Household Deaths Research Articles

A systematic global assessment of the completeness and quality of household death reporting in censuses and surveys since 2000

Many censuses and surveys in low- and middle-income countries ask questions about deaths in the household to fill the evidence gap about mortality. This study undertakes the first published systematic assessment of the completeness and quality of these data. For 82 censuses from 56 countries and 26 surveys from 21 countries since 2000 we calculated completeness of household death reporting using deaths estimated by the United Nations World Population Prospects (UN WPP) and Global Burden of Disease (GBD) as the denominator. The median completeness of reported household deaths in censuses was 89% (inter-quartile range (IQR) 66–102%) and surveys 96% (IQR 80–124%). Completeness was similar for males and females and substantially lower where date of death was asked (census median 73%, IQR 53–91%) than not asked (census median 93%; IQR 74–110%); these differences remained after controlling for other covariates in a linear regression. The ratio of reported household to estimated deaths was higher in younger ages but age-invariant where date of death was asked. In conclusion, household death data in censuses and surveys have major completeness and quality issues. Where date of death was not asked, there appears to be considerable reporting of deaths that occurred outside of the reference period.

Using household death questions from surveys to assess adult mortality in periods of health crisis: An application for Peru, 2018–2022

Using household death questions from surveys to assess adult mortality in periods of health crisis: An application for Peru, 2018–2022

Navigating Challenges: Herdsmen-Crop Farmers Conflict and its Effect on Yam Productivity in Benue State

The conflict between herdsmen and crop farmers in Nigeria has significantly impacted the productivity of yam farmers in the Logo Local Government Area of Benue State. The study investigated this conflict's impact on yam farmers' productivity. Data was collected from a structured questionnaire administered to 400 households affected by the conflict. The study found that the conflict negatively impacts the productivity of yam farmers in the Logo Local Government Area. The study reveals that 67.3% of yam farmers in Benue State are male, with a mean age of 35. The majority are married, have an average household size of 11 people, and have a small-scale farm size. Their low education level may contribute to unabated conflict dynamics. The study reveals that herdsmen attacks significantly reduce the productivity of yam farmers in the study area, with a higher number of respondents producing more output before the attacks and a lower number after the attacks. The logit regression model shows that Fulani attacks, attacks by Fulani herdsmen, and technology led to significant deaths in households, reducing the labour force, destroying farmers' inputs, and instilling terror. In conclusion, the study reveals that herdsmen attacks have significantly reduced the productivity of yam farmers in the study area, affecting not only the labour force but also their inputs and livelihoods, highlighting the detrimental impact of conflict-related violence. It was recommended that the government should also provide easy access to finance for farmers affected by this conflict to recover their lost farm capital.

Enhancing SARS-CoV-2 surveillance in Malawi using telephone syndromic surveillance from July 2020 to April 2022

IntroductionMonitoring the SARS-CoV-2 pandemic in low-resource countries such as Malawi requires cost-effective surveillance strategies. This study explored the potential utility of phone-based syndromic surveillance in terms of its reach, monitoring...

A prospective cohort study of exposure to household pesticide with cardiovascular diseases mortality in older adults

ObjectivesWe examined the associations of self-reported exposures, and urinary metabolites related to household pesticide with cardiovascular disease (CVD) mortality in older adults based on the 2007 to 2014 waves of National Health and Nutrition Examination Survey (NHANES). MethodsInformation on application and urinary metabolites related to household pesticide exposure were collected. We estimated the risks of household pesticide exposure, urinary metabolites with subsequent incident CVD death using Cox proportional hazards regression models. The indirect effects of urinary metabolites and effect modifications were examined. ResultsThe participants who reported exposure to household pesticide had a higher risk of incident CVD death (adjusted HR 1.40, 95% CI 1.08 to 1.81). Per 1-log10 increase in urinary N, N-diethyl-3-methylbenzamide (DEET) related to household insect repellents was associated with a higher risk of incident CVD death (adjusted HR 1.97, 95% CI 1.14 to 3.40). Urinary DEET explained 4.21% of the total association between household pesticide exposure and CVD death risk. The participants who persisted a low level of health diet exhibited pronounced CVD death risks with household pesticide exposures. ConclusionsExposure to household pesticide, especially household insect repellents, was consistently associated with an elevated CVD death risk in older adults. A heatlhy diet could partly attenuate the associations.

Surprising Gendered Age Differences in Rural Malawians' Early COVID-19 Pandemic Prevention Efforts.

We assess how age, the presence of mature adults aged 45+ years, and recent deaths in rural households are associated with coronavirus disease 2019 (COVID-19) preventative actions and the likelihood of getting vaccinated against the virus in Malawi during early stages of the pandemic. We draw upon data from 2,187 rural Malawians who participated in a 2020 COVID-19 Phone Survey. We estimate the log odds of engaging in "low-cost" and "high-cost" COVID-19 preventative actions based on age, gender, household composition, and recent household deaths. Low-cost prevention efforts were washing hands with soap and water frequently, avoiding close contact with people when going out, and avoiding shaking hands. High-cost actions included staying at home and decreasing time spent close to people not living in their household. We also estimate the chances of acquiring the COVID-19 vaccine in early stages of its availability. Mature women (45+ years) in general and younger men (<45 years)-living with at least one mature adult in the household-were less likely than others to comply with low-cost actions. Mature men were more likely than younger men (<45 years) to take on high-cost actions. To some extent, individuals who experienced a recent family death were more likely to engage in high-cost COVID-19 preventative actions as well as getting vaccinated. Gendered age differences in preventing the transmission of COVID-19 offer hints of larger social norms affecting protective efforts. The analyses also inform future COVID-19 public health outreach efforts in Malawi and other rural SSA contexts.

Sex differences in mortality among children, adolescents, and young people aged 0–24 years: a systematic assessment of national, regional, and global trends from 1990 to 2021

Differences in mortality exist between sexes because of biological, genetic, and social factors. Sex differentials are well documented in children younger than 5 years but have not been systematically examined for ages 5-24 years. We aimed to estimate the sex ratio of mortality from birth to age 24 years and reconstruct trends in sex-specific mortality between 1990 and 2021 for 200 countries, major regions, and the world. We compiled comprehensive databases on the mortality sex ratio (ratio of male to female mortality rates) for individuals aged 0-4 years, 5-14 years, and 15-24 years. The databases contain mortality rates from death registration systems, full birth and sibling histories from surveys, and reports on household deaths in censuses. We modelled the sex ratio of age-specific mortality as a function of the mortality in both sexes using Bayesian hierarchical time-series models. We report the levels and trends of sex ratios and estimate the expected female mortality and excess female mortality rates (the difference between the estimated female mortality and the expected female mortality) to identify countries with outlying sex ratios. Globally, the mortality sex ratio was 1·13 (ie, boys were more likely to die than girls of the same age) for ages 0-4 years (90% uncertainty interval 1·11 to 1·15) in 2021. This ratio increased with age to 1·16 (1·12 to 1·20) for 5-14 years, reaching 1·65 for 15-24 years (1·52 to 1·75). In all age groups, the global sex ratio of mortality increased between 1990 and 2021, driven by faster declines in female mortality. In 2021, the probability of a newborn male reaching age 25 years was 94·1% (93·7 to 94·4), compared with 95·1% for a newborn female (94·7 to 95·3). We found a disadvantage of females versus males (compared with countries with similar total mortality) in 2021 in five countries for ages 0-4 years (Algeria, Bangladesh, Egypt, India, and Iran), one country (Suriname) for ages 5-14 years, and 13 countries for ages 15-24 years (including Bangladesh and India). We found the reverse pattern (disadvantage of males vs females compared with countries of similar total mortality) in one country in ages 0-4 years (Vietnam) and eight countries in ages 15-24 years (including Brazil and Mexico). Globally, the number of excess female deaths from birth to age 24 years was 86 563 (-6059 to 164 000) in 2021, down from 544 636 (453 982 to 633 265) in 1990. The global sex ratio of mortality for all age groups in the first 25 years of life increased between 1990 and 2021. Targeted interventions should focus on countries with outlying sex ratios of mortality to reduce disparities due to discrimination in health care, nutrition, and violence. The Bill & Melinda Gates Foundation, US Agency for International Development, and King Abdullah University of Science and Technology.

Low Household Income Status and Death from Pneumonia in People with Type 2 Diabetes Mellitus: A Nationwide Study.

We explored the risk of death from pneumonia according to cumulative duration in low household income state (LHIS) among adults with type 2 diabetes mellitus (T2DM). Using Korean National Health Insurance Service data (2002 to 2018), the hazards of mortality from pneumonia were analyzed according to duration in LHIS (being registered to Medical Aid) during the 5 years before baseline (0, 1-4, and 5 years) among adults with T2DM who underwent health examinations between 2009 and 2012 (n=2,503,581). Hazards of outcomes were also compared in six groups categorized by insulin use and duration in LHIS. During a median 7.18 years, 12,245 deaths from pneumonia occurred. Individuals who had been exposed to LHIS had higher hazards of death from pneumonia in a dose-response manner (hazard ratio [HR], 1.726; 95% confidence interval [CI], 1.568 to 1.899 and HR, 4.686; 95% CI, 3.948 to 5.562 in those exposed for 1-4 and 5 years, respectively) compared to the non-exposed reference. Insulin users exposed for 5 years to LHIS exhibited the highest outcome hazard among six groups categorized by insulin use and duration in LHIS. Among adults with T2DM, cumulative duration in LHIS may predict increased risks of mortality from pneumonia in a graded dose-response manner. Insulin users with the longest duration in LHIS might be the group most vulnerable to death from pneumonia among adults with T2DM.

The Migration Response to Food Insecurity and Household Shocks in Southwestern Ethiopia, 2005–2008

This article examines how severe food insecurity and other shocks impact internal and international migration in southwestern Ethiopia using longitudinal survey data collected between 2005 and 2008 from a random sample of urban and rural households. We found an elevated risk of internal and international migration among sons and daughters in households that experienced severe food insecurity or farm loss. A household member's illness or death also significantly increased the risk of internal migration regardless of a household member's relationship with the household head. We also found that the effects of severe food insecurity and the other shocks were additive. With each additional shock, the risks of migration incrementally increased. This article provides compelling evidence of an international and an internal migration response to food insecurity and other shocks in a context where the prevalence of international migration is increasing and the potential for future international migration is substantial. These results challenge conventional wisdom in the migration literature that food insecurity and other household shocks will have larger relative effects on internal compared to international migration.

Protocol to implement a syndromic surveillance survey of COVID-19 in Malawi

IntroductionMalawi experienced two waves of COVID-19 between April 2020 and February 2021. A High negative impact of COVID-19 was experienced in the second wave, with increased hospital admissions that overwhelmed the healthcare system. This paper describes a protocol to implement a telephone-based syndromic surveillance system to assist public health leaders in the guidance, implementation, and evaluation of programs and policies for COVID-19 prevention and control in Malawi. Study designThis is a serial cross-sectional telephonic-based national survey focusing on the general population and People living with HIV and AIDS. MethodsWe will conduct a serial cross-sectional telephone survey to assess self-reported recent and current experience of influenza-like illness (ILI)/COVID-19-like-illness (CLI), household deaths, access to routine health services, and knowledge related to COVID-19. Structured questionnaires will be administered to two populations: 1) the general population and 2) people living with HIV (PLHIV) on antiretroviral therapy (ART) at EGPAF-supported health facilities. Electronic data collection forms using secure tablets will be used based on randomly selected mobile numbers from electronic medical records (EMR) for PLHIV. We will use random digit dialing (RDD) for the general population to generate phone numbers to dial respondents. The technique uses computer-generated random numbers, using the 10-digit basic structure of mobile phone numbers for the two existing mobile phone companies in Malawi. Interviews will be conducted only with respondents that will verbally consent. A near real-time online dashboard will be developed to help visualize the data and share results with key policymakers. ConclusionThe designed syndromic surveillance system is low-cost and feasible to implement under COVID-19 restrictions, with no physical contact with respondents and limited movement of the study teams and communities. The system will allow estimation proportions of those reporting ILI/CLI among the general population and PLHIV on ART and monitor trends over time to detect locations with possible COVID-19 transmission. Reported household deaths in Malawi, access to health services, and COVID-19 knowledge will be monitored to assess the burden and impact on communities in Malawi.

Depression, anxiety, and psychological distress among caregivers of young children in rural Lesotho: Associations with food insecurity, household death and parenting stress

Good mental health is a critical resource for mothers and caregivers of young children, given the central role of mental health in enabling responsive caregiving. However, fulfilling caregiving responsibilities under challenging circumstances such as extreme poverty, food insecurity, and gender inequality intensifies vulnerability to poor mental health. Previous research focuses on mental health of mothers, while in many LMICs children are cared for by other caregivers, such as grandparents. We examined the prevalence of mental health problems among primary caregivers of young children in rural Lesotho, and investigated factors associated with these mental health problems.We analysed baseline data from a cluster randomised controlled trial, where all caregivers with children between 1 and 5 years old across 34 villages were invited to participate. The analysis included mental health data from 781 caregivers of 998 children. We assessed caregiver mental health using three self-report screening instruments. Univariate and multivariate regression modelling tested associations between caregiver, child and household variables and (1) depression symptoms (PHQ-9), (2) anxiety symptoms (GAD-7), (3) psychological distress (SRQ-20), (4) suicidal ideation and (5) help-seeking for mental health.This study reported a high prevalence of symptoms of psychological distress (46.2%), depression (25.7%), anxiety (17.1%) and suicidal ideation (27.5%) among caregivers. Greater prevalence was associated with food insecurity, parenting stress or recent death in the family/household. Older caregivers reported higher rates of psychological distress and depression, while younger caregivers reported higher rates of anxiety. Suicidal ideation was associated with greater food insecurity and parenting stress, and lower caregiver education.Our findings support the need to address intersecting public health issues to improve conditions for caregivers in these settings. Targeting modifiable risk factors such as food insecurity among individuals within a society who carry disproportionate burdens of caregiving should be prioritised, especially in contexts of scarcity, where mental health is not prioritised.

SARS-CoV-2 seroprevalence among people living with HIV in Guinea–Bissau

ObjectivesIn low-income countries with poor SARS-CoV-2 monitoring and high HIV burden, the prevalence of SARS-CoV-2 is scarcely studied in people living with HIV (PLWH). We set out to measure SARS-CoV-2 seroprevalence in this group. Study designSerosurvey of SARS-CoV-2 in PLWH. MethodsWe measured IgG/IgM antibodies using point-of-care rapid tests in 294 PLWH with HIV-1, HIV-2 or HIV-1/2 dual infection at an HIV clinic in Guinea–Bissau between June 1, 2021, and October 1, 2021. ResultsUnvaccinated PLWH (n = 195), constituting 66% of the total study population, had a seroprevalence of SARS-CoV-2 antibodies of 27.7%. Of SARS-CoV-2 seropositive unvaccinated PLWH, 71.2% reported no symptoms of COVID-19 since the start of the epidemic up to the inclusion date. Among all participants, 90.1% reported never having been tested for SARS-CoV-2 by any test (n = 292). Six participants reported a household death, corresponding to a crude annual death rate of 3.3 per 1000 people. ConclusionsDespite a low number of officially registered cases of SARS-CoV-2 in Bissau, we found a high seroprevalence of SARS-CoV-2 of 27.7% in unvaccinated PLWH. Coupled with few ever tested for SARS-CoV-2, it indicates that official PCR testing likely underestimates prevalence and that SARS-CoV-2 monitoring is challenged for PLWH. The low number of symptoms from seropositives may stem from survival bias, some effect of herd immunity or, coupled with a low crude annual death rate, that disease symptomatology and severity could be lower than expected.

Factors contributing to household wealth inequality in under-five deaths in low- and middle-income countries: decomposition analysis

BackgroundThe burden of under-5 deaths is disproportionately high among poor households relative to economically viable ones in developing countries. Despite this, the factors driving this inequality has not been well explored. This study decomposed the contributions of the factors associated with wealth inequalities in under-5 deaths in low- and middle-income countries (LMICs).MethodsWe analysed data of 856,987 children from 66,495 neighbourhoods across 59 LMICs spanning recent Demographic and Health Surveys (2010-2018). Under-5 mortality was described as deaths among live births within 0 to 59 months of birth and it was treated as a dichotomous variable (dead or alive). The prevalence of under-five deaths was stratified using household wealth status. A Fairlie decomposition analysis was utilized to investigate the relative contribution of the factors associated with household wealth inequality in under-5 deaths at p<0.05. The WHO health equity assessment toolkit Plus was used to assess the differences (D) ratios (R), population attributable risk (PAR), and population attributable fraction (PAF) in household wealth inequalities across the countries.ResultsThe proportion of children from poor households was 45%. The prevalence of under-5 deaths in all samples was 51 per 1000 children, with 60 per 1000 and 44 per 1000 among children from poor and non-poor households (p<0.001). The prevalence of under-5 deaths was higher among children from poor households than those from non-poor households in all countries except in Ethiopia, Tanzania, Zambia, Lesotho, Gambia and Sierra Leone, and in the Maldives. Thirty-four of the 59 countries showed significantly higher under-5 deaths in poor households than in non-poor households (pro-non-poor inequality) and no significant pro-poor inequality. Rural-urban contexts, maternal education, neighborhood socioeconomic status, sex of the child, toilet kinds, birth weight and preceding birth intervals, and sources of drinking water are the most significant drivers of pro-poor inequities in under-5 deaths in these countries.ConclusionsIndividual-level and neighbourhood-level factors were associated with a high prevalence of under-5 deaths among poor households in LMICs. Interventions in countries should focus on reducing the gap between the poor and the rich as well as improve the education and livelihood of disadvantaged people.

Reduced health burden and economic benefits of cleaner fuel usage from household energy consumption across rural and urban China

Energy consumption in the residential sector is increasing rapidly in China. This study applies an integrated assessment model to investigate the adverse impacts of household energy consumption by various fuel types across rural and urban areas on age- and sex-specific premature deaths associated with PM2.5 pollution at provincial levels for 2015. We further estimate the economic and health co-benefits of a switch from solid fuels to electricity within households. We find that energy consumed by Chinese urban households is nearly 1.6 times than that of rural households. However, premature deaths due to household energy usage is 1.1 times higher in rural areas compared to urban areas due to direct use of coal for heating in rural households. The majority of household consumption-related premature deaths are predominately in the Southern area of China due to the population size and aging population. By replacing coal and biomass with electricity, this paper estimates economic benefits equal to 0.09% (95% CI: 0.08%–0.1%) GDP for rural areas and 0.006% (0.005%–0.007%) of GDP for urban areas of China. The results suggest that mitigation measures such as the promotion and subsidization of cleaner fuels, modern stove within rural households would yield these potential significant economic benefits.

Community Mortality Due to Respiratory Syncytial Virus in Argentina: Population-based Surveillance Study.

BackgroundMany deaths in infants from low-middle income countries (LMICs) occur at home or upon arrival to health facilities. Although acute lower respiratory tract illness plays an important role in community mortality, the accuracy of mortality rates due to respiratory syncytial virus (RSV) remains unknown.MethodsAn active surveillance study among children aged under 5 years old (U5) was performed in Buenos Aires, Argentina, between January and December 2019, to define the burden and role of RSV in childhood community mortality.ResultsA total of 63 families of children U5 participated in the study. Based on a combined approach of tissue sampling, verbal autopsies, and expert’s analysis, RSV infection was found in the causal chain of 11 from 12 cases with positive molecular biology results in respiratory samples. The estimated mortality rate due to RSV among infants was 0.27 deaths/1000 live births. The mean age of RSV-related household deaths was 2.8 months of age (standard deviation [SD] 1.7), and 8/12 were male infants (66.7%). Dying at home from RSV was associated with Streptococcus pneumoniae and/or Moraxella catarrhalis lung coinfection (75%), living in slums and settlement (odds ratio [OR], 17.09; 95% confidence interval [CI], 1.3–219.2), and other underlying comorbidities (OR, 14.87; 95% CI, 1.3–164.6).ConclusionsInfant community mortality rates due to RSV are higher than those reported in industrialized countries and similar to those reported in hospital-based studies in the same catchment population.

Surveys about attended births appear to be deceptive in CAR: are the population saying what they think NGO\u2019s want to hear?

BackgroundNon-governmental organizations (NGOs) and donors often promote certain practices to a community, such as in-facility births and then evaluate the efficacy of those interventions, in part, by surveying those populations.MethodsA project to assess the accuracy of birth and death monitoring by local community-based monitors was undertaken with a partner health agency in areas (pop. 94,000) where they supported medical facilities. Thirty clusters of 30 households each were selected at random, probability proportional to size. Half of those households were enrolled for a monthly visitation surveillance process. To gain insights into the effects of the agency’s services, an additional 240 households were selected at random and interviewed from 8 nearby “matched villages” not serviced by any NGO as a comparison sample.ResultsThe 896 households with 4243 living residents within the NGO service area were interviewed about household births and deaths within the past 8 months. They reported an annualized birth rate of 5.6% (95% CI: 4.5–6.7) with only 3% of those births occurring at home. The reported death rate was 4.2/1000/month (95% CI: 3.3–5.0). In the “matched villages,” the population reported a similar birth and death rate, but they reported 29% of births occurring within the home. The monthly surveillance data found over the year that followed that 32% of births occurred at the home. Clinic and hospital birth attendance data suggested an attended annual birth rate of only 2.8%, consistent with the surveillance data implication that a huge fraction of births occur at home.ConclusionIt is believed that because the baseline interviews occurred with a stranger, this induced interviewees to say what they thought the interviewers wanted to hear. This calls into question the validity of household surveys when agencies have a known agenda or position, and highlights the need for external validation or triangulation of survey findings.

Global, regional, and national mortality trends in youth aged 15–24 years between 1990 and 2019: a systematic analysis

SummaryBackgroundThe global health community is devoting considerable attention to adolescents and young people, but risk of death in this population is poorly measured. We aimed to reconstruct global, regional, and national mortality trends for youths aged 15–24 years between 1990 and 2019.MethodsIn this systematic analysis, we used all publicly available data on mortality in the age group 15–24 years for 195 countries, as compiled by the UN Inter-agency Group for Child Mortality Estimation. We used nationally representative vital registration data, estimated the completeness of death registration, and extracted mortality rates from surveys with sibling histories, household deaths reported in censuses, and sample registration systems. We used a Bayesian B-spline bias-reduction model to generate trends in 10q15, the probability that an adolescent aged 15 years would die before reaching age 25 years. This model treats observations of the 10q15 probability as the product of the actual risk of death and an error multiplier that varies depending on the data source. The main outcome that we assessed was the levels of and trends in youth mortality and the global and regional mortality rates from 1990 to 2019.FindingsGlobally, the probability of an individual dying between age 15 years and 24 years was 11·2 deaths (90% uncertainty interval [UI] 10·7–12·5) per 1000 youths aged 15 in 2019, which is about 2·5 times less than infant mortality (28·2 deaths [27·2–30·0] by age 1 year per 1000 live births) but is higher than the risk of dying from age 1 to 5 (9·7 deaths [9·1–11·1] per 1000 children aged 1 year). The probability of dying between age 15 years and 24 years declined by 1·4% per year (90% UI 1·1–1·8) between 1990 and 2019, from 17·1 deaths (16·5–18·9) per 1000 in 1990; by contrast with this total decrease of 34% (27–41), under-5 mortality declined by 59% (56–61) in this period. The annual number of deaths declined from 1·7 million (90% UI 1·7–1·9) in 1990 to 1·4 million (1·3–1·5) in 2019. In sub-Saharan Africa, the number of deaths increased by 20·8% from 1990 to 2019. Although 18·3% of the population aged 15–24 years were living in sub-Saharan Africa in 2019, the region accounted for 37·9% (90% UI 34·8–41·9) of all worldwide deaths in youth.InterpretationIt is urgent to accelerate progress in reducing youth mortality. Efforts are particularly needed in sub-Saharan Africa, where the burden of mortality is increasingly concentrated. In the future, a growing number of countries will see youth mortality exceeding under-5 mortality if current trends continue.FundingUN Children's Fund, Bill & Melinda Gates Foundation, United States Agency for International Development.

The Proof of Economic Welfare Is in the Eating of Nutritious Diets by the Resource-Poor: A Political Economy Analysis of the International Evidence of Dietary Consumption in Rural Africa

This paper provides a summary of the international literature published in the thematic area of household dietary diversity with emphasis on the importance of sustainable approaches to global hunger and malnutrition. The paper highlights the correlation between inadequate household dietary diversity, child mortality and death. It also draws attention to the subtle combinations of social, economic and political interactions in enhancing nutritional welfare. The paper further raises a major argument that contemporary explorations of dietary diversity have failed to sustain the important tension and dialectical debate between diverse empirical realities and wider theorization of the concrete linkage of economic welfare to dietary diversity. The paper sets the tone for wider conceptualization of the phenomenon by clearly outlining the role of multiple relations of low incomes, inadequate maternal-child health care as well as poor environmental sanitation as leading predicators of under-nutrition in rural Africa. This theorization makes the case that, studying the relations and conjunctions of economic welfare via the agency of dietary consumption, is critical for emergent processes of change as the given-evidence of under-nutrition does not allow economists to draw solid conclusions on status of dietary diversity in rural Africa without a dynamic understanding and explicit recognition of the wider abstractions of political economy undercurrents in economic welfare and nutritional well-being literature. That said, the paper re-affirms the subtle evidence that under-nutrition and reduced body-mass of adults, often cited in the development literature as proxy-indicators of poor dietary diversity, needs to be re-evaluated as reduced body-mass in adults could be an indication of other incidences of environmental-stresses rather than of food-energy stress. In this vein, the review sustains a new argument that, resource-poor households modify attitude to food consumption in order to self-protect against income losses in household production systems. This position has implications for economic welfare and nutritional diversity research as food may not always come first for the resource-poor. It also opens new avenues for economic research by projecting the hypothesis that consumption of nutritious diets cannot be seen as a unique object to be sought by resource-poor to the exclusion of all other priorities including raising income frontiers through savings for wealth accumulation. The pre-eminence of food security over income diversification activities of rural households as a broader strategy to reduce malnutrition and poverty in the developing world could be re-examined to give livelihood activities a central role in household dietary diversity research.

Unnatural death in India.

Rising adult mortality is an essential feature of the mortality transition. Vulnerability to disease and infection decreases with age, and adult mortality is more likely to be from unnatural causes such as suicide, homicide and road traffic accidents. This study aimed to assess the patterns of unnatural deaths in India as a whole and for various population subgroups. Data were obtained from the fourth wave of the National Family Health Survey (NFHS-4) conducted in 2015-16 in 29 states and 7 union territories of India. The survey collected information on deaths in households occurring in the 3 years before the survey. Rate of unnatural mortality and years of life lost were calculated separately for males and females as well as for urban and rural populations. Unnatural mortality in India was found to make up 10.3% of total deaths, and was greater among the population aged 10 to 45 years. The unnatural mortality rate in India was 0.67 per 1000 population: 0.84 per 1000 among the male population and 0.49 per 1000 among the female population. A strict positive association was found between the unnatural mortality rate and a state's development level. In addition, a substantial loss of person-years of life due to unnatural mortality was observed. The results serve as a reminder of the need to adopt measures to reduce this avoidable loss of life in India. Prevention strategies should be targeted at the most vulnerable populations to limit young-age fatality, with its resulting loss of productive years of life.

Multilevel survival analysis for under-fives in Indonesia 2015

Background Marking the end of the Millennium Development Goals (MDGs) era, governments continue their plans via the Sustainable Development Goals (SDGs). One of the MDGs that has continued is the reduction in under-five mortality. Even though the trend of under-five mortality in Indonesia is decreasing, more efforts are needed to reduce the under-five mortality rate.&#x0D; Objective To determine the individual and contextual factors of the under-five survival rate and to assess for possible characteristics that may lead to variance among regencies in Indonesia.&#x0D; Methods Data from 2015 Intercensal Population Survey (Survei Penduduk Antar Sensus/SUPAS 2015) in Indonesia were analyzed using multilevel survival analysis. The Intercensal Population Survey covers all regions in Indonesia up to the regency level. Data were collected by direct interviews of selected household members, with regards to demographic and household characteristics, including births and deaths of under-fives. Our sample population was limited to all under-fives who were born and died during the 2010-2015 period. The number of subjects analyzed was 219,413 after exclusion of children with incomplete data.&#x0D; Results Individual factors associated with under-five survival rate were maternal education, maternal age at first birth, work status, sex, previous birth interval, type of birth, place of residence, and sanitation level. The contextual factor (health care facility ratio per 1000 under-fives per regency) was not associated with under-five survival rate. The 5.27% variance can be explained by the differing characteristics among regencies.&#x0D; Conclusion The individual factors affecting the survival of under-fives are maternal education, maternal age at first birth, maternal work status, sex, previous birth interval, type of birth, place of residence, and sanitation level.