indirect mortality (p<0.001), lower expenditures for outpatient medical care (p<0.001), and lower expenditures for home-care services (p<0.001). CONCLUSIONS: This study showed transient increase in indirect mortality and recovery of health and long-term-care system after the earthquake.

Intimate partner violence and symptoms of sexually transmitted infections: are the women from low socio-economic strata in Bangladesh at increased risk.

BACKGROUND: There is little research on whether women who are either poor or illiterate and have experienced intimate partner violence (IPV) have a unique risk of sexually transmitted infections (STIs). Most such research concerns families displaced by wars and conflicts. PURPOSE: Therefore, we aimed to further this important area of inquiry by (1) addressing whether an association exists between experiences of physical and/or sexual IPV within the past year and symptoms of STI and (2) exploring the relationship between low socio-economic status and IPV and the relative roles they play as obstacles to reducing women's risk of STI in a nationally representative sample of Bangladesh. METHOD: This paper used data from the 2007 Bangladesh Demographic Health Survey. The analyses were based on the responses of 4,195 currently married women. Exposure was determined from women's experiences of physical and sexual IPV within the past year. Genital sores and genital discharge were used as proxy outcome variables of the symptoms of STI. Descriptive statistics and multivariate logistic regression analysis were used in the study. RESULTS: Experience of any physical and/or sexual IPV were associated with genital sores (adjusted odds ratio [AOR] = 1.79; 95 % confidence interval [CI], 1.28-2.51) and genital discharge (AOR 1.90, 95 % CI 1.42-2.53). Severity of physical IPV appeared to have more profound consequences on the outcome measured. Findings also demonstrated that for the risk of STI, women at the nexus of poverty or illiteracy and IPV were not more uniquely disadvantaged. CONCLUSIONS: The results suggest that for the risk of STI, the negative effect of having experienced IPV extends across all socio-economic backgrounds and is not limited to women at either at the nexus of poverty or illiteracy and IPV. Findings underscore the calls for protecting women from all forms of physical and sexual violence from their husbands as a part of interventions to reduce the risk of STI.

Inequalities in Use of Antenatal Care and Its ServiceComponents in India.

OBJECTIVES: This study was performed to evaluate the use of individual components of antenatal care (ANC) services by pregnant women across India in addition to counting of ANC visits and then analyze differences according to state, socioeconomic condition, and access to health care services. METHODS: The study used a nationally representative sample of 36,850 women from the National Family Health Survey (2005-2006) of India. Outcome measurements were medication, number of ANC visits, and components of ANC, including physical examination and measurements, laboratory examination, and advice about pregnancy. Differences in these outcomes according to 29 states, socioeconomic conditions, and access to health care services were examined. Independent associations between outcome measures and social and health care factors were analyzed. RESULTS: The percentages of women who used ANC at least once and four times or more were 81.5% (ranges by states: 38.0 -99.9%) and 46.1% (15.2-97.9%), respectively. Among those who used ANC four times or more, 86.4% (54.2-98.9%) received a blood examination, and 85.8% (70.3-96.3%) were advised to deliver in a hospital. Greater wealth (OR=3.38; 95%CI 2.58-4.42) and higher education level (OR=3.19; 95%CI 2.49-4.14) were associated with receiving a blood examination during ANC. Rural residence was negatively associated with using ANC four times or more (OR=0.64; 95%CI 0.59-0.67) and receiving a blood examination (OR=0.67; 95%CI 0.59-0.76). Those who received ANC at community health centers were less likely to receive a blood pressure examination, blood and urine examination, and advice to deliver in a hospital compared with those who received ANC at public hospitals. CONCLUSION: This study showed substantial inequalities in use of ANC and service components of ANC received in India across geographic areas, socioeconomic conditions, and levels of access to health care services. In addition to reducing socioeconomic inequalities, it is necessary to provide quality services to those with limited access to health care services.

Does gender inequity increase the risk of intimate partner violence among women? Evidence from a national Bangladeshi sample.

BACKGROUND: Evidence from developing countries regarding the association between gender inequity and intimate partner violence (IPV) victimization in women has been suggestive but inconclusive. Using nationally representative population-based data from Bangladesh, we examined the association between multidimensional aspects of gender inequity and the risk of IPV. METHODS: We used data from the 2007 Bangladesh Demographic Health Survey. The analyses were based on the responses of 4,467 married women. The main explanatory variable was gender inequity, which reflects the multidimensional aspects of women's autonomy and the relationship inequality between women and their partner. The experience of physical and/or sexual IPV was the main outcome variable of interest. RESULTS: Over 53% of married Bangladeshi women experienced physical and/or sexual violence from their husbands. In the adjusted models, women who had a higher level of autonomy (adjusted odds ratio [AOR] 0.48; 99% confidence interval [CI] 0.37-0.61), a particularly high level of economic-decision-making autonomy (AOR 0.12; 99% CI 0.08-0.17), and a higher level of non-supportive attitudes towards wife beating or raping (AOR 0.61; 99% CI 0.47-0.83) were less likely to report having experienced IPV. Education level, age at marriage, and occupational discrepancy between spouses were also found to be significant predictors of IPV. CONCLUSIONS: In conclusion, dimensions of gender inequities were significant predictors of IPV among married women in Bangladesh. An investigation of the causal link between multidimensional aspects of gender inequity and IPV will be critical to developing interventions to reduce the risk of IPV and should be considered a public health research priority.

Reduction in inequality in antenatal-care use and persistence of inequality in skilled birth attendance in the Philippines from 1993 to 2008.

OBJECTIVE: To assess changes in the inequalities associated with maternal healthcare use according to economic status in the Philippines. DESIGN: An analysis of four population-based data sets that were conducted between 1993 and 2008. SETTING: Philippines. PARTICIPANTS: Women aged 15-49 years who had a live-birth within 1 year in 1993 (n=1707), 1998 (n=1513), 2003 (n=1325) and 2008 (n=1209). OUTCOMES: At least four visits of antenatal care, skilled birth attendance and delivery in a medical facility. RESULTS: The adjusted OR for antenatal-care use when comparing the highest wealth-index quintile with the lowest quintile declined from 1993 to 2008: 3.43 (95% CI 2.22 to 5.28) to 2.87 (95% CI 1.31 to 6.29). On the other hand, the adjusted OR for the other two outcome indicators by the wealth index widened from 1993 to 2008: 9.92 (95% CI 5.98 to 16.43) to 15.53 (95% CI 6.90 to 34.94) for skilled birth attendance and 7.74 (95% CI 4.22 to 14.21) to 16.00 (95% CI 7.99 to 32.02) for delivery in a medical facility. The concentration indices for maternal health utilisation in 1993 and 2008 were 0.19 and 0.09 for antenatal care; 0.26 and 0.24 for skilled birth attendance and 0.41 and 0.35 for delivery in a medical facility. CONCLUSIONS: Over a 16-year period, gradients in antenatal-care use decreased and the high level of inequalities in skilled birth attendance and delivery in a medical facility persisted. The results showed a disproportionate use of institutional care at birth among disadvantaged Filipino women.

Sociocultural factors that reduce risks of homicide in Dar es Salaam: a case control study.

OBJECTIVES: This study was performed to examine the potential contributions of sociocultural activities to reduce risks of death by homicide. METHODS: This study was designed as a case control study. Relatives of 90 adult homicide victims in Dar es Salaam Region, Tanzania, in 2005 were interviewed. As controls, 211 participants matched for sex and 5-year age group were randomly selected from the same region and interviewed regarding the same contents. RESULTS: Bivariate analysis revealed significant differences between victims and controls regarding educational status, occupation, family structure, frequent heavy drinking, hard drug use and religious attendance. Conditional logistic regression analysis indicated that the following factors were significantly related to not becoming victims of homicide: being in employment (unskilled labour: OR=0.04, skilled labour: OR=0.07, others: OR=0.04), higher educational status (OR=0.02), residence in Dar es Salaam after becoming an adult (compared with those who have resided in Dar es Salaam since birth: OR=3.95), living with another person (OR=0.07), not drinking alcohol frequently (OR=0.15) and frequent religious service attendance (OR=0.12). CONCLUSIONS: Frequent religious service attendance, living in the same place for a long time and living with another person were shown to be factors that contribute to preventing death by homicide, regardless of place of residence and neighbourhood environment. Existing non-structural community resources and social cohesive networks strengthen individual and community resilience against violence.

Out-of-pocket Costs of Disabilities and Their Association with Household Socioeconomic Status Among School-aged Children in Vietnam.

OBJECTIVE: The aim of this study was to assess the economic burden of disability of school-aged children and to evaluate the association between disabilities and household socioeconomic status, as well as the economic burden of disability and household socioeconomic status in Vietnam. MATERIALS AND METHODS: Nationally representative data for 9,882 children aged 6 to 17 years from the Vietnam Household Living Standard Survey 2006 were used. Disabilities were measured in six basic functional domains, including vision, hearing, remembering or concentrating, mobility, self-care, and communication. We evaluated the association between area, household income, educational attainment, or occupation of household head, and each difficulty. The ratio of health-care expenditure to per capita household income was compared by presence of a disability as well as household socioeconomic status. RESULTS: The prevalence of difficulty was 1.9% for vision and 2.3% for at least one of the other five domains. Difficulty in vision was more prevalent in the richer households (p=0.001), whereas difficulty in the other five domains was more prevalent in the poorer households (p=0.002). The ratio of health-care expenditure to per capita household income was greater than 0.05 in 4.6% of children. The adjusted odds ratio of children with difficulty in vision having a health-care expenditure share greater than 0.05 compared with children without difficulty was 4.78 (95% CI: 2.95, 7.73; p<0.001), and that for difficulty in the other five domains was 3.13 (95% CI: 2.04, 4.80; p<0.001). Among children with difficulty in at least one of the five domains other than vision, the proportion of children with a health-care expenditure share greater than 0.05 was higher among children from the poorer households (p=0.033). CONCLUSIONS: Children with a disability spent more on health care relative to their income than those without. Visual disability was more prevalent among children from the richer households, whereas other disabilities were more prevalent among children from the poorer households.

The impact of community-based, workshop activities in multiple local dialects on the vaccination coverage, sanitary living and the health status of multiethnic populations in Lao PDR.

Studies on effective community-based intervention in areas inhabited by multiple ethnic groups are limited. The present study was performed to evaluate the impact of workshop activities in multiple local dialects guided by lay facilitators on vaccination coverage, sanitary living and health status in a northern district of Lao PDR. In target villages, facilitators were selected and trained to assist at village meetings to discuss health issues and develop and implement action plans. Manuals and posters with graphics were distributed. Skills were taught through demonstrations by specialists. The vaccination coverage among children and women improved significantly after 1 year. Villagers started using toilets, collecting and burning garbage, and isolating animals from human dwellings, and these activities were continued in 76, 84 and 87% of villages, respectively, 5 years after the start of the activities. The frequency of villagers falling ill was reduced in 67% of the villages. After adjustment for sociocultural characteristics and ethnicity, both the continuous sanitary living index and the reduction in the frequency of villagers falling ill were associated with the higher levels of community participation in the workshop activities. The results demonstrated that the community-based workshop activities improved vaccination coverage, sanitary living and health status. Participatory group discussions in local dialects and village activities led by lay facilitators, supervision and consultation by district trainers who were well recognized by villagers, and the distribution of pictorial educational materials can be an effective and sustainable health promotion approaches among multiethnic groups in under-resourced areas.

Intimate partner violence and use of reproductive health services among married women: evidence from a national Bangladeshi sample.

BACKGROUND: Data from a statewide survey in India and clinic-based studies in developed settings have previously suggested an association between maternal physical intimate partner violence (IPV) experiences and the low use of antenatal care (ANC). This study aimed to explore the association between maternal experiences of physical and sexual IPV and the use of reproductive health care services, using a large nationally representative data set from Bangladesh. METHODS: This paper used data from the 2007 Bangladesh Demographic Health Survey. The analyses were based on the responses of 2001currently married women living with at least one child younger than 5 years. Exposure was determined from maternal reports of physical and sexual IPV. The utilization of ANC according to amount and type of provider and utilization of delivery assistance according to provider type were used as proxy outcome variables for reproductive health care utilization. Descriptive statistics and multivariate logistic regression analysis used in the study. RESULTS: Approximately two out of four (48.2%) respondents had experienced physical IPV. Maternal experience of physical IPV was associated with low use of receiving sufficient ANC (adjusted odds ratio [AOR] 0.69; 95% confidence interval [CI] 0.49-0.96), lower likelihood of receiving ANC (AOR 0.69; 95% CI 0.53-0.89), and assisted deliveries from skilled provider (AOR 0.54; 95% CI 0.37-0.78). Women who had been sexually abused were significantly less likely to have visited a skilled ANC and delivery care provider. Furthermore, severity of physical IPV appeared to have more profound consequences on the outcome measured. CONCLUSIONS: The association between exposure to IPV and use of reproductive health care services suggests that partner violence plays a significant role in lower utilization of reproductive health services among women in Bangladesh. Our findings suggest that, in addition to a wide range of socio-demographic factors, preventing maternal physical and sexual IPV need to be considered as an important psychosocial determinates for the higher utilization of reproductive health care services in Bangladesh.

Health-care provision factors associated with child immunization coverage in a city centre and a rural area in Kabul, Afghanistan.

A total of 1327 households were surveyed in Kabul province, Afghanistan to evaluate child immunization coverage and its association with distance to health facilities, attendance at antenatal care, the place of delivery and contact by outreach activity. The proportion of fully immunized children, those who had received at least 1 dose of BCG, 3 doses of DPT, and 1 dose of measles vaccine, was 84.5% in the city centre and 60.7% in the rural area. Fully immunized status was positively associated with close proximity to a health facility (odds ratio [OR]=1.92, [95%CI, 1.08, 3.39]), and attendance at antenatal care (OR=1.39, [95%CI, 1.00, 1.93]) in the city centre, and outreach contact (OR=11.6, [95%CI, 6.92, 19.4]) in the rural area after adjustment for demography, socio-economic factors, participation in health education and experiences of hardship. Attendance at antenatal care in the rural area (OR=1.91, [95%CI, 1.35, 2.72]), and institutional delivery in the city centre and rural area (OR=2.83, [95%CI, 1.20, 6.71]; OR=2.17, [95%CI, 1.01, 4.64], respectively) were positively associated with antigen specific coverage. Improving multiple community conditions including health-care provision and socio-economic factors through close partnership among various sectors promotes the immunization program.

Factors associated with the health and nutritional status of children under 5 years of age in Afghanistan: family behaviour related to women and past experience of war-related hardships.

BACKGROUND: The present study was performed to assess, beyond socio-economic factors, independent associations between the health and nutritional status of children under 5 years old and (1) family behavioural factors related to women with regard to child care and (2) war-related experience by the household of hardships in Afghanistan. METHODS: The subjects were all children born during the previous 5 years from 1400 households in Kabul Province, Afghanistan and were selected by multistage sampling in March 2006. Height and weight measurements of the children and culturally sensitive interviews with their mothers were conducted by household visits. Child mortality, morbidity and nutritional status were evaluated. Four areas were assessed as variables for family behavioural factors related to women: education of mothers, child marriage of the mothers, maternal autonomy in obtaining healthcare for children and preference for a female physician. Hardships experienced by the family were examined by determining their satisfaction of basic material needs and by any experience of being forced to leave a preferred residence. RESULTS: A total of 2474 children from 1327 households completed the examinations and interviews; among them, 101 children were deceased by the time of the interview visits. Diarrhoea (32.5%) and acute respiratory infection (41.0%) were common child health problems and both emaciation (12.4%) and linear growth retardation (39.9%) were prevalent. Regardless of the influence of economic, demographic, family behavioural or hardships experience factors, a lack of maternal autonomy (79.1%) was associated with the occurrence of acute respiratory infection (odds-ratio = 1.72; 95% confidence interval = 1.23, 2.40), and linear growth retardation of children (odds-ratio = 1.38; 95% confidence interval = 1.01, 1.90); a lack of education of the mother (71.7%) and child marriage of the mothers (18.3%) were associated with diarrhoea (odds-ratio = 1.84; 95% confidence interval = 1.40, 2.41; odds-ratio = 1.46; 95% confidence interval = 1.08, 1.96, respectively); a shortage of basic material needs (59.1%) was associated with diarrhoea (odds-ratio = 1.35; 95% confidence interval = 1.08, 1.68); and migration inside the country (52.9%) was associated with underweight children (odds-ratio = 2.48; 95% confidence interval = 1.13, 5.44). CONCLUSION: A lack of education of the mothers, child marriage, lack of maternal autonomy, shortage of basic material needs and internal displacement showed independent and significant negative associations with child health and nutritional variables in this country that has experienced a long period of conflict.

Impact of conflict on infant immunisation coverage in Afghanistan: a countrywide study 2000-2003.

BACKGROUND: Infant immunisation is an effective public health intervention to reduce the morbidity and mortality of vaccine preventable diseases. However, some developing countries fail to achieve desirable vaccination coverage; Afghanistan is one such country. The present study was performed to evaluate the progress and variation in infant immunisation coverage by district and region in Afghanistan and to assess the impact of conflict and resource availability on immunisation coverage. RESULTS: This study analysed reports of infant immunisation from 331 districts across 7 regions of Afghanistan between 2000 and 2003. Geographic information system (GIS) analysis was used to visualise the distribution of immunisation coverage in districts and to identify geographic inequalities in the process of improvement of infant immunisation coverage. The number of districts reporting immunisation coverage increased substantially during the four years of the study. Progress in Bacillus Calmette-Guerin (BCG) immunisation coverage was observed in all 7 regions, although satisfactory coverage of 80% remained unequally distributed. Progress in the third dose of Diphtheria-Pertussis-Tetanus (DPT3) immunisation differed among regions, in addition to the unequal distribution of immunisation coverage in 2000. The results of multivariate logistic regression analysis indicated a significant negative association between lack of security in the region and achievement of 80% coverage of immunisation regardless of available resources for immunisation, while resource availability showed no relation to immunisation coverage. CONCLUSION: Although progress was observed in all 7 regions, geographic inequalities in these improvements remain a cause for concern. The results of the present study indicated that security within a country is an important factor for affecting the delivery of immunisation services.

Association of household demographic variables with child mortality in Côte d'Ivoire.

The associations between household demographic variables and mortality of children aged less than five years were investigated using data from the 1998 Demographic and Health Survey (DHS) of the Republic of Côte d'Ivoire, Western Africa. Of the total of 1992 children born to women included in the study population during the 5-year period preceding the survey, 260 (13%) had died and 1732 (87%) were alive at the time of the survey. Logistic regression analyses used to compare biosocial variables between the deceased and living children showed that the sex of the child, birth interval and mother's occupation were associated with child's survival status. After adjusting for their effects, household demographic variables (i.e. number of household members, number of household members under 5 years [HM-5Y], number of household members 5 years or older [HM+5Y], the proportion of HM-5Y among all household members, and the ratio of HM-5Y to HM+5Y) were shown to be associated with the child's survival status. This study provided insight into the effects of intra-household competition among children and availability of care-givers as potential determinants of child survival. The results indicate that improvement of the childcare environment and reproductive intervention are necessary to reduce child mortality in West African countries.

Critical contribution of sanitation infrastructure and primary medical care to child health status in Japan from 1955 to 2000.

We examined the associations between prefectural health status of children and sanitation infrastructure, medical care services and socioeconomic status in Japan during 1955-2000. Four indicators of child health status: infant mortality rate (IMR), Ascaris lumbricoides prevalence and height and weight of elementary school children, and five prefectural social indicators: water supply, sewerage, number of physicians, income and women's education, were calculated over five-year intervals and examined by correlation and panel data analyses. Associations between paediatric health and five social indicators were significant (p<0.001) until 1970. After adjustment for income or education, water supply diffusion rate showed a significantly negative association with IMR until the 1980s. A significantly positive correlation was observed between the number of physician and paediatric health from 1955-70 after adjustment for income. Water supply development showed a positive association with paediatric health after adjustment for economic or educational impact during the phases of rapid and steady economic growth, while medical care showed a positive correlation with paediatric health after adjustment for income during only the phase of rapid economic growth. Relationships between child health status and social indicators have changed over time with stage of economic development.