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.

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.

Multilevel analysis of discrimination of people living with HIV/AIDS and associated factors in Ghana: demographic health survey of 2022 Ghana data.

Introduction: The negative effects of stigma and discrimination in communities and families include medication non-adherence, heightened psychological distress, verbal and physical abuse, a lack of social support, isolation, and dangerous health behaviors such as hiding prescriptions. Despite the huge burden of HIV/AIDS discriminatory attitudes, limited studies were conducted in Ghana. Therefore, this study examines the burden of discriminatory attitudes and their determinant factors on people who are living with HIV/AIDS in Ghana. Objective: This study aimed to determine the prevalence of discriminatory attitudes and associated factors among people who are living with HIV/AIDS in Ghana based on recent DHS data. Method: Secondary data analysis was used for this multilevel logistic regression analysis based on the Ghana Demographic Health Survey of 2022. Data extraction, cleaning, and analysis were conducted using Stata version 14. The community of Ghana, from the 15 to 49 age group, was used for this study, with a final sample size of 22,058 participants. Four separate models were fitted, incorporating individual and community levels. Multilevel logistic regression models were calibrated to determine the associated factors at the individual and community level with discriminatory attitudes, with a 95% CI and AOR. Results: The prevalence of discriminatory attitudes toward people living with HIV/AIDS was 60.92%, with a 95% CI (60.13, 61.70) among Ghana DHS. Lower wealth status, having no comprehensive knowledge of HIV, low educational status at the individual level, and low wealth status at the community level, poorest and poorer [AOR =2.03; 95% CI: (1.04, 3.94)] and [AOR = 2.09; 95% CI: (1.84, 8.65)], respectively, no comprehensive knowledge [AOR = 3.42; 95% CI: (1.74, 6.73)], no and primary education [AOR = 3.18; 95% CI: (2.48, 5.51)] and [AOR = 3.78; 95% CI: (2.68, 5.92)], respectively, at the individual level and low wealth status [AOR = 1.58; 95% CI: (1.00, 2.46)] community level were the associated factors. Conclusion: The prevalence of discriminatory attitudes toward people living with HIV/AIDS was high (60.92%) in Ghana's DHS. The associated factors for this study were lower wealth status, having no comprehensive knowledge of HIV, and low educational status at the individual level.

Multilevel analysis of early initiation of breastfeeding in Ethiopia.

Introduction: Breast milk is the ideal food for the infant and is associated with various public health benefits for both the infant and the mother. The recommended time for early initiation of breastfeeding is within one hour after birth. The prevalence of early initiation of breastfeeding was lower than the plan of the Ethiopian Ministry of Health Sector Development program. Thus, the main objective of this study was to identify individual and group-level factors associated with the early initiation of breastfeeding in Ethiopia. Methods: Secondary data on children was obtained from the 2019 Ethiopia mini-demographic and health survey. The survey was a population-based cross-sectional study and was downloaded from the Measure Demographic and Health Survey website (http://www.measuredhs.com). The study included a random sample of 2,125 last-born infants who were born within 24 months before the survey. A multilevel binary logistic regression analysis was employed to identify the factors associated with the early initiation of breastfeeding in Ethiopia. Statistical data was analyzed using the Statistical Analysis System (SAS 9.4). Results: The prevalence of early breastfeeding initiation was 72%. The higher preceding birth interval (AOR = 1.18, 95% CI: 1.1076, 1.5451), the higher gestational age of infants (AOR = 1.38, 95% CI: 1.2796, 1.4782), the higher number of antenatal care visits (AOR = 1.26, 95% CI: 1.2340, 1.2934), delivery at a health facility (AOR = 1.60, 95% CI: 1.4585, 1.7515), vaginal delivery (AOR = 1.11, 95% CI: 1.1019, 1.1123), mothers with primary education (AOR = 1.14, 95% CI: 1.0204, 1.2738), mothers with secondary education (AOR = 1.54, 95% CI: 1.4678, 1.6190), and mothers with higher education (AOR = 2.62, 95% CI: 2.2574, 3.0526) were associated with higher odds of early initiation of breastfeeding. Being a rural dweller (AOR = 0.63, 95% CI: 0.5684, 0.7038) and the age of mothers (AOR = 0.44, 95% CI: 0.3921, 0.4894) were associated with lower odds of early initiation of breastfeeding. Conclusion: Since the prevalence of early initiation of breastfeeding was minimal among rural mothers who delivered their child by caesarean section, this study strongly suggests special supportive care for these mothers.

Antenatal care component utilization and associated factors among pregnant women in Ethiopia: Multilevel analysis of Ethiopian Mini Demographic and Health survey 2019.

INTRODUCTION: Maternal and neonatal health are among the top prioritised agendas of global health care with due emphasis given to developing countries, where the burden is profound. Antenatal care accompanied by its recommended components is highly beneficial for both maternal health and birth outcome. OBJECTIVE: The objective of this study was to identify the proportion of pregnant women who received adequate Antenatal care components and associated factors among Ethiopian women. METHODS AND MATERIALS: We used a nation-wide data from Mini Ethiopian Demographic and Health Survey (MEDHS) of 2019. All women of age 15-49 and who had at least one ANC visit, who were either permanent residents of the selected households or visitors who slept in the household the night before the survey, were eligible to be interviewed. Since we utilised multilevel logistic regression model, the STATA output had two components, the fixed effect and the random effect. In our model, the fixed effect part was displayed by odds ratio while the random effect was addressed by variance and intra-cluster correlation (ICC). RESULTS: From the total women with at least one antenatal care (ANC) visit 55.41% (95% CI 53.60%, 57.20%) of them received adequate components of the care. In the final model after adjusting for the cluster and individual level variables, attending primary (AOR = 1.45; 95% CI: 1.15 to 1.84), secondary (AOR = 2.21; 95% CI: 1.51 to 3.24) and higher education (AOR = 2.42; 95% CI: 1.38 to 4.26) were significantly associated with higher odds of receiving adequate components of ANC. Similarly, wealth index of middle (AOR = 1.51; 95% CI: 1.06, 2.14), richer (AOR = 1.92; 95% CI: 1.32, 2.80), and richest (AOR = 3.86; 95% CI: 2.35, 6.33) compared to poorest index and having two or more ANC visits were significantly associated with receiving adequate components of ANC. On the other hand, being from Oromia region, from female headed household and protestant religion were negatively associated with receiving adequate components of ANC. CONCLUSION: The proportion of women who received adequate ANC component was much lower compared to the universal recommendation for every woman on ANC visit. Educational status, wealth index, number of ANC visit, region of residence and type of health facility were significantly associated with the odds of receiving adequate components of ANC. The government should pay attention to those without any formal education, encouraging pregnant women to receive the optimum number of ANC visits, and devising techniques to address those in poorest wealth index so that the proportion of adequate components of ANC will be increased.

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.

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.

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.

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.

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.

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.

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.

Examining determinants of stunting in Urban and Rural Indonesian: a multilevel analysis using the population-based Indonesian family life survey (IFLS).

BACKGROUND: In Indonesia, chronic malnutrition leading to stunted growth in children represents a significant issue within the public health domain. The prevalence of stunting varies between urban and rural areas, reflecting disparities in access to nutrition, healthcare, and other socioeconomic factors. Understanding these disparities is crucial for developing targeted interventions to address the issue. METHODS: The study used data from the fifth wave of the Indonesian Family Life Survey (IFLS), which is a national cross-sectional population-based survey conducted across approximately 13 provinces in Indonesia in 2014-2015. Multivariate and Multilevel logistic regression models were utilized in the analysis to determine the factors associated with the prevalence of stunting in Indonesian children. RESULTS: The multivariate logistic regression analysis indicated that among children aged 24-59 months in Indonesia, stunting was associated with the age of the child, birth weight, maternal nutritional status, and residence. Subsequently, the multilevel logistic regression analysis revealed that in rural areas, the age of the child and birth weight exhibited significant associations with stunting. Conversely, in urban areas, stunted children were influenced by 7 factors, including the child's age (months), age of weaning, birth weight (kg), mother and father's age, place of birth, and maternal nutritional status. CONCLUSIONS: Variations in childhood stunting between urban and rural regions in Indonesia were observed, indicating a differential prevalence. The study's findings suggests the importance of age-appropriate nutritional support, healthcare interventions, and growth monitoring. Focused interventions are vital, potentially encompassing initiatives such as improving access to maternal and child healthcare services, promoting adequate nutrition during pregnancy and infancy, and facilitate greater parental engagement in childcare responsibilities.

Multi-level analysis of intimate partner violence and its determinants among reproductive age group women in Ethiopia: evidence from Ethiopian Demographic Health Survey, 2016.

BACKGROUND: Intimate partner violence (IPV) is recognized as a main public health challenge, with serious consequences for women's physical, mental, sexual, and reproductive health. Despite its public health importance, most studies of IPV in Ethiopia mainly focused on individual characteristics and didn't identify how factors operating at different levels affect IPV. Thus, there is limited evidence regarding the hierarchical-level factors of IPV and the effect of individual and community-level determinants of IPV. The aim of this study is to assess the individual and community-level factors associated with violence against women among ever-married reproductive-age women in Ethiopia. METHODS: A retrospective analysis of secondary data retrieved from the Ethiopia Demographic and Health Survey was conducted among reproductive age group women (15-49 years of age) who reported ever being married within the available data set for the domestic violence module. STATA 14 was used to conduct the analysis. A two-level mixed-effects logistic regression analysis was used to determine associations between IPV and individual- and community-level factors. IPV variability across the community was assessed using ICC and PCV. The model's fitness was assessed using the Akaike information criterion (AIC), the Bayesian information criterion (BIC), and the likelihood ratio test. RESULT: The life time prevalence of IPV in this study was 33% [95% CI: 30.74, 34.25]. Women's age 20-24 (AOR = 5.85, 95% CI: 201 3.10, 11.04), 25-29 age group (AOR = 6.41, 95% CI; 3.34, 12.32), 30-34 age group (AOR = 9.48, 95% CI: 4.71, 19.06), 35-39 age group (AOR = 9.88, 95% CI: 4.79, 20.39), 40-44 age group (AOR = 11.10, 95% CI: 5.16, 23.89), and 45-49, (AOR = 14.15, 95% CI: 6.01, 32.80), early marriage (AOR = 1.21, 95% CI: 1.08, 1.47), witnessing inter-parental violence during childhood (AOR = 2.80, 95% CI: 2.16, 3.96), having a lot of living children (AOR = 0.45, 95% CI: 0.26, 0.74), having a partner who drank alcohol (AOR = 3.00, 95% CI: 2.42-3.67), decision-making autonomy of the women (AOR = 0.77, 95% CI: 0.62, 0.97), Poor wealth index (AOR = 1.64, 95% CI: 1.23, 2.18), middle wealth index (AOR = 1.86, 95% CI: 1.36, 2.54) and exposure to media (AOR = 1.47, 95% CI: 1.06, 2.00) were all significantly associated with IPV. CONCLUSION AND RECOMMENDATION: This study showed that one-third of the women experienced IPV in their lifetime. The finding suggested that community based interventions and multi-sectorial collaborations are needed to reduce the IPV and its adverse consequences.

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.

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.

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?