Factors that influence married/partnered women’s decisions to use contraception in Zambia

According to the Demographic and Health Surveys (DHSs), Zambia has shown an increasing trend in the percentage of married women using contraceptives in the last three decades. As of 2018, this percentage increased from 34.2% in 2001 to 40.8% in 2007 and from 45% in 2013 to 48% in 2018. Despite the increasing trend in contraceptive use, the unmet needs remain relatively high. The low percentage of contraception use translates into 20% of women of reproductive age who are either married/partnered and want to stop or delay childbearing but are not using contraception. This study analyzed factors other than availability that influence women’s ability to make or influence the decision to use contraception using logistic regression using data from the Zambia 2013/2014 and 2018 DHSs. Furthermore, adjusted odds ratios and predicted probabilities were estimated using the fitted logistic regression. Data on 8,335 women were analyzed, and 13.7% (n = 1,145) had their husband as the sole decision maker for contraception use, while 86.3% (n = 7,189) made the decisions or participated in making the decision. Contrary to most literature, those with primary or secondary school education were less likely to decide than those without education. The data also associate women who contribute to daily household decisions to having a say in deciding to use contraception. Lastly, women using reversible contraception methods, other methods, hormonal methods, and fertility awareness were associated with less likelihood to decide on using contraceptives than those using barrier methods. Women with lower household decision-making powers are less likely to make or influence decisions to use contraception. Consequently, there is a need to prioritize such women in interventions aimed at increasing contraception use decision-making. Furthermore, more studies are required to investigate why uneducated women in Zambia are more likely to choose contraception. Also, the vast odds ratio difference between all other methods compared to barrier methods (condoms) indicates underlying factors that play a role, which warrants further studies

Impact of night travel ban on road traffic crashes and fatalities in Zambia: an interrupted time series analysis

Background The burden of road traffic crashes (RTCs) and road traffic fatalities (RTFs) has been increasing in low-income and middle-income countries (LMICs). Most RTCs and RTFs happen at night. Although few countries, including Zambia, have implemented night travel bans, there is no evidence on the extent to which such policies may reduce crashes and fatalities. Methods We exploit the quasi-experimental set up afforded by the banning of night travel of public service vehicles in Zambia in 2016 and interrupted time series analysis to assess whether the ban had an impact on both levels and trends in RTCs and RTFs. We use annual administrative data for the period 2006—2020, with 10 pre-intervention and 4 post-intervention data points. In an alternative specification, we restrict the analysis to the period 2012—2020 so that the number of data points are the same pre-interventions and post-interventions. We also carry out robustness checks to rule out other possible explanation of the results including COVID-19. Results The night travel ban was associated with a reduction in the level of RTCs by 4131.3 (annual average RTCs before the policy=17 668) and a reduction in the annual trend in RTCs by 2485.5. These effects were significant at below 1%, and they amount to an overall reduction in RTCs by 24%. The policy was also associated with a 57.5% reduction in RTFs. In absolute terms, the trend in RTFs reduced by 477.5 (Annual average RTFs before the policy=1124.7), which is significant at below 1% level. Our results were broadly unchanged in alternative specifications. Conclusion We conclude that a night travel ban may be an effective way of reducing the burden of RTCs and RTFs in Zambia and other LMICs. However, complementary policies are needed to achieve more gains.publishedVersio

Walking and perceived lack of safety: Correlates and association with health outcomes for people living with HIV in rural Zambia

Introduction: Geographic inaccessibility disproportionately affects health outcomes of rural populations due to lack of suitable transport, prolonged travel time, and poverty. Rural patients are left with few transport options to travel to a health facility. One common option is to travel by foot, which may present additional challenges, such as perceived lack of safety while transiting. We examined the correlates of perceived lack of safety when walking to a health facility and its association with treatment and psychosocial outcomes among adults living with HIV. Methods: Data were collected from 101 adults living with HIV in Eastern Province, Zambia. All participants were receiving antiretroviral therapy at one of two health clinics. Perceived lack of safety was measured by asking respondents whether they felt unsafe traveling to and from the health facility in which they were receiving their HIV care. Outcomes included medication adherence, perceived stress, hope for the future, and barriers to pill taking. Linear and logistic regression methods were used to examine the correlates of perceived safety and its association with health outcomes. Results: Being older, a woman, having a primary education, living farther from a health facility, traveling longer to reach a health facility, and owing money were associated with higher likelihood of feeling unsafe when traveling by foot to health facility. Perceived lack of safety was associated with medication nonadherence, higher level of stress, lower level of agency, and more barriers to pill taking. Conclusions: Perceived lack of safety when traveling by foot to a health facility may be a barrier to better treatment and psychosocial outcomes, especially among rural patients. Practitioners and policymakers should consider implementation of differentiated HIV service delivery models to reduce frequent travel to health facilities and to alleviate ART patients' worry about lack of safety when traveling by foot to a health facility

Patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa: a systematic review

Background Morbidity and mortality due to pregnancy and childbearing are high in developing countries. This study aims to estimate patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa. Methods A systematic review of the literature was conducted to identify costing studies published and unpublished, from January 2000 to May 2019. The search was done in Pubmed, EMBASE, Cinahl, and Web of Science databases and grey literature. The study was registered in PROSPERO with registration No. CRD42019119316. All costs were converted to 2018 US dollars using relevant Consumer Price Indices. Results Out of 1652 studies identified, 48 fulfilled the inclusion criteria. The included studies were of moderate to high quality. Spontaneous vaginal delivery cost patients and health systems between USD 6–52 and USD 8–73, but cesarean section costs between USD 56–377 and USD 80–562, respectively. Patient and health system costs of abortion range between USD 11–66 and USD 40–298, while post-abortion care costs between USD 21–158 and USD 46–151, respectively. The patient and health system costs for managing a case of eclampsia range between USD 52–231 and USD 123–186, while for maternal hemorrhage they range between USD 65–196 and USD 30–127, respectively. Patient cost for caring low-birth weight babies ranges between USD 38–489 while the health system cost was estimated to be USD 514. Conclusion This is the first systematic review to compile comprehensive up-to-date patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa. It indicates that these costs are relatively high in this region and that patient costs were largely catastrophic relative to a 10 % of average national per capita income.publishedVersio

Social cost of mining-related lead (Pb) pollution in Kabwe, Zambia, and potential remediation measures

Lead (Pb) pollution has been one of the major environmental problems of worldwide significance. It is a latent factor for several fatal illnesses, whereas the exposure to lead in early childhood causes a lifetime IQ loss. The social cost is the concept to aggregate various adverse effects in a single monetary unit, which is useful in describing the pollution problem and provides foundation for the design of interventions. However, the assessment of the social cost is scarce for developing countries. In this study, we focus on the lead pollution problem of a former mining town, Kabwe, Zambia, where mining wastes abandoned near residential areas has caused a critical pollution problem. We first investigated the social cost of lead pollution that future generations born in 2025–2049 would incur in their lifetime. As the channels of the social cost, we considered the lost income from the IQ loss and the lost lives from lead-related mortality. The results showed that the social cost would amount to 224–593 million USD (discounted to the present value). Our results can be considered conservative, lower bound estimates because we focused only on well-identified effects of lead, but the social cost was still substantial. Then we examined several engineering remediation measures. The results showed that the social cost can be reduced (the benefits of remediations) more than the costs of implementing remediation measures. This study is the first to investigate the social cost of mining-related lead pollution problem in developing countries. Our interdisciplinary approach utilises the micro-level economic, health and pollution data and integrates the techniques in economics, toxicology and engineering.publishedVersio

Protecting essential health services in low-income and middle-income countries and humanitarian settings while responding to the COVID-19 pandemic.

In health outcomes terms, the poorest countries stand to lose the most from these disruptions. In this paper, we make the case for a rational approach to public sector health spending and decision making during and in the early recovery phase of the COVID-19 pandemic. Based on ethics and equity principles, it is crucial to ensure that patients not infected by COVID-19 continue to get access to healthcare and that the services they need continue to be resourced. We present a list of 120 essential non-COVID-19 health interventions that were adapted from the model health benefit packages developed by the Disease Control Priorities project

Social Protection, Health Risk, and Household Welfare in Zambia

Households in sub-Saharan Africa face substantial health risk. This threatens their welfare and predisposes them to poverty. Despite the high risk environment, they have little or no access to social protection–a set of programs that aims to reduce health risk and provides insurance against its effects, key of which are reductions in labor income and increases in household health expenditure. In childhood, health risk may have additional effects; it lowers cognitive abilities as well as educational attainment and these effects persist in adulthood, working to permanently lower lifetime economic outcomes. Yet still, children from poorer backgrounds face a disproportionately larger share of childhood health risk. In this thesis, I examined the extent to which households are protected from the welfare effects of health shocks (illness and injury) in Zambia. I also evaluated some social protection policies focused at the general population and specific groups such as children and individuals from low socioeconomic background. This was achieved in three sub-studies, each of which forms a separate paper. The first one assessed the effect of health shocks on household consumption, income, and health spending, as well as the extent to which households use borrowing and selling assets as coping strategies in the absence of complete social protection systems, during and after structural adjustment reforms (SAPs). Using data from four waves of the living conditions monitoring survey (LCMS) in the period 1996–2006, it was found that health shocks were associated with reduced consumption both during and after structural reforms. Although health shocks were substantially associated with reduced labor income in both periods, the effect on health spending was much greater after the structural reforms. Middle income households were especially vulnerable. To cope with this risk, household employed informal borrowing and selling assets as self insurance mechanisms. In the second paper, the short and long term effects of an important social protection policy–the user fee removal–on medical spending and overall utilization of health services was evaluated. Heterogeneity in utilization response was also examined. Results show that the policy increased overall utilization of health services in the short term and these effects were sustained in the long term. Apart from increasing overall utilization, the policy also led to shifting of use from private to public health services. The greatest increase in utilization of health services occurred among individuals whose household heads were either unemployed or had no education. Further, although the policy reduced the proportion of individuals incurring any spending, overall health expenditure was not affected in any significant way. Third, and finally, the last paper investigated the determinants of childhood health risk, specifically stunting and fever, between 2007–2014, a period of massive scale up of child health interventions as countries braced themselves to meet the 2015 target of the Millennium Development Goal on child health. It assessed whether or not the concentration of health risk among children from poorer households reduced. Importantly, the factors or determinants that could have been driving these changes were investigated. It was found that although the prevalence of stunting in the general population and in all quartiles, except the poorest, reduced, inequality increased significantly. The determinants that contributed the most to the increase in inequality of stunting were maternal height and weight, household wealth, birth order, place of birth (home or facility), breastfeeding duration and maternal education. Socioeconomic inequality in fever also increased and incidence of fever did not fall. The determinants that contributed to the increase in the inequality of fever were household wealth, maternal education, birth order, and duration of breast feeding. I conclude that scaling up social protection programs that aim at providing insurance against health risk would improve household welfare, especially if coverage does not only focus on the poorest but also middle income households, who are found to be most vulnerable. Regarding user fee removal, although this policy may reduce health risk, since it increased utilization of health services, especially among individuals from low socioeconomic backgrounds, it was not successful in reducing health expenditure risk. Other social protection programs need to be considered if there has to be improvement in health spending insurance. In the same vein, childhood health risk became more concentrated among children from poorer households despite the massive scale up in child health interventions. Reducing inequality in the determinants of childhood health such as facility deliveries, wealth, education, nutrition, etc is key to reducing inequalities in childhood health risk. If inequalities of determinants are not eliminated, increasing their coverage may not reduce child health inequality, and may, in fact, increase it

Impact of night travel ban on road traffic crashes and fatalities in Zambia: an interrupted time series analysis

Background The burden of road traffic crashes (RTCs) and road traffic fatalities (RTFs) has been increasing in low-income and middle-income countries (LMICs). Most RTCs and RTFs happen at night. Although few countries, including Zambia, have implemented night travel bans, there is no evidence on the extent to which such policies may reduce crashes and fatalities. Methods We exploit the quasi-experimental set up afforded by the banning of night travel of public service vehicles in Zambia in 2016 and interrupted time series analysis to assess whether the ban had an impact on both levels and trends in RTCs and RTFs. We use annual administrative data for the period 2006—2020, with 10 pre-intervention and 4 post-intervention data points. In an alternative specification, we restrict the analysis to the period 2012—2020 so that the number of data points are the same pre-interventions and post-interventions. We also carry out robustness checks to rule out other possible explanation of the results including COVID-19. Results The night travel ban was associated with a reduction in the level of RTCs by 4131.3 (annual average RTCs before the policy=17 668) and a reduction in the annual trend in RTCs by 2485.5. These effects were significant at below 1%, and they amount to an overall reduction in RTCs by 24%. The policy was also associated with a 57.5% reduction in RTFs. In absolute terms, the trend in RTFs reduced by 477.5 (Annual average RTFs before the policy=1124.7), which is significant at below 1% level. Our results were broadly unchanged in alternative specifications. Conclusion We conclude that a night travel ban may be an effective way of reducing the burden of RTCs and RTFs in Zambia and other LMICs. However, complementary policies are needed to achieve more gains