HIV estimation using population-based surveys with non-response: A partial identification approach.

HIV estimation using data from the demographic and health surveys (DHS) is limited by the presence of non-response and test refusals. Conventional adjustments such as imputation require the data to be missing at random. Methods that use instrumental variables allow the possibility that prevalence is different between the respondents and non-respondents, but their performance depends critically on the validity of the instrument. Using Manski's partial identification approach, we form instrumental variable bounds for HIV prevalence from a pool of candidate instruments. Our method does not require all candidate instruments to be valid. We use a simulation study to evaluate and compare our method against its competitors. We illustrate the proposed method using DHS data from Zambia, Malawi and Kenya. Our simulations show that imputation leads to seriously biased results even under mild violations of non-random missingness. Using worst case identification bounds that do not make assumptions about the non-response mechanism is robust but not informative. By taking the union of instrumental variable bounds balances informativeness of the bounds and robustness to inclusion of some invalid instruments. Non-response and refusals are ubiquitous in population based HIV data such as those collected under the DHS. Partial identification bounds provide a robust solution to HIV prevalence estimation without strong assumptions. Union bounds are significantly more informative than the worst case bounds without sacrificing credibility.

An analysis of the dual burden of childhood stunting and wasting in Myanmar: a copula geoadditive modelling approach.

OBJECTIVE: To analyze the spatial variation and risk factors of the dual burden of childhood stunting and wasting in Myanmar. DESIGN: Analysis was carried out on nationally representative data obtained from the Myan-mar Demographic and Health Survey conducted during 2015-2016. Childhood stunting and wasting are used as proxies of chronic and acute childhood undernutrition. A child with standardized height-for-age Z score (HAZ) below -2 is categorized as stunted while that with a weight-for-height Z score (WHZ) below -2 as wasted. SETTING: A nationally representative sample of households from the 15 states and regions of Myanmar. PARTICIPANTS: Children under the age of five (n 4162). RESULTS: Overall marginal prevalence of childhood stunting and wasting were 28.9% (95% CI 27.5, 30.2) and 7.3% (95% CI 6.5, 8.0) while their concurrent prevalence was 1.6% (95% CI 1.2, 2.0). The study revealed mild positive association between stunting and wasting across Myanmar. Both stunting and wasting had significant spatial variation across the country with eastern regions having higher burden of stunting while southern regions having higher prevalence of wasting. Child age and maternal weight-for-height Z score had significant non- linear association with both stunting and wasting while child gender, ethnicity and household wealth quintile had significant association with stunting. CONCLUSION: The study provides data-driven evidence about the association between stunting and wasting and their spatial variation across Myanmar. The resulting insights can aid in the formulation and implementation of targeted, region-specific interventions towards improving the state of childhood under-nutrition in Myanmar.

GIS-based spatiotemporal mapping of malaria prevalence and exploration of environmental inequalities.

Malaria poses a significant threat to global health, with particular severity in Nigeria. Understanding key factors influencing health outcomes is crucial for addressing health disparities. Disease mapping plays a vital role in assessing the geographical distribution of diseases and has been instrumental in epidemiological research. By delving into the spatiotemporal dynamics of malaria trends, valuable insights can be gained into population dynamics, leading to more informed spatial management decisions. This study focused on examining the evolution of malaria in Nigeria over twenty years (2000-2020) and exploring the impact of environmental factors on this variation. A 5-year-period raster map was developed using malaria indicator survey data for Nigeria's six geopolitical zones. Various spatial analysis techniques, such as point density, spatial autocorrelation, and hotspot analysis, were employed to analyze spatial patterns. Additionally, statistical methods, including Principal Component Analysis, Spearman correlation, and Ordinary Least Squares (OLS) regression, were used to investigate relationships between indicators and develop a predictive model. The study revealed regional variations in malaria prevalence over time, with the highest number of cases concentrated in northern Nigeria. The raster map illustrated a shift in the distribution of malaria cases over the five years. Environmental factors such as the Enhanced Vegetation Index, annual land surface temperature, and precipitation exhibited a strong positive association with malaria cases in the OLS model. Conversely, insecticide-treated bed net coverage and mean temperature negatively correlated with malaria cases in the same model. The findings from this research provide valuable insights into the spatiotemporal patterns of malaria in Nigeria and highlight the significant role of environmental drivers in influencing disease transmission. This scientific knowledge can inform policymakers and aid in developing targeted interventions to combat malaria effectively.

Application of machine learning methods for predicting under-five mortality: analysis of Nigerian demographic health survey 2018 dataset.

BACKGROUND: Under-five mortality remains a significant public health issue in developing countries. This study aimed to assess the effectiveness of various machine learning algorithms in predicting under-five mortality in Nigeria and identify the most relevant predictors. METHODS: The study used nationally representative data from the 2018 Nigeria Demographic and Health Survey. The study evaluated the performance of the machine learning models such as the artificial neural network, k-nearest neighbourhood, Support Vector Machine, Naïve Bayes, Random Forest, and Logistic Regression using the true positive rate, false positive rate, accuracy, precision, F-measure, Matthew's correlation coefficient, and the Area Under the Receiver Operating Characteristics. RESULTS: The study found that machine learning models can accurately predict under-five mortality, with the Random Forest and Artificial Neural Network algorithms emerging as the best models, both achieving an accuracy of 89.47% and an AUROC of 96%. The results show that under-five mortality rates vary significantly across different characteristics, with wealth index, maternal education, antenatal visits, place of delivery, employment status of the woman, number of children ever born, and region found to be the top determinants of under-five mortality in Nigeria. CONCLUSIONS: The findings suggest that machine learning models can be useful in predicting U5M in Nigeria with high accuracy. The study emphasizes the importance of addressing social, economic, and demographic disparities among the population in Nigeria. The study's findings can inform policymakers and health workers about developing targeted interventions to reduce under-five mortality in Nigeria.

Using Total Cohort Fertility in Adolescence (TCFA) to analyse adolescent fertility trends and factors in Niger: Evidence from 1992 to 2012 demographic and health surveys.

Girls aged 10-19 currently represent 12% of Niger's population (2020). And this number continues to grow as the fertility rate is higher while mortality is declining faster. Using Niger's demographic and health surveys carried out between 1992 and 2012, the study investigated adolescent fertility, its trends and associated factors. It mobilised descriptive methods (Total cohort fertility in adolescence (TCFA) computation, distribution of the number of adolescent births, and computation of adolescent cohort childbearing mean age) and multivariate Logistic and Poisson models. The result shows the TCFA went from 1.29 in 1992 to 1.17 in 2012. Early sexual intercourse and marriage, infant mortality, the desire for a large family, and urbanisation are among the factors significantly associated with adolescent fertility in Niger. The study concludes that the high level of adolescent fertility in Niger does not seem to be changing.

Les adolescentes représentent 12 % de la population Nigerienne (2020). Ce chiffre continue de croître car la fécondité reste elevée alors que la mortalité diminue rapidement. Utilisant les enquêtes démographiques et de santé du Niger entre 1992 et 2012, cette étude s'est intéressée aux tendances et facteurs de la descendance finale à l'adolescence (DFA). Elle a mobilisé des méthodes descriptives (calcul de la DFA, distribution du nombre de naissances adolescentes, calcul de l'âge moyen à la maternité adolescente) et des modèles multivariés de régression logistique et de Poisson. Les résultats montrent que la DFA est passée de 1,29 en 1992 à 1,17 en 2012. Les rapports sexuels et le mariage précoces, la mortalité infantile, le désir d'une famille nombreuse et l'urbanisation sont parmi les facteurs significativement associés à la fécondité adolescente au Niger. L'étude conclut que le niveau élevé de la fécondité des adolescentes au Niger ne semble pas évoluer.

Trends in the Intraindividual Double Burden of Overweight/Obesity and Anemia among Adult Women Living in 33 Low- and Middle-Income Countries: A Secondary Analysis of Demographic and Health Surveys from 2000-2019.

BACKGROUND: Changes in overweight/obesity and anemia among women have been investigated in multiple studies, but the rate at which their coexistence at the individual level has evolved remains unknown. OBJECTIVES: We aimed to 1) document trends in the magnitude and inequalities of the co-occurrence of overweight/obesity and anemia; and 2) compare these with overall trends in overweight/obesity, anemia, and the co-occurrence of anemia with normal weight or underweight. METHODS: For this cross-sectional series study, we used 96 Demographic and Health Surveys from 33 countries with available anthropometric and anemia data among nonpregnant adult women (20-49 y old; n = 1,648,308). The primary outcome was defined as the coexistence of overweight or obesity (BMI ≥25kg/m2) and anemia (hemoglobin concentrations <12.0 g/dL) within the same individual. We computed overall and regional trends through multilevel linear regression models and by sociodemographic characteristics (i.e., wealth, education, and residence). Estimates at the country level were calculated through ordinary least square regression models. RESULTS: From 2000 to 2019, the co-occurrence of overweight/obesity and anemia increased modestly at an annual rate of 0.18 percentage points (95% CI: 0.08, 0.28 percentage points; P < 0.001), ranging from 0.73 percentage points in Jordan to -0.56 percentage points in Peru. This trend occurred in parallel with overall increases in overweight/obesity and reductions in anemia. The co-occurrence of anemia with normal weight or underweight was reducing in all countries, except Burundi, Sierra Leone, Jordan, Bolivia, and Timor-Leste. Stratified analyses yielded an upward trend in the co-occurrence of overweight/obesity and anemia across all subgroups but particularly in women from the 3 middle wealth groups, no education, and capital city or rural residents. CONCLUSIONS: The rising trend in the intraindividual double burden suggests that efforts to reduce anemia among women living with overweight/obesity may need to be revisited to accelerate progress toward the 2025 global nutrition target of halving anemia.

An evaluation of truncated birth histories for the rapid measurement of fertility and child survival.

BACKGROUND: Full birth histories (FBHs) are a key tool for estimating fertility and child mortality in low- and middle-income countries, but they are lengthy to collect. This is not desirable, especially for rapid turnaround surveys that ought to be short (e.g., mobile phone surveys). To reduce the length of the interview, some surveys resort to truncated birth histories (TBHs), where questions are asked only on recent births. METHODS: We used 32 Malaria Indicator Surveys that included TBHs from 18 countries in sub-Saharan Africa. Each set of TBHs was paired and compared to an overlapping set of FBHs (typically from a standard Demographic and Health Survey). We conducted a variety of data checks, including a comparison of the proportion of children reported in the reference period and a comparison of the fertility and mortality estimates. RESULTS: Fertility and mortality estimates from TBHs are lower than those based on FBHs. These differences are driven by the omission of events and the displacement of births backward and out of the reference period. CONCLUSIONS: TBHs are prone to misreporting errors that will bias both fertility and mortality estimates. While we find a few significant associations between outcomes measured and interviewer's characteristics, data quality markers correlate more consistently with respondent attributes, suggesting that truncation creates confusion among mothers being interviewed. Rigorous data quality checks should be put in place when collecting data through this instrument in future surveys.

Contraceptive use in South and South-East Asian region: assessment of sustainable development goal 3.7 through indicator 3.7.1.

BACKGROUND: Sustainable Development Goal (SDG) 3.7 concerns modern contraception use among women of reproductive ages. This study evaluated the progress of indicator 3.7.1 in 11 selected countries in South and South-East Asia and assessed the contribution of women's education to modern contraceptive use. METHODS: Generalized linear models for complex surveys were fitted to Demographic and Health Survey (DHS) data from 40 surveys conducted in Afghanistan, Bangladesh, Cambodia, India, Indonesia, Maldives, Myanmar, Nepal, Pakistan, Philippines and Timor Leste between 1990 and 2017, followed by a meta-analysis through forest plots. RESULTS: Modern contraceptive coverage in most of the selected countries climbed or remained stationary over the past decades. In four countries, <50% of women used contraception. In no country was contraception used by ≥80% women. Higher education was associated with 13% higher odds of modern contraceptive use (95% confidence interval: 1.07, 1.18) among women compared to primary level or no education. DISCUSSION: Completion of primary education is insufficient to broaden the coverage of modern contraceptive use. Greater national level effort from the selected countries is needed to lift the education levels of women to meet SDG 3.7 by 2030.

Equity of the HIV epidemic response in 13 African countries.

For over 25 years, new programs to attempt to stem the HIV epidemic have been developed in Africa by country governments as well as external donors. These programs and activities have built and operated facilities, trained clinicians, financed drugs and commodities, supported and helped finance government health planning and operations, and contributed in other ways. Who has benefited from this massive mobilization? While some single country and narrowly focused studies have been done, the issue of equity of HIV programs for vulnerable populations has not been examined in a large set of countries. Using Population-based HIV Impact Assessment (PHIA) data, we examine equity of the HIV programs in 13 African countries to determine if vulnerable groups (such as those with low wealth, rural populations, young adults, and females) have achieved comparable levels of access to HIV program services. In contrast, we also compare the equity of the HIV response to rural and low-wealth populations with the equity of corresponding domestic health systems using Demographic and Health Survey data.This study found that in over half of the countries, the HIV response indicators were equitable for vulnerable population segments including the low-wealth population (in seven countries) and rural population segment (in nine countries). In no country was the domestic health system equitable for these two groups. However, HIV programming does show some clear patterns of inequity for low-wealth and rural populations in some countries. For gender and young adults, the HIV response indicators show that in all 13 countries men and young adults are consistently underserved relative to their counterparts.

Promising trends and influencing factors of complementary feeding practices in Côte d'Ivoire: An analysis of nationally representative survey data between 1994 and 2016.

Poor complementary feeding (CF) challenges early childhood growth. We examined the trends and influencing factors of CF practices among children aged 6-23 months in Côte d'Ivoire. Using data from Demographic and Health Surveys (DHS, 1994-2011) and Multiple Indicator Cluster Surveys (MICS, 2000-2016), the trends and predictors of World Health Organization-United Nations International Children's Emergency Fund CF indicators including the timely introduction of complementary foods (INTRO), minimum meal frequency (MMF), minimum dietary diversity (MDD) and minimum acceptable diet (MAD) were determined. Using 2016 MICS data, we applied multivariate logistic regression models to identify factors associated with CF indicators. Between 1994 and 2016, the mean proportion of children aged 6-8 months achieving INTRO was 56.9% and increased by about 25% points since 2006. Over 2011-2016, the proportion of children aged 6-23 months meeting MMF, MDD and MAD increased from 40.2% to 47.7%, 11.3% to 26.0% and 4.6% to 12.5%, respectively. Older children and those from urban households had higher odds of meeting MDD and MAD. Maternal TV watching was associated with higher odds of meeting MDD. The secondary or higher education levels of mothers significantly predicted higher odds of meeting INTRO and MDD. Currently, breastfeeding was also positively associated with odds of meeting MMF and MAD. Children from poorer households had lower odds of meeting MMF, MDD and MAD. Despite the improvements, CF practices remain suboptimal in Côte d'Ivoire. Influencing factors associated with CF were distributed across individual, household and community levels, calling for future programmes and policies to implement multi-level strategies to improve young children's diet in Côte d'Ivoire.

What is missing in our understanding of urban slum environments and maternal, infant and young child nutrition from publicly available data in Asia and the Pacific?

Given the recent, rapid urbanisation in Asia and the Pacific region, coupled with increases in the triple burden of malnutrition, we need to better understand maternal, infant and young child nutrition (MIYCN) for populations living in urban slum environments. This research used existing large-scale datasets to explore MIYCN indicators for those living in urban slum, compared with urban nonslum, areas. Data since 2015 from available Demographic and Health Surveys (DHS; Afghanistan, India, Indonesia, Myanmar, Pakistan and the Philippines) and Multiple Indicator Cluster Surveys (MICS; Bangladesh, Fiji, Kiribati, Mongolia, Nepal, Thailand and Tuvalu) were analysed. Most urban children in the 13 countries from the region were breastfed within 24 h of birth, with slightly higher rates for those living in slums. Conversely, almost all indicators of infant and young child malnutrition were worse for those in urban slums. For mothers living in slums, underweight prevalence and iron deficiency anaemia were higher while maternal overweight and obesity prevalence were lower. Analysis revealed disparities across countries in the wealth status of those living in slum versus nonslum areas. What is currently missing is representative sampling of households, adequate collection of data both within and across countries, and accurate representation of slum-dwellers in large-scale surveys. Given that limited data for the region show urban poor slum populations are vulnerable to poor nutrition indicators, more data are needed on the poorest urban slum populations to enable effective resource allocation to support optimal MIYCN.

Conditional probability and ratio-based approaches for mapping the coverage of multi-dose vaccines.

Many vaccines are often administered in multiple doses to boost their effectiveness. In the case of childhood vaccines, the coverage maps of the doses and the differences between these often constitute an evidence base to guide investments in improving access to vaccination services and health system performance in low and middle-income countries. A major problem often encountered when mapping the coverage of multi-dose vaccines is the need to ensure that the coverage maps decrease monotonically with successive doses. That is, for doses i $$ i $$ and j $$ j $$ , i < j ⇒ p i ( s ) ≥ p j ( s ) $$ i

Inequalities in prevalence of birth by caesarean section in Ghana from 1998-2014.

BACKGROUND: Caesarean section (CS) is an intervention to reduce maternal and perinatal mortality, for complicated pregnancy and labour. We analysed trends in the prevalence of birth by CS in Ghana from 1998 to 2014. METHODS: Using the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software, data from the 1998-2014 Ghana Demographic and Health Surveys (GDHS) were analysed with respect of inequality in birth by CS. First, we disaggregated birth by CS by four equity stratifiers: wealth index, education, residence, and region. Second, we measured inequality through simple unweighted measures (Difference (D) and Ratio (R)) and complex weighted measures (Population Attributable Risk (PAR) and Population Attributable Fraction (PAF)). A 95% confidence interval was constructed for point estimates to measure statistical significance. RESULTS: The proportion of women who underwent CS increased significantly between 1998 (4.0%) and 2014 (12.8%). Throughout the 16-year period, the proportion of women who gave birth by CS was positively skewed towards women in the highest wealth quintile (i.e poorest vs richest: 1.5% vs 13.0% in 1998 and 4.0% vs 27.9% in 2014), those with secondary education (no education vs secondary education: 1.8% vs 6.5% in 1998 and 5.7% vs 17.2% in 2014) and women in urban areas (rural vs urban 2.5% vs 8.5% in 1998 and 7.9% vs 18.8% in 2014). These disparities were evident in both complex weighted measures of inequality (PAF, PAR) and simple unweighted measures (D and R), although some uneven trends were observed. There were also regional disparities in birth by CS to the advantage of women in the Greater Accra Region over the years (PAR 7.72; 95% CI 5.86 to 9.58 in 1998 and PAR 10.07; 95% CI 8.87 to 11.27 in 2014). CONCLUSION: Ghana experienced disparities in the prevalence of births by CS, which increased over time between 1998 and 2014. Our findings indicate that more work needs to be done to ensure that all subpopulations that need medically necessary CS are given access to maternity care to reduce maternal and perinatal deaths. Nevertheless, given the potential complications with CS, we advocate that the intervention is only undertaken when medically indicated.

Inequalities in antenatal care in Ghana, 1998-2014.

BACKGROUND: In order to effectively and efficiently reduce maternal mortality and ensure optimal outcomes of pregnancy, equity is required in availability and provision of antenatal care. Thus, analysis of trends of socio-economic, demographic, cultural and geographical inequities is imperative to provide a holistic explanation for differences in availability, quality and utilization of antenatal care. We, therefore, investigated the trends in inequalities  in four or more antenatal care visits in Ghana, from 1998 to 2014. METHODS: We used the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software to analyse data from the 1998 to 2014 Ghana Demographic and Health Surveys. We disaggregated four or more antenatal care visits by four equality stratifiers: economic status, level of education, place of residence, and sub-national region. We measured inequality through summary measures: Difference, Population Attributable Risk (PAR), Ratio, and Population Attributable Fraction (PAF). A 95% uncertainty interval (UI) was constructed for point estimates to measure statistical significance. RESULTS: The Difference measure of 21.7% (95% UI; 15.2-28.2) and the PAF measure of 12.4% (95% UI 9.6-15.2) indicated significant absolute and relative economic-related disparities in four or more antenatal care visits favouring women in the highest wealth quintile. In the 2014 survey, the Difference measure of 13.1% (95% UI 8.2-19.1) and PAF of 6.5% (95% UI 4.2-8.7) indicate wide disparities in four or more antenatal care visits across education subgroups disfavouring non-educated women. The Difference measure of 9.3% (95% UI 5.8-12.9) and PAF of 5.8% (95% UI 4.7-6.8) suggest considerable relative and absolute urban-rural disparities in four or more antenatal care visits disfavouring rural women. The Difference measure of 20.6% (95% UI 8.8-32.2) and PAF of 7.1% (95% UI 2.9-11.4) in the 2014 survey show significant absolute and relative regional inequality in four or more antenatal care  visits, with significantly higher coverage among regions like Ashanti, compared to the Northern region. CONCLUSIONS: We found a disproportionately lower uptake of four or more antenatal care visits among women who were poor, uneducated and living in rural areas and the Northern region. There is a need for policymakers to design interventions that will enable disadvantaged subpopulations to benefit from four or more antenatal care visits to meet the Sustainable Development Goal  3.1 that aims to reduce the maternal mortality ratio (MMR) to less than  70/100, 000 live births by 2030. Further studies are essential to understand the underlying factors for the  inequalities in antenatal care visits.

Safer If Connected? Mobile Technology and Intimate Partner Violence.

Mobile phones are an invaluable economic asset for low-income individuals and an important tool for strengthening social ties. They may also help women overcome physical boundaries, especially those who are separated from support networks and are bound within their husbands' social spheres. Using micro-level data on women and men from recent Demographic and Health Surveys, including new information on mobile phone ownership, this study examines whether women's ownership of mobile phones is associated with their likelihood of having experienced intimate partner violence (IPV) across 10 low- and middle-income countries. Findings show that women's ownership of mobile phones is associated with a 9%-12% decreased likelihood of emotional, physical, and sexual violence over the previous 12 months, even after controlling for characteristics proxying for socioeconomic status, household resources, and local development within the community. Estimates are negative in seven out of the 10 countries and results are robust to the use of nonparametric matching techniques and instrumental variables built through georeferenced ancillary sources. In exploring two potential mechanisms, I show that mobile phone ownership is positively associated with women's decision-making power within the household (decision-making power) and male partners' lower acceptability of IPV (attitudes). Findings speak to scholars and policymakers interested in how technology diffusion relates to dynamics of women's empowerment and global development.

Trends in total fertility rate in Ghana by different inequality dimensions from 1993 to 2014.

BACKGROUND: The past few decades witnessed a considerable decline in total fertility rates globally. However in Ghana, there has been a slight increase in the fertility rate with little understanding of the reason for the increment. To understand this change, it is important to first examine the trend over a considerable period of time while taking into consideration some important inequality dimensions. This informed the need for this present study as we examined the trends in total fertility rate in Ghana by different inequality dimensions from 1993 to 2014. METHODS: Data from the 1993-2014 Ghana Demographic and Health Surveys were used for the study, and we relied on the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software for the analysis. The analysis involved disaggregation of TFR by wealth index, education, place of residence and region. This was followed by the estimation of inequality by Difference, Population Attributable Risk, Ratio and Population Attributable Fraction. In the analysis, we set the statistical significance at a 95% confidence interval. RESULTS: For all surveys, the total fertility rate was consistently highest among the poorest women (7.00, 6.28, 6.77, 6.61 and 6.29 in 1993, 1998, 2003, 2008 and 2014, respectively). The highest total fertility rate was recorded among women with no formal education in all the survey years. For instance, in the 2014 survey, the total fertility rate for women with no formal education was 5.98 and those with secondary/higher had a total fertility rate of 3.40. Women in rural areas had a higher total fertility rate compared to those in urban areas (4.90 vs. 3.40 in 2014). In terms of sub-national regions, the Northern region was the region where women consistently had the highest total fertility rate. CONCLUSION: There is a need for a collective effort to design interventions and policies to create awareness among the people of Ghana especially girls and women on the implications of high fertility.

Associated factors, inequalities, and spatial distribution of the use of modern contraceptive methods among women of reproductive age in Peru: a population-based cross-sectional study.

BACKGROUND: The use of contraceptive methods in Peru has remarkably increased in recent decades. Nevertheless, despite the completeness and accessibility of family planning methods, modern contraceptive methods utilization in Peru remains below the South American average. Thus, this study aimed to elucidate the factors associated with modern contraceptive use, as well as the presence of inequalities and the spatial distribution in Peruvian women aged 15-49 years in 2019. METHODS: A secondary data analysis was conducted using information from the 2019 Peruvian Demographic and Health Survey. We performed descriptive statistics, bivariate analysis, and Poisson multiple regression. Inequalities were estimated through concentration curves and Erreygers' normalized concentration index. Spatial analysis included choropleth map, Global Moran's I, Kriging interpolation and Getis-Ord-Gi* statistic. RESULTS: The prevalence of modern contraceptive use was 39.3% among Peruvian women of reproductive age. Modern contraceptive use was directly associated with youth (aPR 1.39), women having their first sexual intercourse before the age of 18 (aPR 1.41), and being married but not together (aPR 1.87). In addition, speaking Quechua or Aymara (aPR 0.87) and having no children (aPR 0.59) were inversely associated with utilization of modern contraceptives. We found the presence of inequalities in the use of contraceptive methods (pro-rich distribution), although the magnitude was low. Spatial analysis unveiled the presence of a clustered distribution pattern (Moran's Index = 0,009); however, there was inter-departmental and intra-departmental heterogeneity in the predicted prevalence of the use of modern contraceptives. In addition, significant hot and cold spots were found in Peru. CONCLUSION: Two out of five Peruvian women of reproductive age used modern contraceptives. It was associated with younger women's age, younger age at first sexual intercourse, being married or cohabitant, among others. No substantial inequality was found in modern contraceptive use. The prevalence was heterogeneous at the intra- and inter-departmental level. Those departments located in the south, south-east, and north-east had the lowest prevalence. Therefore, nonfinancial barriers must be tackled through multi- and cross-sectoral efforts and continue to universally provide modern contraceptives.

Spatial and multilevel analysis of unskilled birth attendance in Chad.

BACKGROUND: Unskilled birth attendance is a major public health concern in Sub-Saharan Africa (SSA). Existing studies are hardly focused on the socio-demographic correlates and geospatial distribution of unskilled birth attendance in Chad (a country in SSA), although the country has consistently been identified as having one of the highest prevalence of maternal and neonatal deaths in the world. This study aimed to analyse the socio-demographic correlates and geospatial distribution of unskilled birth attendance in Chad. METHODS: The study is based on the latest Demographic and Health Survey (DHS) data for Chad. A total of 10,745 women aged between 15 and 49 years were included in this study. A multilevel analysis based on logistic regression was conducted to estimate associations of respondents' socio-demographic characteristics with unskilled birth attendance. Geographic Information System (GIS) mapping tools, including Getis-Ord Gi hotspot analysis tool and geographically weighted regression (GWR) tool, were used to explore areas in Chad with a high prevalence of unskilled birth attendance. RESULTS: The findings show that unskilled birth attendance was spatially clustered in four Chad departments: Mourtcha, Dar-Tama, Assoungha, and Kimiti, with educational level, occupation, birth desire, birth order, antenatal care, and community literacy identified as the spatial predictors of unskilled birth attendance. Higher educational attainment, higher wealth status, cohabitation, lowest birth order, access to media, not desiring more births, and higher antenatal care visits were associated with lower odds of unskilled birth attendance at the individual level. On the other hand, low community literacy level was associated with higher odds of unskilled birth attendance in Chad whereas the opposite was true for urban residency. CONCLUSIONS: Unskilled birth attendance is spatially clustered in some parts of Chad, and it is associated with various disadvantaged individual and community level factors. When developing interventions for unskilled birth attendance in Chad, concerned international bodies, the Chad government, maternal health advocates, and private stakeholders should consider targeting the high-risk local areas identified in this study.

Disability and sexual and reproductive health service utilisation in Uganda: an intersectional analysis of demographic and health surveys between 2006 and 2016.

BACKGROUND: The United Nations through universal health coverage, including sexual and reproductive health (SRH), pledges to include all people, leaving no one behind. However, people with disabilities continue to experience multiple barriers in accessing SRH services. Studies analysing the impacts of disability in conjunction with other social identities and health determinants reveal a complex pattern in SRH service use. Framed within a larger mixed methods study conducted in Uganda, we examined how disability, among other key social determinants of health (SDH), was associated with the use of SRH services. METHODS: We analysed data from repeated cross-sectional national surveys, the Uganda Demographic and Health Surveys (DHS) of 2006, 2011, and 2016. The three outcomes of interest were antenatal care visits, HIV testing, and modern contraception use. Our main exposure of interest was the type of disability, classified according to six functional dimensions: seeing, hearing, walking/climbing steps, remembering/concentrating, communicating, and self-care. We performed descriptive and multivariable logistic regression analyses, which controlled for covariates such as survey year, sex, age, place of residence, education, and wealth index. Interaction terms between disability and other factors such as sex, education, and wealth index were explored. Regression analyses were informed by an intersectionality framework to highlight social and health disparities within groups. RESULTS: From 2006 to 2016, 15.5-18.5% of study participants lived with some form of disability. Over the same period, the overall prevalence of at least four antenatal care visits increased from 48.3 to 61.0%, while overall HIV testing prevalence rose from 30.8 to 92.4% and the overall prevalence of modern contraception use increased from 18.6 to 34.2%. The DHS year, highest education level attained, and wealth index were the most consistent determinants of SRH service utilisation. People with different types of disabilities did not have the same SRH use patterns. Interactions between disability type and wealth index were associated with neither HIV testing nor the use of modern contraception. Women who were wealthy with hearing difficulty (Odds Ratio (OR) = 0.15, 95%CI 0.03 - 0.87) or with communication difficulty (OR = 0.17, 95%CI 0.03 - 0.82) had lower odds of having had optimal antenatal care visits compared to women without disabilities who were poorer. CONCLUSION: This study provided evidence that SRH service use prevalence increased over time in Uganda and highlights the importance of studying SRH and the different disability types when examining SDH. The SDH are pivotal to the attainment of universal health coverage, including SRH services, for all people irrespective of their social identities.

Endogenous inclusion in the Demographic and Health Survey anthropometric sample: Implications for studying height within households.

Development economists study both anthropometry and intra-household allocation. In these literatures, the Demographic and Household Surveys (DHS) are essential. The DHS censors its anthropometric sample by age: only children under five are measured. We document several econometric consequences, especially for estimating birth-order effects. Child birth order and mothers' fertility are highly correlated in the age-censored anthropometric subsample. Moreover, family structures and age patterns that permit within-family comparisons of siblings' anthropometry are unrepresentative. So strategies that could separate birth order and fertility in other data cannot here. We show that stratification by mother's fertility is important. We illustrate this by comparing India and sub-Saharan Africa (SSA). Children in India born to higher-fertility mothers are shorter, on average, than children of lower-fertility mothers. Yet, later-born children in India are taller, adjusted for age, than earlier-born children of the same sibsize. In SSA, neither of these associations is large.