Health In sub-Saharan Africa Research Articles

21st century research in urban WASH and health in sub-Saharan Africa: methods and outcomes in transition

ABSTRACTTackling global inequalities in access to Water, Sanitation and Hygiene (WASH) remains an urgent issue – 58% of annual diarrhoeal deaths are caused by inadequate WASH provision. A global context of increasing urbanisation, changing demographics and health transitions demands an understanding and impact of WASH on a broad set of health outcomes. We examine the literature, in terms of health outcomes, considering WASH access and interventions in urban sub-Saharan Africa from 2000 to 2017. Our review of studies which evaluate the effectiveness of specific WASH interventions, reveals an emphasis of WASH research on acute communicable diseases, particularly diarrhoeal diseases. In contrast, chronic communicable and non-communicable health outcomes were notable gaps in the literature as well as a lack of focus on cross-cutting issues, such as ageing, well-being and gender equality. We recommend a broader focus of WASH research and interventions in urban Africa to better reflect the demographic and health transitions happening.Abbreviations: CBA: Controlled Before and After; GSD: Government Service Delivery; IWDSSD: International Drinking-Water, Supply and Sanitation Decade (IDWSSD); KAP: Knowledge, Attitudes and Practices; IBD: Irritable Bowel Diseases; MDG: Millennium Development Goals; NTD: Neglected Tropical Diseases; PSSD: Private Sector Service Delivery; SDG: Sustainable Development Goals; SSA: Sub Saharan Africa; SODIS: Solar Disinfection System; STH: Soil Transmitted Helminths; RCT: Randomised Control Trial; WASH: Water Sanitation and Hygiene; WHO: World Health Organization

Adaptation of health systems to climate-related migration in Sub-Saharan Africa: Closing the gap.

Health systems worldwide need to be adapted to cope with growing numbers of migrants and to climate-exacerbated morbidity. Heatwaves, water stress, desertification, flooding, and sea level rise are environmental stressors that increase morbidity, mortality, and poor mental health in Sub-Saharan Africa. While most migration is intra-African, climate change is also affecting migration patterns outside the continent. To tackle the health challenges induced by these events, such as infectious diseases and malnutrition, health care providers in Sub-Saharan Africa and in receiving countries in Europe must adapt their systems to provide appropriate health services to these communities. While health systems differ greatly across the global north and south, adaptation measures are similar and should be integrated. We present recommendations for adaptation of health systems to climate-related migration, including strengthening health systems, providing access to healthcare, culturally-appropriate services, policy-oriented research and training, and inter-sectoral collaboration.

The epidemiology of chronic kidney disease and the association with non-communicable and communicable disorders in a population of sub-Saharan Africa.

In sub-Saharan Africa (SSA), epidemiological data for chronic kidney disease (CKD) are scarce. We conducted a prospective cross-sectional study including 952 patients in an outpatient clinic in Tanzania to explore CKD prevalence estimates and the association with cardiovascular and infectious disorders. According to KDIGO, we measured albumin-to-creatinine ratio and calculated eGFR using CKD-EPI formula. Factors associated with CKD were calculated by logistic regression. Venn diagrams were modelled to visualize interaction between associated factors and CKD. Overall, the estimated CKD prevalence was 13.6% (95% CI 11–16%). Ninety-eight patients (11.2%) (95% CI 9–14%) were categorized as moderate, 12 (1.4%) (95% CI 0–4%) as high, and 9 (1%) (95% CI 0–3%) as very high risk according to KDIGO. History of tuberculosis (OR 3.75, 95% CI 1.66–8.18; p = 0.001) and schistosomiasis (OR 2.49, 95% CI 1.13–5.18; p = 0.02) were associated with CKD. A trend was seen for increasing systolic blood pressure (OR 1.02 per 1 mmHg, 95% CI 1.00–1.03; p = 0.01). Increasing BMI (OR 0.92 per 1kg/m2, 95% CI 0.88–0.96; p = <0.001) and haemoglobin (OR 0.82 per 1g/dL, 95% CI 0.72–0.94; p = 0.004) were associated with risk reduction. Diabetes was associated with albuminuria (OR 2.81, 95% CI 1.26–6.00; p = 0.009). In 85% of all CKD cases at least one of the four most common factors (hypertension, diabetes, anaemia, and history of tuberculosis or schistosomiasis) was associated with CKD. A singular associated factor was found in 61%, two in 14%, and ≥3 in 10% of all CKD cases. We observed a high prevalence estimate for CKD and found that both classical cardiovascular and neglected infectious diseases might be associated with CKD in a semi-rural population of SSA. Our finding provides further evidence for the hypothesis that the “double burden” of non-communicable and endemic infectious diseases might affect kidney health in SSA.

Temporal trends in the nutritional status of women and children under five years of age in sub-Saharan African countries: ecological study.

While the global prevalence of obesity is rapidly increasing, this pandemic has received less attention in sub-Saharan Africa, particularly in the light of the persistent undernutrition that exists in the context of maternal and child health. We aimed to describe obesity trends among women of childbearing age over recent decades, along with trends in over and undernutrition among children under five years of age, in sub-Saharan African countries. Ecological study with temporal trend analysis in 13 sub-Saharan African countries. This was a description of temporal trends in nutritional status: adult obesity, childhood overweight, low height-for-age (stunting), low weight-for-height (wasting), low weight-for-age (underweight) and low birth weight. Publicly available data from repeated cross-sectional national surveys (demographic and health surveys and multiple-indicator cluster surveys) were used. We chose 13 sub-Saharan African countries from which at least four surveys conducted since 1993 were available. We investigated women aged 15-49 years and children under five years of age. In multilevel linear models, the prevalence of obesity increased by an estimated 6 percentage points over 20 years among women of childbearing age, while the prevalence of overweight among children under 5 years old was stable. A major decrease in stunting and, to a lesser extent, wasting accompanied these findings. The upward trend in obesity among women of childbearing age in the context of highly prevalent childhood undernutrition suggests that the focus of maternal and child health in sub-Saharan Africa needs to be expanded to consider not only nutritional deficiencies but also nutritional excess.

A scoping review on community mobilisation for maternal and child health in sub-Saharan Africa: Impact on empowerment

ABSTRACTThis review integrates evidence on community mobilisation (CM) for maternal and child health in sub-Saharan Africa (SSA) to identify the impact on empowerment. For the purposes of this review we use the following definition of CM: ‘a capacity-building process through which community members, groups or organizations plan, carry out and evaluate activities on a participatory and sustained basis to improve their health and other conditions, either on their own initiative or stimulated by others’, [Howard-Grabman, L., Storti, C., Hummer, P., Pooler, B., & Geneva: USAID (2007). Demystifying community mobilization: An effective strategy to improve maternal and newborn health. Retrieved from http://pdf.usaid.gov/pdf_docs/pnadi338.pdf, p. 5]. A scoping review was chosen to conduct a search and analysis of the literature due to the broad, complex nature of the topic. The search yielded 136 articles, and 19 met the inclusion criteria. This review illustrates CM as an important research process for engaging the community, ensuring that interventions are meeting the needs of the community, take context into account and are sustainable. Community mobilisation was associated with positive behaviour change and/or health outcomes. However, community mobilisation was not defined or operationalised consistently among the identified studies. Empowerment was also not defined, measured, or reported on in the articles. This review provides recommendations for the reporting of CM and its influence on empowerment in communities in sub-Saharan Africa.

Polygynous marriage and child health in sub-Saharan Africa: What is the evidence for harm?

Researchers from a variety of disciplines have presented data indicating that polygynous marriage is damaging to child health. This work has been used to support the classification of polygyny as a ‘harmful cultural practice’ and to advocate for marital re

Quality of care in six sub-Saharan Africa countries: a provider-based study on adherence to WHO's antenatal care guideline.

Quality of care may help explain the high burden of disease in maternal, newborn and child health in low- and middle-income countries even as access to care is improved. We explored the determinants of quality of antenatal care (ANC) in sub-Saharan Africa (SSA). Cross-sectional study. Multilevel Generalized Linear Latent Mixed-Effect models with logit link function were employed to obtain the adjusted odds ratios (AORs) and 95% confidence interval (CI). We used Service Provision Assessment data from six countries in SSA, including Kenya, Malawi, Namibia, Rwanda, Tanzania and Uganda. Seven thousand, five hundred and seventy seven observed antenatal clients across the six countries. Quality of ANC services, measured using indexes of quality of clinical care and quality of information provided. Providers in facilities that had ANC guideline (AOR = 1.26; 95% CI, 1.08-1.48), were well-equipped (AOR = 1.65; 95% CI, 1.41-1.92), were classified as upper level facility (AOR = 1.32; 95% CI, 1.05-1.66), had central electricity supply (AOR = 2.19; 95% CI, 1.81-2.65), and piped water (AOR = 1.30; 95% CI, 1.09-1.55) were more likely to provide optimal quality of clinical care. Moreover, those having ANC guideline (AOR = 1.81; 95% CI, 1.43-2.28) and central electricity supply (AOR = 2.67; 95% CI, 2.01-3.44) were more likely to provide optimal information as well. Provider's qualification and experience were also important in information provision and clinical care independently. The lack of some very basic facility equipment and amenities compromised quality of care in sub-Saharan countries. Policy actions and investment on facility and providers will enable provision of quality services necessary to improve maternal, newborn and child health in SSA.

Roadmap to Achieve 25% Hypertension Control in Africa by 2025.

The Pan-African Society of Cardiology (PASCAR) has identified hypertension as the highest area of priority action to reduce heart disease and stroke on the continent. The aim of this PASCAR roadmap on hypertension was to develop practical guidance on how to implement strategies that translate existing knowledge into effective action and improve detection, treatment and control of hypertension and cardiovascular health in sub-Saharan Africa (SSA) by the year 2025. Development of this roadmap started with the creation of a consortium of experts with leadership skills in hypertension. In 2014, experts in different fields, including physicians and nonphysicians, were invited to join. Via face-to-face meetings and teleconferences, the consortium made a situation analysis, set a goal, identified roadblocks and solutions to the management of hypertension and customized the World Heart Federation roadmap to Africa. Hypertension is a major crisis on the continent but very few randomized controlled trials have been conducted on its management. Also, only 25.8% of the countries have developed or adopted guidelines for management of hypertension. Other major roadblocks are either government and health-system related or health care professional or patient related. The PASCAR hypertension task force identified a 10-point action plan to be implemented by African ministries of health to achieve 25% control of hypertension in Africa by 2025. Hypertension affects millions of people in SSA and if left untreated, is a major cause of heart disease and stroke. Very few SSA countries have a clear hypertension policy. This PASCAR roadmap identifies practical and effective solutions that would improve detection, treatment and control of hypertension on the continent and could be implemented as is or adapted to specific national settings.

Readiness of Sub-Saharan Africa Healthcare Systems for the New Pandemic, Diabetes: A Systematic Review.

Background Effective health systems are needed to care for the coming surge of diabetics in sub-Saharan Africa (SSA). Objective We conducted a systematic review of literature to determine the capacity of SSA health systems to manage diabetes. Methodology We used three different databases (Embase, Scopus, and PubMed) to search for studies, published from 2004 to 2017, on diabetes care in SSA. Results Fifty-five articles met the inclusion criteria, covering the different aspects related to diabetes care such as availability of drugs and diagnostic tools, the capacity of healthcare workers, and the integration of diabetes care into HIV and TB platforms. Conclusion Although chronic care health systems in SSA have developed significantly in the last decade, the capacity for managing diabetes remains in its infancy. We identified pilot projects to enhance these capacities. The scale-up of these pilot interventions and the integration of diabetes care into existing robust chronic disease platforms may be a feasible approach to begin to tackle the upcoming pandemic in diabetes. Nonetheless, much more work needs to be done to address the health system-wide deficiencies in diabetes care. More research is also needed to determine how to integrate diabetes care into the healthcare system in SSA.

A meta-synthesis on gender, disability and reproductive health in sub-Saharan Africa

Reproductive health remains a major global health issue. People with disabilities face additional discrimination and barriers to access which need to be better understood. To contribute to future interventions, we examined the intersections between gender and disability related to reproductive health in sub-Saharan Africa in the qualitative literature. We conducted a meta-synthesis, using a taxonomic analysis. An inductive and iterative approach was adopted to allow exploration of new and emergent semantic variations in themes. NVivo 11 Plus was used to code themes. Ten qualitative studies from six sub-Saharan African countries were analysed. Two main thematic areas emerged from the analysis: 1) gendered roles of people with disabilities are programmed by sociocultural normativity, including perceptions about sexuality. They are exacerbated by the hegemony of ableism and influenced by the type of reproductive health issues experienced by people with disabilities; and 2) experiences of disability in interaction with a reproductive health issue are exacerbated by the type of disability, influenced by the type of barriers to access, and perceived differently depending upon the actors involved. The intersections between gender and disability embodied by people with disabilities are multiple and complex. Not only do imposed gendered roles influence the lives of people with disabilities, but their experiences of disability are also intricately linked to gender. An intersectional analysis is proposed as a useful support to developing future perspectives.

Unmasking the Practices of Nurses and Intercultural Health in Sub-Saharan Africa: A Useful Way to Improve Health Care?

In 2001 and 2013, the World Health Organization (WHO) published the WHO Traditional Medicine Strategy 2002-2005 and 2014-2023, respectively, to address policy, ethics, quality, and integration of complementary health therapies (CHT). Despite the adoption of these strategic frameworks, sub-Saharan African (SSA) countries largely run dualistic and inclusive health care system. A recent article published in Complementary Therapies in Clinical Practice analyzed the role of practicing nurses in CHT integration and intercultural health in an SSA country setting. Drawing on the Complementary and Alternative Medicine Health Belief Questionnaire, the study specifically examined nurses’ knowledge, practices, and attitudes toward CHT. The study revealed that nurses had low knowledge about CHT, which reflected in their ineptitude to engage in professional practices of CHT. In spite of the knowledge deficit, nurses generally held favorable attitudes toward CHT and the majority supported the need for “safe” and evidence-based integrative model. Efforts to improve CHT-related knowledge of nurses may enhance medical integration in SSA. This commentary proposes novel political will and investment in CHT education and research as well as an inclusion of CHT modules in the nurses’ training programs; viabilities to achieve intercultural health and improved care in SSA.

Task Shifting on Provision of Contraceptives and Abortion Services in Maternal and Reproductive Health in Sub-Saharan Africa to achieve Universal Health Coverage: A Narrative Review

Introduction: Improving maternal and reproductive health is a target for Sustainable Development Goals 3. Accessibility to contraceptives and abortion services is important in improving maternal and reproductive health. In 2014 in sub-Saharan Africa, over 40% of women aged 15-49 years wanted to avoid pregnancy but only 50% or 55 million of these could access contraceptives. Shortage of skilled health workers, which is worse in Africa, has been associated with these challenges. Universal Health Coverage (UHC) is a target for world nations. To achieve UHC adequate skilled healthcare workers is one key factor needed. In 2013, globally, this shortage was 7.2 million and projected to be 12.9 million by 2035. Task shifting has been thought as a possible solution to this shortage. Therefore, the objective of this review is to establish the outcome of task shifting in the provision of contraceptives and abortion services in sub-Saharan Africa. Methods: A systematic approach was adopted. Medline, PsycINFO, EBM Reviews databases were searched. Google scholar and hand searching bibliographies of retrieved studies were also done. A quality appraisal using Mixed Method Appraisal Tool was done. Data were extracted using a customized form and themes identified. A narrative synthesis of the results was reported. Results: A total of 319 records were retrieved and a set inclusion and exclusion criteria eleven studies were included in the final analysis. The quality of studies was poor as only one random control trial was retrieved limiting the quality of the evidence. Results suggest that task shifting may be a safe and effective method inimproving contraceptives and abortion service accessibility in sub-Saharan Africa. Conclusion: To cover healthcare staff shortages task shifting of contraceptive and abortion services can be considered in healthcare practices and included national human resource policies. Further research is required to cover gaps in long-term outcome these services.

Remittances, education and health in Sub-Saharan Africa

This study investigates the effects of remittances on education and health outcomes using a 5-year interval data on 46 Sub-Saharan African (SSA) countries from 1975 to 2014. Employing system GMM, r...

Armed Conflicts and National Trends in Reproductive, Maternal, Newborn and Child Health in Sub-Saharan Africa: What Can National Health Surveys Tell Us?

Background: Armed conflicts are widespread in sub-Saharan Africa and considered to be an important factor in slowing down national progress in reproductive, maternal, newborn and child health (RMNCH). Methods: Among Sub-Saharan countries that had experienced major conflicts, 13 countries were selected based on battle-related deaths and national survey data availability. National levels and trends in RMNCH intervention coverage, wasting and stunting in children under 5 years of age and under-five mortality were analysed in related to the timing of the conflict and compared to sub-regional trends during 1990-2016. Results: The 13 countries conducted 53 DHS or MICS surveys since 1986. Most surveys did not report major sampling or implementation problems. In comparison to the regional averages for either West and Central Africa or Eastern and Southern Africa, conflict-affected countries generally had lower coverage of RMNCH interventions during the conflict phase or immediately post-conflict, and often experienced rapid coverage improvements following the end of the conflict. Levels and trends in wasting, but not stunting, and under-five mortality followed a similar pattern with higher levels and/or slower declines during the conflicts and a recovery post-conflict in most countries. In several countries, however, the levels and trends in surveys showed only limited or no effect of a conflict on one or more indicators of national coverage, child growth or mortality. Interpretation: National surveys provide a useful source of data for the measurement of the longer-term national impact of conflicts on RMNCH intervention coverage, child growth and under-five mortality. The results vary considerably between countries, requiring more in-depth analysis of surveys and other data to estimate the full impact of conflicts as well as improved data collection. Funding: This work was supported by a grant of the Bill and Melinda Gates Foundation to the Countdown to 2030 for Women’s, Children’s and Adolescents’ Health. Declaration of Interest: We have no conflict of interest. Ethical Approval: This paper was exempted from obtaining ethical approval since it was entirely based on data available in the public domain.

Performance-Based Financing Empowers Health Workers Delivering Prevention of Vertical Transmission of HIV Services and Decreases Desire to Leave in Mozambique.

Background: Despite increased access to treatment and reduced incidence, vertical transmission of HIV continues to pose a risk to maternal and child health in sub-Saharan Africa. Performance-based financing (PBF) directed at healthcare providers has shown potential to improve quantity and quality of maternal and child health services. However, the ways in which these PBF initiatives lead to improved service delivery are still under investigation. Methods: Therefore, we implemented a longitudinal-controlled proof-of-concept PBF intervention at health facilities and with community-based associations focused on preventing vertical transmission of HIV (PVT) in rural Mozambique. We hypothesized that PBF would increase worker motivation and other aspects of the workplace environment in order to achieve service delivery goals. In this paper, we present two objectives from the PBF intervention with public health facilities (n=6): first, we describe the implementation of the PBF intervention and second, we assess the impact of the PBF on health worker motivation, key factors in the workplace environment, health worker satisfaction, and thoughts of leaving. Implementation (objective 1) was evaluated through quantitative service delivery data and multiple forms of qualitative data (eg, quarterly meetings, participant observation (n=120), exit interviews (n=11)). The impact of PBF on intermediary constructs (objective 2) was evaluated using these qualitative data and quantitative surveys of health workers (n=83) at intervention baseline, midline, and endline. Results: We found that implementation was challenged by administrative barriers, delayed disbursement of incentives, and poor timing of evaluation relative to incentive disbursement (objective 1). Although we did not find an impact on the motivation constructs measured, PBF increased collegial support and worker empowerment, and, in a time of transitioning implementing partners, decreased against desire to leave (objective 2). Conclusion: Areas for future research include incentivizing meaningful quality- and process-based performance indicators and evaluating how PBF affects the pathway to service delivery, including interactions between motivation and workplace environment factors.

Irene Agyepong: building capacity in Ghana's public health system

As a lead author of the Lancet Commission on the future of health in sub-Saharan Africa, Irene Agyepong's ambition is to make a lasting contribution to health in Africa. “One of my driving passions is building health policy and systems research, policy, and practice capacity in west Africa. To conduct research, to advance research evidence and decision making, and ultimately to improve outcomes”, she says. “I am really interested in transformation and health outcomes, and human development in sub-Saharan Africa. You need a critical cohort—a certain stable capacity, and that is what drives me.” A Specialist of Public Health in the Ghana Health Service (the public provider agency of the Ministry of Health), Agyepong is a Member of the Faculty of Public Health of the Ghana College of Physicians and Surgeons and also undertakes research. Her work combines practical and theoretical strands, always with a view to finding solutions for Africa's health issues informed by her first-hand experience of the health system. The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan AfricaSub-Saharan Africa's health challenges are numerous and wide-ranging. Most sub-Saharan countries face a double burden of traditional, persisting health challenges, such as infectious diseases, malnutrition, and child and maternal mortality, and emerging challenges from an increasing prevalence of chronic conditions, mental health disorders, injuries, and health problems related to climate change and environmental degradation. Although there has been real progress on many health indicators, life expectancy and most population health indicators remain behind most low-income and middle-income countries in other parts of the world. Full-Text PDF

The Effect of Early Marriage Timing on Women's and Children's Health in Sub-Saharan Africa and Southwest Asia

BackgroundAge of marriage is a barrier to mother's health care around pregnancy and children health outcomes. ObjectiveWe provide evidence on the health benefits of postponing early marriage among young wives (from age 10-14 to age 15-17) on women's health care and children's health for sub-Saharan Africa (SSA) and Southwest Asia (SWA). MethodsWe use data for 39 countries from the Demographic and Health Surveys to estimate the effects of postponing early marriage for women's health care and children's health outcomes and immunization using matching techniques. We also assess whether women's health empowerment and health constraints are additional barriers. FindingsWe found that in SSA, delaying the age of marriage from age 10-14 to age 15-17 and from age 15-17 to age 18 or older leads to an increase in maternal neotetanus vaccinations of 2.4% and 3.2%, respectively; gains in the likelihood of postnatal checks are larger for delayed marriage among the youngest wives (aged 10-14). In SWA, the number of antenatal visits increases by 34% and the likelihood of having a skilled birth attendant goes up to 4.1% if young wives postpone marriage. In SSA, the probability of children receiving basic vaccinations is twice as large and their neonatal mortality reduction is nearly double if their mothers married between ages 15-17 instead of at ages 10-14. The extent of these benefits is also shaped by supply constraints and cultural factors. For instance, we found that weak bargaining power on health decisions for young wives leads to 11% fewer antenatal visits (SWA) and 13% less chance of attending postnatal checks (SSA). ConclusionsDelaying age of marriage among young wives can lead to considerable gains in health care utilization and children health in SSA and SWA if supported by policies that lessen supply constraints and raise women's health empowerment.

Cognition, Health, and Well-Being in a Rural Sub-Saharan African Population

Cognitive health is an important dimension of well-being in older ages, but few studies have investigated the demography of cognitive health in sub-Saharan Africa's (SSA) growing population of mature adults (= persons age 45+). We use data from the Malawi Longitudinal Study of Families and Health (MLSFH) to document the age and gender patterns of cognitive health, the contextual and life-course correlates of poor cognitive health, and the understudied linkages between cognitive and physical/mental well-being. Surprisingly, the age-pattern of decline in cognitive health is broadly similar to that observed in the U.S. We also find that women have substantially worse cognitive health than men, and experience a steeper age-gradient in cognitive ability. Strong social ties and exposure to socially complex environments are associated with higher cognitive health, as is higher socioeconomic status. Poor cognitive health is associated with adverse social and economic well-being outcomes such as less nutrition intake, lower income, and reduced work efforts even in this subsistence agriculture context. Lower levels of cognitive health are also strongly associated with increased levels of depression and anxiety, and are associated with worse physical health measured through both self-reports and physical performance. Our findings suggest that cognition plays a key-but understudied-role in shaping late-life well-being in low-income populations.

Improving postpartum care delivery and uptake by implementing context-specific interventions in four countries in Africa: a realist evaluation of the Missed Opportunities in Maternal and Infant Health (MOMI) project

Postpartum care (PPC) has remained relatively neglected in many interventions designed to improve maternal and neonatal health in sub-Saharan Africa. The Missed Opportunities in Maternal and Infant Health project developed...

Governance and the effectiveness of public health subsidies: Evidence from Ghana, Kenya and Uganda

Distributing subsidized health products through existing health infrastructure could substantially and cost-effectively improve health in sub-Saharan Africa. There is, however, widespread concern that poor governance – in particular, limited health worker accountability – seriously undermines the effectiveness of subsidy programs. We audit targeted bed net distribution programs to quantify the extent of agency problems. We find that around 80% of the eligible receive the subsidy as intended, and up to 15% of subsidies are leaked to ineligible people. Supplementing the program with simple financial or monitoring incentives for health workers does not improve performance further and is thus not cost-effective in this context.