Mapping 123 million neonatal, infant and child deaths between 2000 and 2017.

Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2-to end preventable child deaths by 2030-we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000-2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations.

Description of the design of a mixed-methods study to assess the burden and determinants of malaria transmission for tailoring of interventions (microstratification) in Ibadan and Kano metropolis.

BACKGROUND: Rapid urbanization in Nigerian cities may lead to localized variations in malaria transmission, particularly with a higher burden in informal settlements and slums. However, there is a lack of available data to quantify the variations in transmission risk at the city level and inform the selection of appropriate interventions. To bridge this gap, field studies will be undertaken in Ibadan and Kano, two major Nigerian cities. These studies will involve a blend of cross-sectional and longitudinal epidemiological research, coupled with longitudinal entomological studies. The primary objective is to gain insights into the variation of malaria risk at the smallest administrative units, known as wards, within these cities. METHODS/RESULTS: The findings will contribute to the tailoring of interventions as part of Nigeria's National Malaria Strategic Plan. The study design incorporates a combination of model-based clustering and on-site visits for ground-truthing, enabling the identification of environmental archetypes at the ward-level to establish the study's framework. Furthermore, community participatory approaches will be utilized to refine study instruments and sampling strategies. The data gathered through cross-sectional and longitudinal studies will contribute to an enhanced understanding of malaria risk in the metropolises of Kano and Ibadan. CONCLUSIONS: This paper outlines pioneering field study methods aimed at collecting data to inform the tailoring of malaria interventions in urban settings. The integration of multiple study types will provide valuable data for mapping malaria risk and comprehending the underlying determinants. Given the importance of location-specific data for microstratification, this study presents a systematic process and provides adaptable tools that can be employed in cities with limited data availability.

Permutation-based multiple testing corrections for P $$ P $$ -values and confidence intervals for cluster randomized trials.

In this article, we derive and compare methods to derive P-values and sets of confidence intervals with strong control of the family-wise error rates and coverage for estimates of treatment effects in cluster randomized trials with multiple outcomes. There are few methods for P-value corrections and deriving confidence intervals, limiting their application in this setting. We discuss the methods of Bonferroni, Holm, and Romano and Wolf and adapt them to cluster randomized trial inference using permutation-based methods with different test statistics. We develop a novel search procedure for confidence set limits using permutation tests to produce a set of confidence intervals under each method of correction. We conduct a simulation-based study to compare family-wise error rates, coverage of confidence sets, and the efficiency of each procedure in comparison to no correction using both model-based standard errors and permutation tests. We show that the Romano-Wolf type procedure has nominal error rates and coverage under non-independent correlation structures and is more efficient than the other methods in a simulation-based study. We also compare results from the analysis of a real-world trial.

Proximate determinants and decomposition of changes in fertility levels across Nigeria regions: Evidence from Nigeria Demographic Health Survey, 2003-2018.

There is disparity in fertility level across the six geopolitical zones in Nigeria. Deeper uunderstanding about the drivers of fertility trends are necessary to prioritize zonal specific strategies for fertility reduction in Nigeria. Thus, this study examined the proximate determinants (PDs) of fertility and decomposed the change in its level across the six geo-political zones in Nigeria. Data from Nigeria Demographic and Health Surveys of 2003 and 2018 were analyzed. Fertility data were based on the report of full birth history from women of reproductive age. The Revised Bongaarts framework was used to estimate PDs and fertility levels. The contribution of each PDs to the observed changes in fertility levels was quantified using Das Gupta's five- factor decomposition method. The Total fertility rate (TFR) in 2003 and 2008 across the zones are South-South (5.04 vs 4.36), South-West (4.88 vs 4.26), North West (7.25 vs 6.85), North East (6.87 vs 6.54), North Central (5.72 vs 5.48), South East (5.06 vs 4.86), Nigeria (6.00 vs 5.59). Across the zones, there was a change in the fertility inhibiting effect of Contraception (Cc) between 2003 and 2018. The fertility inhibiting effect of Postpartum Infecundability (Ci) and Abortion was the highest and smallest respectively across the zones. Delayed sexual exposure (Cm) and contraceptive use (Cc) contributed the most to the change across the regions. The percentage contribution of Cm in South-South, South West, and South East was 87.04%, 52.89%, and 172.85% respectively. Furthermore, most of the fertility change observed in North Central was attributable to Cc. Abortion index was not an important inhibiting factor of fertility in Nigeria. Delayed sexual exposure and contraceptive use accounted for the largest change observed in fertility levels across the six geo-political zones in Nigeria between 2003 and 2018. Strategies that promote delayed sexual exposure, contraceptive use and breast feeding practices will enhance fertility transition in Nigeria.

The spread of COVID-19 outbreak in the first 120 days: a comparison between Nigeria and seven other countries.

BACKGROUND: COVID-19 is an emerging public health emergency of international concern. The trajectory of the global spread is worrisome, particularly in heavily populated countries such as Nigeria. The study objective was to assess and compare the pattern of COVID-19 spread in Nigeria and seven other countries during the first 120 days of the outbreak. METHODS: Data was extracted from the World Bank's website. A descriptive analysis was conducted as well as modelling of COVID-19 spread from day one through day 120 in Nigeria and seven other countries. Model fitting was conducted using linear, quadratic, cubic and exponential regression methods (α=0.05). RESULTS: The COVID-19 spread pattern in Nigeria was similar to the patterns in Egypt, Ghana and Cameroun. The daily death distribution in Nigeria was similar to those of six out of the seven countries considered. There was an increasing trend in the daily COVID-19 confirmed cases in Nigeria. During the lockdown, the growth rate in Nigeria was 5.85 (R2=0.728, p< 0.001); however, it was 8.42 (R2=0.625, p< 0.001) after the lockdown was relaxed. The cubic polynomial model (CPM) provided the best fit for predicting COVID-19 cumulative cases across all the countries investigated and there was a clear deviation from the exponential growth model. Using the CPM, the predicted number of cases in Nigeria at 3-month (30 September 2020) was 155,467 (95% CI:151,111-159,824, p< 0.001), all things being equal. CONCLUSIONS: Improvement in COVID-19 control measures and strict compliance with the COVID-19 recommended protocols are essential. A contingency plan is needed to provide care for the active cases in case the predicted target is attained.

Social contexts of fertility desire among non-childbearing young men and women aged 15-24 years in Nigeria.

BACKGROUND: Reduction in ideal number of children has been suggested as a necessary precursor for fertility decline especially in high fertility countries of Western and Central Africa. In this study, we explored the social contexts of fertility desires by documenting the effects of individual, household as well as contextual characteristics among young men and women in Nigeria. METHODS: Data source was the male and female recode file of 2018 Nigeria Demographic and Health Survey. Analytical sample comprised 2674 males and 9637 females aged 15-24 years. The main outcome variable was desire for large family size (DLFS) defined as ideal number of children greater than four. Analysis involved use of descriptive statistics and random-effect logit models fitted in four stages. RESULTS: DLFS was 71% among young men and 53% in women. Individual-level factors associated with DLFS among men includes Islam religion (OR = 3.95, CI 2.68-5.83), household size (OR = 1.05) and richer (OR = 0.47, CI 0.29-0.75) or richest wealth index (OR = 0.28, CI 0.16-0.75). Geo-political region and high level of negative attitude to family planning (OR = 1.72, CI 1.23-2.40) were the main contextual factors associated with DLFS. For women, individual-level correlates were education, religion, ethnicity, marital status, household size, and wealth index. Contextual factors include geo-political region, community education (OR = 0.68, CI 0.52-0.89), child mortality experience (OR = 1.29, CI 1.11-1.51) and negative attitude to family planning (OR = 1.36, CI 1.13-1.65). The influence of religion, household wealth and attitude to family planning differ between young men and women. CONCLUSION: Active communication and programmatic interventions are needed so that desire for large family size by young men and women do not become a clog for fertility transition in Nigeria.

Reduction in ideal number of children has been suggested as a necessary condition for fertility decline especially in high fertility countries of Western and Central Africa. In this study, we explored the effects of individual, household as well as community characteristics on fertility desires among young men and women aged 15­24 years in Nigeria. We analysed data for 2674 males and 9637 females aged 15­24 years extracted from the 2018 Nigeria Demographic and Health Survey. The outcome variable was desire for large family size (DLFS) defined as ideal number of children greater than four. Results showed that DLFS was 71% among men and 53% in women. Individual-level factors associated with DLFS among men include Islam religion, household size and wealth status. Geo-political region and high level of negative attitude to family planning were the main community-level factors associated with DLFS. For women, individual-level positively associated with DLFS were Islam religion, and being currently married. Compared to Yoruba, other ethnic groups were more likely to favour DLFS. The negative factors associated with DLFS among young women include higher education and wealth status. At the community-level, Northern geo-political regions, child mortality experience and negative attitude to family planning were positively associated with DLFS. The influence of religion, household wealth and attitude to family planning differ between young men and women. Multi-dimensional strategies with active communication and programmatic interventions are needed so that desire for large family size by young men and women do not slow down fertility transition in Nigeria.

Demography of remarriage and fertility desire among women receiving antiretroviral therapy in South West Nigeria.

Background: In view of sociocultural norms surrounding marriage and childbearing in South West Nigeria, fertility desire may be stronger among remarried women living with HIV. This article describes the characteristics of remarriage and its relationship to fertility desire.Method: A cross-sectional study was conducted among HIV-positive women aged 18-49 years at the Antiretroviral Treatment (ART) clinic, College of Medicine/University College Hospital, Ibadan, Nigeria between November and December 2015. Data were analysed using descriptive statistics and generalised linear models.Results: Overall, 123 (17.3%) of 711 women had experienced remarriage. Significant factors among remarried women were a lack of formal education (ORadj = 3.35, CI: 1.46-7.72); polygamous family (ORadj = 2.65, CI: 1.71-4.12), and serodiscordant union (ORadj = 1.97, CI: 1.14-3.41). Fertility desire was expressed by 410 women (57.7%). After controlling for demographic, socio-economic, and HIV-care characteristics, remarried women were 2.5 times as likely to have fertility desire compared to their counterparts who never remarried (ORadj = 2.49, CI: 1.43-4.33). Younger age was significantly associated with higher odds of fertility desire. Other factors negatively associated with fertility desire were education (ORadj = 0.30, CI: 0.12-0.74) and number of surviving children (ORadj = 0.28, CI: 0.22-0.34).Conclusion: HIV-care and treatment programmes need to pay attention to reproductive concerns, especially among women in second and higher order marriages.

How soon do single mothers have another child? A competing risk analysis of second premarital childbearing in sub-Saharan African countries.

BACKGROUND: A considerable number of previous studies have examined the trends, correlates, and consequences of premarital childbearing among adolescents and young women in Africa. However, very little is known about whether and how soon single mothers have another premarital birth in sub-Saharan African countries. This study examines the timing of a second premarital birth among single mothers and assesses how it may differ across key socio-demographic variables. METHODS: We pooled recent Demographic and Health Surveys from 25 sub-Saharan African countries to create a database of 57, 219 single mothers aged 15-49 years. Cumulative incidence graphs and Fine and Gray's competing risk models were used to delineate the timing of a second premarital birth and its socio-demographic correlates. RESULTS: More than one-third of single mothers in 16 countries have had a second premarital birth in their reproductive life. We also observed that more than 15% of the single mothers in Angola, Benin, the Republic of Chad, Liberia, Namibia, Nigeria, Sierra Leone, and Uganda, have had another premarital birth three years after the first. The incidence of a second premarital birth was significantly lower among women with secondary or higher education, compared to women with less than secondary education (p < 0.05) in most countries. Residence in an urban area compared to rural, was also significantly associated with a low incidence of second premarital birth in 10 countries (p < 0.05). CONCLUSIONS: Findings indicate a rapid progression to having a second premarital birth in some sub-Sahara African countries, particularly among socio-economically disadvantaged women. The findings suggest the need for tailored interventions for improving the quality of life of single mothers, to reduce the associated burden and consequences of having a premarital birth.

Does education offset the effect of maternal disadvantage on childhood anaemia in Tanzania? Evidence from a nationally representative cross-sectional study.

BACKGROUND: Despite being preventable, anaemia is a major public health problem that affects a sizable number of children under-five years globally and in Tanzania. This study examined the maternal factors associated with the risk of anaemia among under-five children in Tanzania. We also assessed whether higher maternal education could reduce the risks of anaemia among children of women with poor socio-economic status. METHODS: Data was drawn from the 2015-16 Tanzania demographic and health survey and malaria indicator survey for 7916 children under five years. Adjusted odds ratios were estimated by fitting a proportional odds model to examine the maternal risk factors of anaemia. Stratified analysis was done to examine how the relationship differed across maternal educational levels. RESULTS: The findings revealed that maternal disadvantage evident in young motherhood [AOR:1.43, 95%CI:1.16-1.75], no formal education [AOR:1.53, 95%CI:1.25-1.89], unemployment [AOR:1.31, 95%CI:1.15-1.49], poorest household wealth [AOR:1.50, 95%CI:1.17-1.91], and non-access to health insurance [AOR:1.26, 95%CI: 1.03-1.53] were risk factors of anaemia among children in the sample. Sub-group analysis by maternal education showed that the risks were not evident when the mother has secondary or higher education. However, having an unmarried mother was associated with about four-times higher risk of anaemia if the mother is uneducated [AOR:4.04, 95%CI:1.98-8.24] compared with if the mother is currently in union. CONCLUSION: Findings from this study show that a secondary or higher maternal education may help reduce the socio-economic risk factors of anaemia among children under-5 years in Tanzania.

Household relationships and healthcare seeking behaviour for common childhood illnesses in sub-Saharan Africa: a cross-national mixed effects analysis.

BACKGROUND: Intra-household dynamics play crucial roles in utilisation of healthcare services for children. We investigated the influence of household relationships on healthcare seeking behaviour for common childhood illnesses in four sub-Sahara African regions. METHODS: Data on 247,061 under-five children were extracted from recent Demographic and Health Surveys conducted between 2012 and 2016 in 25 countries. Data were combined and analysed per sub-region. Dependent variables (DVs) were uptake of health facility care for diarrhea and Acute Respiratory Tract Infection (ARI) symptoms. The main independent variable (IV) was household relationship which was represented by maternal marital profile (marital status, family type and number of marriages) and maternal relationship to household head. Mixed effects logit models were fitted to assess independent relationship between the IVs and DVs with adjustment for relevant demographic and socio-economic characteristics at 5% significance level. RESULTS: The percentage of children who received care for diarrhea and ARI symptoms from health facilities across sub-regions was: Western Africa (WA) 42.4, 44.1%; Central Africa (CA) 32.6, 33.9%; Eastern Africa (EA) 41.5, 48.7% and Southern Africa (SA) 58.9, 62.7%. Maternal marital profile was not associated with healthcare seeking behaviour for diarrhea and ARI symptoms in any of the sub-regions. Children whose mothers were daughter/daughter-in-law to household head were significantly less likely to be taken to health facility for diarrhea treatment in Eastern Africa (AOR = 0.81, CI: 0.51-0.95). Having a mother who is the head of household was significantly associated with higher odds of facility care for ARI symptoms for children from Western (AOR = 1.20, CI: 1.02-1.43) and Southern Africa (AOR = 1.49, CI: 1.20-1.85). CONCLUSION: The type of relationship between mother of under-fives and head of households affect health seeking behaviour for treatment of diarrhea and ARI symptoms in Eastern, Western and Southern Africa. Countries in these regions need to adapt best practices for promoting healthcare utilisation for children such that household relationship does not constitute barriers.

Does Female Autonomy Affect Contraceptive Use among Women in Northern Nigeria?

Literature identified female empowerment as a predictor of positive health behaviour. However, in the context of conservative and traditional society, this is yet to be explored. This paper explores the role of female autonomy in contraceptive use among currently married women in northern Nigeria. Nationally representative Nigeria Demographic and Health Survey (NDHS, 2013) data for 18,534 currently married women in northern Nigeria was analysed. Complimentary log-logistic regression (cloglog) was used to analyse the data. Current use of modern contraceptive was 6.6% among currently married women in northern Nigeria. Results show that female autonomy was significantly associated with modern contraceptive use. Respondents' education, wealth status and desire for no more children were associated with higher contraceptive use. Despite the conservative and religious context of northern Nigeria, female autonomy significantly predicts modern contraceptive use. Thus, empowering women in northern Nigeria, especially by education, will enable them to participate in healthy contraceptive decision making.

Ethnic heterogeneity in the determinants of HIV/AIDS stigma and discrimination among Nigeria women.

BACKGROUND: Stigma and discrimination remains a barrier to uptake of HIV/AIDS counselling and treatment as well as effective HIV reduction programmes. Despite ethnic diversity of Nigeria, studies on determinants of HIV stigma incorporating the ethnic dimension are very few. This paper provides empirical explanation of the ethnic dimension of determinant of HIV stigma and discrimination in Nigeria. METHODS: Nationally representative data from Nigerian Demographic and Health Survey 2013 (Individual recode) was analysed to explore ethnic differentials and homogeneity in the determinants of HIV/AIDS stigma and discrimination among women in multi-ethnic Nigeria. RESULTS: Result shows that determinants of HIV stigma and discrimination varies by ethnicity in Nigeria. Significant ethnic differentials in HIV/AIDS stigma and discrimination by Secondary school education exist among Hausa and Igbo respectively (OR = 0.79; CI: 1.49-2.28 and OR=1.62; CI: 1.18-2.23, p<0.05). Wealth status significantly influenced HIIV/AIDS stigma and discrimination among Hausa, Igbo and Yoruba ethnic groups (p<0.05). Knowledge of HIV/AIDS was significantly associated with lower odds of discriminating attitudes among the Hausa and Fulani ethnic groups (OR = 0.45; CI: 0.30-0.67 and OR=0.36; CI: 0.16-0.83, p<0.05). CONCLUSIONS: Identifying ethnic differential and homogeneity in predictors of HIV/AIDS stigma is key to reducing HIV/AIDS prevalence in Nigeria and countries with similar settings.

Fertility, Family Size Preference and Contraceptive Use in Sub-Saharan Africa: 1990-2014.

In view of an unusual transition in sub-Saharan Africa (SSA) fertility, periodic re-appraisal is necessary. Using an ecological design, data from Demographic and Health Surveys between 1990 and 2014 were analysed to investigate trends in completed family size (CFS), total fertility rate (TFR), family size preference (FSP), and contraceptive prevalence rate (CPR). The correlates of changes in fertility levels, FSP and CPR were explored. Results showed that CFS declined and was lowest in Southern and Western Africa. However, average CFS for Central African countries appeared virtually the same over the period. Changes in TFR and FSP followed patterns similar to CFS. Western and Central region had very slow increase in CPR with many below 20% as at 2014. Eastern and Southern Africa had faster increase in CPR with some countries achieving almost 60%. Regression results showed that contraceptive prevalence (ß= -1.96, p=0.027) and median age at first marriage (ß= -0.23, p=0.06) were negatively related to TFR while employment (ß= -21.7, p <0.001) was negatively related to FSP. In summary, fertility levels and family size preference declined while contraceptive use improved particularly in Southern and the Eastern Africa. Increased female labour force participation is another potential route to fertility decline in SSA.

The effect of internal migration, individual and contextual characteristics on contraceptive use among Nigerian women.

We investigated the relation of internal migration to contraceptive use and adjusted for individual and contextual (community) characteristics. Multilevel logistic regression models were fitted to nationally representative data of 28,876 women from 884 communities in Nigeria. Only about one out of every 10 women (10.4%) currently used a contraceptive method. Contraceptive prevalence according to the migration status were rural-urban (12.5%), urban-rural (13.8%), rural nonmigrants (6.2%) and urban nonmigrants (17.1%). The relationship between internal migration and contraceptive use was fully explained by individual and community characteristics. Programs aimed at increasing contraceptive prevalence should address contextual challenges alongside socioeconomic factors.

Independent and combined effects of maternal smoking and solid fuel on infant and child mortality in sub-Saharan Africa.

OBJECTIVE: To estimate the independent and combined risks of infant and child mortality associated with maternal smoking and use of solid fuel in sub-Saharan Africa. METHODS: Pooled weighted data on 143 602 under-five children in the most recent demographic and health surveys for 15 sub-Saharan African countries were analysed. The synthetic cohort life table technique and Cox proportional hazard models were employed to investigate the effect of maternal smoking and solid cooking fuel on infant (age 0-11 months) and child (age 12-59 months) mortality. Socio-economic and other confounding variables were included as controls. RESULTS: The distribution of the main explanatory variable in households was as follows: smoking + solid fuel - 4.6%; smoking + non-solid fuel - 0.22%; no smoking + solid fuel - 86.9%; and no smoking + non-solid fuel - 8.2%. The highest infant mortality rate was recorded among children exposed to maternal smoking + solid fuel (72 per 1000 live births); the child mortality rate was estimated to be 54 per 1000 for this group. In full multivariate models, the risk of infant death was 71% higher among those exposed to maternal smoking + solid fuel (HR = 1.71, CI: 1.29-2.28). For ages 12 to 59 months, the risk of death was 99% higher (HR = 1.99, CI: 1.28-3.08). CONCLUSIONS: Combined exposures to cigarette smoke and solid fuel increase the risks of infant and child mortality. Mothers of under-five children need to be educated about the danger of smoking while innovative approaches are needed to reduce the mortality risks associated with solid cooking fuel.

Patterns and determinants of dropout from maternity care continuum in Nigeria.

BACKGROUND: The maternal, newborn and child health care continuum require that mother/child pair should receive the full package of antenatal, intrapartum and postnatal care in order to derive maximum benefits. Continuity of care is a challenge in sub-Saharan Africa. In this study, we investigate the patterns and factors associated with dropout in the continuum of maternity (antenatal, delivery and postnatal) care in Nigeria. METHOD: Using women recode file from the 2013 Nigeria Demographic and Health Survey, we analysed data on 20,467 women with an index birth within 5 years prior to data collection. Background characteristics and pattern of dropouts were summarised using descriptive statistics. The outcome variable was dropout which we explored in three stages: antenatal, antenatal-delivery, delivery-6 weeks postnatal visit. Multilevel logistic regression models were fitted to identify independent predictors of dropout at each stage. Measure of effect was expressed as Odds Ratio (OR) with 95 % confidence interval (CI). RESULTS: Overall, 12,392 (60.6 %) of all women received antenatal care among whom 38.1 % dropout and never got skilled delivery assistance. Of those who received skilled delivery care, 50.8 % did not attend postnatal visit. The predictors of dropout between antenatal care and delivery include problem with getting money for treatment (OR = 1.18, CI: 1.04-1.34), distance to health facility (OR = 1.31, CI: 1.13-1.52), lack of formal education, being in poor wealth quintile (OR = 2.22, CI: 1.85-2.67), residing in rural areas (OR = 1.98, CI: 1.63-2.41). Regional differences between North East, North West and South West were significant. Between delivery and postnatal visit, the same factors were also associated with dropout. CONCLUSION: The rate of dropout from maternity care continuum is high in Nigeria and driven by low or lack of formal education, poverty and healthcare access problems (distance to facility and difficulty with getting money for treatment). Unexpectedly, dropouts are high in South east and South south as well as in the Northern regions. Intervention programs focusing on community outreach about the benefits of continuum of maternal healthcare package should be introduced especially for women in rural areas and lower socio-economic strata.

Review of Sexuality Studies in Africa: Setting a New Post-2015 Research Agenda.

At the nexus between reproductive health, population and development is the subject of sexuality which has generated extensive discourse in the past two decades. In this paper, we review Africa sexuality studies published between 1994 and 2015 with the aim of synthesizing the available evidence and suggesting a new research agenda for post-2015. Review findings showed that previous studies covered the five components of sexuality - practices, partners, pleasure/pressure/pain, procreation and power to different extents. Risky sexual behaviour was prevalent from adolescence till older ages. Literature on pleasure, pain, procreation and power reflect the complex diversity driven by traditional norms, gender roles and attitudes across the continent. Knowledge gaps were highlighted and new agenda suggested for sexuality research.

Household structure, maternal characteristics and childhood mortality in rural sub-Saharan Africa.

INTRODUCTION: The household dynamics of childhood mortality in rural areas of sub-Saharan Africa is less researched despite the fact that mortality rates are almost two times that of urban settings. This study aimed to investigate the influence of household structure on childhood mortality while controlling for household and maternal characteristics in rural sub-Saharan Africa. METHODS: Eight countries with recent demographic and health survey data not earlier than the year 2010 were selected, two from each sub-region of sub-Saharan Africa. The outcome variables were risk of infant and child death while the main independent variables included sex of household head and household structure. Descriptive statistics were generated for all variables. Mortality rates disaggregated by sex of household head and household structure were estimated using the Kaplan-Meier method. Cox proportional hazard regression models were fitted to investigate the relationship between the outcome and explanatory variables in each country. RESULTS: The percentage of children living in female-headed households (FHHs) ranged from 5.2% in Burkina Faso to 49.1% in Namibia while those living in extended family households ranged from 27.4% in Rwanda to 59.9% in Namibia. Multivariate hazard regression showed that, in the majority of the countries, there was no significant relationship between living in FHHs and childhood mortality, but the direction and magnitude of effect varied across countries. A significant negative effect of FHHs on infant mortality was observed in Burkina Faso (HR=1.64, 95% confidence interval (CI): 1.09-2.48) and Zambia (HR=1.49, 95%CI: 1.02-2.17). Likewise, children in extended family households had a higher risk of child mortality in Burkina Faso (HR=1.33, 95%CI: 1.04-1.69) and Zambia (HR=1.59, 95%CI: 1.02-2.49). There was not much difference in the effect of FHHs between infancy (0-11 months) and childhood (12-59 months) in the other countries. The pooled adjusted hazard ratio (HR) showed that the risk of death in childhood was 23% higher in extended family households (HR=1.23, 95%CI: 1.09-1.39) than in nuclear family households. CONCLUSIONS: In rural sub-Saharan Africa, children in FHHs do not have significantly higher infant and child mortality. Also, there was no difference in infant mortality between nuclear and extended family households but the latter constitute a higher risk for child mortality.

Phenotyping Stroke in Sub-Saharan Africa: Stroke Investigative Research and Education Network (SIREN) Phenomics Protocol.

BACKGROUND: As the second leading cause of death and the leading cause of adult-onset disability, stroke is a major public health concern particularly pertinent in Sub-Saharan Africa (SSA), where nearly 80% of all global stroke mortalities occur, and stroke burden is projected to increase in the coming decades. However, traditional and emerging risk factors for stroke in SSA have not been well characterized, thus limiting efforts at curbing its devastating toll. The Stroke Investigative Research and Education Network (SIREN) project is aimed at comprehensively evaluating the key environmental and genomic risk factors for stroke (and its subtypes) in SSA while simultaneously building capacities in phenomics, biobanking, genomics, biostatistics, and bioinformatics for brain research. METHODS: SIREN is a transnational, multicentre, hospital and community-based study involving 3,000 cases and 3,000 controls recruited from 8 sites in Ghana and Nigeria. Cases will be hospital-based patients with first stroke within 10 days of onset in whom neurovascular imaging will be performed. Etiological and topographical stroke subtypes will be documented for all cases. Controls will be hospital- and community-based participants, matched to cases on the basis of gender, ethnicity, and age (±5 years). Information will be collected on known and proposed emerging risk factors for stroke. STUDY SIGNIFICANCE: SIREN is the largest study of stroke in Africa to date. It is anticipated that it will shed light on the phenotypic characteristics and risk factors of stroke and ultimately provide evidence base for strategic interventions to curtail the burgeoning burden of stroke on the sub-continent.

Temporal distribution of baseline characteristics and association with early mortality among HIV-positive patients at University College Hospital, Ibadan, Nigeria.

The first six months of HIV care and treatment are very important for long-term outcome. Early mortality (within 6 months of care initiation) undermines care and treatment goals. This study assessed the temporal distribution in baseline characteristics and early mortality among HIV patients at the University College Hospital, Ibadan, Nigeria from 2006-2013. Factors associated with early mortality were also investigated. This was a retrospective analysis of data from 14 857 patients enrolled for care and treatment at the adult antiretroviral clinic of the University College Hospital, Ibadan, Nigeria. Effects of factors associated with early mortality were summarised using a hazard ratio with a 95% confidence interval obtained from Cox proportional hazard regression models. The mean age of the subjects was 36.4 (SD=10.2) years with females being in the majority (68.1%). While patients' demographic characteristics remained virtually the same over time, there was significant decline in the prevalence of baseline opportunistic infections (2006-2007=55.2%; 2011-2013=38.0%). Overall, 460 (3.1%) patients were known to have died within 6 months of enrollment in care/treatment. There was no significant trend in incidence of early mortality. Factors associated with early mortality include: male sex, HIV encephalopathy, low CD4 count (< 50 cells), and anaemia. To reduce early mortality, community education should be promoted, timely access to care and treatment should be facilitated and the health system further strengthened to care for high risk patients.