Magister Public Health - MPH / Ethiopia has achieved its target for Millennium Development Goal 4 by recording 69 %reduction in its under-five mortality. The proportion of fully immunized children in Ethiopia has increased from 14 % in 2000 to 24 % in 2011. Though progress has been made, about 3 out of 4 children still remain incompletely immunized. The purpose of this study is to determine the socio-demographic and socioeconomic factors associated with incomplete immunization among children aged 12-23 months in Ethiopia. This study is based on secondary analysis of the 2011 Ethiopia Demographic and Health Survey. Information on 1,889 mothers of children aged 12–23 months were extracted from the children dataset. Records from vaccination cards and mothers’ self-reported data were used to determine vaccine coverage. The association between child immunization status and determinants of non-utilization of immunization services was assessed using bivariate and multivariate analyses. The findings of this study showed that the prevalence of incompletely immunized children is 70.9%. Children of mothers from the poor (AOR = 2.27; 95 % CI: 1.34 – 3.82) wealth quintile were more likely to be incompletely immunized. Children of mothers from Affar (AOR = 15.80; 95 % CI: 7.12 – 35.03), Amhara (AOR = 4.27; 95 %CI: 2.31 – 7.88), Oromiya (AOR = 8.10; 95 % CI: 4.60 – 14.25), Somali (AOR = 4.91;95 % CI: 2.65 – 9.10), Benishangul-Gumuz (AOR = 4.20; 95% CI: 2.34 – 7.57),Southern Nations Nationalities and Peoples’ (AOR = 4.76; 95 % CI: 2.53 – 8.94), Gambela (AOR = 7.75; 95 % CI: 3.68 – 16.30) and Harari (AOR = 3.22; 95 % CI: 1.77 –5.89) regions were more likely to be incompletely immunized. Mothers with inadequate exposure to media (AOR = 1.60; 95% CI: 1.21 – 2.14), who are not aware of community conversation programme (AOR = 1.80; 95% CI: 1.40 – 2.32) and who attended no antenatal care (AOR = 2.21; 95% CI: 1.72 – 2.83) were more likely to have incompletely immunized children. Despite efforts to increase rates of childhood immunization, the proportion of children with incomplete immunization in Ethiopia is considerably high. Therefore, targeted interventions at the identified socio-demographic factors are needed to increase immunization rates.

The usefulness of secondary exposure and health data to improve public health in South Africa will be assessed. Given the tremendous health impact of air pollution exposure the focus of this thesis is on primary prevention, that is the identification of outdoor air pollution and the use of dirty fuels (wood, animal dung, crop residues, coal, paraffin) for cooking and heating as risk factors, whilst controlling for confounding. Hourly averaged outdoor PM10 mass, NO2, NO, SO2, O3 data (1 August 1998 - 31 July 2003) from Cape Town were analysed in a nonparametric Spearman’s Rho correlation analysis to determine the seasonal spatial correlation between the monitoring sites. Trend and descriptive analyses were conducted on the outdoor hourly and daily PM10 mass data to investigate the current and future health implications in the Khayelitsha sub-district, Cape Town. The 1998 South African Demographic and Health Survey (SADHS) data were analysed. The survey involved 13 826 individuals in 12763 households. Univariate and multivariate logistic regression analyses generated crude and adjusted odds ratios and 95% confidence intervals in order to assess the influence of dirty fuel use for cooking and heating on adult (> 15 years) respiratory health, childhood (< 59 months) respiratory health and 1-59 month mortality. It was found that outdoor air pollution is not homogenously distributed in Cape Town during all seasons. Elevated PM10 mass concentrations are frequently present in the Khayelitsha sub-district. There is a strong case for acknowledging the large public health risk arising from air pollution exposure in South Africa, despite the limitations of the 1998 SADHS data. Not much progress has been made in air pollution epidemiology in the country during this investigation due to the identified limitations. Secondary exposure and health data are thus only useful in improving public health in South Africa by supplying baseline data for trend analysis or hypotheses generation. It is recommended that the country must develop environmental public health tracking networks, which incorporates various data sources from multi-sectoral collaborative intervention projects with analytic study designs, in all major cities in the country. / Thesis (PhD)--University of Pretoria, 2006. / School of Health Systems and Public Health (SHSPH) / PhD / Unrestricted

京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第21033号 / 社医博第87号 / 新制||社医||10(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 中山 健夫, 教授 木原 正博, 教授 西渕 光昭 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

Introduction: Access to water, sanitation and hygiene (WASH) is a basic human right, yet globally748 million people lack access to improved drinking water, 2.5 billion lack access to improved sanitation and 946 million still practice open defecation. Sub-Saharan Africa accounts for 66% of the global new HIV infections. Access to improved WASH is an important issue, especially for people living with HIV/AIDS. They are more prone to opportunistic infections like diarrhea arising from the lack of proper sanitation and access to clean water. In Kenya, there is a dearth of literature examining the association between HIV status and the access to improved water and sanitation. This study sought to address this topic. Aim: We set out to determine the association between HIV status and the access to improved water and sanitation in Kenya using the 2008 -2009 Kenya Demographic and Health Survey (KDHS). Methods: The study analyzed 3753 HIV negative households and 422 HIV positive households. For descriptive statistics, a weighted sample was used to obtain the frequencies and percentages. Weighted bivariate and multivariable logistic regression was used to establish the association between HIV status and the independent variables of interest. Results: There were no statistically significant associations in access to improved water or improved sanitation comparing HIV status and covariates measuring the access to improved water and sanitation. We did find, however, a statistically significant higher odds of HIV positive households reporting treating their drinking water compared to HIV negative households (adjusted odds ratio = 1.4; 95% confidence interval 1.11, 1.84). Discussion: HIV positive patients are more vulnerable to opportunistic infections than the rest of the population.It is imperative for the Kenyan gorvenment to tailor specific interventions that are targeted to this particular group,through scaling up the access to basic sanitation and piped water as well as emphasizing appropriate water treatment methods at the point of use.

Introduction: Millions of children worldwide die before they reach their fifth birthday. Approximately 50% of all deaths in children are associated with malnutrition. Although remarkable improvements have been seen in the past few decades, child malnutrition remains a major public health problem in Ethiopia. Malnutrition has been linked to various morbidities and as the underlying cause of 57% of mortality in the country. It is caused by complex and multidimensional biological, social economic, and environmental factors. There are scarce literatures examining the environmental factors, such as access to water and sanitation, on the likelihood of child malnutrition as measured by stunting, wasting, and underweight in Ethiopia, which the current study sought to investigate. Aim: The primary aim of this study was to examine the relationship between households’ access to water and sanitation facilities and the likelihood that a child will become stunted or wasted or underweight. Methods: The study utilized a nationally representative data from 2011 Ethiopia Demographic and Health Survey. The sample size was 9,611 children aged 0-59 months. A weighted descriptive statistical analysis was performed to examine the frequency distribution of the study’s primary independent variables (sanitation and water), dependent variables (childhood stunting, wasting, and underweight), and all other variables included in the study. Weighted bivariate analysis was conducted using logistic regression to quantify association between stunting, wasting, and being underweight and different independent variables. Weighted multivariate logistic regression analysis was performed to control for potential confounders while examining the relationship between the primary independent and dependent variables. Odds ratios, 95% confidence limits, and p-value were calculated. We considered three sets of potential confounders: child’s (child’s gender, child’s age, and child’s size at birth diarrheal disease, fever), maternal (maternal education) and household characteristics (maternal BMI, place of residence, wealth index, stool disposal, time to get water). Only variables that showed significant association (p-value Main results: Approximately 44%, 10%, and 29% of the children under-five years of age were stunted, wasted, and underweight, respectively. About 54% of the study population used unimproved source of drinking water and about 82% used unimproved sanitation facility. Our bivariate logistic analysis revealed that children in households with unimproved source of drinking water had higher odds of stunting compared to children in households with improved drinking water source (OR: 1.2; 95% CL 1.02-1.34). Adjustment for child’s characteristics yielded AOR: 1.2; 95% CL 1.0-1.4. Addition of maternal characteristics attenuated this association (AOR: 1.1; 95% CL 1.0-1.3 1.0; 95% CL 0.8-1.2). Finally, inclusion of household characteristics showed stunting was not associated with unimproved source of drinking water (AOR: 1.0; 95% 0.8-1.2). The bivariate analysis revealed household access to unimproved source of drinking water was not significantly associated with wasting (OR: 1.0; 95% CL 0.8-1.3) and underweight (OR: 1.2; 95% CL 1.0-1.4). Adjustment of child, maternal, and household characteristic showed an inverse association between source of drinking water and wasting (AOR: 0.7; 95% CL 0.6-0.9). In the bivariate analysis, access to unimproved sanitation was significantly associated with stunting (OR: 1.3; 95% CL 1.02-1.74) and underweight (OR: 1.5; 95% CL 1.1-2.1). Compared to children living in homes with access to improved sanitation facility, children in household with unimproved sanitation facility had 1.4 increased odds of being stunted (95% CL 1.1-1.9) after adjustment for child’s characteristics. Adjustment of child, maternal, and household characteristics attenuated this association (AOR: 1.1; 95% CL 0.8-1.5). Children in household with unimproved sanitation facility had higher odds of being underweight after adjusting for child characteristics (AOR: 1.6; 95% CL 1.2-2.2). Addition of maternal characteristic reduced the association (AOR: 1.5; 95% CL 1.1-2.0). Finally, the addition of household characteristics further attenuated this association (AOR: 1.4; 95% CL 1.1-1.9). Children from households with improved water but unimproved sanitation had higher odds of wasting and being underweight compared to children living in household with both services: AORs adjusted for child’s characteristics were 2.3 (95% CL 1.3-4.3) for wasting and 2.4 (95% CL 1.6-3.6) for underweight; when maternal characteristics were included, AORs were 2.2 (95% CL 1.2-4.1) and 2.1 (95% 1.4-3.3) for wasting and underweight, correspondingly; finally, when household characteristics were included AORs were 2.0 (95% CL 1.1-3.9) and 1.9 (95% CL 1.2-3.0), respectively. Conclusion: Our results suggest that household access to unimproved source of drinking water and sanitation increase the likelihood of malnutrition. Therefore, initiatives to increase access to improved sources of drinking water and sanitation facilities along with nutritional intervention could help alleviate the high burden of malnutrition in Ethiopia.

Student Number : 0411802R - MSc (Med) research report - Faculty of Health Sciences / Unintended pregnancy among the youth is a serious public health problem for it exposes the young women and the foetuses to higher risk of morbidity and mortality. Although recognised as a major public health problem, studies on it have been limited and localised in South Africa. Using the 1998 South African Demographic and Health Survey (SADHS) data set, this study examines the distribution of and factors associated with unintended pregnancy among South African youth. The 1998 SADHS was a nationally representative cross-sectional survey with a probability sample of twelve thousand (12 000) women between the ages of 15 and 49. The survey used a structured questionnaire to collect information on fertility issues in general from the respondents. Analysis was based on 1 395 observations which was arrived at after sub setting observations of women aged 15-24 that had pregnancy at the time of and/or three years preceding the survey. Logistic regression model was employed to estimate the effects of identified predictors on unintended pregnancy. The results show a high level of unintended pregnancy with only 29% of the pregnancies wanted. The level of unintended pregnancy varies by region and some socio-economic variables. Respondents from KwaZulu Natal had the highest percentage (81%) of unintended pregnancy while North West had the lowest at 56%. It was also found that the higher the educational level of the respondents, the higher the incidence of unwanted pregnancy. Among the respondents using modern method of contraception, 74% reported having unintended pregnancy while the probability of unintended pregnancy was found to decrease with increase in age at first intercourse. Overall, about 69% of respondents who reported unintended pregnancy had last sexual relation with their regular partners, 21% with marital partners and 10% with casual partners. Using stepwise logistic regression, five critical predictors of unintended pregnancy among South African youth were identified. These are: age group, region, marital status, education and relationship to the last sexual partner. The findings of this study have implications for reproductive health policies and programs in designing appropriate national programs for reducing the incidence of unintended pregnancy among South African youth. The need for further research into this area using triangulated methodology is recommended.

Tanzania, one of many nations in Africa with high infant mortality to preventable diseases, continues to experience relatively low vaccination rates for childhood diseases. In this paper, we examine the maternal barriers to obtaining vaccines for their children in Tanzania. The risk and protective factors we analyzed include age of the mother and children, education level of the mother, number of children, maternal decision-making practices, power dynamics and others. Lack of control, limited decision practices, and decreased maternal empowerment were identified as key barriers to obtaining vaccines for children. Overall, this data is consistent with previous studies regarding barriers to vaccinations in Tanzania and other African nations.

Background: As high HIV transmission rates persist in Sub-Saharan Africa, the effect of wealth inequality rather than solely absolute wealth as a potential driver of the HIV epidemic has been given increased attention in recent research, but has not yet been investigated in the Nigerian setting. As, particularly in contexts of socioeconomic inequality, individuals may face barriers to both obtaining health-related knowledge and translating this knowledge into actual engagement in preventive measures, it is relevant to assess the level of HIV-related knowledge in the Nigerian population. Furthermore, it is of interest to investigate its socioeconomic predictors, and to identify risk-groups for low HIV-related knowledge, which consequentially are also potential risk groups for high HIV transmission. This will ultimately facilitate the targeting and implementation of more appropriate and effective preventive interventions among these groups. Due to the country’s high HIV prevalence and its ethnic and socioeconomic heterogeneity, it is both an interesting and highly relevant setting in which to analyse the socioeconomic determinants of HIV-related knowledge. Methods: Utilizing data from the Nigerian Demographic and Health Survey, Paper 1 of this thesis investigates wealth inequality as a predictor of low HIV-related knowledge in the Nigerian population through logistic regression modeling. The effects of other sociodemographic factors such as sex, literacy and rural or urban residence on HIV-related knowledge are also explored. In paper 2, a trend analysis is conducted of HIV-related knowledge in the country from 2003 to 2013, with changes in these trends represented graphically, stratified by various sociodemographic factors. ARIMA models were fit to the 2003-2013 trend data. Finally, Paper 3 presents a systematic review (using the Medline and Embase databases) and meta-analysis (conducted in R) of HIV-related knowledge interventions in Sub-Saharan Africa or among the African Diaspora, synthesising the available evidence for the efficacy of such interventions in 1) improving HIV-related knowledge, 2) resulting in increased engagement in preventive measures and safe sexual practices, and 3) reducing HIV incidence. Random-effects models were used for the meta- analyses. Results: The logistic regression model indicated that females were more than twice as likely as males to have low HIV-related knowledge in each wealth inequality category. In addition, females were more likely to have correct knowledge of mother-to-child transmission than males, but were over 1.5 times more likely to have poor knowledge of HIV risk reduction measures. Individuals with lower literacy levels were almost twice as likely as literate respondents to have low HIV-related knowledge. Ethnicity, religious affiliation, relationship status, and residing in rural areas were additional significant predictors of HIV-related knowledge. The trend analysis indicated an overall increase in HIV-related knowledge between 2003 and 2013, but a decrease in knowledge of mother-to-child-transmission. In addition, State-level disparities in knowledge regarding HIV risk reduction increased over time. The meta-analysis of HIV education interventions demonstrated significantly higher odds of correct knowledge of transmission routes as well as condom use, but insignificantly lower odds of HIV incidence. Conclusions: HIV-related knowledge in this sample is generally low among females, those with low literacy levels, the poor, the unemployed, those residing in rural areas, those with traditional religious beliefs, and those living in states with the highest wealth inequality ratios. The meta-analysis of HIV-related knowledge interventions in Paper 3 indicates that such interventions are generally effective at improving not only HIV-related knowledge but also increasing condom use, and should thus be targeted at the risk groups identified in Papers 1 and 2, in order to work towards the reduction of HIV transmission.

Background Teenage pregnancy is a public and global health concern that remains a substantial challenge in Low-income countries, particularly the densely populated countries, including Rwanda. The factors that contribute to teenage pregnancies are broad, with the most common are socioeconomic factors. The study aims to investigate the association of socioeconomic, demographic factors of teenagepregnancy in Rwanda. Methods This study uses a cross-sectional study of Demographic and Health Survey data from the national Representative of Rwanda Demographic and Health Survey done between 2014 and 2015. Our study Analysis used a weighted data sample of adolescents aged 19-24 years. Bivariate descriptive and logistic regression was used to examine the associated factors of Teenage Pregnancy. Results Descriptive bivariate analysis exhibit place of residence, wealth index and education attainment variables are statistically significant. Multivariate analysis found positive association with teenage pregnancy after adding all variables to control potential confounders in bivariate logistic regression. For example, education attainment (no education and primary); Religion (Protestant and Adventist); wealth index (poor and middle) teenager’s women and girls who lived in the eastern region were associated with pregnancy among women who were Below 20 years old. Conclusion There is a substantial increase in teenage pregnancy in Rwanda. The study results demonstrate that potential factors (economic status and education attainment) are more likely to correlate to teenage pregnancy in Rwanda. Socioeconomic and demographics factors should be strongly considered when designing policies to address teenage pregnancy in Rwanda. / <p>Thesis presentation of Socio-economic factors associated with teenage pregnancy in Rwanda: A secondary analysisof Rwanda Demographic and Health Survey data from 2014-2015 by Kalisa Francois</p>

Introduction: In Timor-Leste, anemia affects approximately 21% of reproductive age of women. The established risk factor for anemia is poor nutritional status, but recently solid fuel use in the household has emerged as a possible risk factors. The association between solid fuel and anemia has been studied in children and pregnant women, but there hasn’t been a study conducted to find the association among all reproductive age women from 15-49 years old. Aim: The objective of this study is to determine if use of solid fuels (charcoal, wood, and straw/shrubs/grass) compared to cleaner fuels (electricity, LPG. natural gas, biogas, and kerosene) associated with the increasing of the prevalence of anemia among reproductive age women (15-49 years old) in Timor-Leste. Methods: This study used data from the Timor-Leste Demographic Health Survey (TLDHS) 2009-2010. The data used was based on the individual level within household from 13 districts in Timor-Leste. Bivariable logistic regression analysis was performed to assess associations between each independent variable (type of fuels, age group, BMI group, residence, wealth index, education level and smoking behavior) and the outcome variable (anemia) and mutlivariable logistic regression model was also performed with significant covariates. Results: The association based on the type of fuels showed that the odds ratio for anemia in women using solid fuels was 1.73 (OR: 95% CI: 1.49 - 2.01) compared to the women using cleaner fuels. After adjustment for other covariates, the odds ratio for anemia in women that use solid fuels was 1.43 (95% CI: 1.29-1.64) compared to women using cleaner fuels. Discussion: Based on our study population, this study found that reproductive age women 15-49 years old in Timor-Leste who used solid fuel as a source of energy for cooking or heating activities in the household were at higher risk for anemia.