Abstract Background: Studies into risk factors and causes of childhood mortality present the opportunity to identify intervention programs appropriate in different populations in our attempt to reach the WHO Millennium Development Goals. Objectives: To determine whether there is an association between parental labour migration and child mortality in the Agincourt Health and Demographic Surveillance Site (HDSS) in 2002. Methods: Secondary data extracted from the longitudinal database from the Agincourt Health and Demographic Surveillance System were used to study the association between father’s migration and child mortality in 2002 using logistic regression and survival analysis. The analysis included 10050 children born between 01 January 1998 and 31 December 2002. Results: The child mortality in 2002 was 12.9 deaths per 1000 person years. There was a statistically significant difference in death rate in infants (50.9 deaths per 1000 person years), and in children aged 1-4 years (9.6 deaths per 1000 person years). There was no association observed between migration and child mortality (OR: 0.97, 95% CI 0.59-1.60). The factors associated with mortality were the age of the child, the number of siblings that a child had, the refugee status of the mother, age of the mother at birth, breast feeding and whether the mother was deceased or not. The chances of dying were lower in older children compared to younger ones (OR: 0.58, 95% CI 0.50-0.68). Children who had one or more siblings were less likely to die (OR: 0.62, 95% CI 0.51-0.93) compared to those with none. Child mortality risk was higher in children born to refugees than to local residents (OR: 1.56, 95% CI 1.05-2.33). Those children who were not breast fed had increased chances of dying than those breast fed (OR: 5.33, 95% CI 2.60-10.95). The death of a mother increased the risk of the child dying (OR: 9.35, 95% CI 5.02-17.40). About 84.3% of migrants were sending remittances to members of the households remaining behind but there was no significant difference in child mortality among remitters and nonremitters. The leading causes of death among households with migrant father and those with a non-migrant father were infectious diseases (mainly HIV/AIDS related illness) with 47% and 50% respectively. Conclusion: The results from this study suggest that on average children of migrants in a rural area in South Africa do not experience increased mortality compared to children of non-migrants. The findings from this study where no association between fathers’ migration and child mortality was observed were rather inconclusive. So far, this area of research has not been adequately addressed and much remains to be learned about the lives of children left behind by fathers migrating to seek employment elsewhere. For future studies it would be advisable to study in great depth the long term effects of migration on child mortality particularly in Africa.

MSc (Med), Population-Based Epidemiology, Faculty of Health Sciences, University of the Witwatersrand, 2010

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The world has made important efforts to meet the Millennium Development Goals (MDG) by 2015. However, it is still insufficient and inequalities prevail in the poorest settings. We tracked selected MDG, barriers for their achievement, and community actions that help to accelerate the pace of their accomplishment in two Nicaraguan communities (León and Cuatro Santos). In the first two studies we track the progress of MDG4 (reduce child mortality) using the under-five mortality rate. Inequalities in mortality were mainly assessed by means of maternal education, but other social stratifications were performed on rural-urban residence and sub-regional comparisons between both communities. The last two studies describe community interventions in Cuatro Santos and their association with progress toward MDG1 (poverty reduction). Participation in interventions and poverty were visualized geographically in this remote rural community between 2004 and 2009. Other selected MDG targets were also tracked. These communities will possibly meet MDG4 even before 2015. In León, MDG progress has been accompanied by a decline in child mortality. Despite social inequalities with regard to mortality persisting in education and places of residence, these have decreased. However, it is crucial to reduce neonatal mortality if MDG4 is to be achieved. For example, in León the percentage of under-five deaths in the neonatal period has doubled from 1970 to 2005. In the remote rural area of Cuatro Santos, progress has been accelerated and no child mortality differences were observed despite the level of a mother’s education. Cuatro Santos has also progressed in the reduction of poverty and extreme poverty. The participation of the population in such community interventions as microcredit, home gardening, technical training, safe drinking water, and latrines has increased. Microcredit was an intervention that was unequally distributed in this rural area, where participation was lower in poor and extremely poor households than in non-poor households. In those households that transitioned from poor to non-poor status, microcredit, home gardening, and technical training were associated with this transition. Furthermore spatial analysis revealed that clusters of low participation in interventions overlapped with clusters of high poverty households.

Between 1980 and 2000, mortality rates of children under the age of five and maternal mortality ratios declined across sub-Saharan Africa. During the same period, Kenya's mortality rates continued to rise until 2005 when the Kenyan Ministry of Health (MOH) introduced the Kenya Essential Package for Health (KEPH) in an effort to reverse its declining health indicators. The KEPH defined six service delivery levels which included the new community level, also known as level one. The Ministry of Health's plan for delivering services at the community level, known as the Community Health Strategy (CHS), called for the creation of Community Health Workers (CHWs) which the MOH hoped would produce the expected outcomes of the CHS. CHWs would be trained volunteers that were both members of the community they would serve, and selected by their community. Their training would allow them to recognize health problems, provide basic first aid, refer patients with serious problems to health facilities, conduct surveys, maintain records, provide education, and distribute supplies. In 2010, the Division of Community Health Services released an evaluation of the relevance, efficiency, and sustainability of the community health strategy. Their results showed that CHWs could produce many of the CHS's expected outcomes. In 2013, researchers from the Boston University School of Public Health and Moi University resolved to conduct a cross-sectional study for the Kenyan Ministry of Public Health and Sanitation to assess the effectiveness of the CHWs in Kajiado County. The county faced numerous health challenges and an overburdened health system. Data collection was completed over a seven-day period in June of 2013 by fourteen teams. Data was collected from 12 communities located in the areas of Rombo, Entonet, and Central Divisions of the Loitokitok sub-county within Kajiado County in rural South Kenya. Six of the selected communities had CHWs mobilized and were the intervention communities. Six communities had no registered CHWs and served as the controls. Eligibility to participate in the study was limited to permanent members of randomly selected households that housed at least one child less than five years of age and no active CHWs. Mothers of children less than five years of age were the preferred respondents. The primary and secondary outcomes were selected to address as many of the CHS's expected outcomes as possible. In an effort to compensate for the study's cross-sectional design, results were analyzed by stratifying them by each community's proximity to a hospital, the time since the CHW's last visit, and the respondent's knowledge of their CHW's name. Data was collected from 316 households, half of which were from intervention communities, and was entered into CSPro 5.0 before being exported to EpiInfo 7.1.1 for analysis. Analysis of the results suggests that the Community Health Strategy has been largely ineffective at producing its expected outcomes in Kajiado County as communities with active community health workers typically did not fare significantly better than non-CHW communities. The CHS was not entirely unsuccessful however, as mothers in CHW communities were significantly more likely to give birth at a health facility (PR: 1.41; CI: 1.15-1.72) than in non-CHW communities. Results also indicated that a community's proximity to a hospital could be a confounder in the relationship between a community's CHW status and health outcomes. The success of CHWs may have been masked by their tendency to visit households with worse health indicators more frequently.

Measuring levels of childhood mortality is important for low and middle-income countries to monitor overall development and progress towards improved child health. The overall aim of this research is to estimate the level and trend of childhood mortality in South Africa over time, and to examine the factors associated with and the determinants of childhood mortality. The study discovered that significant progress has been made to reduce the levels of childhood mortality in the country. The estimates derived through direct estimation using the 2016 South African Demographic and Health Survey (SADHS) for the period between 2012-2016 revealed age-specific mortality rates were: Neonatal Mortality Rate (NMR) was 22.0 per 1 000 live births, Post-neonatal Mortality Rate (PNMR) 13.1, 1q0 34.9, 1q4 5.5 and 5q0 40.2 per 1 000 live births. Investigation of the factors associated with childhood mortality revealed significant differentials in age group, sex, population group, province, socio-economic status and household characteristics. Overall, children aged less than one month and those aged between one to two months had a higher mortality risk than the other age groups; male children had an increased risk of dying than females; Black and Coloured children had an increased risk of dying compared to children in other population groups; children in Mpumalanga, Eastern Cape and North West had a higher risk of dying compared to children in other provinces; children whose mothers had below secondary education had higher risks of mortality; and children with poor water source and toilet facility were more likely to die than other children with better facilities. The results were generally in agreement with the existing literature. Although the study found significant improvement in the level of childhood mortality over the period 1996-2016, further progress is achievable as many children still continue to die of preventable or treatable causes. The findings of this study may assist government, policymakers and researchers to plan, and implement targeted interventions that will further reduce the levels of childhood mortality in South Africa.

The objectives of this study are to provide a comprehensive assessment of inequalities in infant and under-five years' child survival, access to and utilisations of child health services among different socio-economic groups in Ethiopia; and identify issues for policies and programmes at national and sub-national levels. This thesis examines the effect of parental socioeconomic status, maternal and delivery care services, mothers' bio-demographic and background characteristics on the level of differences in infant and under-five years' child survival and access to and utilisation of child health services. Descriptive and multivariate analyses were carried out for selected variables in the literature which were consider as the major determinants of infant mortality rate (IMR) and under-five years' child mortality rate (U5MR); access to and utilisations of child health services based on data from Ethiopian demographic and health survey (EDHS), covering the years 2000-2005. In the multivariate analysis a logit regression model was used to estimates inequalities in infant and under-five years' child survival, and inequalities in access to and utilisation of child health services. In Ethiopia, little was known about inequalities in IMR and U5MR, and inequalities in access to and utilisation of child health services. Besides, there is no systematic analysis of health inequalities and into its determinants using logistic regression. According to the available literature, this is the first comprehensive and systematic analysis of inequality of health in Ethiopia. The findings show that compared to under-five years' children of mothers' partners with no work, mothers' partners in professional, technical and managerial occupations had 13 times more chance of under-five years child survival for 2000 weighted observations. In addition, compared to infants of mothers who were gave birth to one child in last 5 years preceding the survey, infants of mothers who were gave birth to 2 children in last 5 years preceding the survey had 70% less chance of infant survival while infants of mothers who were gave birth to 3 or more children had 89% less chance of infant survival for 2000 weighted observations. Moreover, this study finding also indicates that inequalities increased significantly in the five years period between 2000 and 2005 among mothers with different birth interval. Most of the relations between birth interval and receiving childhood immunisation for vaccine-preventable diseases were statistically significant. Moreover compared to non-educated mothers, mothers who completed secondary and higher education were nearly 10 times more likely to receive DPT3 immunisation for their young children. This study concludes that policy measures that tackle health inequalities will have a positive impact in the implementation of health sector strategy of Ethiopia. Health inequalities studies in Ethiopia and Sub-Saharan Africa (SSA) countries should focus on systematic analysis of different socio-economic groups. The finding of this study support investing in the Ethiopia's health extension package (HEP) is a necessary but not sufficient condition for addressing rural poor health problem. HEP is successful in increasing primary health care coverage in rural Ethiopia to 89.6% (FMOH, 2009) but unable to reduce Ethiopia's higher level of IMR and U5MR. HEP is one of the success stories that address the rural poor health problem and can also be adapted to developing countries of SSA. The finding also shows that the success stories such as health insurance programs like Rwanda (World Bank, 2008a) and Ethiopia (FMOH, 2009/10) will play a key role in achieving country's health care financing goal of universal coverage. This can also be replicated in the developing SSA countries.

Thesis (M.Sc. (Statistics)) -- University of Limpopo, 2014 / The health and survival of children are important measures of the social wellbeing and health status of the community. The World Community made a commitment to reduce under-five mortality by two-thirds between 1990 and 2015. The purpose of this study was to identify factors that have influence on child survival. The Dikgale Health and Demographic Surveillance System (HDSS) data for children born between 01 January 1996 and 31 December 2010 were analysed using cross-tabulation, logistic regression and survival analysis to determine factors that have influence on child survival. The findings revealed that mother’s survival status and child birth weight are significantly associated with child survival. The results showed that the odds that children born to mothers who are alive survive beyond five years are almost four times the odds that children born to mothers who are not alive survive beyond five years. The study also found that the odds that children born with birth weight 2.5kg or more survive beyond five years are almost two times that of children born with birth weight less than 2.5kg. The results of this study may help in formulating strategies and interventions that improve the lifespan of children and assist in the reduction of child mortality. KEY CONCEPTS Child survival, Health Demographic Surveillance System, Cross-tabulation, Logistic regression, Survival analysis, Mother’s survival status, Birth weight.

The objectives of this study are to provide a comprehensive assessment of inequalities in infant and under-five years¿ child survival, access to and utilisations of child health services among different socio-economic groups in Ethiopia; and identify issues for policies and programmes at national and sub-national levels. This thesis examines the effect of parental socioeconomic status, maternal and delivery care services, mothers¿ bio-demographic and background characteristics on the level of differences in infant and under-five years¿ child survival and access to and utilisation of child health services. Descriptive and multivariate analyses were carried out for selected variables in the literature which were consider as the major determinants of infant mortality rate (IMR) and under-five years¿ child mortality rate (U5MR); access to and utilisations of child health services based on data from Ethiopian demographic and health survey (EDHS), covering the years 2000-2005. In the multivariate analysis a logit regression model was used to estimates inequalities in infant and under-five years¿ child survival, and inequalities in access to and utilisation of child health services. In Ethiopia, little was known about inequalities in IMR and U5MR, and inequalities in access to and utilisation of child health services. Besides, there is no systematic analysis of health inequalities and into its determinants using logistic regression. According to the available literature, this is the first comprehensive and systematic analysis of inequality of health in Ethiopia. The findings show that compared to under-five years¿ children of mothers¿ partners¿ with no work, mothers¿ partners¿ in professional, technical and managerial occupations had 13 times more chance of under-five years¿ child survival for 2000 weighted observations. In addition, compared to infants of mothers who were gave birth to one child in last 5 years preceding the survey, infants of mothers who were gave birth to 2 children in last 5 years preceding the survey had 70% less chance of infant survival while infants of mothers who were gave birth to 3 or more children had 89% less chance of infant survival for 2000 weighted observations. Moreover, this study finding also indicates that inequalities increased significantly in the five years period between 2000 and 2005 among mothers with different birth interval. Most of the relations between birth interval and receiving childhood immunisation for vaccine-preventable diseases were statistically significant. Moreover compared to non-educated mothers, mothers who completed secondary and higher education were nearly 10 times more likely to receive DPT3 immunisation for their young children. This study concludes that policy measures that tackle health inequalities will have a positive impact in the implementation of health sector strategy of Ethiopia. Health inequalities studies in Ethiopia and Sub-Saharan Africa (SSA) countries should focus on systematic analysis of different socio-economic groups. The finding of this study support investing in the Ethiopia¿s health extension package (HEP) is a necessary but not sufficient condition for addressing rural poor health problem. HEP is successful in increasing primary health care coverage in rural Ethiopia to 89.6% (FMOH, 2009) but unable to reduce Ethiopia¿s higher level of IMR and U5MR. HEP is one of the success stories that address the rural poor health problem and can also be adapted to developing countries of SSA. The finding also shows that the success stories such as health insurance programs like Rwanda (World Bank, 2008a) and Ethiopia (FMOH, 2009/10) will play a key role in achieving country¿s health care financing goal of universal coverage. This can also be replicated in the developing SSA countries.