Relationship Between Household Socio-Economic Status and under-five Mortality in Rufiji DSS, Tanzania.

Disparities in health outcomes between the poor and the better off are increasingly attracting attention from researchers and policy makers. However, policies aimed at reducing inequity need to be based on evidence of their nature, magnitude, and determinants. The study aims to investigate the relationship between household socio-economic status (SES) and under-five mortality, and to measure health inequality by comparing poorest/least poor quintile mortality rate ratio and the use of a mortality concentration index. It also aims to describe the risk factors associated with under-five mortality at Rufiji Demographic Surveillance Site (RDSS), Tanzania. This analytical cross sectional study included 11,189 children under-five residing in 7,298 households in RDSS in 2005. Principal component analysis was used to construct household SES. Kaplan-Meier survival incidence estimates were used for mortality rates. Health inequality was measured by calculating and comparing mortality rates between the poorest and least poor wealth quintile. We also computed a mortality concentration index. Risk factors of child mortality were assessed using Poisson regression taking into account potential confounders. Under-five mortality was 26.9 per 1,000 person-years [95% confidence interval (CI) (23.7-30.4)]. The poorest were 2.4 times more likely to die compared to the least poor. Our mortality concentration index [-0.16; 95% CI (-0.24, -0.08)] indicated considerable health inequality. Least poor households had a 52% reduced mortality risk [incidence rate ratio (IRR) = 0.48; 95% CI 0.30-0.80]. Furthermore, children with mothers who had attained secondary education had a 70% reduced risk of dying compared to mothers with no education [IRR = 0.30; 95% CI (0.22-0.88)]. Household socio-economic inequality and maternal education were associated with under-five mortality in the RDSS. Targeted interventions to address these factors may contribute towards accelerating the reduction of child mortality in rural Tanzania

Applications of transcranial direct current stimulation for understanding brain function

In recent years there has been an exponential rise in the number of studies employing transcranial direct current stimulation (tDCS) as a means of gaining a systems-level understanding of the cortical substrates underlying behaviour. These advances have allowed inferences to be made regarding the neural operations that shape perception, cognition, and action. Here we summarise how tDCS works, and show how research using this technique is expanding our understanding of the neural basis of cognitive and motor training. We also explain how oscillatory tDCS can elucidate the role of fluctuations in neural activity, in both frequency and phase, in perception, learning, and memory. Finally, we highlight some key methodological issues for tDCS and suggest how these can be addressed

Improved multitasking following prefrontal tDCS

We have a limited capacity for mapping sensory information onto motor responses. This processing bottleneck is thought to be a key factor in determining our ability to make two decisions simultaneously - i.e., to multitask ( Pashler, 1984, 1994; Welford, 1952). Previous functional imaging research ( Dux, Ivanoff, Asplund, & Marois, 2006; Dux etal., 2009) has localised this bottleneck to the posterior lateral prefrontal cortex (pLPFC) of the left hemisphere. Currently, however, it is unknown whether this region is causally involved in multitasking performance. We investigated the role of the left pLPFC in multitasking using transcranial direct current stimulation (tDCS). The behavioural paradigm included single- and dual-task trials, each requiring a speeded discrimination of visual stimuli alone, auditory stimuli alone, or both visual and auditory stimuli. Reaction times for single- and dual-task trials were compared before, immediately after, and 20min after anodal stimulation (excitatory), cathodal stimulation (inhibitory), or sham stimulation. The cost of responding to the two tasks (i.e., the reduction in performance for dual- vs single-task trials) was significantly reduced by cathodal stimulation, but not by anodal or sham stimulation. Overall, the results provide direct evidence that the left pLPFC is a key neural locus of the central bottleneck that limits an individual's ability to make two simple decisions simultaneously

Disrupting prefrontal cortex prevents performance gains from sensory-motor training

Humans show large and reliable performance impairments when required to make more than one simple decision simultaneously. Such multitasking costs are thought to largely reflect capacity limits in response selection (Welford, 1952; Pashler, 1984, 1994), the information processing stage at which sensory input is mapped to a motor response. Neuroimaging has implicated the left posterior lateral prefrontal cortex (pLPFC) as a key neural substrate of response selection (Dux et al., 2006, 2009; Ivanoff et al., 2009). For example, activity in left pLPFC tracks improvements in response selection efficiency typically observed following training (Dux et al., 2009). To date, however, there has been no causal evidence that pLPFC contributes directly to sensory-motor training effects, or the operations through which training occurs. Moreover, the left hemisphere lateralization of this operation remains controversial (Jiang and Kanwisher, 2003; Sigman and Dehaene, 2008; Verbruggen et al., 2010). We used anodal (excitatory), cathodal (inhibitory), and sham transcranial direct current stimulation (tDCS) to left and right pLPFC and measured participants' performance on high and low response selection load tasks after different amounts of training. Both anodal and cathodal stimulation of the left pLPFC disrupted training effects for the high load condition relative to sham. No disruption was found for the low load and right pLPFC stimulation conditions. The findings implicate the left pLPFC in both response selection and training effects. They also suggest that training improves response selection efficiency by fine-tuning activity in pLPFC relating to sensory-motor translations

Equity in community health insurance schemes: evidence and lessons from Armenia

Introduction Community health insurance (CHI) schemes are growing in importance in low-income settings, where health systems based on user fees have resulted in significant barriers to care for the poorest members of communities. They increase revenue, access and financial protection, but concerns have been expressed about the equity of such schemes and their ability to reach the poorest. Few programmes routinely evaluate equity impacts, even though this is usually a key objective. This lack of evidence is related to the difficulties in collecting reliable data on utilization and socio-economic status. This paper describes the findings of an evaluation of the equity of Oxfam's CHI schemes in rural Armenia

Attitudes to routine HIV counselling and testing, and knowledge about prevention of mother to child transmission of HIV in eastern Uganda: a cross-sectional survey among antenatal attendees

<p>Abstract</p> <p>Background</p> <p>HIV testing rates have exceeded 90% among the pregnant women at Mbale Regional Referral Hospital in Mbale District, eastern Uganda, since the introduction of routine antenatal counselling and testing for HIV in June 2006. However, no documented information was available about opinions of pregnant women in eastern Uganda about this HIV testing approach. We therefore conducted a study to assess attitudes of antenatal attendees towards routine HIV counselling and testing at Mbale Hospital. We also assessed their knowledge about mother to child transmission of HIV and infant feeding options for HIV-infected mothers.</p> <p>Methods</p> <p>The study was a cross-sectional survey of 388 women, who were attending the antenatal clinic for the first time with their current pregnancy at Mbale Regional Referral Hospital from August to October 2009. Data were collected using a pre-tested questionnaire and analysed using descriptive statistics and logistic regression. Permission to conduct the study was obtained from the Makerere University College of Health Sciences, the Uganda National Council of Science and Technology, and Mbale Hospital.</p> <p>Results</p> <p>The majority of the antenatal attendees (98.5%, 382/388) had positive attitudes towards routine HIV counselling and testing, and many of them (more than 60%) had correct knowledge of how mother to child transmission of HIV could occur during pregnancy, labour and through breastfeeding, and ways of preventing it. After adjusting for independent variables, having completed secondary school (odds ratio: 2.5, 95% confidence interval: 1.3-4.9), having three or more pregnancies (OR: 2.5, 95% CI: 1.4-4.5) and belonging to a non-Bagisu ethnic group (OR: 1.7, 95% CI: 1.0-2.7) were associated with more knowledge of exclusive breastfeeding as one of the measures for prevention of mother to child transmission of HIV. Out of 388 antenatal attendees, 386 (99.5%) tested for HIV and 382 (98.5%) received same-day HIV test results.</p> <p>Conclusions</p> <p>Routine offer of antenatal HIV counselling and testing is largely acceptable to the pregnant women in eastern Uganda and has enabled most of them to know their HIV status as part of the prevention of mother to child transmission of HIV package of services. Our findings call for further strengthening and scaling up of this HIV testing approach in many more antenatal clinics countrywide in order to maximize its potential benefits to the population.</p

Vitamin A supplementation in Tanzania: the impact of a change in programmatic delivery strategy on coverage.

BACKGROUND\ud \ud Efficient delivery strategies for health interventions are essential for high and sustainable coverage. We report impact of a change in programmatic delivery strategy from routine delivery through the Expanded Programme on Immunization (EPI+) approach to twice-yearly mass distribution campaigns on coverage of vitamin A supplementation in Tanzania\ud \ud METHODS\ud \ud We investigated disparities in age, sex, socio-economic status, nutritional status and maternal education within vitamin A coverage in children between 1 and 2 years of age from two independent household level child health surveys conducted (1) during a continuous universal targeting scheme based on routine EPI contacts for children aged 9, 15 and 21 months (1999); and (2) three years later after the introduction of twice-yearly vitamin A supplementation campaigns for children aged 6 months to 5 years, a 6-monthly universal targeting scheme (2002). A representative cluster sample of approximately 2,400 rural households was obtained from Rufiji, Morogoro Rural, Kilombero and Ulanga districts. A modular questionnaire about the health of all children under the age of five was administered to consenting heads of households and caretakers of children. Information on the use of child health interventions including vitamin A was asked.\ud \ud RESULTS\ud \ud Coverage of vitamin A supplementation among 1-2 year old children increased from 13% [95% CI 10-18%] in 1999 to 76% [95%CI 72-81%] in 2002. In 2002 knowledge of two or more child health danger signs was negatively associated with vitamin A supplementation coverage (80% versus 70%) (p = 0.04). Nevertheless, we did not find any disparities in coverage of vitamin A by district, gender, socio-economic status and DPT vaccinations.\ud \ud CONCLUSION\ud \ud Change in programmatic delivery of vitamin A supplementation was associated with a major improvement in coverage in Tanzania that was been sustained by repeated campaigns for at least three years. There is a need to monitor the effect of such campaigns on the routine health system and on equity of coverage. Documentation of vitamin A supplementation campaign contacts on routine maternal and child health cards would be a simple step to facilitate this monitoring

Error sources and data limitations for the prediction ofsurface gravity: a case study using benchmarks

Gravity-based heights require gravity values at levelled benchmarks (BMs), whichsometimes have to be predicted from surrounding observations. We use EGM2008 andthe Australian National Gravity Database (ANGD) as examples of model and terrestrialobserved data respectively to predict gravity at Australian national levelling network(ANLN) BMs. The aim is to quantify errors that may propagate into the predicted BMgravity values and then into gravimetric height corrections (HCs). Our results indicatethat an approximate ±1 arc-minute horizontal position error of the BMs causesmaximum errors in EGM2008 BM gravity of ~ 22 mGal (~55 mm in the HC at ~2200 melevation) and ~18 mGal for ANGD BM gravity because the values are not computed atthe true location of the BM. We use RTM (residual terrain modelling) techniques toshow that ~50% of EGM2008 BM gravity error in a moderately mountainous regioncan be accounted for by signal omission. Non-representative sampling of ANGDgravity in this region may cause errors of up to 50 mGals (~120 mm for the Helmertorthometric correction at ~2200 m elevation). For modelled gravity at BMs to beviable, levelling networks need horizontal BM positions accurate to a few metres, whileRTM techniques can be used to reduce signal omission error. Unrepresentative gravitysampling in mountains can be remedied by denser and more representative re-surveys,and/or gravity can be forward modelled into regions of sparser gravity

A mediation approach to understanding socio-economic inequalities in maternal health-seeking behaviours in Egypt.

BACKGROUND: The levels and origins of socio-economic inequalities in health-seeking behaviours in Egypt are poorly understood. This paper assesses the levels of health-seeking behaviours related to maternal care (antenatal care [ANC] and facility delivery) and their accumulation during pregnancy and childbirth. Secondly, it explores the mechanisms underlying the association between socio-economic position (SEP) and maternal health-seeking behaviours. Thirdly, it examines the effectiveness of targeting of free public ANC and delivery care. METHODS: Data from the 2008 Demographic and Health Survey were used to capture two latent constructs of SEP: individual socio-cultural capital and household-level economic capital. These variables were entered into an adjusted mediation model, predicting twelve dimensions of maternal health-seeking; including any ANC, private ANC, first ANC visit in first trimester, regular ANC (four or more visits during pregnancy), facility delivery, and private delivery. ANC and delivery care costs were examined separately by provider type (public or private). RESULTS: While 74.2% of women with a birth in the 5-year recall period obtained any ANC and 72.4% delivered in a facility, only 48.8% obtained the complete maternal care package (timely and regular facility-based ANC as well as facility delivery) for their most recent live birth. Both socio-cultural capital and economic capital were independently positively associated with receiving any ANC and delivering in a facility. The strongest direct effect of socio-cultural capital was seen in models predicting private provider use of both ANC and delivery. Despite substantial proportions of women using public providers reporting receipt of free care (ANC: 38%, delivery: 24%), this free-of-charge public care was not effectively targeted to women with lowest economic resources. CONCLUSIONS: Socio-cultural capital is the primary mechanism leading to inequalities in maternal health-seeking in Egypt. Future studies should therefore examine the objective and perceived quality of care from different types of providers. Improvements in the targeting of free public care could help reduce the existing SEP-based inequalities in maternal care coverage in the short term