WHAT'S NEW THIS THURSDAY: FOUR ON ACCESS AND MORTALITY

Wednesday, 19th of September 2012

• FOUR ON ACCESS AND MORTALITY
   
• HOW ACCESS TO HEALTH CARE RELATES TO U5MR IN SUB-SAHARAN AFRICA: SYSTEMATIC REVIEW

Conclusions below; full text is at http://onlinelibrary.wiley.com/doi/10.1111/j.1365-3156.2010.02497.x/full

 Improving access to health care holds great potential for the reduction of child death rates in SSA. Although ecological studies and community intervention trials have suggested a protective effect of health service access against child death, investigations that provide more convincing associations are rare in SSA. Moreover, studies that have investigated specific access factors have historically done so primarily through traditional variables, such as distance and health care cost. Their findings have been inconclusive. Qualitative research emphasises the importance of additional barriers, but these are frequently overlooked in quantitative research, and their exact impact remains unknown. However, several recent studies, which have investigated additional facilitators and barriers, including social support and autonomy, show strong associations between these factors and child death. These findings suggests that they are at least as important as traditional barriers.

In this review, we employ a definition of access that includes variables beyond cost and distance to a health facility. This broader understanding of health care access needs to be distinguished from that of health-seeking behaviour. Health-seeking behaviour has a large literature, albeit mostly ethnographic (Baume et al. 2000; Mbagaya et al. 2005; Ahorlu et al. 2006; Kamat 2006; Rutebemberwa et al. 2009) and the measures considered may overlap with those that reflect access. However, the focus is different and may be best explained by understanding access to be concerned only with obstacles in the way of those who would otherwise choose to seek health care. It is also important to note that we focus on a single endpoint, mortality, avoiding issues associated with disease-specific foci.

We contend that access to health care is multidimensional, and both traditional and additional barriers need to be considered by those planning health care services. Clearly, there is a need for more large-scale, longitudinal research that evaluates the impact of health care access on child health outcomes in SSA. Future research should assess traditional and additional variables in the same study within a structured framework, adopt measures that accurately reflect the total geographic and financial barriers to health care and include indicators culturally relevant to the research setting. If Millennium Goal IV is to be achieved, greater insights are required into the factors that influence access to health care to facilitate meaningful and effective interventions.

• EFFECT OF GEOGRAPHICAL ACCESS TO HEALTH FACILITIES ON CHILD MORTALITY IN RURAL ETHIOPIA: A COMMUNITY BASED CROSS SECTIONAL STUDY

Abstract below; http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0033564

Background There have been few studies that have examined associations between access to health care and child health outcomes in remote populations most in need of health services. This study assessed the effect of travel time and distance to health facilities on mortality in children under five years in a remote area of rural north-western Ethiopia. Methods and Findings This study involved a randomly selected cross sectional survey of 2,058 households. Data were collected during home visits to all resident women of reproductive age (15–49 years). A geographic information system (GIS) was used to map all households and the only health centre in the district. The analysis was restricted to 2,206 rural children who were under the age of five years during the five years before the survey. Data were analysed using random effects Poisson regression. 90.4% (1,996/2,206) of children lived more than 1.5 hours walk from the health centre. Children who lived ≥1.5 hrs from the health centre had a two to three fold greater risk of death than children who lived <1.5 hours from the health centre (children with travel time 1.5–<2.5 hrs adjusted relative risk [adjRR] 2.3[0.95–5.6], travel time 2.5–<3.5 hrs adjRR 3.1[1.3–7.4] and travel time 3.5–<6.5 hrs adjRR 2.5[1.1–6.2]).

Conclusion Distance to a health centre had a marked influence on under five mortality in a poor, rural, remote area of Ethiopia. This study provides important information for policy makers on the likely impact of new health centres and their most effective location in remote areas.

• INFANT MORTALITY IN SOUTH AFRICA - DISTRIBUTION, ASSOCIATIONS AND POLICY IMPLICATIONS, 2007: AN ECOLOGICAL SPATIAL ANALYSIS

Int J Health Geogr. 2011; 10: 61.

Abstract below; full text is at

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3250938/?tool=pubmed

Background

Many sub-Saharan countries are confronted with persistently high levels of infant mortality because of the impact of a range of biological and social determinants. In particular, infant mortality has increased in sub-Saharan Africa in recent decades due to the HIV/AIDS epidemic. The geographic distribution of health problems and their relationship to potential risk factors can be invaluable for cost effective intervention planning. The objective of this paper is to determine and map the spatial nature of infant mortality in South Africa at a sub district level in order to inform policy intervention. In particular, the paper identifies and maps high risk clusters of infant mortality, as well as examines the impact of a range of determinants on infant mortality. A Bayesian approach is used to quantify the spatial risk of infant mortality, as well as significant associations (given spatial correlation between neighbouring areas) between infant mortality and a range of determinants. The most attributable determinants in each sub-district are calculated based on a combination of prevalence and model risk factor coefficient estimates. This integrated small area approach can be adapted and applied in other high burden settings to assist intervention planning and targeting.

Results

Infant mortality remains high in South Africa with seemingly little reduction since previous estimates in the early 2000's. Results showed marked geographical differences in infant mortality risk between provinces as well as within provinces as well as significantly higher risk in specific sub-districts and provinces. A number of determinants were found to have a significant adverse influence on infant mortality at the sub-district level. Following multivariable adjustment increasing maternal mortality, antenatal HIV prevalence, previous sibling mortality and male infant gender remained significantly associated with increased infant mortality risk. Of these antenatal HIV sero-prevalence, previous sibling mortality and maternal mortality were found to be the most attributable respectively.

Conclusions

This study demonstrates the usefulness of advanced spatial analysis to both quantify excess infant mortality risk at the lowest administrative unit, as well as the use of Bayesian modelling to quantify determinant significance given spatial correlation. The "novel" integration of determinant prevalence at the sub-district and coefficient estimates to estimate attributable fractions further elucidates the "high impact" factors in particular areas and has considerable potential to be applied in other locations. The usefulness of the paper, therefore, not only suggests where to intervene geographically, but also what specific interventions policy makers should prioritize in order to reduce the infant mortality burden in specific administration areas.

• ASSOCIATION BETWEEN PROXIMITY TO A HEALTH CENTER AND EARLY CHILDHOOD MORTALITY IN MADAGASCAR

Abstract below; full text is at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0038370

Objective

To evaluate the association between proximity to a health center and early childhood mortality in Madagascar, and to assess the influence of household wealth, maternal educational attainment, and maternal health on the effects of distance.

Methods

From birth records of subjects in the Demographic and Health Survey, we identified 12565 singleton births from January 2004 to August 2009. After excluding 220 births that lacked global positioning system information for exposure assessment, odds ratios (ORs) and their 95% confidence intervals (CIs) for neonatal mortality and infant mortality were estimated using multilevel logistic regression models, with 12345 subjects (level 1), nested within 584 village locations (level 2), and in turn nested within 22 regions (level 3). We additionally stratified the subjects by the birth order. We estimated predicted probabilities of each outcome by a three-level model including cross-level interactions between proximity to a health center and household wealth, maternal educational attainment, and maternal anemia.

Results

Compared with those who lived >1.5–3.0 km from a health center, the risks for neonatal mortality and infant mortality tended to increase among those who lived further than 5.0 km from a health center; the adjusted ORs for neonatal mortality and infant mortality for those who lived >5.0–10.0 km away from a health center were 1.36 (95% CI: 0.92–2.01) and 1.42 (95% CI: 1.06–1.90), respectively. The positive associations were more pronounced among the second or later child. The distance effects were not modified by household wealth status, maternal educational attainment, or maternal health status.

Conclusions

Our study suggests that distance from a health center is a risk factor for early childhood mortality (primarily, infant mortality) in Madagascar by using a large-scale nationally representative dataset. The accessibility to health care in remote areas would be a key factor to achieve better infant health.