What are the trends in seeking health care for fever in children under-five in Sierra Leone? evidence from four population-based studies before and after the free health care initiative.

BACKGROUND: In 2010, the government of Sierra Leone implemented the Free Health Care Initiative (FHCI) in the country with the objective of reducing the high maternal, infant, and child mortality rates and improving general health indicators. The objective of this study was to assess the trends in the prevalence of health care-seeking and to identify the determinants of healthcare service utilization by caregivers of children younger than five years. METHODS: The analysis of health-care-seeking behavior was done using data from four population-based surveys in Sierra Leone before (2008) and after (2013, 2016, 2019) the FHCI was implemented. Care-seeking behavior was assessed with regard to caregivers seeking care for children under-five in the two weeks prior to each survey. We compared the percentages of healthcare-seeking behavior change and identify factors associated with healthcare-seeking using a modified Poisson regression model with generalized estimating equations. RESULTS: In 2008, a total of 1208 children with fever were recorded, compared with 2823 children in 2013, 1633 in 2016, and 1464 in 2019. Care-seeking for children with fever was lowest in 2008 (51%; 95% CI (46.4-55.5)) than in 2013 (71.5%; 95% CI (68.4-74.5)), 2016 (70.3%; 95% CI (66.6-73.8)), and 2019 (74.6%; 95% CI (71.6-77.3)) (p < 0.001). Care-seeking in 2013, 2016 and 2019 was at least 1.4 time higher than in 2008 (p < 0.001) after adjusting for mother's age, wealth, religion, education level, household head and the child's age. Care-seeking was lowest for children older than 12 months, mothers older than 35 years, children living in the poorest households, and in the northern region. A trend was observed for the sex of the household head. The level of care-seeking was lowest when the household head was a man. CONCLUSIONS: The increase in healthcare-seeking for children under-five with fever followed the introduction of the FHCI in Sierra Leone. Care-seeking for fever varied by the child's age, caregiver's age, household wealth, the sex of the household head and region. Maintaining the FHCI with adequate strategies to address other barriers beyond financial ones is essential to reduce disparities between age groups, regions and, households.

Diet Quality and Urbanization in Mozambique.

Robust income growth combined with the highest urban population growth in the world is driving rapid changes in the food system of sub-Saharan Africa. Demand is increasing for higher quality as well as more processed foods. Countries are increasingly experiencing a double burden of over and under nutrition as the overweight and obesity epidemic spreads. In this context, we seek to understand the key drivers and likely evolution of diet quality in Mozambique, in both its positive and negative dimensions, while specifically examining the role of farm ownership among increasingly urban populations. We use national household expenditure survey data and a set of ordinary least square and analysis of variance regressions to observe patterns of current diet quality across city size categories, household income, household education, and other demographic variables. We then anticipate the likely directions of change in diet quality over these same dimensions based on expected income growth and expenditure elasticities developed for several alternative nutrients. We find that growing incomes and the consumption of processed foods are associated with a worsening of negative factors in the diet. Furthermore, urbanization, controlling for income, is associated more strongly with a worsening of negative factors than with an improvement in positive factors in the diet. The effect on diet quality of farm ownership, however, is positive and significant, primarily driven by these households purchasing fewer unhealthy foods. African cities need to consider what mix of policies will counteract the negative effects of continued urbanization and rising incomes on diets.