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Objectives: To reduce the incidence of mother-to-child transmission (MTCT) of HIV in Malawi, interventions have been created for women to be informed about the MTCT of HIV and for women living with HIV to be entered into the HIV care cascade to ensure safer deliveries. Our study aimed to examine the effectiveness of these strategies by exploring the determinants of adequate knowledge of MTCT of HIV among women living with HIV in Malawi., Methods: We used the 2015-16 Malawi Demographic and Health Survey data and applied logistics regression analysis to explore the determinants of adequate knowledge of MTCT of HIV among women living with HIV., Results: Our findings estimated that 75% of women living with HIV possessed adequate knowledge of MTCT of HIV. We also found that compared to those with no formal education, women with primary education (OR = 1.88, 95% CI = 1.04, 3.41) and secondary education or higher (OR = 2.61, 95% CI = 1.21, 5.62) were more likely to have adequate knowledge of MTCT of HIV. Furthermore, women who were resident in rural areas (OR = 2.97, 95% CI = 1.58, 5.57), were more likely to have adequate knowledge of MTCT of HIV relative to those in urban areas. Finally, women who had adequate HIV knowledge (OR = 1.85, 95% CI = 1.19, 2.89) and those who rejected the endorsement of HIV stigma and discrimination (OR = 2.30, 95% CI = 1.39, 3.81) were more likely to have adequate knowledge about the MTCT of HIV., Conclusion: Based on our findings, there is an urgent need to offer women living with HIV in Malawi the opportunity to increase their knowledge of MTCT of HIV if the country is to make progress towards the elimination of MTCT of HIV as part of the overall strategy to contain new HIV infections in the country., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Climate change and non-communicable diseases (NCDs) are considered the 21st Century's major health and development challenges. Both pose a disproportionate burden on low- and middle-income countries that are unprepared to cope with their synergistic effects. These two challenges pose risks for achieving many of the sustainable development goals (SDGs) and are both impacted by globalization through different pathways. While there are important insights on how climate change and or globalization impact NCDs in the general literature, comprehensive research that explores the influence of climate change and or globalization on NCDs is limited, particularly in the context of Africa. This review documents the pathways through which climate change and or globalization influence NCDs in Africa. We conducted a comprehensive literature search in eight electronic databases-Web of Science, PubMed, Scopus, Global Health Library, Science Direct, Medline, ProQuest, and Google Scholar. A total of 13864 studies were identified. Studies that were identified from more than one of the databases were automatically removed as duplicates (n = 9649). Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a total of 27 studies were eventually included in the final review. We found that the impacts of climate change and or globalization on NCDs act through three potential pathways: reduction in food production and nutrition, urbanization and transformation of food systems. Our review contributes to the existing literature by providing insights into the impact of climate change and or globalization on human health. We believe that our findings will help enlighten policy makers working on these pathways to facilitate the development of effective policy and public health interventions to mitigate the effects of climate change and globalization on the rising burden of NCDs and goal 3 of the SDG, in particular., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Siiba et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Sub-Saharan Africa is undergoing an epidemiological transition driven by rapid, unprecedented demographic, socio-cultural, and economic transitions. These transitions are driving increases in the risk and prevalence of diabetes and other non-communicable diseases (NCDs). As NCDs rise, several attempts have been made to understand the individual level factors that increase NCDs risks, knowledge, and attitudes around specific NCDs as well as how people live and manage NCDs. While these studies are important, and enhance knowledge on chronic diseases, little attention has been given to the role of social and cultural environment in managing chronic NCDs in underserved settings. Using purposive sampling among persons living with Diabetes Mellitus (PLWD) and participating in diabetes programs from regional and municipal hospitals in the three underserved regions in Ghana (n = 522), we assessed diabetes management and supportive care needs of PLWDs using linear latent and mixed models (gllamm) with binomial and a logit(log) link function. The result indicates that PLWDs with strong perceived social support (OR = 2.27, p ≤ 0.05) were more likely to report good diabetes management compared to PLWDs with weak perceived social support. The built environment, living with other health conditions, household wealth, ethnicity and age were associated with diabetes management. Overall, the study contributes to wider discussions on the role changing built and socio-cultural environments in the rise of diet-related diseases and their management as many Low- and Middle-Income Countries (LMICs) experience rapid epidemiological and nutrition transitions., (© 2023. The Author(s).)

Objectives: We sought to determine if trust in government institutions mediate the relationship between experiences of discrimination and health care utilization during the COVID-19 pandemic., Methods: We used data from Statistics Canada's Crowdsourcing Data: Impacts of COVID-19 on Canadians-Experiences of Discrimination. We used generalized linear latent and mixed models (Gllamm) with a binomial and logit link function as well as generalized structural equation modeling (GSEM) to determine if reported discrimination and trust were associated with difficulties in accessing health services, health care, and the likelihood of experiencing negative health impacts. We also examined if trust mediated the relationship between experiences of discrimination and these health outcomes. Our analytical sample consisted of 2568 individuals who self-identified as belonging to a visible minority group., Results: The multivariate results indicate that experiences of discrimination during COVID-19 were associated with higher odds of reporting difficulties in accessing general health services (OR = 1.99, p ≤ 0.01), receiving care (OR = 1.65, p ≤ 0.01), and higher likelihood of reporting negative health impacts (OR = 1.68, p ≤ 0.01). Our mediation analysis indicated that trust in public institutions explained a substantial portion of the association between reported discrimination and all the health outcomes, although the effects of experiencing discrimination remain significant and robust., Conclusion: The findings show that building and maintaining trust is important and critical in a pandemic recovery world to build back better., (© 2023. W. Montague Cobb-NMA Health Institute.)

In sub-Saharan Africa (SSA), cervical cancer (CC) is the second leading cause of cancer-related deaths, with human immunodeficiency virus (HIV) seropositive women being particularly vulnerable. Despite the benefits of early CC screening in reducing HIV-related CC deaths, CC screening uptake remains limited, with wide disparities in access across SSA. As part of a larger study, this paper examines the determinants of CC screening among HIV-seropositive women of reproductive age (15-49 years) in Zimbabwe. Using the 2015 Zimbabwe Demographic and Health Survey, we conducted multilevel analyses of CC screening among 1490 HIV-seropositive women, nested in 400 clusters. Our findings revealed that, even though 74% of HIV-seropositive women knew about CC, only 17.6% of them reported ever screening for it. Women who held misconceptions about HIV (OR = 0.47, p = 0.01) were less likely to screen for CC compared to those with accurate knowledge about HIV and CC. HIV-seropositive women with secondary or higher education were more likely to screen (OR = 1.39, p = 0.04) for CC compared to those with a primary or lower level of education. Age was positively associated with screening for CC. Furthermore, locational factors, including province and rural-urban residence, were associated with CC screening. Based on these findings, we call for integrated care and management of HIV and non-communicable diseases in Southern Africa, specifically, Zimbabwe due to the legacy of HIV in the region., (© The Author(s) 2023. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Cholera, which is caused by Vibrio cholerae, persists as a devastating acute diarrheal disease. Despite availability of information on socio-cultural, agent and hosts risk factors, the disease continues to claim lives of people in Tanzania. The present study explores spatial patterns of cholera cases during a 2015-16 outbreak in Mwanza, Tanzania using a geographical information system (GIS) to identify concentrations of cholera cases. This cross-sectional study was conducted in Ilemela and Nyamagana Districts, Mwanza City. The two-phase data collection included: 1) retrospectively reviewing and capturing 852 suspected cholera cases from clinical files during the outbreak between August, 2015, and April, 2016, and 2) mapping of residence of suspected and confirmed cholera cases using global positioning systems (GPS). A majority of cholera patients were from Ilemela District (546, 64.1%), were males (506, 59.4%) and their median age was 27 (19-36) years. Of the 452 (55.1%) laboratory tests, 352 (77.9%) were confirmed to have Vibrio cholerae infection. Seven patients (0.80%) died. Cholera cases clustered in certain areas of Mwanza City. Sangabuye, Bugogwa and Igoma Wards had the largest number of confirmed cholera cases, while Luchelele Ward had no reported cholera cases. Concentrations may reflect health-seeking behavior as much as disease distribution. Topographical terrain, untreated water, physical and built environment, and health-seeking behaviors play a role in cholera epidemic in Mwanza City. The spatial analysis suggests patterns of health-seeking behavior more than patterns of disease. Maps similar to those generated in this study would be an important future resource for identifying an impending cholera outbreak in real-time to coordinate community members, community leaders and health personnel for guiding targeted education, outreach, and interventions., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Madullu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Following a decade of declining food insecurity, the global undernourished population has increased successively in the last three years. This increasing trend highlights the challenge of meeting the zero hunger and nutrition targets of Sustainable Development Goal (SDG) 2. Malawi is one of the most food insecure countries in Africa, with a significant proportion of its population being undernourished. Amid evidence of the counter-productive effects of input-intensive agriculture in this context, including the narrowing of the food basket and unequal access to subsidized inputs, some scholars have argued that alternative diversified agricultural approaches, combined with attention to underlying inequalities, maybe more promising in addressing undernutrition. Agroecology is one such approach which promotes biodiversity and pays attention to socio-political inequalities. That notwithstanding, there is limited research on the potential role of agroecology in improving household food outcomes. Drawing theoretical insights from political ecology and using Difference-in-Difference and mediation techniques, we examine the impact of agroecology on household production diversity and dietary diversity using data from a five-year agroecological intervention in Malawi (n = 514 agroecology-practicing farming households and 400 non-agroecology households). Findings from the Difference-in-Difference analysis show a positive treatment effect of agroecology on both production diversity (β = 0.289, p < 0.01) and dietary diversity (β = 0.390, p < 0.01). Results from the mediation analysis indicate that generally, production diversity is directly associated with dietary diversity (β = 0.18, p < 0.01), although the relationship is stronger for households practicing agroecology (β = 0.19, p < 0.01) compared to non-agroecology households (β = 0.14, p < 0.01). These findings provide evidence of the potential for agroecology to improve nutrition in smallholder farming contexts and contribute to achieving SDGs 2. Malawi is currently grappling with widespread micronutrient deficiencies. Given that smallholder farmers typically draw a significant proportion of their diet from what they produce, farming approaches like agroecology, which emphasizes the cultivation of diverse crops, may be promising for improving household nutrition., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Burundi is a fragile and conflict-affected state characterized by persistent conflict and political violence. Amid this conflict, Burundi has one of the highest maternal mortality rates globally-548 per 100,000 births as of 2017, such deaths could be prevented with antenatal care (ANC). This cross-sectional study aimed to examine the association between conflict and ANC and skilled birth attendant (SBA) utilization. Logistic regression analysis was conducted using the 2016-2017 Burundi Demographic and Health Survey (n = 8581), as well as a Near Analysis Geographic Information System exploration. Results show that women in extremely high conflict regions were less likely to have four antenatal visits (odds ratio [OR] = 0.79, p < 0.05). However, they were more likely to use a SBA (OR = 2.31, p < 0.001) and to deliver in a hospital (OR = 1.69, p < 0.001). As well, gender equality, education, and watching television were correlated with an increased likelihood of utilization. In contrast, unwanted pregnancies and increased parity were correlated with decreased use. Moreover, with renewed violence erupting in 2015, uptake of care has likely further stagnated or declined. If Sustainable Development Goal 3.1's objective of reducing maternal mortality globally is to be achieved, women's access to maternal healthcare services in conflicted-affected areas such as Burundi must be improved., (© 2021 John Wiley & Sons Ltd.)

Maternal mortality represents one of the widest gaps between developed and developing countries. Ninety-nine percent of maternal deaths occur in developing countries, with over half occurring in sub-Saharan Africa. This health indicator became a global priority when the United Nations' Sustainable Development Goal 3.1 set out to decrease the global maternal mortality rate to less than 70 per 100 000 births by 2030. In the Democratic Republic of the Congo (DRC), 473 of every 100 000 women who give birth die due to pregnancy-related complications. These deaths could be prevented through enhanced access and utilization of antenatal care services and skilled birth attendants. However, amid prolonged conflict, violence, and authoritarian governments, the Democratic Republic of the Congo has been classified as a fragile and conflict-affected situation and women are prone to face difficulties accessing maternal health services. This study examined the utilization of antenatal care and skilled birth attendants in the Democratic Republic of Congo using logistic regressions. Our findings show that women living in regions with extremely high levels of prolonged conflict were significantly less likely than those in regions with moderate levels of conflict to have their first antenatal care visit within the first trimester (OR = 0.29, p < 0.01), and to have four visits (OR = 0.46, p < 0.01). Overall, women in regions with extremely high levels of conflict (OR = 0.41, p < 0.01) were less likely to meet the World Health Organization's antenatal care recommendations compared to those in regions with moderate levels of conflict. The findings suggest that conflict-affected countries, such as the Democratic Republic of the Congo, require context-specific interventions if progress is to be made towards achieving Sustainable Development Goal 3.1., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

While literature attempts to explain why self-reported subjective wellbeing (SWB) generally increases with age in most high-income countries based on a social determinants of a health framework, little work attempts to explain the low levels of self-report SWB among older persons in sub-Saharan Africa. Using the 2013 Uganda Study on Global Aging and Health with 470 individuals, this research examines (i) direct and indirect effects of age on SWB through social and structural determinants, and (ii) how direct and indirect effects vary by gender. Results show a significant direct and negative effect of age on SWB ( β = 0.42, p = 0.01). Six indirect paths were statistically significant and their indirect effects on wellbeing varied by gender. Providing support, education, working status, asset level, financial status and financial improvement were significantly positively associated with men's SWB, whereas younger age, providing community support, participating in group activities, number of close friends/relatives, government assistance and all socio-economic variables were significantly positively associated with women's SWB. Strategies to address gendered economic, social and political inequalities among and between elderly populations are urgently needed.

Water security is critical to the health and well-being of people around the world, especially among populations experiencing water stresses and rapid urbanization in low- to middle-income countries (LMICs). Recent research suggests water insecurity is associated with negative mental health outcomes. Despite global improvement in access to safe water across the world, the World Health Organization (WHO) reports that access to safe water in urban areas has not changed significantly or has stagnated in certain countries. In most African cities, entrepreneurial water vendors have stepped up to fill supply gaps in the formal delivery system by selling vended water. As part of a larger research program that aims to assess and analyze public perceptions around vended water, this paper explores the links connecting water insecurity and emotional distress among urban slum dwellers who mostly use vended water in Accra, Ghana. We used a parallel mixed-methods approach. Our quantitative results show that water-insecure households (OR = 2.23, p = 0.01) were more likely to report emotional distresses compared to water-secure households. However, households with improved sanitation (OR = 0.28, p = 0.01) and those willing to participate for improved water and sanitation (OR = 0.28, p = 0.01) were less likely to report emotional distress. Our qualitative results offered support for the quantitative results, as participants not only hold various perceptions regarding the safety and quality of vended water but expressed emotional distresses such as fear of contamination, discomfort, worry over arbitrary change in prices, and anxiety. The implications of the results for policy and practice, specifically to ensuring access to safe water, are discussed.

Objective: To describe trends in obesity in Zambian women of reproductive age and to identify factors that may have contributed to changes in trends and nutrition outcomes. Materials and Methods: We obtained data on body mass index and individual factors of women from the Zambia Demographic and Health Survey for the period 2002 to 2014. From these data, we calculated descriptive statistics and examined the extent to which factors link to the odds of obesity over time. We also reviewed primary and secondary data sources, such as government documents, theses, and search engines to identify factors that may have contributed to trends and changes in nutrition outcomes. Results: The proportion of obesity doubled from 2002 (12.5%) to 2014 (22.3%). The odds were higher among educated, currently married and wealthy women, and it increased with age. Rural residence and working in agricultural-related jobs were linked to lower odds for obesity. This disparity varies by province. In addition, despite the presence of many nutrition policies and strategies, the increase in obesity occurred within the past two decades when urbanization and other factors ( e.g. , sedentary work, a proliferation of fast food restaurants, and advertisements) may have affected changes in nutrition outcomes for women. Conclusions: We identified increasing trends in obesity in women of reproductive age over time. The rapid urbanization and other factors that occurred in Zambia during this period are significant risk factors for obesity in Zambian women. The findings will be of interest to countries that are undergoing a nutrition transition.

Existing evidence suggests that rising inequality is detrimental to population wellbeing. However, the mediums through which inequality affects wellbeing in the context of low to middle-income countries (LMICs), where absolute and relative deprivation are extreme, remain unknown. As part of a larger research program that aims to develop a Global Index of Wellbeing (GLOWING), this paper explores the linkages between inequality and wellbeing in Ghana. We used key constructs from the capability and ecosocial theoretical frameworks, and a parallel mixed-methods approach. Through path analysis, we examined the pathways between different measures of inequality and wellbeing. Further, qualitative interviews were used to explore perceptions of inequality and links with wellbeing; this provided context and depth to our quantitative results. Results show that inequalities may affect wellbeing by constraining access to basic amenities like water, food, and housing and also through community social capital and cohesion. The implications of the results for policy and practice, specifically to ensuring shared prosperity, are discussed., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objectives: Breast cancer contributes substantially to morbidity and mortality in Namibia as is the case in most countries in Sub-Saharan Africa (SSA). However, there is a dearth of nationally representative studies that examine the odds of screening for breast cancer in Namibia and SSA at large. This paper aims to fill this gap by examining the determinants of breast cancer screening guided by the Health Belief Model., Methods: We applied hierarchical binary logit regression models to explore the determinants of breast cancer screening using the 2013 Namibia Demography and Health Survey (NDHS). We accounted for the effect of unobserved heterogeneity that may affect breast cancer, testing behaviours among women cluster level. The NDHS is a nationally representative dataset that has recently started to collect information on cancer screening., Results: The results show that women who have health insurance coverage (odds ratio (OR) = 1.62, p ≤ 0.01), maintain contact with health professionals (OR = 1.47, p = 0.01), and who have secondary (OR = 1.38, p = 0.01) and higher (OR = 1.77, p ≤ 0.01) education were more likely to be screened for breast cancer. Factors that influence women's perception of their susceptibility to breast cancer such as birthing experience, age, region and place of residence were associated with screening in this context., Conclusions: Overall, the health belief model predicted women's testing behaviours and also revealed the absence of relevant risk factors in the NDHS data that might influence screening. Overall, our results show that strategies for early diagnosis of breast cancer should be given major priority by cancer control boards as well as ministries of health in SSA. These strategies should centre on early screening and may involve reducing or eliminating barriers to health care, access to relevant health information and encouraging breast self-examination.

Despite the declining HIV/AIDS prevalence globally, nearly half of all new HIV infections still occur among youth, especially in sub-Saharan Africa. While determinants of risky sexual behaviour have received copious attention in the literature, we still lack multi-country studies that track regional changes in sexual risk among youth in sub-Saharan Africa. This study seeks to fill part of this gap by identifying the determinants of risky sexual behaviours among adolescents in Ghana, Central African Republic (CAR) and Eswatini (formerly Swaziland). We used nationally representative sample data from the Multi Indicator Cluster survey, round four (MICS4). Results of the descriptive analysis show that overall consistent condom use is still extremely low in sub-Saharan Africa. In Ghana, only 8.5% of male youth and 7% of female youth consistently use condoms. In CAR this figure is 8% and 4% in male youth and female youth respectively. In Eswatini, with one of highest HIV prevalence in the world, the prevalence of consistent condom use is at 29% in males and 20% in females, higher than both in Ghana and CAR. Results of hierarchical models show that age at first sex does not predict risky sexual behaviour in Ghana, but it does predict risky sexual behaviour in CAR although only among young males. In Swaziland, age at first sex predicts risky sexual behaviour in both male and female youth but the relationship is not in the expected direction. Low socio-economic status predicts inconsistent condom use in all the three countries, but only among young females. This paper provides relevant policy lessons and recommendations.

Background: With antenatal care (ANC) coverage now widely seen as a success story in Sub-Sahara Africa (SSA), attention has begun to shift towards exploring the full life-saving potential that ANC holds., Objectives: This study examines association between pregnancy intention and gestational age at first antenatal care (ANC) visit in Rwanda, where ANC coverage is nearly universal., Methods: We use survival analysis and apply the lognormal model in Stata SE 15 to compute time ratios (TR) that provide a direct metric for time to first ANC check-up., Results: Despite nearly universal coverage, only 25% of pregnant mothers start ANC within the timeframe recommended by WHO. Women with unintended pregnancies are even more likely to delay ANC (TR = 11.4%, Z = 2.48, p < 0.05) than women with intended pregnancies. The effect of pregnancy intention on time to first ANC accentuates when we control for parity in the hazard models. There is also educational divide, with early start of ANC limited to pregnant women with secondary education or higher. Interaction effects suggest significant interaction between parity (≥ 4) and unintended pregnancy (TR = 11.1%, Z = -2.07, p < 0.05) on gestational age at first ANC. Other predictors of time to first ANC are contact with health care provider and perceived barriers., Conclusion: With near universal coverage, the next big challenge to harness the full life-saving potential of ANC in Rwanda would be ramping up prompt start of prenatal care, timeliness of successive checkup intervals, and adherence to recommended number of visits, as opposed to simply increasing attendance. Preventing unwanted pregnancies in multiparous mothers through family planning would also significantly to the goal of universal ANC coverage in Rwanda., (Copyright © 2018. Published by Elsevier Ltd.)

In the post war era, Gross Domestic Product (GDP) has been extensively used as the primary indicator of population wellbeing. More recently, population wellbeing has increasingly been seen as more than merely the value of economic activity undertaken within a given period of time. Rather, several alternative measures have been proposed to correct some of the weaknesses of GDP. Yet these measures focus primarily on countries in the so-called developed world and ignore geographical variations in socio-cultural, ecological and collective discourses that accompany the 'good life'. We have embarked on a larger research program to develop a global index of wellbeing (GLOWING) through the exploration of national wellbeing in low and middle income countries (LMICs). As such, this paper explores public perceptions and the meanings attached to population wellbeing in the Ghanaian context. Informed by eco-social and capabilities theoretical frameworks, we conducted focus group discussions and key informant interviews to explore participants' conceptions of wellbeing. Results reveal that the descriptions or definitions that people ascribe to wellbeing are complex, socially and context dependent, and comprise the embodiment of both material and immaterial circumstances. The results, therefore, support the view that national wellbeing is complex and multi-dimensional and reflect the lived experiences of people and communities. Furthermore, although the specific domains are similar to existing frameworks such as the Canadian Index of Wellbeing and OECD better life indices, the constituents of these domains differed in the Ghanaian context, underscoring the importance of place in the conceptualization and measurement of wellbeing., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

As part of a larger research programme undertaking the development of a global index of wellbeing (GLOWING) through the exploration of population wellbeing in low to middle income countries (LMICs), this paper examines the role of inequality in shaping experiences of wellbeing. The paper explores various conceptualizations of wellbeing and inequality and outlines an integrated framework for understanding the importance of measuring the wellbeing of places. We conclude by urging geographers to explicitly engage with theory and cross-disciplinary research in order to adequately conceptualize the role of place in 'Beyond GDP' and progress measures., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Purpose: This study explores the relationships between neighborhood structural differences such as socioeconomic status (SES), income inequality, and ethnic diversity on women's mental health in Accra, Ghana., Methods: The study used secondary data from the 2009 Women Health Survey Accra II, linked with the 2010 sub-metro level census figures on income inequality. The analytical sample consists of 2814 women nested within 195 enumeration areas (clusters) in the Accra Metropolitan Area (AMA). Multilevel binary logit and complimentary log-log models were used to analyze the data., Results: Results suggest that social capital and neighborhood socioeconomic structural factors such SES, ethnic diversity, and housing ownership were associated with depressive symptoms, feeling downhearted, and self-reported health., Conclusions: These findings suggest that policies and programs that improve the physical and economic conditions of deprived neighborhoods, as well as civic initiatives that improve social capital and cohesion, may be important for promoting collective actions and improving health outcomes in urban settings like Accra.

Early cervical cancer screening has been shown to be beneficial in reducing cervical cancer related deaths. Despite the benefits of early cervical cancer screening, uptake remains limited, with wide disparities in access and uptake in most developing countries. As part of a larger study, this paper uses a socio-ecological framework to explain the determinants of cervical cancer knowledge and screening among women of reproductive age (15-49 years) in Kenya. We conducted a multilevel analysis of cervical cancer knowledge (n = 11,138) and screening (n = 10,333) using the 2014 Kenya Demographic and Health Survey (KDHS). Results show regional disparities in cancer knowledge and the utilization of cervical cancer screening services; regions with high wealth inequality (OR = 0.70, 95% CI [0.56-0.87]) emerged as vulnerable regions where women were less likely to screen for cervical cancer. Gender equity, health insurance coverage and education level significantly predicted cervical cancer screening rates. Results further revealed regional as well as rural-urban wealth inequalities in cervical cancer screening. We argue that given that Kenyan women are highly exposed to human papilloma virus (HPV) due to the legacy of human immunodeficiency virus (HIV) in the country, cervical cancer may be the next epidemic if integrated measures are not adopted to increase cervical cancer knowledge and overcome the barriers to utilizing early screening services. The paper concludes with policy recommendations and directions for future research., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

This paper assesses the relationship between agroecology, food security, and human health. Specifically, we ask if agroecology can lead to improved food security and human health among vulnerable smallholder farmers in semi-humid tropical Africa. The empirical evidence comes from a cross-sectional household survey (n=1000) in two districts in Malawi, a small country in semi-humid, tropical Africa. The survey consisted of 571 agroecology-adoption and 429 non-agroecology-adoption households. Ordered logistics regression and average treatment effects models were used to determine the effect of agroecology adoption on self-reported health. Our results show that agroecology-adoption households (OR=1.37, p=0.05) were more likely to report optimal health status, and the average treatment effect shows that adopters were 12% more likely to be in optimal health. Furthermore, being moderately food insecure (OR=0.59, p=0.05) and severely food insecure (OR=0.89, p=0.10) were associated with less likelihood of reporting optimal health status. The paper concludes that with the adoption of agroecology in the semi-humid tropics, it is possible for households to diversify their crops and diets, a condition that has strong implications for improved food security, good nutrition and human health., (Copyright © 2016 Elsevier B.V. All rights reserved.)

As the world draws curtains on the implementation of Millennium Development Goals (MDGs), there is increasing interest in evaluating the performance of countries on the goals and assessing related challenges and opportunities to inform the upcoming Sustainable Development Goals (SDGs). This study examined changes in the timing and utilisation of maternal health care services in Nigeria and Malawi; using multivariate negative log-log and logistic regression models fitted to demographic and health survey data sets. Predicted probabilities were also computed to observe the net differences in the likelihood of both the first and the required number of antenatal care (ANC) visits for each of the three analysis years. Women in Nigeria were 7% less likely in 2008 compared to 2003, and in Malawi, 32% more likely in 2013 compared to 2000, to utilise ANC in the first trimester of pregnancy. Timing of first ANC visit was strongly influenced by wealth in Nigeria but not in Malawi. The findings in our case studies show how various contextual factors may enable or inhibit policy performance. Maternal and child health, SDGs should incorporate both wealth and degrees of urbanicity into country level implementation strategies.

Despite recent modest progress in reducing maternal and infant mortality rates in sub-Saharan Africa, Nigeria and Malawi were still in the top 20 countries with highest rates of mortalities globally in 2015. Utilisation of professional services at delivery - one of the indictors of MDG 5 - has been suggested to reduce maternal mortality by 50%. Yet, contextual, socio-cultural and economic factors have served as barriers to uptake of such critical service. In this paper, we examined the impact of residential wealth index on utilisation of Skilled Birth Attendant in Nigeria (2003, 2008 and 2013), and Malawi (2000, 2004 and 2010) using Demographic and Health Survey data sets. The findings from multivariate logistic regressions show that women in Nigeria were 23% less likely to utilise skilled delivery services in 2013 compared to 2003. In Malawi, women were 75% more likely to utilise skilled delivery services in 2010 than in 2000. Residential wealth index was a significant predictor of utilisation of skilled delivery services over time in both Nigeria and Malawi. These findings illuminate progress made - based on which we make recommendations for achievement of SDG-3: ensure healthy lives and promote well-being for all at all ages in Nigeria and Malawi, and similar context.

Background: Very little is known about reproductive health service (RHS) availability and adolescents' use of these services in post-conflict settings. Such information is crucial for targeted community interventions that aim to improve quality delivery of RHS and outcomes in post-conflict settings. The objectives of this study therefore was to examine the density of RHS availability; assess spatial patterns of RHC facilities; and identify youth-friendly practices associated with adolescents' use of services in post-conflict Burundi., Methods: A cross-sectional survey was conducted from a full census of all facilities (n = 892) and provider interviews in Burundi. Surveyed facilities included all public, private, religious and community association owned-centers and hospitals. At each facility efforts were made to interview the officer-in-charge and a group of his/her staff. We applied both geospatial and non-spatial analyses, to examine the density of RHS availability and density, and to explore the association between youth-friendly practices and adolescents' use of RHS in post-conflict Burundi., Results: High spatial patterning of distances of RHC facilities was observed, with facilities clustered predominantly in districts exhibiting persistent violence. But, use of services remained undeterred. We further found a stronger association between use of RHS and facility and programming characteristics. Community outreach, designated check-in/exam rooms, educational materials (posters, print, and pictures) in waiting rooms, privacy and confidentiality were significantly associated with adolescents' use of RHS across all facility types. Cost was associated with use only at religious facilities and youth involvement at private facilities. No significant association was found between provider characteristics and use of RHS at any facility., Conclusions: Our findings indicate the need to improve youth-friendly service practices in the provision of RHS to adolescents in Burundi and suggest that current approaches to provider training may not be adequate for improving these vital practices. Our mixed methods approach and results are generalizable to other countries and post-conflict settings. In post-conflict settings, the methods can be used to identify service availability and spatial patterns of RHC facilities to plan for targeted service interventions, to increase demand and uptake of services by youth and young adults.

Objectives: To examine the relationship between pregnancy intention and gestational age at first antenatal visit in Namibia., Methods: This study uses secondary data from the 2013 Namibia Demographic and Health Survey (NDHS). Log-normal survival models are used to examine the independent effect of pregnancy intention on gestational age at first antenatal visit while controlling for relevant sociodemographic and socioeconomic covariates., Results: This study finds that those who indicated unwanted pregnancies were significantly more likely to delay initiating antenatal care (ANC). Other variables also associated with gestational age at first antenatal visit include contact with a health worker, health insurance, media exposure to safe motherhood messages, birth order, relationship with head of household, maternal education, and urban residence., Conclusions: Timely ANC is necessary to identify and mitigate risk factors in pregnancy but many mothers in Namibia do not receive such care. Reducing unwanted pregnancies through family planning may limit ANC delays. After unwanted pregnancies occur, women may benefit from further education and resources that empower them to pursue ANC promptly.

This paper examines the relationship between circumcision status and timing of sexual debut among unmarried youth in Sub-Saharan Africa using Demographic and Health Surveys. Results from survival analysis indicate that the association between circumcision and timing of first sex is place and context specific. Compared to uncircumcised, circumcised men in Rwanda, Uganda and Namibia hasten sexual initiation, whilst circumcised youth in Ethiopia and Mali delayed sex initiation. In Togo however, we found parity in timing to sexual debut. Our multivariate results reveal that, knowledge of HIV/AIDS risk and educational level also feed into the association between circumcision and timing of sex initiation- implying that efforts to prevent new HIV infection through circumcision could benefit from a proper understanding of how diverse set of factors interact in specific contexts to shape youth's decisions to initiate early sex.

In Liberia, 75% of those who died from 2014 Ebola epidemic were women and the effects of this gruelling epidemic were more severely felt by pregnant women. This immediately raised fears about the long-term impacts of the epidemic on maternal and child health. As part of a larger study, this paper uses Andersen's behavioural model of health care utilization and Goffman's stigma theory to explain the timing and utilization of maternal health services before the outbreak of the Ebola epidemic as a background to the potential long-term effects on maternal health. We conducted survival and multiple regression analysis using the 2007 (N = 3524) and 2013 (N = 5127) Liberia's Demographic and Health Survey (LDHS) data. Our sample consisted of women of reproductive age (15-49 years) that had given birth in the last five years preceding the survey year. The findings show that from 2007 to 2013, there was an overall improvement in the timing of first antenatal care (ANC) visits (TR = 0.92, p < 0.001), number of ANC visits and delivery with skilled birth attendants. The results also show county and regional disparities in the utilization of ANC services with South Eastern A region emerging as a relatively vulnerable place. Also, access to ANC services defined by distance to a health facility strongly predicted utilization. We argue that the Ebola epidemic likely eroded many of the previous gains in maternal health care, and may have left a lingering negative effect on the access and utilization of maternal health services in the long-term. The study makes relevant policy recommendations., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objectives. Although research demonstrates the public health burden of prostate cancer among men in the Caribbean, relatively little is known about the factors that underlie the low levels of testing for the disease among this population. Study Design. A cross-sectional study of prostate cancer testing behaviours among men aged 40-60 years in Dominican Republic using the Demographic and Health Survey (2013). Methods. We use hierarchical binary logit regression models and average treatment effects combined with propensity score matching to explore the determinants of prostate screening as well as the average effect of health insurance coverage on screening. The use of hierarchical binary logit regression enabled us to control for the effect of unobserved heterogeneity at the cluster level that may affect prostate cancer testing behaviours. Results. Screening varied significantly with health insurance coverage, knowledge of cholesterol level, education, and wealth. Insured men were more likely to test for prostate cancer (OR = 1.65, p = 0.01) compared to the uninsured. Conclusions. The expansion and restructuring of Dominican Republic universal health insurance scheme to ensure equity in access may improve health access that would potentially impact positively on prostate cancer screening among men.

Objectives. Although a growing body of evidence demonstrates the public health burden of prostate cancer in SSA, relatively little is known about the underlying factors surrounding the low levels of testing for the disease in the context of this region. Using Namibia Demographic Health Survey dataset (NDHS, 2013), we examined the factors that influence men's decision to screen for prostate cancer in Namibia. Methods. We use complementary log-log regression models to explore the determinants of screening for prostate cancer. We also corrected for the effect of unobserved heterogeneity that may affect screening behaviours at the cluster level. Results. The results show that health insurance coverage (OR = 2.95, p = 0.01) is an important predictor of screening for prostate cancer in Namibia. In addition, higher education and discussing reproductive issues with a health worker (OR = 2.02, p = 0.05) were more likely to screening for prostate cancer. Conclusions. A universal health insurance scheme may be necessary to increase uptake of prostate cancer screening. However it needs to be acknowledged that expanded screening can have negative consequences and any allocation of scarce resources towards screening must be guided by evidence obtained from the local context about the costs and benefits of screening.

Objectives: We examined the influence of knowledge and information, health care access and different socio-economic variables on women's decision to screen for cervical cancer using a nationally representative dataset., Methods: We use hierarchical binary logit regression models to explore the determinants of screening for cervical cancer among women who reported hearing about cervical cancer. This enabled us to include the effect of unobserved heterogeneity at the cluster level that may affect screening behaviors., Results: Among women who have heard about cervical cancer (N=6542), only 39% of them did undergo screening with a mean age of 33 years. The univariate results reveal that women who are educated, insured, can afford money needed for treatment and reported distance not a barrier to accessing healthcare were more likely to screen. Our multivariate results indicate that insured women (OR=1.89, p=0.001) and women who had access to information through education and contact with a health worker (OR=1.41, p=0.001) were more likely to undertake screening compared to uninsured women and those with no contact with a health personnel, after controlling for relevant variables., Conclusions: The adoption of a universal health insurance scheme that ensures equity in access to health care and extension of public health information targeting women in rural communities especially within the Caprivi region may be needed for a large scale increase in cervical cancer screening in Namibia., (Copyright © 2015 Elsevier Inc. All rights reserved.)