Black Americans' Diminished Return of Educational Attainment on Tobacco Use in Baltimore City.

BACKGROUND: Socioeconomic status (SES) indicators such as educational attainment are fundamental factors affecting health. One mechanism through which education affects health is by reducing the likelihood of engaging in high-risk behaviors such as smoking. However, according to the marginalization-related diminished returns (MDRs) theory, the association between education and health may be weaker for marginalized populations such as Black than White, primarily due to racism and discrimination. However, little is known about the racial variations in the differential associations between educational attainment and tobacco use in a local setting. AIM: This study aimed to investigate the differential association between educational attainment and tobacco use among racial groups in a community sample in Baltimore City. METHODS: This cross-sectional study used data from a community survey conducted in 2012-2013 in Baltimore City among adults aged 18 years or older. The participants were 3501 adults. Univariate, bivariate, and logistic regression analyses were performed using Stata to investigate the racial difference in the association between education and two outcomes: current smoking status and menthol tobacco product use. RESULTS: The study found that adults with a graduate degree were less likely to be current smokers (adjusted odds ratio [AOR]: 0.10, 95% confidence interval [CI]: 0.08-0.13) and menthol tobacco users (AOR: 0.10, 95% CI: 0.07-0.14) compared to those with less than high school diploma. The inverse associations between educational attainment and current smoking (AOR: 1.83, 95% CI: 1.05-3.21) and menthol tobacco product use (AOR: 4.73, 95% CI: 2.07-10.80) were weaker for Back individuals than those who were White. CONCLUSION: Due to MDRs of educational attainment, while highly educated White adults show a low risk of tobacco use, educated Black adults remain at a disproportionately increased risk. The study emphasizes the need for better policies and programs that address minorities' diminished return of education for tobacco use.

Association of Soluble Markers of Inflammation With Peri-coronary Artery Inflammation in People With and Without HIV Infection and Without Cardiovascular Disease.

Background: Inflammation is linked to elevated cardiovascular disease (CVD) risk in people with HIV (PWH) on antiretroviral therapy (ART). Fat attenuation index (FAI) is a measure of peri-coronary inflammation that independently predicts CVD risk in HIV-uninfected persons. Whether FAI is associated with soluble inflammatory markers is unknown. Methods: Plasma levels of inflammatory markers were measured in 58 PWH and 16 controls without current symptoms or prior known CVD who underwent coronary computed tomography angiography and had FAI measurements. A cross-sectional analysis was performed, and associations of markers with FAI values of the right coronary artery (RCA) and left anterior descending artery (LAD) were assessed using multivariable regression models adjusted for the potential confounders age, sex, race, low-density lipoprotein cholesterol, body mass index, and use of lipid-lowering medication. Results: Several inflammatory markers had significant associations with RCA or LAD FAI in adjusted models, including sCD14, sCD163, TNFR-I, and TNFR-II, CCL5, CX3CL1, IP-10. Conclusions: The associations between indices of systemic and peri-coronary inflammation are novel and suggest that these systemic markers and FAI together are promising noninvasive biomarkers that can be applied to assess asymptomatic CVD in people with and without HIV; they also may be useful tools to evaluate effects of anti-inflammatory interventions.

Mental Health History and DECIDE (Decision-Making Education for Choices in Diabetes Everyday) Diabetes Support Program Outcomes Among African Americans With Type 2 Diabetes.

PURPOSE: The purpose of this study was to determine behavioral and clinical outcomes of the DECIDE (Decision-Making Education for Choices in Diabetes Everyday) diabetes support program trial participants with and without a mental health (MH) history by treatment arm. METHODS: A secondary analysis was conducted of data from the DECIDE trial sample of urban African American adults with type 2 diabetes (T2DM; N = 137) who received the DECIDE diabetes support program in 1 of 3 delivery formats: self-study (n = 46), individual (n = 45), and group (n = 46). Positive screen on the Patient Health Questionnaire-2 and/or reported MH diagnosis were coded as MH history. Self-management, knowledge, problem-solving, and A1C data at baseline and 1 week and 6 months postintervention were analyzed for participants with and without MH history. RESULTS: Prevalence of MH history was 37% in the sample. Among those with no MH history, knowledge and problem-solving improved at 6 months postintervention in all intervention arms. For those with MH history, knowledge and problem-solving improved in the self-study and individual arms but not in the group arm. Clinically but not statistically significant changes in A1C were observed at 6 months. CONCLUSIONS: In an urban minority T2DM sample, those with an MH history benefited from the intervention, but delivery format mattered, with robust improvements when participants with an MH history received self-directed or one-on-one formats rather than group.

Predictors of same-admission cholecystectomy in mild, acute, biliary pancreatitis.

BACKGROUND: Failure to perform same-admission cholecystectomy (SA-CCY) for mild, acute, biliary pancreatitis (MABP) is a recognized risk factor for recurrence and readmission. However, rates of SA-CCY are low and factors associated with these low rates require elucidation. METHODS: Primary MAPB admissions were pooled from NIS 2000-2014 (weighted n = 578 258). Patients with chronic pancreatitis, pancreatic masses, alcohol-related disorders, hypertriglyceridemia, acute cholecystitis and AP-related organ dysfunction or complications were excluded. Annual rates of SA-CCY were calculated. Regression model for prediction of SA-CCY was built on 2010-2011 subset (weighted n = 74 169), yielding 96.3% of complete observations. RESULTS: Nationwide rate of SA-CCY in the U.S. was 40.8%. In multivariate analysis, SA-CCY was positively associated with BMI>30 (OR = 1.4, 95%CI 1.2-1.6), Asian ethnicity (vs. Black; OR = 1.2, 95%CI 1.0-1.5), private insurance (vs. Medicare; OR = 1.1, 95%CI 1.0-1.3), large (vs. small; OR = 1.3, 95%CI 1.2-1.4) urban hospitals (vs. rural; OR = 1.5 95%CI 1.3-1.7) of the South (vs. Northeast; OR = 1.5, 95%CI 1.3-1.7), as well as with chronic cholecystitis (OR = 17.0, 95%CI 15.4-18.7) and abdominal-wall hernias (OR = 5.2; 95%CI 3.0-8.9); the latter two predictors were not included in the final model. SA-CCY was negatively associated with age >40 (OR = 0.72; 95%CI 0.66-0.79), male gender (OR = 0.86, 95%CI 0.80-0.93), dementia (OR = 0.88, 95%CI 0.72-1.1), chronic comorbidities (OR = 0.64; 95%CI 0.54-0.77) and ostomies (OR = 0.51; 95%CI 0.31-0.86). CONCLUSION: Adherence to SA-CCY guidelines for MABP remains inadequate. Independent geographic variation in SA-CCY rates may be related to reimbursement differences, ownership of AP patients, accessibility to surgical care, or cultural characteristics of the patient population.

Trouble Sleeping and Depression Among US Women Aged 20 to 30 Years.

INTRODUCTION: Depression in women is common, and 1 woman in 4 is likely to have an episode of major depression at some point in her life. Sleep disturbances, which are significantly associated with depression, are increasingly recognized as a determinant of women's health and well-being. Although studies have examined the association between depression and sleep disorders, little research has explored this association among young women. Our study investigated the relationship between sleep problems and depression among women aged 20 to 30. METHODS: We used data on 1,747 women from the US National Health and Nutrition Examination Survey (NHANES) 2009-2016. In addition to univariate and bivariate analysis, we used unadjusted and adjusted logistic regression models to estimate depression in the previous 2 weeks among women who reported ever having trouble sleeping. RESULTS: Of 1,747 study participants, 19.6% reported trouble sleeping and 9.3% reported symptoms of depression. Weighted logistic regression results showed that women who had trouble sleeping were more than 4 times (odds ratio, 4.36; 95% confidence interval, 3.06-6.21; P < .001) more likely than women who did not have trouble sleeping to have had depression in the previous 2 weeks. The results were similar (adjusted odds ratio, 4.11; 95% confidence interval, 2.78-6.06; P < .001) after adjusting for other covariates. CONCLUSION: We found a significant relationship between trouble sleeping and depression among US women aged 20 to 30. Findings suggest the need for regular screening and treatment of sleep disturbances among young women, which may improve their psychological health and reduce depression.

Association between number of sexual partners and utilization of family planning and sexually transmitted infection services by men aged 15-44 in the United States.

Unintended pregnancy and sexually transmitted infections (STIs) pose a huge public health problem in the United States. Efforts towards reducing unintended pregnancies have previously focused on women, but the role of men in family planning and preventing unwanted pregnancy is becoming clearer. The primary objective of the study was to fully examine the utilization of family planning services by men in the US, and to determine whether factors such as race, health insurance type and number of sexual partners influenced their utilization and receipt of family planning services and STI-related health services. Data were from the 2006-2010 National Survey on Family Growth (NSFG) study conducted in the US. The study sample comprised 7686 men aged 14-44 who ever had sex with women, and who had had at least one sexual partner in the 12 months before the survey. The receipt of family planning and STI-related health services by this group of men was estimated. The results showed that non-Hispanic Black men were more likely to receive family planning and STI-related services than Hispanic and non-Hispanic White males. Given that non-Hispanic Black men are disproportionately affected by STIs and are a high-risk group, the finding that this group received more family planning and STI services is a positive step towards reducing the disproportionately high prevalence of STIs in men in this under-privileged population.

Examining the Health Belief Model Risk Factors on PrEP Use Among African-American Women Ages 20-44.

Truvada, also referred to as Pre-Exposure Prophylaxis (PrEP), is the first medication approved for the purpose of preventing HIV infection. This study examined the odds of PrEP use solely among African-American women by comparing, by demographic profile, the relationship between risk taking behaviors of the Health Belief Model and the likelihood of PrEP use. A secondary data analysis from the 2013 National Survey on the potential adoption of PrEP was analyzed in this study. The sample for this study was 791 African-American women aged 20-44. The Health Belief Model constructs served as predictor risk factors for PrEP use. Results indicated that younger women of lower socioeconomic status (SES), higher levels of barriers, and higher levels of perceived susceptibility were more willing to take PrEP. This has significant implications for public health practice, policy, and opportunities for further research to establish interventions that incorporate increasing self-efficacy in PrEP use.

Association between spousal violence and the incidence of acute respiratory infection among children under five: random-effect modelling using data from Nigeria and Bangladesh.

Acute respiratory infection (ARI) is a major cause of mortality among children under the age of five in developing countries. This paper examines Demographic and Health Survey (DHS) data on maternal recall of episodes of ARI in the contrasting settings of Bangladesh and Nigeria, where about 11.1% and 3.3% of under-5 children, respectively, are reported to have symptoms of ARI. The surveys found that about 25.6% of married Bangladeshi women and 15.4% of married Nigerian women reported experiencing spousal violence in the past year. To test the proposition that women's experience of intimate partner violence (IPV) is associated with adversity in their children, the study examined the relationship between spousal violence in the past year and childhood ARI in the past 2 weeks among children under the age of five in Bangladesh and Nigeria. Data were taken from a nationally representative sample of mothers aged 15-49 years obtained from the 2007 Bangladesh DHS and 2008 Nigeria DHS. Random-effects multiple logistic regression models were estimated to assess the association of maternal exposure to IPV with the incidence of ARI in the past 2 weeks among under-5 children after controlling for the potentially confounding effects of maternal social and demographic characteristics. Results from Nigeria suggest that the odds of ARI incidence among children of mothers who were IPV victims were almost two times higher than among their counterparts whose mothers had not experienced IPV (OR = 1.78; 95% CI: 1.45-2.19; p <0.001). Similarly, the odds for the children of Bangladeshi IPV victims were elevated one and half times (OR = 1.61; 95% CI: 1.21-2.14; p <0.001). The findings suggest that under-5 children suffer indirect health consequences of gender-based violence.

Association Between Socioeconomic Status and Tumor Grade Among Black Men with Prostate Cancer.

BACKGROUND: Prostate cancer affects black men disproportionately. Black men have an increased incidence of prostate cancer diagnoses at earlier ages and higher grade as indicated by Gleason score, compared to other races. This study investigates the impact of socioeconomic status (SES) on prostate cancer tumor grade among black men. METHODS: Black men with a prostate cancer diagnosis during 1973-2011 were examined using individual-level data from the SEER NLMS database. Logistic regression model estimated the likelihood of receiving a diagnosis of high versus low grade prostate cancer based on self-reported SES status at the time of diagnosis. RESULTS: Men who completed high school only were statistically significantly more likely to have a higher prostate cancer grade than those with a bachelor's degree or higher. However, there was no dose-response effect across educational strata. Retirees were 30% less likely to have higher grade tumors compared to those who were employed. CONCLUSIONS: SES differences among black men did not fully explain the high grade of prostate cancer. Further research is needed on the biology of the disease and to assess access to medical care and prostate health education, discrimination, stress exposures, and social norms that might contribute to the aggressiveness of prostate cancer among black men.

Factors associated with high cardiovascular risk in a primarily African American, urban HIV-infected population.

OBJECTIVE: To determine factors associated with increased risk of developing cardiovascular disease in a high-risk patient population. DESIGN: Cross-sectional analysis of a retrospective cohort study. METHODS: One-hundred patients at an inner city HIV clinic in 2008 were reviewed. The atherosclerotic vascular disease risk score was calculated using the Pooled Cohort Equation. Chi-square test was performed to identify associations of potential risk factors with elevated atherosclerotic vascular disease risk. RESULTS: Eighty-one participants were included in the final analysis. In total, 95.1% were African American, and 38.3% were women. The median atherosclerotic vascular disease risk score was 8.8% and 8.1% in 2008 and 2012, respectively. The medical co-morbidities associated with increased atherosclerotic vascular disease risk were hepatitis C infection (X2 = 3.93; p value = 0.048), elevated triglycerides levels (X2 = 4.0; p value = 0.046), and low albumin (X2 = 4.65; p value = 0.031). There were a higher number of women with known atherosclerotic vascular disease despite lower median atherosclerotic vascular disease risk score compared to men. CONCLUSION: An elevated risk of developing cardiovascular disease persists in high-risk demographic groups of the HIV epidemic even in the current HIV era. There is an unexplained gender disparity and some non-traditional risk factors not accounted for in the Pooled Cohort Equation may be contributing to the excess cardiovascular disease risk observed among HIV-infected patients.

Maternal Intimate Partner Violence: Relationships with Language and Neurological Development of Infants and Toddlers.

Objectives This longitudinal study examined the influence of Intimate Partner Violence (IPV) experience of pregnant women participating in the Domestic Violence Enhanced Home Visitation Program on the language and neurological development of infants and toddlers. Methods A total of 210 infants and toddlers born to women reporting low, moderate, and high levels of IPV were included in the analysis. Logistic regression analysis was used to determine the bivariate association between maternal IPV and risk of language and neurological delay of infants and toddlers and between covariates and language and neurological delay. Generalized estimating equation models with logit link was used to predict the risk of language and neurological delay of infants and toddlers as a result of maternal IPV. Results Infants and toddlers born to women exposed to moderate levels of IPV had increased odds of language delay compared to infants and toddlers of women who experienced low levels of violence (OR 5.31, 95 % CI 2.94, 9.50, p < 0.001). Infants and toddlers born to women who experienced moderate and high levels of IPV were at higher risk of neurological delay respectively, compared to infants and toddlers of women who experienced low levels of IPV (OR 5.42, 95 % CI 2.99, 9.82, p < 0.001 and OR 2.57, 95 % CI 1.11, 5.61, p = 0.026). Conclusions for Practice Maternal IPV is associated with increased risk of language and neurological delay of infants and toddlers. These findings have implications for health care for women and infants exposed to IPV. Clinicians including pediatricians working with pregnant women should screen for IPV throughout pregnancy to identify women and children at risk. Interventions to reduce maternal IPV and early intervention services for infants and toddlers exposed to IPV are necessary for optimal maternal and child health.

Maternal Depressive Symptoms and Attained Size Among Children in the First 2 Years of Life.

OBJECTIVE: To evaluate the relation of maternal depressive symptoms with attained size and whether it is stronger for young children in low-income families. METHODS: Secondary analysis was performed of longitudinal data from enrollment and parents surveys from the Healthy Steps for Young Children National Evaluation among 4745 children who made at least one visit to a Healthy Steps site. Length and weight data from medical records were converted to z scores and percentiles for length for age and weight for length at 6, 12, and 24 months using 2000 Centers for Disease Control and Prevention growth standards. Analyses evaluated the relation of maternal depressive symptoms at 2 to 4 months using a modified 14-item Center for Epidemiologic Depression Scale with attained size and child, maternal, and family characteristics. Regression models estimated the relation of symptoms with z scores and logistic regression the relation for short stature (below 10th percentile for length for age), adjusted for covariates. RESULTS: Maternal depressive symptoms were associated with z scores for length for age at 6, 12, and 24 months and short stature at 6 and 24 months for children in low/middle-income families. The z scores at 24 months remained significantly lower for children in low/middle-income families whose mothers reported depressive symptoms, after adjustment for covariates. The odds of short stature were significantly increased at 6 months in the total sample and among low/middle-income families for children whose mothers reported symptoms. Other measures of attained size were not associated with depressive symptoms. CONCLUSIONS: The link between maternal symptoms and young children's risk of short stature reinforces recommendations for increased screening for postpartum depressive symptoms and for clinicians to review growth charts with parents for impaired/unfavorable patterns.

The effect of depressive symptoms and CD4 count on adherence to highly active antiretroviral therapy in sub-Saharan Africa.

BACKGROUND: Studies have identified several programmatic and nonprogrammatic indicators that affect adherence to highly active antiretroviral therapy (HAART). Depression has been shown to impact adherence to HAART. This cross-sectional analysis of data collected from Nigeria, Uganda, Zambia, and Tanzania in 2008 examined the relationship between levels of depressive symptoms, clinical progression, and adherence to HAART. METHODS: A multinational, multicenter, observational, retrospective cross-sectional evaluation of a population of focus comprised randomly selected patients on HAART. The dependent variable was adherence to HAART. The primary variable of interest to be assessed was patients' level of depressive symptom score. A multivariable logistic regression model was used to examine the relationship between explanatory variables and adherence to HAART. RESULTS: A total of 2344 patients were recruited for adherence survey. About 70% of the study sample reported having some level of depression. Logistic regression results show that patients who reported, respectively, low, moderate, and high levels of depressive symptoms are 35% (P < .001), 56% (P < .001), and 64% (P < .001) less likely to adhere to HAART than those who reported having no depressive symptoms. At multivariate analysis, adherence to HAART was independently associated with the levels of depressive symptoms, older age, CD4 count >200 cells/mm3, Truvada (tenofovir [TDF]/emtricitabine [FTC])-based regimens, good knowledge about HAART, and longer period on therapy. CONCLUSIONS: These results indicate that mental health and clinical parameters are significant factors in determining patients' adherence to their HAART, which need to be more aggressively addressed as a critical component of care and treatment support.

Are female college students who are diagnosed with depression at greater risk of experiencing sexual violence on college campus?

We examined the association between depression and sexual violence among 18-24 year-old female college students using National College Health Assessment survey. Data were collected from a nationally representative sample of 10,541 female students on 33 college campuses. Results showed that female students who were reportedly ever diagnosed with depression were 1.56 times more likely than those who had never been diagnosed with depression to have experienced sexual violence. Female students who had one or more sexual partners currently were found 3.17 times more likely than those who had no sexual partner to have experienced sexual violence; similarly, female students who engaged in binge drinking in the previous two weeks were found about two times more likely than their counterparts to have experienced sexual violence. Depression is a public health issue and must be addressed sooner rather than later in order to reduce and prevent sexual violence on college campuses.

The effect of depressive symptoms and CD4 count on adherence to highly active antiretroviral therapy in sub-Saharan Africa.

BACKGROUND: Studies have identified several programmatic and nonprogrammatic indicators that affect adherence to highly active antiretroviral therapy (HAART). Depression has been shown to impact adherence to HAART. This cross-sectional analysis of data collected from Nigeria, Uganda, Zambia, and Tanzania in 2008 examined the relationship between levels of depressive symptoms, clinical progression, and adherence to HAART. METHODS: A multinational, multicenter, observational, retrospective cross-sectional evaluation of a population of focus comprised randomly selected patients on HAART. The dependent variable was adherence to HAART. The primary variable of interest to be assessed was patients' level of depressive symptom score. A multivariable logistic regression model was used to examine the relationship between explanatory variables and adherence to HAART. RESULTS: A total of 2344 patients were recruited for adherence survey. About 70% of the study sample reported having some level of depression. Logistic regression results show that patients who reported, respectively, low, moderate, and high levels of depressive symptoms are 35% (P < .001), 56% (P < .001), and 64% (P < .001) less likely to adhere to HAART than those who reported having no depressive symptoms. At multivariate analysis, adherence to HAART was independently associated with the levels of depressive symptoms, older age, CD4 count >200 cells/mm3, Truvada (tenofovir [TDF]/emtricitabine [FTC])-based regimens, good knowledge about HAART, and longer period on therapy. CONCLUSIONS: These results indicate that mental health and clinical parameters are significant factors in determining patients' adherence to their HAART, which need to be more aggressively addressed as a critical component of care and treatment support.

High cancer-related mortality in an urban, predominantly African-American, HIV-infected population.

OBJECTIVE: To determine mortality associated with a new cancer diagnosis in an urban, predominantly African-American, HIV-infected population. DESIGN: Retrospective cohort study. METHODS: All HIV-infected patients diagnosed with cancer between 1 January 2000 and 30 June 2010 were reviewed. Mortality was examined using Kaplan-Meier estimates and Cox proportional hazards models. RESULTS: There were 470 cases of cancer among 447 patients. Patients were predominantly African-American (85%) and male (79%). Non-AIDS-defining cancers (NADCs, 69%) were more common than AIDS-defining cancers (ADCs, 31%). Cumulative cancer incidence increased significantly over the study period. The majority (55.9%) was taking antiretroviral therapy (ART) at cancer diagnosis or started afterward (26.9%); 17.2% never received ART. Stage 3 or 4 cancer was diagnosed in 67%. There were 226 deaths during 1096 person years of follow-up, yielding an overall mortality rate of 206 per 1000 person years. The cumulative mortality rate at 30 days, 1 year, and 2 years was 6.5, 32.2, and 41.4%, respectively. Mortality was similar between patients on ART whether they started before or after the cancer diagnosis but was higher in patients who never received ART. In patients with a known cause of death, 68% were related to progression of the underlying cancer. CONCLUSION: In a large cohort of urban, predominantly African-American patients with HIV and cancer, many patients presented with late-stage cancer. There was substantial 30-day and 2-year mortality, although ART had a significant mortality benefit. Deaths were most often caused by progression of cancer and not from another HIV-related or AIDS-related event.

Weight status in US youth: the role of activity, diet, and sedentary behaviors.

OBJECTIVES: To assess associations of physical activity, diet, and sedentary behaviors with overweight and obesity. METHODS: Analyses of the NHANES 2003-06 were conducted among 2368 US adolescents, ages 12-19. Self-reported diet and sedentary behavior measures were used; physical activity was assessed using accelerometers. RESULTS: Television/video viewing (OR=1.84; CI=1.24, 2.69), physical activity (OR=0.75; CI=0.59, 0.95), and fiber intake (OR=0.96; CI=0.92, 0.99) were associated with obesity whereas television/video viewing was a risk factor for overweight (OR=1.57; CI=1.1, 2.63). CONCLUSIONS: Findings using accelerometer-measured physical activity are consistent with results from other studies using self-reported measurements. No interactions with ethnicity and gender were found.

Birth interval and risk of stillbirth or neonatal death: findings from rural north India.

Short birth intervals have been associated with adverse birth outcomes. This study examines the association between preceding interval and risk of stillbirth or neonatal death in rural north India (n = 80 164). Adjusted odds ratios (OR) and 95% confidence interval (CI) of stillbirth and neonatal mortality were calculated. The odds of stillbirth were significantly greater among birth intervals of <18 months (OR 3.10; CI: 2.69-3.57), 18-35 months (OR 1.47; CI 1.30-1.68) and >59 months (OR 1.44; CI 1.19-1.73), compared with intervals of 36-59 months. Neonatal death was associated with birth intervals of <18 months (OR 4.12; CI 3.74-4.55) and 18-35 months (OR 1.78; CI 1.63-1.94), compared to births spaced 36-59 months. Previous history of either stillbirth or neonatal death was significantly associated with risk of stillbirth and neonatal death, respectively, as were multiple births.

The effect of women's status on infant and child mortality in four rural areas of Bangladesh.

In South Asia women are often the primary decision-makers regarding child health care, family health and nutrition. This paper examines the proposition that constraints on women's status adversely affect the survival of their children. Survey data are used to construct indices of women's household autonomy and authority, which are then linked to longitudinal data on survival of their children. Proportional hazard models indicate that enhanced autonomy significantly decreases post-neonatal mortality. Enhanced household authority significantly decreases child mortality. A simulation based on estimated effects of eliminating gender inequality suggests that achieving complete gender equality could reduce child mortality by nearly fifty per cent and post-neonatal mortality by one-third.