Childhood mortality in sub-Saharan Africa : cross-sectional insight into small-scale geographical inequalities from Census data

Objectives To estimate and quantify childhood mortality, its spatial correlates and the impact of potential correlates using recent census data from three sub-Saharan African countries (Rwanda, Senegal and Uganda), where evidence is lacking. Design Cross-sectional. Setting Nation-wide census samples from three African countries participating in the 2010 African Census round. All three countries have conducted recent censuses and have information on mortality of children under 5 years. Participants 111 288 children under the age of 5 years in three countries. Primary and secondary outcome measures Under-five mortality was assessed alongside potential correlates including geographical location (where children live), and environmental, bio-demographic and socioeconomic variables. Results Multivariate analysis indicates that in all three countries the overall risk of child death in the first 5 years of life has decreased in recent years (Rwanda: HR=0.04, 95% CI 0.02 to 0.09; Senegal: HR=0.02 (95% CI 0.02 to 0.05); Uganda: HR=0.011 (95% CI 0.006 to 0.018). In Rwanda, lower deaths were associated with living in urban areas (0.79, 0.73, 0.83), children with living mother (HR=0.16, 95% CI 0.15 to 0.17) or living father (HR=0.38, 95% CI 0.36 to 0.39). Higher death was associated with male children (HR=1.06, 95% CI 1.02 to 1.08) and Christian children (HR=1.14, 95% CI 1.05 to 1.27). Children less than 1 year were associated with higher risk of death compared to older children in the three countries. Also, there were significant spatial variations showing inequalities in children mortality by geographic location. In Uganda, for example, areas of high risk are in the south-west and north-west and Kampala district showed a significantly reduced risk. Conclusions We provide clear evidence of considerable geographical variation of under-five mortality which is unexplained by factors considered in the data. The resulting under-five mortality maps can be used as a practical tool for monitoring progress within countries for the Millennium Development Goal 4 to reduce under-five mortality in half by 2015

No. 08: The Urban Food System of Windhoek, Namibia

The surprisingly high rate of supermarket patronage in low-income areas of Windhoek, Namibia’s capital and largest city, is at odds with conventional wisdom that supermarkets in African cities are primarily patronized by middle and high-income residents and therefore target their neighbourhoods. What is happening in Namibia and other Southern African countries that make supermarkets so much more accessible to the urban poor? What are they buying at supermarkets and how frequently do they shop there? Further, what is the impact of supermarket expansion on informal food vendors? This report, which presents the findings of the South African Supermarkets in Growing African Cities project research in 2016-2017 in Windhoek, looks at the evidence and tries to answer these questions and others. The research and policy debate on the relationship between the supermarket revolution and food security is also discussed. Here, the issues include whether supermarket supply chains and procurement practices mitigate rural food insecurity through providing new market opportunities for smallholder farmers; the impact of supermarkets on the food security and consumption patterns of residents of African cities; and the relationship between supermarket expansion and governance of the food system, particularly at the local level

No. 26: The Supermarket Revolution and Food Security in Namibia

The surprisingly high rate of supermarket patronage in low-income areas of Windhoek, Namibia’s capital and largest city, is at odds with conventional wisdom that supermarkets in African cities are primarily patronized by middle and high-income residents and therefore target their neighbourhoods. What is happening in Namibia and other Southern African countries that make supermarkets so much more accessible to the urban poor? What are they buying at supermarkets and how frequently do they shop there? Further, what is the impact of supermarket expansion on informal food vendors? This report, which presents the findings from the South African Supermarkets in Growing African Cities project research in 2016-2017 in Windhoek, looks at the evidence and tries to answer these questions and others. The research and policy debate on the relationship between the supermarket revolution and food security is also discussed. Here, the issues include whether supermarket supply chains and procurement practices mitigate rural food insecurity through providing new market opportunities for smallholder farmers; the impact of supermarkets on the food security and consumption patterns of residents of African cities; and the relationship between supermarket expansion and governance of the food system, particularly at the local level

Using structured additive regression models to estimate risk factors of malaria: analysis of 2010 Malawi malaria indicator survey data.

BACKGROUND: After years of implementing Roll Back Malaria (RBM) interventions, the changing landscape of malaria in terms of risk factors and spatial pattern has not been fully investigated. This paper uses the 2010 malaria indicator survey data to investigate if known malaria risk factors remain relevant after many years of interventions. METHODS: We adopted a structured additive logistic regression model that allowed for spatial correlation, to more realistically estimate malaria risk factors. Our model included child and household level covariates, as well as climatic and environmental factors. Continuous variables were modelled by assuming second order random walk priors, while spatial correlation was specified as a Markov random field prior, with fixed effects assigned diffuse priors. Inference was fully Bayesian resulting in an under five malaria risk map for Malawi. RESULTS: Malaria risk increased with increasing age of the child. With respect to socio-economic factors, the greater the household wealth, the lower the malaria prevalence. A general decline in malaria risk was observed as altitude increased. Minimum temperatures and average total rainfall in the three months preceding the survey did not show a strong association with disease risk. CONCLUSIONS: The structured additive regression model offered a flexible extension to standard regression models by enabling simultaneous modelling of possible nonlinear effects of continuous covariates, spatial correlation and heterogeneity, while estimating usual fixed effects of categorical and continuous observed variables. Our results confirmed that malaria epidemiology is a complex interaction of biotic and abiotic factors, both at the individual, household and community level and that risk factors are still relevant many years after extensive implementation of RBM activities

Care-seeking for diarrhoea in Southern Malawi : attitudes, practices and implications for diarrhoea control

This paper examined care-seeking behaviour and its associated risk factors when a family member had diarrhoea. Data was obtained from a survey conducted in Chikwawa, a district in Southern Malawi. Chikwawa is faced with a number of environmental and socioeconomic problems and currently diarrhoea morbidity in the district is estimated at 24.4% statistically higher than the national average at 17%. Using hierarchically built data from a survey of 1,403 households nested within 33 communities, a series of two level binary logistic regression models with Bayesian estimation were used to determine predictors of care-seeking behaviour. The results show that 68% of mothers used oral rehydration solutions (ORS) last time a child in their family had diarrhoea . However, when asked on the action they take when a member of their household has diarrhoea two thirds of the mothers said they visit a health facility. Most respondents (73%) mentioned distance and transport costs as the main obstacles to accessing their nearest health facility and the same proportion of respondents mentioned prolonged waiting time and absence of health workers as the main obstacles encountered at the health facilities. The main predictor variables when a member of the family had diarrhoea were maternal age, distance to the nearest health facility, school level, and relative wealth, household diarrhoea endemicity, and household size while the main predictor variables when a child had diarrhoea were existence of a village health committee (VHC), distance to the nearest health facility, and maternal age . Most households use ORS for the treatment of diarrhoea and village health committees and health surveillance assistants (HSAs) are important factors in this choice of treatment. Health education messages on the use and efficacy of ORS to ensure proper and prescribed handling are important. There is need for a comprehensive concept addressing several dimensions of management and proper coordination of delivery of resources and services; availability of adequate healthcare workers at all levels; affordability to accessibility of healthcare resources and services to all communities; acceptability and quality of care; intensification of health education messages on the use and management of ORS, and prompt and timely treatment of diarrhoeal illness

The pattern of variation between diarrhoea and malaria coexistence with corresponding risk factors in, Chikhwawa, Malawi : a bivariate multilevel analysis

Developing countries face a huge burden of infectious diseases, a number of which co-exist. This paper estimates the pattern and variation of malaria and diarrhea coexistence in Chikhwawa, a district in Southern Malawi using bivariate multilevel modelling with Bayesian estimation. A probit link was employed to examine hierarchically built data from a survey of individuals (n = 6,727) nested within households (n = 1,380) nested within communities (n = 33). Results show significant malaria [σ2ul = 0.901 (95% CI : 0.746,1.056) ] and diarrhea [σ2ul = 1.009  (95% CI : 0.860,1.158) ] variations with a strong correlation between them [ru(1,2) = 0.565 ] at household level. There are significant malaria [σ2v1 = 0.053 (95% CI : 0.018,0.088) ] and diarrhea [σ2v2 = 0.099 (95% CI : 0.030,0.168 ] variations at community level but with a small correlation [rv(1,2) = 0.124 ] between them. There is also significant correlation between malaria and diarrhea at individual level [re(1,2) 0.241]. These results suggest a close association between reported malaria-like illness and diarrheal illness especially at household and individual levels in Southern Malawi

No. 33: Containing the Informal Food Sector in Windhoek, Namibia

Policy responses to the growth of the informal food sector in African cities vary from benign neglect to active destruction. The eradication of street food vending is the dominant mode of governance. Alternative approaches that recognize the inevitability of informality and the role of the sector in making food accessible to the urban poor have begun to emerge. One is an enclose-and-contain model, which creates spaces for trading and seeks to confine trading to these spaces through active policing outside them. This strategy has been pursued in Windhoek but has been compromised by consumer demand that is not satisfied by the city’s approved markets and by the actions of street traders who cluster at key locations and force tacit official recognition. This paper examines the origins and development of this hybrid model of informalized containment, as well as the profile of consumers who patronize both types of market

No. 55: Food Clusters, Food Security and the Urban Food System of Northern Namibia

A central feature of the transformation of urban food systems in cities of the Global South is the growing presence of supermarkets and their supply chains, often termed supermarketization or a supermarket revolution. A key issue in the African context is whether supermarkets are a threat to other sources of food including informal sector vendors. Most research on the supermarket revolution and competition with other food retailers focuses on large urban conurbations with little attention paid to the role of supermarkets in secondary urban centres. This paper aims to rectify this situation through a case study of the role of supermarkets in three smaller urban centres in Northern Namibia. The paper uses data from a representative household food security survey in 2018 which collected detailed information on household food consumption and food purchasing patterns. We show that supermarkets have established a dominant role in the local food system and are patronized by almost all households. However, the informal food sector displays considerable resilience and is patronized on a regular basis by low-income households. Future research on the impact of the secondary supermarket revolution should examine the experience and strategies of informal food vendors and whether the relationship with supermarkets is truly symbiotic or not

No. 58: Wild Foods, the Nutrition Transition and Urban Food Security in Northern Namibia

Rapid urbanization and food system transformation in Africa have been accompanied by growing food insecurity, reduced dietary diversity and an epidemic of non-communicable disease. While the contribution of wild and indigenous foods (WIF) to the quality of rural household diets has been of longstanding attention, research on their consumption and role amongst urban households is much more recent. This paper focuses on the consumption of WIF in three towns in northern Namibia with close ties to the surrounding rural agricultural areas. Based on data from a household survey of food sourcing and consumption patterns in 2018, the paper shows that most households do consume wild foods acquired through informal market channels or sent by rural family members. These WIF food remittances play different roles in the food security of different types of households. Poorer, food insecure households tend to consume WIF more frequently and that while these foods play a role in diversifying diets, they are insufficient to lift these households out of chronic food insecurity. Higher-income households consume wild foods less frequently and more for reasons of cultural preference and taste than necessity. The paper raises several issues for future research including the reasons for continued urban household consumption of WIF, the nature of the supply chains that bring WIF to urban consumers and the impact of climate change on the future supply of WIF to urban areas

No. 26: Supermarkets and Informal Food Vendors in Windhoek, Namibia

Much of the literature on urban food systems has focused on the expansion of supermarkets and their ability to reach urban consumers. However, the current pace of urbanization and rising urban poverty have been accompanied by a major upsurge in informality and a growing role for the informal food sector. One of the persistent arguments in the literature on supermarkets is that the expansion of modern retail undermines the informal food sector. Critics of this argument suggest that there are two conditions under which this may not occur: first, when there is spatial differentiation with supermarkets servicing higher income areas and the informal sector targeting low-income areas. The second is when there is market segmentation – when the formal and informal sectors focus on the sale of different product types. This paper examines the case of Windhoek, Namibia, which has undergone a major supermarket revolution in the last two decades. It suggests that the informal food sector is vibrant and growing but that neither explanation fully accounts for its resilience. By examining the strategies of vendors, it suggests the concept of cohabitation as an alternative explanation. This concept may be a pertinent factor in other cities too