Knowledge and attitude to HIV pre exposure prophylaxis among women in five sub-Saharan African countries: a multilevel model analysis of population-based survey 2021-2022.

BACKGROUND: HIV Pre-Exposure Prophylaxis (HIV PrEP) may help reduce the rate of HIV infection among women in sub-Saharan Africa (SSA). This study aimed to assess women's knowledge and attitudes toward PrEP, a crucial component of HIV prevention, using nationwide data. It is the first study of its kind conducted in five SSA countries: Burkina Faso, Ghana, Côte d'Ivoire, Kenya, and Tanzania. The primary objective was to examine women's knowledge and attitudes toward PrEP for the prevention of HIV infection, as well as to explore individual- and community-level factors associated with it. METHODS: The current study utilized the 2021/22 demographic and health survey datasets from five African nations, namely Burkina Faso, Côte d'Ivoire, Ghana, Kenya, and Tanzania. The analysis was performed using Stata 17. A weighted sample of 77,052 women of reproductive age participated in the survey. Univariate and multivariable multilevel logistic regressions were conducted to assess parameters related to knowledge and attitudes toward PrEP in these countries. In both the univariate regression and the final model, the significance of variables was determined using P values of ≤ 0.2 and < 0.05. RESULTS: Overall, only about 13.88 (95% CI: 13.64,14.12) of women had knowledge and attitudes toward HIV PrEP. The highest (34.29%) and lowest (5.61%) values were observed for Kenya and Tanzania respectively. Higher rates of knowledge, and attitude toward HIV PrEP among women were independently associated with age 25-34 years old (AOR = 1.52, 95% CI:1.41,1.64), and 35-49 years old (AOR = 1.56, 95% CI:1.43,1.69), primary education level (AOR = 1.79,95% CI:1.65,1.95), and secondary/higher education level (AOR = 2.92, 95% CI: 2.67,3.20), richer (AOR = 1.14, 95% CI:1.02,1.27), and richest (AOR = 1.21, 95% CI:1.06,1.37), employed women (AOR = 1.82, 95% CI:1.65,1.99), had media exposure (AOR = 1.49,95% CI:1.40,1.59),knowledge of modern contraception (AOR = 2.62, 95% CI: 1.94,3.43), had at least one ANC visit (AOR = 1.99, 95% CI:1.47,2.69), gave birth at health institutions (AOR = 1.17, 95% CI: 1.02,1.37), ever had given birth (AOR = 1.53, 95% CI: 1.41,1.66), female household heads (AOR = 1.24, 95% CI:1.17,1.31), rural women (AOR = 0.83, 95% CI: 0.76,0.89). Similarly, women from communities with high ANC coverage (AOR = 1.84, 95% CI: 1.61,2.11), high community mass media exposure (AOR = 1.62, 95% CI: 1.39,1.88), and high community wealth level (AOR = 1.48, 95% CI: 1.30,1.68), and women from the high illiteracy rate community (AOR = 0.71, 95% CI: 0.61,0.82) showed statistically significant associations with the outcome variable in the final model. CONCLUSIONS: Less than one-seventh of women exhibited knowledge of and positive attitudes toward HIV PrEP. All stakeholders involved in HIV/AIDS prevention and control have recognized the significance of the factors mentioned above. Enhancing maternal health services, such as promoting institutional delivery, contraception, antenatal care (ANC), and women's empowerment, alongside harnessing the power of media and embracing these transformative changes, will contribute to a greater understanding of and more favorable attitudes toward HIV PrEP within the population.

Association between school context and occurrence of multiple sexual partners: cross-sectional study with multilevel analysis. / Associação entre o contexto escolar e a ocorrência de múltiplos parceiros sexuais: um estudo transversal com análise multinível.

The objective was to investigate the association between the school context and the occurrence of multiple partners among adolescents, considering individual variables (age, gender, Bolsa Família, LGB, early sexual initiation and use of alcohol or drugs in the last sex). Cross-sectional study with multilevel analysis carried out in 2018 with adolescent students from Olinda, Brazil. The variable (multiple partners) was collected based on the 'Youth Risk Behavior Survey' questionnaire. School context variables were time in school (regular school vs. full/semi-full school) and the Social Vulnerability Index of the school district. Of 2,500 participants, 1,044 were analyzed for being sexually active and most had two or more partners (63.89%). Regular school students were more likely (OR 1.47, CI 1.10-1.97) to have multiple sexual partners compared to those in full-day schools/half-day schools. However, no association was found in relation to the SVI of the schools' neighborhoods (OR 1.18, IC 0.82-1.70). More time spent at school was associated with fewer chances of multiple sexual partners, while studying in schools located in highly vulnerable neighborhoods was not associated with the occurrence of multiple sexual partners among adolescents.

O estudo investiga a associação entre o contexto escolar e a ocorrência de múltiplos parceiros entre adolescentes, considerando as variáveis individuais. Estudo transversal com análise multinível, realizado no período de fevereiro a junho de 2018 com estudantes de 14 a 19 anos. A variável desfecho (múltiplos parceiros sexuais) foi coletada com base no questionário Youth Risk Behavior Survey (YRBS). As variáveis do contexto escolar foram tempo na escola (escola regular vs escola integral/semi-integral) e índice de vulnerabilidade social (IVS) do bairro onde a escola está localizada. De 2.500 participantes, 1.044 foram analisados por serem sexualmente ativos. A maioria dos adolescentes (63,89%) teve dois ou mais parceiros. Estudantes de escola regular (mínimo de 4h diárias) tiveram mais chances (OR 1.47, IC 1.10-1.97) de terem múltiplos parceiros sexuais quando comparados àqueles de escola integral/semi-integral (mínimo de 7h diárias). Porém, não houve associação em relação ao IVS dos bairros das escolas (OR 1.18, IC 0.82-1.70). Maior tempo na escola esteve associado a menor chance de múltiplos parceiros sexuais, enquanto estudar em escolas localizadas em bairro de alta vulnerabilidade não esteve associado à ocorrência de múltiplos parceiros sexuais entre adolescentes.

Multilevel analysis of determinants in postnatal care utilisation among mother-newborn pairs in India, 2019-21.

Background: Postnatal care (PNC) utilisation within 24 hours of delivery is a critical component of health care services for mothers and newborns. While substantial geographic variations in various health outcomes have been documented in India, there remains a lack of understanding regarding PNC utilisation and underlying factors accounting for these geographic variations. In this study, we aimed to partition and explain the variation in PNC utilisation across multiple geographic levels in India. Methods: Using India's 5th National Family Health Survey (2019-21), we conducted four-level logistic regression analyses to partition the total geographic variation in PNC utilisation by state, district, and cluster levels, and to quantify how much of theses variations are explained by a set of 12 demographic, socioeconomic, and pregnancy-related factors. We also conducted analyses stratified by selected states/union territories. Results: Among 149 622 mother-newborn pairs, 82.29% of mothers and 84.92% of newborns were reported to have received PNC within 24 hours of delivery. In the null model, more than half (56.64%) of the total geographic variation in mother's PNC utilisation was attributed to clusters, followed by 26.06% to states/union territories, and 17.30% to districts. Almost 30% of the between-state variation in mother's PNC utilisation was explained by the demographic, socioeconomic, and pregnancy-related factors (i.e. state level variance reduced from 0.486 (95% confidence interval (CI) = 0.238, 0.735) to 0.320 (95% CI = 0.152, 0.488)). We observed consistent results for newborn's PNC utilisation. State-specific analyses showed substantial geographic variation attributed to clusters across all selected states/union territories. Conclusions: Our findings highlight the consistently large cluster variation in PNC utilisation that remains unexplained by compositional effects. Future studies should explore contextual drivers of cluster variation in PNC utilisation to inform and design interventions aimed to improve maternal and child health.

Incomplete immunization uptake and associated factors among children aged 12-23 months in sub-Saharan African countries; multilevel analysis evidenced from latest demography and health survey data, 2023.

BACKGROUND: In 1974, the World Health Organization (WHO) established the Expanded Program on Immunization to control vaccine-preventable diseases, saving millions of lives annually. However, the coverage of basic vaccines recommended by the WHO in Africa was only 75%, which fell short of the goal of 90% by 2015. To formulate effective policies and implementation programs to reduce incomplete vaccination rates, it is important to conduct a study to determine the factors contributing to incomplete immunization among children aged 12-23 months. METHODS: The study was conducted in 16 sub-Saharan African countries, using data extracted from the latest DHS data. It was a community-based cross-sectional survey that used two-stage stratified probability sampling sample designs. The vaccination coverage was assessed using vaccination cards and mother recalls. Multilevel multivariable logistic regression was used to determine the extent of incomplete immunization and the individual and community-level factors associated with partial immunization among children aged 12-23 months. Variables with a p-value less than 0.05 were considered statistically significant predictors of incomplete immunization. RESULT: A total of 35, 193 weighted samples were used to determine the pooled prevalence of partial immunization. The pooled prevalence of incomplete immunization was 36.06%. In the final model factors significantly associated were: being uneducated mother(AOR:1.75;95%CI:1.48,2.05), being an unemployed mother (AOR:1.16;95%CI:1.09,1.23), no history of family planning utilization (AOR: 1.71; 95% CI: 1.61, 1.84), non-antenatal care (AOR: 1.79; 95% CI: 1.58, 2.04), non-postnatal care (AOR: 1.25; 95%CI: 1.17, 1.35), rural residence(AOR:1.50;95%CI:1.37,1.63), home delivery (AOR: 2.04; 95%CI:1.89, 2.21), having children more than five (AOR: 1.56; 95%CI: 1.13, 2.17), and non-utilization of health insurance (AOR: 1.74; 95%CI: 1.48, 2.05). CONCLUSION: The pooled prevalence of incomplete immunization was found to be high in this investigation. Based on the findings of the study we recommended that policymakers and stakeholders prioritize enhancing prenatal and postnatal care, contraception, and reducing home birth rates to minimize the rate of incomplete immunization.

Recommended homemade fluid utilization for the treatment of diarrhea and associated factors among children under five in sub-Saharan African countries: a multilevel analysis of the recent demographic and health survey.

INTRODUCTION: Diarrhea is a common public health problem and the third leading cause of death in the world among children under the age of five years. An estimated 2 billion cases and 1.9 million deaths are recorded among children under the age of five years every year. It causes body fluid loss and electrolyte imbalance. Even though, early initiation of recommended homemade fluid is a simple and effective approach to prevent diarrhea-related complications and mortality of children, recommended homemade fluid utilization for the treatment of diarrhea is still low in sub-Saharan African countries. Therefore, this study aimed to assess the magnitude of recommended homemade fluid utilization for the treatment of diarrhea and associated factors among children under five in sub-Saharan African countries. METHOD: The most recent Demographic and Health Survey dataset of 21 sub-Saharan African countries from 2015 to 2022 was used for data analysis. A total of 33,341 participants were included in this study as a weighted sample. Associated factors were determined using a multilevel mixed-effects logistic regression model. Significant factors in the multilevel mixed-effect logistic regression model were declared significant at p-values < 0.05. The adjusted odds ratio (AOR) and confidence interval (CI) were used to interpret the results. RESULT: The overall recommended homemade fluid utilization for the treatment of diarrhea among children under five in sub-Saharan African countries was 19.08% (95% CI = 18.66, 19.51), which ranged from 4.34% in Burundi to 72.53% in South Africa. In the multivariable analysis, being an educated mother/caregiver (primary and secondary level) (AOR = 1.15, 95% CI: 1.04, 1.27) and (AOR = 1.30, 95% CI: 1.15, 1.1.47), the primary and secondary level of fathers education (AOR = 1.53, 95% CI: 1.37, 1.71) and (AOR = 1.41, 95% CI: 1.19, 1.1.68), having antenatal care follow-up (AOR = 1.16, 95% CI: 1.01, 1.33), having multiple children (AOR = 1.17, 95% CI: 1.07, 1.28), and being an urban dweller (AOR = 1.15, 95% CI: 1.04, 1.27) were factors associated with recommended homemade fluid utilization. CONCLUSION: The overall recommended homemade fluid utilization for the treatment of diarrhea was low. Individual and community-level variables were associated with recommended homemade fluid utilization for the treatment of diarrhea. Therefore, special consideration should be given to rural dwellers and caregivers who have three and below children. Furthermore, better to strengthen the antenatal care service, mother/caregiver education, and father's education to enhance recommended homemade fluid utilization for the treatment of diarrhea.

Factors influencing optimal diabetes care and clinical outcomes in Thai patients with type 2 diabetes mellitus: a multilevel modelling analysis.

BACKGROUND: Increasing levels of poor glycaemic control among Thai patients with type 2 diabetes mellitus (T2DM) motivated us to compare T2DM care between urban and suburban primary care units (PCUs), to identify gaps in care, and to identify significant factors that may influence strategies to enhance the quality of care and clinical outcomes in this population. METHODS: We conducted a cross-sectional study involving 2160 patients with T2DM treated at four Thai PCUs from 2019 to 2021, comprising one urban and three suburban facilities. Using mixed effects logistic regression, we compared care factors between urban and suburban PCUs. RESULTS: Patients attending suburban PCUs were significantly more likely to undergo eye (adjusted OR (AOR): 1.83, 95% CI 1.35 to 1.72), foot (AOR: 1.61, 95% CI 0.65 to 4.59) and HbA1c (AOR: 1.66, 95% CI 1.09 to 2.30) exams and achieved all ABC (HbA1c, blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C)) goals (AOR: 2.23, 95% CI 1.30 to 3.83). Conversely, those at an urban PCU were more likely to undergo albuminuria exams. Variables significantly associated with good glycaemic control included age (AOR: 1.51, 95% CI 1.31 to 1.79), T2DM duration (AOR: 0.59, 95% CI 0.41 to 0.88), FAACE (foot, HbA1c, albuminuria, LDL-C and eye) goals (AOR: 1.23, 95% CI 1.12 to 1.36) and All8Q (AOR: 1.20, 95% CI 1.05 to 1.41). Chronic kidney disease (CKD) was significantly linked with high triglyceride and HbA1c levels (AOR: 5.23, 95% CI 1.21 to 7.61). Elevated HbA1c levels, longer T2DM duration, insulin use, high systolic BP and high lipid profile levels correlated strongly with diabetic retinopathy (DR) and CKD progression. CONCLUSION: This highlights the necessity for targeted interventions to bridge urban-suburban care gaps, optimise drug prescriptions and implement comprehensive care strategies for improved glycaemic control, DR prevention and CKD progression mitigation among in Thai patients with T2DM. The value of the clinical target aggregate (ABC) and the process of care aggregate (FAACE) was also conclusively demonstrated.

Contextual factors associated with diarrhea among under-five children in the Gambia: a multi-level analysis of population-based data.

BACKGROUND: Diarrhea poses a significant threat to the lives of children in The Gambia, accounting for approximately 9% of all deaths among children under the age of five. Addressing and reducing child mortality from diarrhea diseases is crucial for achieving the Sustainable Development Goal (SDG) 3, specifically target 3.2, which aims to eliminate preventable deaths in newborns and children under the age of five by 2030. Thus, this research aims to assess the prevalence and contextual factors associated with diarrhea among under-five children in The Gambia. METHODS: This research employed secondary data from the 2019/20 Gambia Demographic Health Survey (GDHS). The study initially involved 8,362 women aged between 15 and 49 years. Of these, 6,929 women with children under five were included in this analysis. Data were analyzed using STATA with cross-tabulation and model fitting. Multilevel logistic regression was applied to accommodate the hierarchical structure of the demographic health survey data. The model comparison parameters were BIC, AIC, deviance, and LLR. Variables with a p-value less than 0.05 were selected for multivariable analysis. The statistical significance of the factors was determined using an adjusted odds ratio with a 95% confidence interval (CI) and a p-value of less than 0.05. RESULTS: The prevalence of diarrhea in under-five children was 53.2% in males and 46.8% in females. In the final model, Kerewan (aOR = 0.58; 95% CI = 0.33-0.98) and Basse (aOR = 0.59; 95% CI = 0.35-0.98) have significantly lower odds of childhood diarrhea compared to Banjul, female children show slightly lower, yet significant, odds of diarrhea compared to males (aOR = 0.96; 95% CI = 0.86-0.98), deliveries at government health centers are associated with higher odds of childhood diarrhea compared to home births (aOR = 1.24; 95% CI = 1.01-1.52). Mothers with post-secondary education had significantly lower odds of having children with diarrhea than those without any education (aOR = 0.50; 95% CI = 0.26-0.99) after controlling for confounders. CONCLUSION: The study findings indicate that several factors significantly impact the risk of childhood diarrhea in The Gambia. These factors include region of residence, sex of the child, place of delivery, and education level of the mother. The study suggests that existing interventions aimed at improving child health outcomes in the country should take into consideration these influential factors. Addressing these modifiable factors can enhance the effectiveness of interventions and promote better health outcomes for children in Gambia.

Multilevel analysis on prevalence and associated factors of modern contraceptive uptake in Somaliland: based on The Somaliland Health and Demographic Survey 2020.

INTRODUCTION: Contraception is the deliberate prevention of unwanted pregnancy through various contraceptive methods. Its uptake is low in Sub-Saharan African countries, particularly in east Africa. This might be linked to the high prevalence of unwanted pregnancies and the high fertility rate in the area. Although studies reporting the prevalence and associated factors of modern contraceptive uptake are available in other African countries, no study has been conducted in Somaliland. Therefore, the current study aimed to assess its prevalence and associated factors in Somaliland using Somaliland Health and Demographic Survey (SLHDS) data. METHODS AND MATERIALS: The study used Somaliland Demographic Health Survey (SLDHS) 2020 data. The survey was a national-level survey using a cross-sectional study design. A total of 3656 reproductive-age women were included in the current study. To determine independent predictors of modern contraceptive uptake, a multi-level multivariable logistic regression analysis was done. Random effect analysis, standard error (SE) and intra-cluster correlation (ICC) were computed. RESULTS: The proportion of modern contraceptive uptake among reproductive age groups in Somaliland is 1%. Modern contraceptive uptake is significantly associated with the residence, educational level and wealth index of participants. Women from nomadic communities had lower odds (AOR: 0.25; 95% CI: 0.10, 0.66) of modern contraceptive uptake compared to those from urban areas. Being in the highest wealth quintiles (AOR: 17.22; 95% CI: 1.99, 155.92) and having a tertiary educational level (AOR: 2.11; 95% CI: 1.29, 9.11) had higher odds of using the modern contractive method compared to those with the lowest wealth quintiles and non-formal education, respectively. CONCLUSION: The prevalence of modern contraceptive uptake in Somaliland was very low. It is associated with the level of education, wealth index and residence of the women.

Determinants of early initiation of breastfeeding following birth in West Africa: A multilevel analysis using data from multi-country national health surveys.

BACKGROUND: Early initiation of breastfeeding (EIBF), within the first hour of birth, is crucial for promoting exclusive breastfeeding and establishing optimal nursing practices. However, global EIBF rates remain low, with even lower rates observed in Africa. Despite existing research gaps, this study aims to determine the prevalence of EIBF and identify maternal and child-related factors associated with its practice in West Africa. METHODS: This study utilized West African Demographic and Health Survey (DHS) data from 13 countries, including 146,964 children's records. To assess model fit, likelihood test and deviance were used. Similarly, intraclass correlation coefficient, median odds ratio, and proportional change in variance were employed for random effect. A multilevel logistic regression model was used to identify individual- and community-level factors influencing EIBF due to the hierarchical nature of the data. Variables with p-values ≤0.2 in the binary model and <0.05 in the final analysis were considered significantly associated with EIBF. RESULTS: The pooled prevalence of EIBF in West African nations was 50.60% (95% CI; 50.34-50.85%). The highest prevalence rate was observed in Serra Leone (75.33%) and the lowest prevalence was found in Senegal (33.94%). In the multilevel multiple logistic regression model, maternal education (AOR = 1.10, 95% CI, 1.03,1.16), marital status AOR = 1.07, 95% CI, 1.01,1.13), birth weight (AOR = 0.91, CI 0.86,0.96), birth orders (AOR = 1.09, CI 1.03,1.16), and (AOR = 1.11, CI 1.03,1.19), place of residence (AOR = 1.14, CI 1.07,1.21), and mode of delivery type (AOR = 0.26, CI 0.24,0.29) were significantly correlated with EIBF in West Africa. CONCLUSIONS: The incidence of EIBF in West Africa was found to be low. The study emphasizes the need for targeted behavioral change communication programs to address timely breastfeeding initiation, specifically targeting mothers and child characteristics. Factors such as education, delivery mode, marital status, birth weight, birth order, and place of residence were significantly associated with EIBF. Special attention should be given to improving EIBF rates among women undergoing caesarean sections, infants with low birth weight, and primiparous mothers, along with structural improvements in the healthcare sector in West Africa.

Clarifications on the intersectional MAIHDA approach: A conceptual guide and response to Wilkes and Karimi (2024).

Intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) has been welcomed as a new gold standard for quantitative evaluation of intersectional inequalities, and it is being rapidly adopted across the health and social sciences. In their commentary "What does the MAIHDA method explain?", Wilkes and Karimi (2024) raise methodological concerns with this approach, leading them to advocate for the continued use of conventional single-level linear regression models with fixed-effects interaction parameters for quantitative intersectional analysis. In this response, we systematically address these concerns, and ultimately find them to be unfounded, arising from a series of subtle but important misunderstandings of the MAIHDA approach and literature. Since readers new to MAIHDA may share confusion on these points, we take this opportunity to provide clarifications. Our response is organized around four important clarifications: (1) At what level are the additive main effect variables defined in intersectional MAIHDA models? (2) Do MAIHDA models have problems with collinearity? (3) Why does the Variance Partitioning Coefficient (VPC) tend to be small, and the Proportional Change in Variance (PCV) tend to be large in MAIHDA? and (4) What are the goals of MAIHDA analysis?

Multilevel analysis of dropout from maternal continuum of care and its associated factors: Evidence from 2022 Tanzania Demographic and Health Survey.

BACKGROUND: The maternal continuum of care (CoC) is a cost-effective approach to mitigate preventable maternal and neonatal deaths. Women in developing countries, including Tanzania, face an increased vulnerability to significant dropout rates from maternal CoC, and addressing dropout from the continuum remains a persistent public health challenge. METHOD: This study used the 2022 Tanzania Demographic and Health Survey (TDHS). A total weighted sample of 5,172 women who gave birth in the past 5 years and had first antenatal care (ANC) were included in this study. Multilevel binary logistic regression analyses were used to examine factors associated with dropout from the 3 components of maternal CoC (i.e., ANC, institutional delivery, and postnatal care (PNC)). RESULTS: The vast majority, 83.86% (95% confidence interval (CI): 82.83%, 84.83%), of women reported dropout from the maternal CoC. The odds of dropout from the CoC was 36% (AOR = 0.64, (95% CI: 0.41, 0.98)) lower among married women compared to their divorced counterparts. Women who belonged to the richer wealth index reported a 39% (AOR = 0.61, (95% CI: 0.39, 0.95)) reduction in the odds of dropout, while those belonged to the richest wealth index demonstrated a 49% (AOR = 0.51, (95% CI: 0.31, 0.82)) reduction. The odds of dropout from CoC was 37% (AOR = 0.63, (95% CI: 0.45,0.87)) lower among women who reported the use of internet in the past 12 months compared to those who had no prior exposure to the internet. Geographical location emerged as a significant factor, with women residing in the Northern region and Southern Highland Zone, respectively, experiencing a 44% (AOR = 0.56, 95% CI: 0.35-0.89) and 58% (AOR = 0.42, 95% CI: 0.26-0.68) lower odds of dropout compared to their counterparts in the central zone. CONCLUSION: The dropout rate from the maternity CoC in Tanzania was high. The findings contribute to our understanding of the complex dynamics surrounding maternity care continuity and underscore the need for targeted interventions, considering factors such as marital status, socioeconomic status, internet usage, and geographical location.

Prompt treatment of fever and its associated factors among under-five children in sub-Saharan Africa: A multilevel analysis of evidence from 36 countries.

INTRODUCTION: Despite the decrease in the global under-five mortality rate, the highest rates of mortality are reported in sub-Saharan Africa. More than one-third of all deaths among under-five children are either from lower respiratory tract infections, diarrhea, or malaria. Poor treatment-seeking behavior for fever among mothers of under-five children is a big concern in sub-Saharan Africa. However, the pooled prevalence of prompt treatment of fever and its associated factors among under-five children in the region using nationally representative data is not known. Therefore, the findings of this study will inform policymakers and program managers who work on child health to design interventions to improve the timely and appropriate treatment of fever among under-five children. METHODS: Data from the recent demographic and health surveys of 36 countries in sub-Saharan Africa conducted between 2006 and 2022 were used. A total weighted sample of 71,503 living children aged under five years with a fever was included in the study. Data extracted from DHS data sets were cleaned, recorded, and analyzed using STATA/SE version 14.0 statistical software. Multilevel mixed-effects logistic regression was used to determine the factors associated with the outcome variable. Intra-class correlation coefficient, likelihood ratio test, median odds ratio, and deviance (-2LLR) values were used for model comparison and fitness. Finally, variables with a p-value <0.05 and an adjusted odds ratio with a 95% confidence interval were declared statistically significant. RESULTS: The pooled prevalence of prompt treatment of fever among under-five children in sub-Saharan African countries was 26.11% (95% CI: 25.79%, 26.44%). Factors like maternal education [AOR = 1.18; 95% CI (1.13, 1.25)], maternal working status [AOR = 1.34; 95% CI (1.27, 1.41)], media exposure [AOR = 1.05; 95% CI (1.01, 1.10)], household wealth index [AOR = 1.13; 95% CI (1.06, 1.19)], distance to a health facility [AOR = 1.18; 95% CI (1.13, 1.23)], healthcare decisions [AOR = 1.34; 95% CI (1.01, 1.77)], visited healthcare facility last 12 months [AOR = 1.45; 95% CI (1.38, 1.52)], antenatal care attendance [AOR = 1.79; 95% CI (1.61, 1.99)], place of delivery [AOR = 1.55; 95% CI (1.47, 1.63)], and community-level antenatal care utilization [AOR = 1.08; 95% CI (1.02,1.14)] were significantly associated with prompt treatment of fever among under-five children. CONCLUSION: The pooled prevalence of prompt treatment of fever among under-five children in sub-Saharan African countries was low. Educated women, working mothers, having media exposure, rich household wealth status, perceiving distance to a health facility was not a big problem, making healthcare decisions with husband or partner, visiting healthcare facility in the last 12 months, antenatal care attendance, health facility delivery, and high community-level antenatal care utilization increase the odds of prompt treatment of fever. Therefore, women's empowerment, information dissemination through mass media, maintaining regular visits to healthcare facilities, and strengthening health facility delivery and antenatal care services are strongly recommended.

Individual and community level determinants of delayed antenatal care initiation in Ethiopia: A multilevel analysis of the 2019 Ethiopian Mini Demographic Health Survey.

BACKGROUND: Antenatal care (ANC) is essential health care and medical support provided to pregnant women, with the aim of promoting optimal health for both the mother and the developing baby. Pregnant women should initiate ANC within the first trimester of pregnancy to access a wide range of crucial services. Early initiation of ANC significantly reduces adverse pregnancy outcomes, yet many women in Sub-Saharan Africa delay its initiation. The aim of this study was to assess prevalence and determinants of delayed ANC initiation in Ethiopia. METHODS: We conducted a secondary data analysis of the 2019 Ethiopian Mini Demographic and Health Survey (EMDHS). The study involved women of reproductive age who had given birth within the five years prior to the survey and had attended ANC for their most recent child. A total weighted sample of 2,895 pregnant women were included in the analysis. Due to the hierarchical nature of the data, we employed a multi-level logistic regression model to examine both individual and community level factors associated with delayed ANC initiation. The findings of the regressions were presented with odds ratios (OR), 95% confidence intervals (CI), and p-values. All the statistical analysis were performed using STATA-14 software. RESULTS: This study showed that 62.3% (95% CI: 60.5, 64.1) of pregnant women in Ethiopia delayed ANC initiation. Participants, on average, began their ANC at 4 months gestational age. Women with no education (AOR = 2.1; 95% CI: 1.4, 3.0), poorest wealth status (AOR = 1.9; 95% CI: 1.3, 2.8), from the Southern Nations, Nationalities, and Peoples (SNNP) region (AOR = 2.1; 95% CI: 1.3, 3.3), and those who gave birth at home (AOR = 1.4; 95% CI: 1.1, 1.7) were more likely to delay ANC initiation. CONCLUSIONS: The prevalence of delayed ANC initiation in Ethiopia was high. Enhancing mothers' education, empowering them through economic initiatives, improving their health-seeking behavior towards facility delivery, and universally reinforcing standardized ANC, along with collaborating with the existing local community structure to disseminate health information, are recommended measures to reduce delayed ANC initiation.

Individual and community level factors associated with modern contraceptive utilization among women in Ethiopia: Multilevel modeling analysis.

BACKGROUND: Modern contraceptive utilization is the most effective intervention to tackle unintended pregnancy and thereby reduce abortion and improve maternal, child, and newborn health. However, multilevel factors related to low modern contraceptive utilization and the robust analysis required for decision-making were scarce in Ethiopia. OBJECTIVE: To investigate the individual and community-level predictors of modern contraceptive utilization among reproductive-age women in Ethiopia. METHODS: We utilized data from a cross-sectional 2019 Performance Monitoring for Action Ethiopia survey. The survey employed a stratified two-stage cluster sampling method to select households for inclusion. In Stata version 16.0, the data underwent cleaning, aggregation, and survey weighting, following which a descriptive analysis was performed utilizing the "svy" command. Subsequently, the primary analysis was executed using R software version 4.1.3. We fitted a two-level mixed effects logistic regression model on 6,117 reproductive-age women nested within 265 enumeration areas (clusters). The fixed effect models were fitted. The measures of variation were explained by intra-cluster correlation, median odds ratio, and proportional change in variance. The shrinkage factor was calculated to estimate the effects of cluster variables using the Interval odds ratio and proportion opposed odds ratio. Finally, the independent variables with a significance level of (P<0.05) and their corresponding Adjusted Odds ratios and 95% confidence intervals were described for the explanatory factors in the final model. RESULTS: In Ethiopia, the prevalence of modern contraceptive utilization was only 37.% (34.3 to 39.8). Women who attained primary, secondary, and above secondary levels of education were more likely to report modern contraceptive utilization with AOR of 1.47, 1.73, and 1.58, respectively. Divorced/widowed women were less likely to report modern contraceptive utilization (AOR:0.18, 95% CI 0.13,0.23) compared to never-married women. Discussions between women and healthcare providers at the health facility about family planning were positively associated with modern contraceptive utilization (AOR:1.84, 95% CI: 1.52, 2.23). Community-level factors have a significant influence on modern contraceptive utilization, which is attributed to 21.9% of the total variance in the odds of using modern contraceptives (ICC = 0.219). Clusters with a higher proportion of agrarian (AOR: 2.27, 95% CI 1.5, 3.44), clusters with higher literacy (AOR: 1.46, 95% CI 1.09, 1.94), clusters with empowered women and girls about FP (AOR: 1.47, 95% CI 1.11, 1.93) and clusters with high supportive attitudes and norms toward FP (AOR: 1.37, 95% CI 1.04, 1.81) had better modern contraceptive utilization than their counterparts. CONCLUSION: In Ethiopia, understanding the factors related to modern contraceptive use among women of reproductive age requires consideration of both individual and community characteristics. Hence, to enhance family planning intervention programs, it is essential to focus on the empowerment of women and girls, foster supportive attitudes towards family planning within communities, collaborate with education authorities to enhance overall community literacy, pay special attention to pastoralist communities, and ensure that reproductive-age women as a whole are targeted rather than solely focusing on married women.

Geographical variation in hotspots of stunting among under-five children in Ethiopia: A geographically weighted regression and multilevel robust Poisson regression analysis.

INTRODUCTION: Childhood stunting is a global public health concern, associated with both short and long-term consequences, including high child morbidity and mortality, poor development and learning capacity, increased vulnerability for infectious and non-infectious disease. The prevalence of stunting varies significantly throughout Ethiopian regions. Therefore, this study aimed to assess the geographical variation in predictors of stunting among children under the age of five in Ethiopia using 2019 Ethiopian Demographic and Health Survey. METHOD: The current analysis was based on data from the 2019 mini Ethiopian Demographic and Health Survey (EDHS). A total of 5,490 children under the age of five were included in the weighted sample. Descriptive and inferential analysis was done using STATA 17. For the spatial analysis, ArcGIS 10.7 were used. Spatial regression was used to identify the variables associated with stunting hotspots, and adjusted R2 and Corrected Akaike Information Criteria (AICc) were used to compare the models. As the prevalence of stunting was over 10%, a multilevel robust Poisson regression was conducted. In the bivariable analysis, variables having a p-value < 0.2 were considered for the multivariable analysis. In the multivariable multilevel robust Poisson regression analysis, the adjusted prevalence ratio with the 95% confidence interval is presented to show the statistical significance and strength of the association. RESULT: The prevalence of stunting was 33.58% (95%CI: 32.34%, 34.84%) with a clustered geographic pattern (Moran's I = 0.40, p<0.001). significant hotspot areas of stunting were identified in the west and south Afar, Tigray, Amhara and east SNNPR regions. In the local model, no maternal education, poverty, child age 6-23 months and male headed household were predictors associated with spatial variation of stunting among under five children in Ethiopia. In the multivariable multilevel robust Poisson regression the prevalence of stunting among children whose mother's age is >40 (APR = 0.74, 95%CI: 0.55, 0.99). Children whose mother had secondary (APR = 0.74, 95%CI: 0.60, 0.91) and higher (APR = 0.61, 95%CI: 0.44, 0.84) educational status, household wealth status (APR = 0.87, 95%CI: 0.76, 0.99), child aged 6-23 months (APR = 1.87, 95%CI: 1.53, 2.28) were all significantly associated with stunting. CONCLUSION: In Ethiopia, under-five children suffering from stunting have been found to exhibit a spatially clustered pattern. Maternal education, wealth index, birth interval and child age were determining factors of spatial variation of stunting. As a result, a detailed map of stunting hotspots and determinants among children under the age of five aid program planners and decision-makers in designing targeted public health measures.

Time to first birth and its predictors among reproductive-age women in Ethiopia: multilevel analysis using shared frailty model.

OBJECTIVE: To determine the time to first birth and its predictors among reproductive-age women in Ethiopia. DESIGN, SETTING AND PARTICIPANTS: Nationwide secondary data analysis using mini Ethiopian Demographic and Health Survey, 2019. A stratified, two-stage cluster sampling technique was used to select the sample. Among 9012 women of age 15-49 years, 8885 completed the interview yielding a response rate of 99%. MAIN OUTCOMES MEASURED: Time to first birth was determined. Kaplan-Meier method was used to estimate the time to first birth. The lognormal inverse Gaussian shared frailty model was used to model the data at a 95% CI. CI and adjusted time ratio (ATR) were reported as effect size. Statistical significance was declared at p-value<0.05. RESULTS: The overall median time to give first birth was 18 years (IQR: 15, 21). Age 20-29 (ATR=1.08; 95% CI, 1.05 to 1.12), Age>29 years (ATR=1.08; 95% CI, 1.05 to 1.11), northern regions (ATR=1.06; 95% CI, 1.03 to 1.08), rural residence (ATR=0.95; 95% CI, 0.93 to 0.98), never using contraceptive methods (ATR=0.98; 95% CI, 0.96 to 0.99), sex of household head (ATR=1.01; 95% CI, 1 to 1.03), poorest wealth index (ATR=1.04; 95% CI, 1.02 to 1.06) and richest wealth index (ATR=1.07; 95% CI, 1.04 to 1.1) were the significant predictors of time to first birth among reproductive-age women. CONCLUSION: In Ethiopia, women often gave birth to their first child at a younger age than what is recommended. Explicitly, women aged 20-29 and over 29, living in the northern region, leading a household as females, and belonging to the poorest or wealthiest wealth index tended to have a slightly delayed first childbirth. On the other hand, women in rural areas and those who had never used contraception were more likely to have an early first birth. The findings indicated the necessity of implementing targeted measures for rural Ethiopian women, especially those lacking knowledge about contraception.

Determinants of household decision making autonomy among rural married women based on Ethiopian demography health survey: a multilevel analysis.

INTRODUCTION: Decisions made at the household level have great impact on the welfare of the individual, the local community, as well as the welfare of the nation. Women's independent decision on reproductive health increases women's access to health information and utilization of reproductive services. This has great impact on maternal and child health outcomes. However, women in developing or low-income countries often have limited autonomy and control over their household decisions. Therefore the main purpose of this research project is to investigate the potential determinants of rural women's household decision making autonomy. METHODS: A multi level analysis was performed using the fourth Ethiopian Demographic and Health Survey (EDHS) 2016 data set. A weighted sample of 8,565 married rural women was included in the final analysis. Women were considered to be autonomous if they made decisions alone or jointly with their husband in all three household decision components. It was dichotomized as yes = 1 and no = 0. Multico linearity and chi-square tests were checked and variables which did not fulfill the assumptions were excluded from the analysis. Four models were fitted. Variables with p-value ≤ 0.25 in the bi-variable multilevel logistic regression were included in the multivariable multilevel logistic regression. The Adjusted Odds Ratio (AOR) with a 95% confidence interval (95% CI) was computed. Variables with a P-value of less than 0.05 in the multi-variable multilevel logistic regression were declared as statistically significant predictors. RESULT: A total of 8,565 weighted participants involved. From the total respondents, 68.55% (CI: 67.5%, 69.5%) of women had decision making autonomy. wealth index (poor: AOR: 0.84; 95% CI: 0.72, 0.97 and middle: AOR: 0.85; 95% CI 0.73, 0.98), literacy (illiterate: AOR: 0.75; 95% CI: 0.66, 0.86), respondents working status (Not working; AOR 0.68; 95% CI; 0.60, 0.76) ,who decides on marriage (parents: AOR 0.76; 95% CI; 0.67, 0.87), and proportion of early marriage in the community (high proportion of early marriage AOR: 1.35; 95% CI; 1.10, 1.72). CONCLUSION: Women decision making autonomy was significantly determined by women economic participation (their wealth and their working status), women's literacy, proportion of early marriage in the community and women's involvement in decision of their marriage. Improving women's economic participation and enhancing women's participation to decide on their marriage will enhance women's decision making autonomy.

Multilevel analysis of COVID-19 vaccination intention: the moderating role of economic and cultural country characteristics.

BACKGROUND: Predictors of COVID-19 (coronavirus) vaccination have been extensively researched; however, the contextual factors contributing to understanding vaccination intention remain largely unexplored. The present study aimed to investigate the moderating role of economic development (Gross domestic product - GDP per capita), economic inequality (Gini index), the perceived corruption index and Hofstede's measurements of cultural values-index of individualism/collectivism and power distance index-in the relationship between determinants of satisfaction with the healthcare system, trust in political institutions, conspiracy beliefs and COVID-19 vaccination intention. METHODS: A multilevel modelling approach was employed on a sample of approximately 51 000 individuals nested within 26 countries. Data were drawn from the European Social Survey Round 10. The model examined the effect of individual- and country-level predictors and their interaction on vaccination intention. RESULTS: Satisfaction with the healthcare system had a stronger positive effect on intention to get vaccinated in countries with lower perceived corruption and more individualistic countries. Trust in political institutions had a stronger positive effect on vaccination intention in countries with higher economic development and lower perceived corruption, while a negative effect of conspiracy beliefs on vaccination intention was stronger in countries with lower economic development, higher perceived corruption and a more collectivistic cultural orientation. CONCLUSION: Our findings highlight the importance of considering individual and contextual factors when addressing vaccination intention.

Predictors of maternal health services uptake in West African region: a multilevel multinomial regression analysis of demographic health survey reports.

BACKGROUND: Pursuant to studies, receiving the three key maternal health services (Antenatal Care, Skilled Delivery Service, and Postnatal Care) in a continuum could prevent 71% of global maternal deaths. Despite the Western African region being known for its high maternal death and poor access to maternal health services, there is a dearth of studies that delve into the spectrum of maternal health services uptake. Hence, this study aimed to assess the level and predictors of partial and adequate utilization of health services in a single analytical model using the most recent Demographic and Health Survey (DHS) data (2013-2021). METHODS: This study was based on the appended women's (IR) file of twelve West African countries. STATA software version 16 was used to analyze a weighted sample of 89,504 women aged 15-49 years. A composite index of maternal health service utilization has been created by combining three key health services and categorizing them into 'no', 'partial', or 'adequate' use. A multilevel multivariable multinomial logistic regression analysis was carried out to examine the effects of each predictor on the level of service utilization. The degree of association was reported using the adjusted relative risk ratio (aRRR) with a corresponding 95% confidence interval, and statistical significance was declared at p < 0.05. RESULTS: 66.4% (95% CI: 64.9, 67.7) and 23.8% (95% CI: 23.3, 24.2) of women used maternal health services partially and adequately, respectively. Togo has the highest proportion of women getting adequate health care in the region, at 56.7%, while Nigeria has the lowest proportion, at 11%. Maternal education, residence, wealth index, parity, media exposure (to radio and television), enrolment in health insurance schemes, attitude towards wife beating, and autonomy in decision-making were identified as significant predictors of partial and adequate maternal health service uptake. CONCLUSION: The uptake of adequate maternal health services in the region was found to be low. Stakeholders should plan for and implement interventions that increase women's autonomy. Program planners and healthcare providers should give due emphasis to those women with no formal education and from low-income families. The government and the private sectors need to collaborate to improve media access and increase public enrolment in health insurance schemes.

Predictors of late initiation of breastfeeding practice in Ethiopia: a multilevel mixed-effects analysis of recent evidence from EDHS 2019.

OBJECTIVES: To identify the predictors of late initiation of breastfeeding practice in Ethiopia. DESIGN: Cross-sectional study design. SETTING: Ethiopia. PARTICIPANTS: A total of 1982 weighted samples of mothers with children aged under 24 months were included. OUTCOME MEASURE: Late initiation of breastfeeding practice. RESULTS: The prevalence of late breastfeeding initiation practice is 26.4% (95 CI 24.4 to 28.3). Being a young mother (15-24 years) (adjusted odds ratio (AOR) =1.66; 95 CI 1.06 to 2.62), no antenatal care (ANC) visit (AOR=1.45; 95 CI 1.04 to 2.02), caesarean section (AOR=4.79; 95 CI 3.19 to 7.21) and home delivery (AOR=1.53; 95 CI 1.14 to 2.06) were found to be the determinants of late initiation of breast feeding. CONCLUSION: More than one-fourth of newborn children do not start breast feeding within the WHO-recommended time (first hour). Programmes should focus on promoting the health facility birth and increasing the ANC visits. Further emphasis should be placed on young mothers and those who deliver via caesarean section to improve the timely initiation of breast feeding.