Profiling malaria infection among under-five children in the Democratic Republic of Congo.

INTRODUCTION: In 2018, Malaria accounted for 38% of the overall morbidity and 36% of the overall mortality in the Democratic Republic of Congo (DRC). This study aimed to identify malaria socioeconomic predictors among children aged 6-59 months in DRC and to describe a socioeconomic profile of the most-at-risk children aged 6-59 months for malaria infection. MATERIALS AND METHODS: This study used data from the 2013 DRC Demographic and Health Survey. The sample included 8,547 children aged 6-59 months who were tested for malaria by microscopy. Malaria infection status, the dependent variable, is a dummy variable characterized as a positive or negative test. The independent variables were child's sex, age, and living arrangement; mother's education; household's socioeconomic variables; province of residence; and type of place of residence. Statistical analyses used the chi-square automatic interaction detector (CHAID) model and logistic regression. RESULTS: Of the 8,547 children included in the sample, 25% had malaria infection. Four variables-child's age, mother's education, province, and wealth index-were statistically associated with the prevalence of malaria infection in bivariate analysis and multivariate analysis (CHAID and logistic regression). The prevalence of malaria infection increases with child's age and decreases significantly with mother's education and the household wealth index. These findings suggest that the prevalence of malaria infection is driven by interactions among environmental factors, socioeconomic characteristics, and probably differences in the implementation of malaria programs across the country. The effect of mother's education on malaria infection was only significant among under-five children living in Ituri, Kasaï-Central, Haut-Uele, Lomami, Nord-Ubangi, and Maniema provinces, and the effect of wealth index was significant in Mai-Ndombe, Tshopo, and Haut-Katanga provinces. CONCLUSION: Findings from this study could be used for targeting malaria interventions in DRC. Although malaria infection is common across the country, the prevalence of children at high risk for malaria infection varies by province and other background characteristics, including age, mother's education, wealth index, and place of residence. In light of these findings, designing provincial and multisectoral interventions could be an effective strategy to achieve zero malaria infection in DRC.

Situation analysis for delivering integrated comprehensive sexual and reproductive health services for displaced population of Kasaï, Democratic Republic of Congo: Protocol for a mixed method study.

INTRODUCTION: Delivering integrated sexual and reproductive health services (SRHS) in emergencies is important in order to save lives of the most vulnerable as well as to combat poverty, reduce inequities and social injustice. More than 60% of preventable maternal deaths occur in conflict areas and especially among the internally displaced persons (IDP). Between 2016 and 2018, unprecedented violence erupted in the Kasaï's region, in the Democratic Republic of Congo (DRC), called the Kamuina Nsapu Insurgency. During that period, an estimated three million of adolescent girls and women were forced to flee; and have faced growing threat to their health, safety, security, and well-being including significant sexual and reproductive health challenges. Between August 2016 and May 2017, the "Sous-Cluster sur les violences basées sur le genre (SC-VBG)" in DRC (2017) reported 1,429 Gender Based Violence (GBV) incidents in the 49 service delivery points in the provinces of Kasaï, Kasaï Central and Kasaï Oriental. Rape cases represented 79% of reported incidents whereas sexual assault and forced marriage accounted for respectively 11% and 4% of Gender Based Violence (GBV) among women and adolescent girls. This study aims to assess the availability of SRHS in the displaced camps in Kasaï; to evaluate the SRHS needs of young girls and women in the reproductive age (12-49). Studies of sexual and reproductive health (SRH) in the Democratic Republic of Congo (DRC) have often included adolescent girls under the age of 15 because of high prevalence of child marriage and early onset of childbearing, especially in the humanitarian context. According to the 2013 Demographic and Health Survey (DHS), about 16% of surveyed women got married by age 14 while the prevalence of early child marriage (marriage by 15) was estimated at 30%; to assess the use of SRHS services and identify barriers as well as challenges for SRH service delivery and use. Findings from this study will help provide evidence to inform towards more needs-based and responsive SRH service delivery. This is hoped for ultimately improve the quality and effectiveness of services, when considering service delivery and response in humanitarian settings. DATA AND METHODS: We will conduct a mixed-methods study design, which will combine quantitative and qualitative approaches. Based on the estimation of the sample size, quantitative data will be drawn from the community-based survey (500 women of reproductive age per site) and health facility assessments will include assessments of 45 health facilities and 135 health providers' interviews. Qualitative data will comprise materials from 30 Key Informant Interviews (KII) and 24 Focus Group Discussions (FGDs), which are believed to achieve the needed saturation levels. Data analysis will include thematic and content analysis for the KIIs and FGDs using ATLAS.ti software for the qualitative arm. For the quantitative arm, data analysis will combine frequency and bivariate chi-square analysis, coupled with multi-level regression models, using Stata 15 software. Statistic differences will be established at the significance level of 0.05. We submitted this protocol to the national ethical committee of the ministry of health in September 2019 and it was approved in January 2020. It needs further approval from the Scientific Oversee Committee (SOC) and the Provincial Ministry of Health. Prior to data collection, informed consents will be obtained from all respondents.

THE DUAL BURDEN OF NUTRITION TRANSITION AMONG WOMEN IN SUB-SAHARAN AFRICA: A CASE STUDY OF UNDERWEIGHT IN NIGERIA.

In sub-Saharan Africa, nutrition research has primarily focused on under-nutrition, particularly among vulnerable children. However, there is increasing evidence of an emerging nutrition transition with extremely high rates of obesity, and malnutrition in women may be a problem that is insufficiently recognized and inadequately documented. This analysis was based on the 2008 Nigerian Demographic and Health Survey (NDHS), which included 27,967 women aged 15-49 years. Individual-level data were collected for socio-demographic characteristics and aggregated to the country's 37 states. A Bayesian geo-additive mixed model was used to map the geographic distribution of under-nutrition at the state level, accounting for individual-level risk factors. The results reveal that 12.0% of the population were underweight, while 20.9% were either overweight or obese, based on BMI. The northern states of Sokoto and Yobe/Borno and the southern state of Delta had the highest prevalence of underweight, while states in the centre had the lowest underweight prevalence. Underweight women were more likely to be from poorer households compared with their counterparts from the richest wealth index, which were consistently associated with lower odds of being underweight (posterior odds ratio (POR) and 95% credible region (CR): 0.56 [0.46, 0.70]). On the other hand Muslim women (1.61 [1.10, 2.23]), those of traditional religion (2.12 [1.44, 3.00]), those from the Fulani ethnic group (2.90 [1.64, 5.55]) and those living in Yobe state were all consistently associated with higher odds of being underweight. This study demonstrates that underweight is a major public health problem in Nigeria affecting adult females in the northern states of Nigeria. Identifying risk factors and the need to account for sex, spatial and socio-cultural issues are crucial to develop and implement evidence-informed strategies and interventions for lifestyle health promotion.

Prompt access to effective malaria treatment among children under five in sub-Saharan Africa: a multi-country analysis of national household survey data.

BACKGROUND: Scaling up diagnostic testing and treatment is a key strategy to reduce the burden of malaria. Delays in accessing treatment can have fatal consequences; however, few studies have systematically assessed these delays among children under five years of age in malaria-endemic countries of sub-Saharan Africa. This study identifies predictors of prompt treatment with first-line artemisinin combination therapy (ACT) and describes profiles of children who received this recommended treatment. METHODS: This study uses data from the most recent Demographic and Health Survey, Malaria Indicator Survey, or Anaemia and Parasite Prevalence Survey conducted in 13 countries. A Chi square automatic interaction detector (CHAID) model was used to identify factors associated with prompt and effective treatment among children under five years of age. RESULTS: The percentage of children with fever who received any anti-malarial treatment varies from 3.6 % (95 % CI 2.8-4.4 %) in Ethiopia to 64.5 % (95 % CI 62.7-66.2 %) in Uganda. Among those who received prompt treatment with any anti-malarial medicine, the percentage who received ACT ranged from 32.2 % (95 % CI 26.1-38.4 %) in Zambia to nearly 100 % in Tanzania mainland and Zanzibar. The CHAID analysis revealed that country of residence is the best predictor of prompt and effective treatment (p < 0.001). Depending on the country, the second best predictor was maternal education (p = 0.004), place of residence (p = 0.008), or household wealth index (p < 0.001). CONCLUSIONS: This study reveals that country of residence, maternal education, place of residence, and socio-economic status are key predictors of prompt access to malaria treatment. Achieving universal coverage and the elimination agenda will require effective monitoring to detect disparities early and sustained investments in routine data collection and policy formulation.

Pregnancy-related mortality in Africa and Asia: evidence from INDEPTH Health and Demographic Surveillance System sites.

BACKGROUND: Women continue to die in unacceptably large numbers around the world as a result of pregnancy, particularly in sub-Saharan Africa and Asia. Part of the problem is a lack of accurate, population-based information characterising the issues and informing solutions. Population surveillance sites, such as those operated within the INDEPTH Network, have the potential to contribute to bridging the information gaps. OBJECTIVE: To describe patterns of pregnancy-related mortality at INDEPTH Network Health and Demographic Surveillance System sites in sub-Saharan Africa and southeast Asia in terms of maternal mortality ratio (MMR) and cause-specific mortality rates. DESIGN: Data on individual deaths among women of reproductive age (WRA) (15-49) resident in INDEPTH sites were collated into a standardised database using the INDEPTH 2013 population standard, the WHO 2012 verbal autopsy (VA) standard, and the InterVA model for assigning cause of death. RESULTS: These analyses are based on reports from 14 INDEPTH sites, covering 14,198 deaths among WRA over 2,595,605 person-years observed. MMRs varied between 128 and 461 per 100,000 live births, while maternal mortality rates ranged from 0.11 to 0.74 per 1,000 person-years. Detailed rates per cause are tabulated, including analyses of direct maternal, indirect maternal, and incidental pregnancy-related deaths across the 14 sites. CONCLUSIONS: As expected, these findings confirmed unacceptably high continuing levels of maternal mortality. However, they also demonstrate the effectiveness of INDEPTH sites and of the VA methods applied to arrive at measurements of maternal mortality that are essential for planning effective solutions and monitoring programmatic impacts.

The non-specific effects of vaccines and other childhood interventions: the contribution of INDEPTH Health and Demographic Surveillance Systems.

Most childhood interventions (vaccines, micronutrients) in low-income countries are justified by their assumed effect on child survival. However, usually the interventions have only been studied with respect to their disease/deficiency-specific effects and not for their overall effects on morbidity and mortality. In many situations, the population-based effects have been very different from the anticipated effects; for example, the measles-preventive high-titre measles vaccine was associated with 2-fold increased female mortality; BCG reduces neonatal mortality although children do not die of tuberculosis in the neonatal period; vitamin A may be associated with increased or reduced child mortality in different situations; effects of interventions may differ for boys and girls. The reasons for these and other contrasts between expectations and observations are likely to be that the immune system learns more than specific prevention from an intervention; such training may enhance or reduce susceptibility to unrelated infections. INDEPTH member centres have been in an ideal position to document such additional non-specific effects of interventions because they follow the total population long term. It is proposed that more INDEPTH member centres extend their routine data collection platform to better measure the use and effects of childhood interventions. In a longer perspective, INDEPTH may come to play a stronger role in defining health research issues of relevance to low-income countries.

Trend in the use of modern contraception in sub-Saharan Africa: Does women's education matter?

BACKGROUND: Existing literature revealed positive association between women's education and modern contraceptive use in sub-Saharan Africa (SSA). Overall modern contraception prevalence (MCP) and proportion of women with formal education have increased in region. However, little is known about how much the change in the prevalence of modern contraceptive methods is relative to the compositional change in population and how much of the change is actually due to increases in the number of women adopting the new behavior. OBJECTIVE(S): This study aims to (1) describe trends in modern contraception prevalence by female education; and (2) identify the source of changes in modern contraceptive use by educational attainment (changes in structure or in population behavior). STUDY DESIGN: This is a cross-sectional study using Demographic and Health Surveys from 27 SSA countries where at least two comparable surveys have been conducted. RESULTS: Overall modern contraception prevalence (MCP) has increased in SSA over the study period. The ongoing increase in the contraceptive use is due to changes in behavior consistent with the ongoing family planning promotion over the past 30 years. By contrast, an increase in the proportion of women with secondary education does not explain the change in MCP in most SSA countries. CONCLUSION(S): To achieve universal access to family planning, efforts in promoting female education should be complemented with economic, cultural and geographical access to MCP. Household-based sensitization, general hospitals, mobile family planning clinics, and community-based distributors of modern contraceptive methods are key strategies to improve access to modern contraceptive use. IMPLICATION: Findings from this study suggest that countries should combine social investments, including health services and education, with family planning programs using reproductive health services, mobile family planning clinics and community-based distributors of modern contraceptive methods. Therefore, governments' legislation measures that promote universal secondary education as well as universal access to modern contraception can be put in place.

Child mortality in the Democratic Republic of Congo: cross-sectional evidence of the effect of geographic location and prolonged conflict from a national household survey.

BACKGROUND: The child mortality rate is a good indicator of development. High levels of infectious diseases and high child mortality make the Democratic Republic of Congo (DRC) one of the most challenging environments for health development in Sub-Saharan Africa (SSA). Recent conflicts in the eastern part of the country and bad governance have compounded the problem. This study aimed to examine province-level geographic variation in under-five mortality (U5M), accounting for individual- and household-level risk factors including environmental factors such as conflict. METHODS: Our analysis used the nationally representative cross-sectional household sample of 8,992 children under five in the 2007 DRC Demographic and Health Survey. In the survey year, 1,005 deaths among this group were observed. Information on U5M was aggregated to the 11 provinces, and a Bayesian geo-additive discrete-time survival mixed model was used to map the geographic distribution of under-five mortality rates (U5MRs) at the province level, accounting for observable and unobservable risk factors. RESULTS: The overall U5MR was 159 per 1,000 live births. Significant associations with risk of U5M were found for <24 month birth interval [posterior odds ratio and 95% credible region: 1.14 (1.04, 1.26)], home birth [1.13 (1.01, 1.27)] and living with a single mother [1.16 (1.03, 1.33)]. Striking variation was also noted in the risk of U5M by province of residence, with the highest risk in Kasaï-Oriental, a non-conflict area of the DRC, and the lowest in the conflict area of North Kivu. CONCLUSION: This study reveals clear geographic patterns in rates of U5M in the DRC and shows the potential role of individual child, household and environmental factors, which are unexplained by the ongoing conflict. The displacement of mothers to safer areas may explain the lower U5MR observed at the epicentre of the conflict in North Kivu, compared with rates in conflict-free areas. Overall, the U5M maps point to a lack of progress towards the Millennium Development Goal of reducing U5M by half by 2015.

UNAIDS 'multiple sexual partners' core indicator: promoting sexual networks to reduce potential biases.

UNAIDS proposed a set of core indicators for monitoring changes in the worldwide AIDS epidemic. This paper explores the validity and effectiveness of the 'multiple sexual partners' core indicator, which is only partially captured with current available data. The paper also suggests an innovative approach for collecting more informative data that can be used to provide an accurate measure of the UNAIDS's 'multiple sexual partners' core indicator. Specifically, the paper addresses three major limitations associated with the indicator when it is measured with respondents' sexual behaviors. First, the indicator assumes that a person's risk of contracting HIV/AIDS/STIs is merely a function of his/her own sexual behavior. Second, the indicator does not account for a partner's sexual history, which is very important in assessing an individual's risk level. Finally, the 12-month period used to define a person's risks can be misleading, especially because HIV/AIDS theoretically has a period of latency longer than a year. The paper concludes that, programmatically, improvements in data collection are a top priority for reducing the observed bias in the 'multiple sexual partners' core indicator.

Identifying HIV most-at-risk groups in Malawi for targeted interventions. A classification tree model.

OBJECTIVES: To identify HIV-socioeconomic predictors as well as the most-at-risk groups of women in Malawi. DESIGN: A cross-sectional survey. SETTING: Malawi PARTICIPANTS: The study used a sample of 6395 women aged 15-49 years from the 2010 Malawi Health and Demographic Surveys. INTERVENTIONS N/A PRIMARY AND SECONDARY OUTCOME MEASURES: Individual HIV status: positive or not. RESULTS: Findings from the Pearson χ(2) and χ(2) Automatic Interaction Detector analyses revealed that marital status is the most significant predictor of HIV. Women who are no longer in union and living in the highest wealth quintiles households constitute the most-at-risk group, whereas the less-at-risk group includes young women (15-24) never married or in union and living in rural areas. CONCLUSIONS: In the light of these findings, this study recommends: (1) that the design and implementation of targeted interventions should consider the magnitude of HIV prevalence and demographic size of most-at-risk groups. Preventive interventions should prioritise couples and never married people aged 25-49 years and living in rural areas because this group accounts for 49% of the study population and 40% of women living with HIV in Malawi; (2) with reference to treatment and care, higher priority must be given to promoting HIV test, monitoring and evaluation of equity in access to treatment among women in union disruption and never married or women in union aged 30-49 years and living in urban areas; (3) community health workers, households-based campaign, reproductive-health services and reproductive-health courses at school could be used as canons to achieve universal prevention strategy, testing, counselling and treatment.

Accounting for recent trends in the prevalence of diarrhoea in the Democratic Republic of Congo (DRC): results from consecutive cross-sectional surveys.

OBJECTIVES: To analyse trends in diarrhoea prevalence by maternal education, access to clean water and improved sanitation, household wealth index; to identify the sources of variation and assess contribution of changes in socioeconomic characteristics in the Democratic Republic of Congo (DRC). DESIGN: Consecutive cross-sectional surveys. SETTING: DRC. PARTICIPANTS: The databases contain information on 9748 children from the 2001 Multiple Indicators Cluster Survey and 7987 children from the 2007 Demographic and Health Survey. INTERVENTIONS: N/A. PRIMARY AND SECONDARY OUTCOME MEASURES: Whether the child had diarrhoea 14 days preceding the survey. RESULTS: The overall prevalence of diarrhoea decreased by 26 percent (from 22.1% in 2001 to 16.4% in 2007). Findings from the three complementary statistical methods are consistent and confirm a significant decrease in diarrhoea regardless of socioeconomic characteristics. Changes in behaviour and/or in public health policy seem to be the likely main source of the change. There were no significant changes in diarrhoea prevalence associated with variation of the population structure. It is worth mentioning that the decrease in diarrhoea prevalence is in contrast to the generalised poor living conditions of the population. Therefore, it is difficult to ascertain whether the decline in diarrhoea prevalence was due to real improvement in public-health policy or to data quality issues. CONCLUSIONS: The decline of diarrhoea prevalence in our study need to be further investigated by conducting district-based or provincial-based studies to validate findings from household surveys such as Demographic and Health Surveys and Multiple Indicators Cluster Survey taking into account the current context of the country: ongoing conflict, poor socioeconomic and poor health infrastructure. However, improvement in living conditions such as access to clean water and improved sanitation will contribute to accelerate the reduction of diarrhoea prevalence as well as reduction of child mortality.

Health and demographic surveillance systems: a step towards full civil registration and vital statistics system in sub-Sahara Africa?

BACKGROUND: In the developed world, information on vital events is routinely collected nationally to inform population and health policies. However, in many low-and middle-income countries, especially those in sub-Saharan Africa (SSA), there is a lack of effective and comprehensive national civil registration and vital statistics system. In the past decades, the number of Health and Demographic Surveillance Systems (HDSSs) has increased throughout SSA. An HDSS monitors births, deaths, causes of death, migration, and other health and socio-economic indicators within a defined population over time. Currently, the International Network for the Continuous Demographic Evaluation of Populations and Their Health (INDEPTH) brings together 38 member research centers which run 44 HDSS sites from 20 countries in Africa, Asia and Oceana. Thirty two of these HDSS sites are in SSA. DISCUSSION: This paper argues that, in the absence of an adequate national CRVS, HDSSs should be more effectively utilised to generate relevant public health data, and also to create local capacity for longitudinal data collection and management systems in SSA. If HDSSs get strategically located to cover different geographical regions in a country, data from these sites could be used to provide a more complete national picture of the health of the population. They provide useful data that can be extrapolated for national estimates if their regional coverage is well planned. HDSSs are however resource-intensive. Efforts are being put towards getting them linked to local or national policy contexts and to reduce their dependence on external funding. Increasing their number in SSA to cover a critical proportion of the population, especially urban populations, must be carefully planned. Strategic planning is needed at national levels to geographically locate HDSS sites and to support these through national funding mechanisms. SUMMARY: The paper does not suggest that HDSSs should be seen as a replacement for civil registration systems. Rather, they should serve as a short- to medium-term measure to provide data for health and population planning at regional levels with possible extrapolation to national levels. HDSSs can also provide useful lessons for countries that intend to set up nationally representative sample vital registration systems in the long term.

Malnutrition among children under the age of five in the Democratic Republic of Congo (DRC): does geographic location matter?

BACKGROUND: Although there are inequalities in child health and survival in the Democratic Republic of Congo (DRC), the influence of distal determinants such as geographic location on children's nutritional status is still unclear. We investigate the impact of geographic location on child nutritional status by mapping the residual net effect of malnutrition while accounting for important risk factors. METHODS: We examine spatial variation in under-five malnutrition with flexible geo-additive semi-parametric mixed model while simultaneously controlling for spatial dependence and possibly nonlinear effects of covariates within a simultaneous, coherent regression framework based on Markov Chain Monte Carlo techniques. Individual data records were constructed for children. Each record represents a child and consists of nutritional status information and a list of covariates. For the 8,992 children born within the last five years before the survey, 3,663 children have information on anthropometric measures.Our novel empirical approach is able to flexibly determine to what extent the substantial spatial pattern of malnutrition is driven by detectable factors such as socioeconomic factors and can be attributable to unmeasured factors such as conflicts, political, environmental and cultural factors. RESULTS: Although childhood malnutrition was more pronounced in all provinces of the DRC, after accounting for the location's effects, geographic differences were significant: malnutrition was significantly higher in rural areas compared to urban centres and this difference persisted after multiple adjustments. The findings suggest that models of nutritional intervention must be carefully specified with regard to residential location. CONCLUSION: Childhood malnutrition is spatially structured and rates remain very high in the provinces that rely on the mining industry and comparable to the level seen in Eastern provinces under conflicts. Even in provinces such as Bas-Congo that produce foods, childhood malnutrition is higher probably because of the economic decision to sell more than the population consumes. Improving maternal and child nutritional status is a prerequisite for achieving MDG 4, to reduce child mortality rate in the DRC.