Accounting for recent trends in the prevalence of diarrhoea in the Democratic Republic of Congo (DRC) : results from consecutive cross-sectional surveys

Objectives: To analyse trends in diarrhoea prevalence by maternal education, access to clean water and improved sanitation, household wealth index; to identify the sources of variation and assess contribution of changes in socioeconomic characteristics in the Democratic Republic of Congo (DRC). Design: Consecutive cross-sectional surveys. Setting: DRC. Participants: The databases contain information on 9748 children from the 2001 Multiple Indicators Cluster Survey and 7987 children from the 2007 Demographic and Health Survey. Interventions: N/A. Primary and secondary outcome measures Whether the child had diarrhoea 14 days preceding the survey. Results: The overall prevalence of diarrhoea decreased by 26 percent (from 22.1% in 2001 to 16.4% in 2007). Findings from the three complementary statistical methods are consistent and confirm a significant decrease in diarrhoea regardless of socioeconomic characteristics. Changes in behaviour and/or in public health policy seem to be the likely main source of the change. There were no significant changes in diarrhoea prevalence associated with variation of the population structure. It is worth mentioning that the decrease in diarrhoea prevalence is in contrast to the generalised poor living conditions of the population. Therefore, it is difficult to ascertain whether the decline in diarrhoea prevalence was due to real improvement in public-health policy or to data quality issues. Conclusions: The decline of diarrhoea prevalence in our study need to be further investigated by conducting district-based or provincial-based studies to validate findings from household surveys such as Demographic and Health Surveys and Multiple Indicators Cluster Survey taking into account the current context of the country: ongoing conflict, poor socioeconomic and poor health infrastructure. However, improvement in living conditions such as access to clean water and improved sanitation will contribute to accelerate the reduction of diarrhoea prevalence as well as reduction of child mortality

Engaging Men in Family Planning: Perspectives From Married Men in Lomé, Togo.

Family planning programs have made vast progress in many regions of sub-Saharan Africa in the last decade, but francophone West Africa is still lagging behind. More emphasis on male engagement might result in better outcomes, especially in countries with strong patriarchal societies. Few studies in francophone West Africa have examined attitudes of male involvement in family planning from the perspective of men themselves, yet this evidence is necessary for development of successful family planning projects that include men. This qualitative study, conducted in 2016, explored attitudes of 72 married men ages 18-54 through 6 focus groups in the capital of Togo, Lomé. Participants included professional workers as well as skilled and unskilled workers. Results indicate that men have specific views on family planning based on their knowledge and understanding of how and why women might use contraception. While some men did have reservations, both founded and not, there was an overwhelmingly positive response to discussing family planning and being engaged with related decisions and services. Four key findings from the analyses of focus group responses were: (1) socioeconomic motivations drive mens interest in family planning; (2) men strongly disapprove of unilateral decisions by women to use family planning; (3) misconceptions surrounding modern methods can hinder support for family planning; and (4) limited method choice for men, insufficient venues to receive services, and few messages that target men create barriers for male engagement in family planning. Future attempts to engage men in family planning programs should pay specific attention to mens concerns, misconceptions, and their roles in family decision making. Interventions should educate men on the socioeconomic and health benefits of family planning while explaining the possible side effects and dispelling myths. To help build trust and facilitate open communication, family planning programs that encourage counseling of husbands and wives in their homes by community health workers, trusted men, or couples who have successfully used or are currently using family planning to achieve their desired family size will be important

Effectiveness of interventions to reduce indoor air pollution and/or improve health in homes using solid fuel in lower and middle income countries : protocol for a systematic review

Peer reviewedPublisher PD

Effectiveness of interventions to reduce household air pollution and/or improve health in homes using solid fuel in low-and-middle income countries : A systematic review and meta-analysis

Peer reviewedPostprin

Child mortality in the Democratic Republic of Congo: cross-sectional evidence of the effect of geographic location and prolonged conflict from a national household survey

Background The child mortality rate is a good indicator of development. High levels of infectious diseases and high child mortality make the Democratic Republic of Congo (DRC) one of the most challenging environments for health development in Sub-Saharan Africa (SSA). Recent conflicts in the eastern part of the country and bad governance have compounded the problem. This study aimed to examine province-level geographic variation in under-five mortality (U5M), accounting for individual- and household-level risk factors including environmental factors such as conflict. Methods Our analysis used the nationally representative cross-sectional household sample of 8,992 children under five in the 2007 DRC Demographic and Health Survey. In the survey year, 1,005 deaths among this group were observed. Information on U5M was aggregated to the 11 provinces, and a Bayesian geo-additive discrete-time survival mixed model was used to map the geographic distribution of under-five mortality rates (U5MRs) at the province level, accounting for observable and unobservable risk factors. Results The overall U5MR was 159 per 1,000 live births. Significant associations with risk of U5M were found for < 24 month birth interval [posterior odds ratio and 95% credible region: 1.14 (1.04, 1.26)], home birth [1.13 (1.01, 1.27)] and living with a single mother [1.16 (1.03, 1.33)]. Striking variation was also noted in the risk of U5M by province of residence, with the highest risk in Kasaï-Oriental, a non-conflict area of the DRC, and the lowest in the conflict area of North Kivu. Conclusion This study reveals clear geographic patterns in rates of U5M in the DRC and shows the potential role of individual child, household and environmental factors, which are unexplained by the ongoing conflict. The displacement of mothers to safer areas may explain the lower U5MR observed at the epicentre of the conflict in North Kivu, compared with rates in conflict-free areas. Overall, the U5M maps point to a lack of progress towards the Millennium Development Goal of reducing U5M by half by 2015

Diarrhoea, acute respiratory infection, and fever among children in the Democratic Republic of Congo

Several years of war have created a humanitarian crisis in the Democratic Republic of Congo (DRC) with extensive disruption of civil society, the economy and provision of basic services including health care. Health policy and planning in the DRC are constrained by a lack of reliable and accessible population data. Thus there is currently a need for primary research to guide programme and policy development for reconstruction and to measure attainment of the Millennium Development Goals (MDGs). This study uses the 2001 Multiple Indicators Cluster Survey to disentangle children's health inequalities by mapping the impact of geographical distribution of childhood morbidity stemming from diarrhoea, acute respiratory infection, and fever. We observe a low prevalence of childhood diarrhoea, acute respiratory infection and fever in the western provinces (Kinshasa, Bas-Congo and Bandundu), and a relatively higher prevalence in the south-eastern provinces (Sud-Kivu and Katanga). However, each disease has a distinct geographical pattern of variation. Among covariate factors, child age had a significant association with disease prevalence. The risk of the three ailments increased in the first 8–10 months after birth, with a gradual improvement thereafter. The effects of socioeconomic factors vary according to the disease. Accounting for the effects of the geographical location, our analysis was able to explain a significant share of the pronounced residual geographical effects. Using large scale household survey data, we have produced for the first time spatial residual maps in the DRC and in so doing we have undertaken a comprehensive analysis of geographical variation at province level of childhood diarrhoea, acute respiratory infection, and fever prevalence. Understanding these complex relationships through disease prevalence maps can facilitate design of targeted intervention programs for reconstruction and achievement of the MDGs

Monitoring of Health and Demographic Outcomes in Poor Urban Settlements: Evidence from the Nairobi Urban Health and Demographic Surveillance System

The Nairobi Urban Health and Demographic Surveillance System (NUHDSS) was set up in Korogocho and Viwandani slum settlements to provide a platform for investigating linkages between urban poverty, health, and demographic and other socioeconomic outcomes, and to facilitate the evaluation of interventions to improve the wellbeing of the urban poor. Data from the NUHDSS confirm the high level of population mobility in slum settlements, and also demonstrate that slum settlements are long-term homes for many people. Research and intervention programs should take account of the duality of slum residency. Consistent with the trends observed countrywide, the data show substantial improvements in measures of child mortality, while there has been limited decline in fertility in slum settlements. The NUHDSS experience has shown that it is feasible to set up and implement long-term health and demographic surveillance system in urban slum settlements and to generate vital data for guiding policy and actions aimed at improving the wellbeing of the urban poor

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation