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Objective: To explore intersections of social determinants of maternal healthcare utilization using the Classification and Regression Trees (CART) algorithm which is a machine-learning method used to construct prediction models. Methods: Institutional review board approval for this study was granted from Public Health Service—Ethical Review Board (PHS-ERB) and from the Health Ministry Screening Committee (HMSC) facilitated by Indian Council for Medical Research (ICMR). IRB review and approval for the current analyses was obtained from University of California, San Diego. Cross-sectional data were collected from women with children aged 0–11 months (n = 5,565) from rural households in 25 districts of Uttar Pradesh, India. Participants were surveyed on maternal healthcare utilization including registration of pregnancy (model-1), receipt of antenatal care (ANC) during pregnancy (model-2), and delivery at health facilities (model -3). Social determinants of health including wealth, social group, literacy, religion, and early age at marriage were captured during the survey. The Classification and Regression Tree (CART) algorithm was used to explore intersections of social determinants of healthcare utilization. Results: CART analyses highlight the intersections, particularly of wealth and literacy, in maternal healthcare utilization in Uttar Pradesh. Model-1 documents that women who are poorer, illiterate and Muslim are less likely to have their pregnancies registered (71.4% vs. 86.0% in the overall sample). Model-2 documents that poorer, illiterate women had the lowest ANC coverage (37.7% vs 45% in the overall sample). Model-3, developed for deliveries at health facilities, highlighted that illiterate and poor women have the lowest representation among facility deliveries (59.6% vs. 69% in the overall sample). Conclusion: This paper explores the interactions between determinants of maternal healthcare utilization indicators. The findings in this paper highlights that the interaction of wealth and literacy can play a very strong role in accentuating or diminishing healthcare utilization among women. The study also reveals that religion and women’s age at marriage also interact with wealth and literacy to create substantial disparities in utilization. The study provides insights into the effect of intersections of determinants, and highlights the importance of using a more nuanced understanding of the impact of co-occurring forms of marginalization to effectively tackle inequities in healthcare utilization. [ABSTRACT FROM AUTHOR]

Background: Against a backdrop of more than four decades of war, conflict and insecurity, Afghanistan is recognised as suffering from endemic violence and children are exposed to multiple forms of violence, including at the family and school levels. This paper presents the results of an evaluation of school-based peace education and a community-based intervention to change harmful social norms and practices related to gender and the use of violence in conflict resolution, implemented in Afghanistan with the aim of reducing violence against and between children. Methods: The evaluation consisted of a cross-sectional, interrupted time series design with three data collection points over 12 months. Data was collected from students in 11 secondary schools (seven girls’ and four boys’ schools) in Jawzjan province of Afghanistan, with a total of 361 boys and 373 girls sampled at endline. All children were interviewed with a questionnaire developed for the study. Key outcomes included children’s experience of peer violence (both perpetration and victimization) at school, corporal punishment both at home and at school, and observation of family violence. Other outcomes included children’s gender equitable attitudes, attitudes towards child punishment, depression and school performance. Results: Between baseline and endline evaluation points, there were significant reductions in various forms of violence at the school level, including both boys’ and girls’ past month experience of peer violence victimization, peer violence perpetration, and corporal punishment by teachers. There were also significant reductions in boys’ and girls’ experience of corporal punishment at home and observation of family violence, with a particularly strong effect observed among girls. Both boys and girls had significantly more equitable gender attitudes and significantly less violence-supportive attitudes in relation to children’s punishment, and significantly fewer symptoms of depression. Girls’ school attendance was also significantly higher at endline. Discussion: To our knowledge this is the first time that a peace education program has been evaluated in Afghanistan, with or without a community intervention to change harmful social norms and practices related to gender and the use of violence for conflict resolution. The evaluation suggests that the intervention may have led to a reduction in various forms of violence, including children’s peer violence, corporal punishment of children both at school and at home, and in children’s reports of domestic violence against women at the household level. [ABSTRACT FROM AUTHOR]

ICD-10(International Classification of Diseases 10th revision) is a classification of a disease, symptom, procedure, or injury. Diseases are often described in patients’ medical records with free texts, such as terms, phrases and paraphrases, which differ significantly from those used in ICD-10 classification. This paper presents an improved approach based on the Longest Common Subsequence (LCS) and semantic similarity for automatic Chinese diagnoses, mapping from the disease names given by clinician to the disease names in ICD-10. LCS refers to the longest string that is a subsequence of every member of a given set of strings. The proposed method of improved LCS in this paper can increase the accuracy of processing in Chinese disease mapping. [ABSTRACT FROM AUTHOR]

Recent study shows that 617 million children and adolescents–or six out of 10 globally- are not acquiring minimum levels in literacy and mathematics, indicating the magnitude of the learning acquisition problem. For children with disabilities in context of conflict, the situation is arguably even worse: the literature shows that they face difficulties to access the education system due to multiple barriers, and when they do access, they are not learning. Our paper examines if an active education policy promoting inclusion since 2005 in Afghanistan, a protracted crisis context, has been effective. Using two cross sectional household surveys carried out eight years apart (2005–2013), our study shows that access to school and literacy did not improve between 2005 and 2013 for children and youth with disabilities. Both access and literacy outcomes were worse for girls with disabilities, those with a mental, learning or associated disability and those living in household where the head was uneducated. Finally, odds of being mentally distressed significantly declined between 2005 and 2013 indicating that schools might play a protective role for children with disabilities in Afghanistan. Our findings suggest that a multilevel multi-pronged adaptation of the existing system to improve the learning experience and promote children’s resilience, particularly for children with disabilities, in conflict context such as Afghanistan, is required. [ABSTRACT FROM AUTHOR]

The demand for district level statistics has increased tremendously in Bangladesh due to existence of decentralised approach to governance and service provision. The Bangladesh Demographic Health Surveys (BDHS) provide a wide range of invaluable data at the national and divisional level but they cannot be used directly to produce reliable district-level estimates due to insufficient sample sizes. The small area estimation (SAE) technique overcomes the sample size challenges and can produce reliable estimates at the district level. This paper uses SAE approach to generate model-based district-level estimates of diarrhoea prevalence among under-5 children in Bangladesh by linking data from the 2014 BDHS and the 2011 Population Census. The diagnostics measures show that the model-based estimates are precise and representative when compared to the direct survey estimates. Spatial distribution of the precise estimates of diarrhoea prevalence reveals significant inequality at district-level (ranged 1.1–13.4%) with particular emphasis in the coastal and north-eastern districts. Findings of the study might be useful for designing effective policies, interventions and strengthening local-level governance. [ABSTRACT FROM AUTHOR]

Background: Violence against women by an intimate partner (DV) is a serious public health and human rights issue. Attitudes justifying DV strongly predict its perpetration and victimisation. This paper presents gendered ecological analyses of the societal acceptance of DV in 49 low- and middle-income countries (LMICs) across geographical regions. Methods and findings: We utilised data from 49 Demographic and Health Surveys conducted between 2005 and 2017, United Nations Statistics and topic-specific meta-databases. DV acceptance was measured as the justification of ‘wife-beating’ in at least one of five circumstances, and by the summative scale. Stepwise multiple linear regression examined country-level social, economic and political empowerment predictors of societal acceptance of DV amongst women, men, and the aggregate gender difference. Women were more likely than men to justify DV in Sub-Saharan Africa and South (east) Asia with societal acceptance of DV being more widespread in these regions compared with Latin America, the Caribbean, Central/West Asia and Europe. Political conflict and limited economic rights for women were associated with higher levels of DV acceptance amongst women and men. Men in more democratic countries were less likely to justify DV. Amongst women, higher national female literacy rates predicted lower levels of justification. There were higher levels of DV acceptance amongst women and a wider aggregate gender difference in countries with a larger representation of women in national parliament. Conclusion: Justification of DV is widespread amongst women and men in LMICs with acceptance rates varying across countries and regions. Gender differences in the impact of contextual factors on DV acceptance supports a gendered approach to national-level interventions. Our findings highlight the need for tailored interventions targeting DV acceptance in conflict-impacted societies. The emphasis of inter(national) policies on the ‘empowerment’ domains of widely-used gender (in)equality indices need to be coupled with strategies tackling discriminatory gender norms. [ABSTRACT FROM AUTHOR]

Background: Child peer violence is a global problem and seriously impacts children’s physical and psychological health, and their education outcomes. There are few research studies on children’s peer violence available in South Asian countries, particularly in Afghanistan. This paper describes the prevalence of children’s peer violence perpetration and victimization and associated factors among school children in Afghanistan. Methods: A total of 770 children were recruited into a baseline study conducted as part of an intervention evaluation in 11 schools (seven girls’ and four boys’ schools). All children were interviewed with a questionnaire developed for the study. The main outcome is a three-level peer violence variable consisting of (a) no violence, (b) victimization only, or (c) perpetration (with or without victimization). Peer violence victimization was measured through the Multidimensional Peer-Victimization Scale, and peer violence perpetration was measured through an adjusted version of the same scale with wording changed to measure perpetration. Results: 49.7% of boys and 43.3% of girls reported having experienced more than one instance of violence victimization in the past month, and 31.7% of boys and 17.6% of girls disclosed perpetration of more than one instance of violence in the past month, with considerable overlap found between experience of victimization and perpetration, particularly among boys. Multinomial models of factors associated with peer violence show that for boys, food insecurity was associated with perpetration of peer violence but not with victimization, and experiencing corporal punishment at school in the last month was significantly associated with both peer victimization and perpetration. For girls, food insecurity, more depressive symptoms and experiencing any beating at home were associated with both violence victimization and perpetration. Having a disability was associated with victimization only, and having witnessed their father fighting and experiencing any kind of corporal punishment were associated with peer violence perpetration only. Discussion: Peer violence in Afghanistan is linked to food insecurity, exposure of children to witnessing family violence, and children’s experience of physical violence at home and corporal punishment at school. School-based settings provide an important platform for interventions to reduce and prevent peer violence; however, such interventions may benefit from broader violence-prevention initiatives conducted at the community level. [ABSTRACT FROM AUTHOR]

Bangladesh is a culturally conservative nation with limited freedom for women. A number of studies have evaluated intimate partner violence (IPV) and spousal physical violence in Bangladesh; however, the views of women have been rarely discussed in a quantitative manner. Three nationwide surveys in Bangladesh (2007, 2011, and 2014) were analyzed in this study to characterize the most vulnerable households, where women themselves accepted spousal physical violence as a general norm. 31.3%, 31.9% and 28.7% women in the surveys found justification for physical violence in household in 2007, 2011 and 2014 respectively. The binary logistic model showed wealth index, education of both women and their partner, religion, geographical division, decision making freedom and marital age as significant household contributors for women’s perspective in all the three years. Women in rich households and the highly educated were found to be 40% and 50% less likely to accept domestic physical violence compared to the poorest and illiterate women. Similarly, women who got married before 18 years were 20% more likely accept physical violence in the family as a norm. Apart from these particular groups (richest, highly educated and married after 18 years), other groups had around 30% acceptance rate of household violence. For any successful attempt to reduce spousal physical violence in the traditional patriarchal society of Bangladesh, interventions must target the most vulnerable households and the geographical areas where women experience spousal violence. Although this paper focuses on women’s attitudes, it is important that any intervention scheme should be devised to target both men and women. [ABSTRACT FROM AUTHOR]

This paper aimed to investigate the role of parental education in child disability in China. We used nationally representative data from China’s National Sample Survey on Disability, iterated twice, in 1987 and 2006, with data of 764,718 children aged 0–14 years. Logit models were used for statistical analysis. Results showed that the prevalence of child disability was significantly associated with each parent’s education. Maternal education was more important than paternal education in child disability in both surveys. The analysis of marginal effect indicated a one-year increase in maternal and paternal schooling led to an average decrease of 0.121% and 0.091% in the probability of child disability in 1987, and 19 years later, these figures had dwindled to 0.091% and 0.072%, respectively. [ABSTRACT FROM AUTHOR]

Introduction: Inconsistency in the time trade-off (TTO) task in EQ-5D-5L occurs when a respondent gives a higher value to a logically worse health state, the occurrence of inconsistency compromises the quality of the data. It is not yet clear which factors are associated with individual level inconsistency. Relating inconsistency to the characteristics of the respondent, interviewer, and the interview process could be helpful in understanding the causes of inconsistency. The objective of this paper is to discover the factors associated with individual level inconsistencies. Methods: Twenty interviewers interviewed 1,296 respondents and each respondent valued 10 health states using the EQ-VT platform in 5 cities in China. At the respondent level, inconsistency was identified in terms of severity and quantity and related to the respondent’s background characteristics, the time and iterations spent on the wheelchair example task, and the formal TTO tasks, using multilevel multinomial regression analyses. Interviewers’ impact on inconsistencies was analyzed using single level multinomial regression analyses. Results: In the full dataset, slight inconsistency was more related to the interview process (Time spent on TTO task: RRR = 1.246 with 95%CI: 1.076,1.441; time spent on Wheelchair example: RRR = 0.815 with 95%CI:0.699,0.952) while severe inconsistency was more related to respondent’s gender (Gender: RRR = 2.347 with 95%CI:1.429,3.855). One Interviewer (Interviewer 7: RRR = 7.335 with 95%CI:1.908,28.195) and interviewer’s experience (Sequence: RRR = 0.511 with 95%CI:0.385,0.678) in general showed strong influence over inconsistency in the TTO task. Conclusion: In conclusion, logical inconsistency in the valuation of EQ-5D-5L health states is associated not only with respondents’ characteristics but also with interviewers’ performance and the interview process. The role of interviewers and the importance of interviewer training may be more crucial than hitherto believed. This finding could be generalizable to other interviewer-administered health-state valuation study. [ABSTRACT FROM AUTHOR]

Background: While women and girls face special risks from lack of access to sanitation facilities, their ability to participate and influence household-level sanitation is not well understood. This paper examines the association between women's decision-making autonomy and latrine construction in rural areas of Odisha, India. Methods: We conducted a mixed-method study among rural households in Puri district. This included a cross sectional survey among 475 randomly selected households. These were classified as either having a functional latrine, a non-functional latrine or no latrine at all. We also conducted 17 in-depth interviews and 9 focus group discussions among household members of these three categories of households. Results: Decisions on the construction of household level sanitation facilities were made exclusively by the male head in 80% of households; in 11% the decision was made by men who consulted or otherwise involved women. In only 9% of households the decision was made by women. Households where women were more involved in general decision making processes were no more likely to build a latrine, compared to households where they were excluded from decisions. Qualitative research revealed that women’s non-involvement in sanitation decision making is attributed to their low socio-economic status and inability to influence the household’s financial decisions. Female heads lacked confidence to take decisions independently, and were dependent on their spouse or other male family members for most decisions. The study revealed the existence of power hierarchies and dynamics within households, which constrained female’s participation in decision-making processes regarding sanitation. Conclusions: Though governments and implementers emphasize women’s involvement in sanitation programmes, socio-cultural factors and community and household level dynamics often prevent women from participating in sanitation-related decisions. Measures are needed for strengthening sanitation policies and effective implementation of programmes to address gender power relations and familial relationships that influence latrine adoption and use. [ABSTRACT FROM AUTHOR]

Out-of-pocket spending at out-patient departments (OPD) by households is relatively less analyzed compared to hospitalization expenses in India. This paper provides new evidence on the levels and drivers of expenditure on out-patient care, as well as choice of providers, using household survey data from 8 districts in 3 states of India. Results indicate that the economically vulnerable spend more on OPD as a proportion of per capita consumption expenditure, out-patient care remains overwhelmingly private and switches of providers—while not very prevalent—is mostly towards private providers. A key result is that choice of public providers tend to lower OPD spending significantly. It indicates that an improvement in the overall quality and accessibility of government facilities still remain an important tool that should be considered in the context of financial protection. [ABSTRACT FROM AUTHOR]

Despite various efforts for enhancing women’s autonomy in developing countries, many women are deprived of their capacity in decision-making on their household affairs as well as social issues. This paper aimed to examine women’s autonomy and its associated factors in the Kapilvastu district of Nepal. We measured women’s autonomy using a recently developed women’s autonomy measurement scale from June to October 2014. Descriptive statistics, chi-square test and logistic multivariate modeling technique were applied for assessing the association of demographic and socio-economic characteristics of women and their autonomy. Mean score for women’s autonomy was 23.34± 8.06 out of the possible maximum 48. It was found to be positively associated with higher age difference at marriage, advantaged caste/ethnicity, better employment for the husband, couple’s education more than 10 years schooling, and higher economic status of the household. We found strong direct effect of women’s education (OR = 8.14, CI = 3.77–17.57), husband’s education (OR = 2.63, CI = 1.69–4.10) and economic status of household (OR = 1.42, CI = 1.01–2.03) on women’s autonomy. When we adjusted women’s education for husband’s education, the odds ratio decreased by around 22% {from (OR = 8.14, CI = 3.77–17.57) to (OR = 6.32, CI = 2.77–14.46)} and was a mediator effect. The economic status of household also had mediator effect on women’s autonomy through their education. Education status of women is a key predictor of women’s autonomy in Kapilvastu district. Husband’s education and economic status of the household are other important predictors of women’s autonomy which have a mediator effect on women’s autonomy. Improving educational status and economic conditions of both women and their husbands may be the best solution to promote women’s autonomy. [ABSTRACT FROM AUTHOR]