Individual-level Determinants Research Articles

Individual and community-level factors associated with repeat induced abortion among women in Ghana: a multivariable complex sample logistic regression analysis of 2017 Ghana maternal health survey

BackgroundRepeat induced abortion is a serious public health issue that has been linked to adverse maternal health outcomes. However, knowledge about repeat induced abortion and its associated factors among reproductive age women in Ghana is very scarce. The objective of this study is to examine individual and community factors associated with repeat induced abortion in Ghana which would be helpful to design appropriate programmes and policies targeted at improving the sexual and reproductive health of women.MethodsWe used secondary cross-sectional data from the 2017 Ghana Maternal Health Survey. The study included a weighted sample of 4917 women aged 15–49 years with a history of induced abortion. A multivariable complex sample logistic regression analysis was used to investigate individual and community factors associated with repeat induced abortion among women in Ghana. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) was used to measure the association of variables.ResultsOf the 4917 reproductive women with a history of abortion, 34.7% have repeat induced abortion. We find that, compared to women who experience single induced abortion, women who experience repeat abortion are age 25–34 years (AOR:2.16;95%CI = 1.66–2.79) or 35–49 years (AOR:2.95;95%CI:2.18–3.99), have Middle/JHS education (AOR:1.69;95%CI = 1.25–12.27), use contraceptive at the time of conception (AOR:1.48: 95%CI = 1.03–2.14), had sexual debut before 18 years (AOR:1.57; 95%CI: 1.33–1.85) and reside in urban areas (AOR:1.29;95%CI = 1.07–1.57). On the other hand, women who reside in Central (AOR:0.68;95%CI: 0.49–0.93), Northern (AOR:0.46;95%CI:0.24–0.88), Upper West (AOR:0.24; 95%CI: 0.12–0.50) and Upper East (AOR:0.49; 95%CI = 0.24–0.99) regions were less likely to have repeat induced abortion.ConclusionThe study showed that both individual and community level determinants were significantly associated with repeat induced abortion. Based on the findings, it is recommended to promote sexual and reproductive health education and more emphasis should be given to adult, those with early sexual debut, those with Middle/JHS education and those who live in urban centers.

Knowledge of fertility period among reproductive age women in Kenya: a multilevel analysis based on 2022 Kenyan demographic and health survey

BackgroundKnowledge of the fertility period aids women in refraining and engaging in sexual intercourse to avoid and to get pregnant, respectively. The effect of community-level factors on knowledge of the fertility period was not yet known in Kenya. Therefore, we aimed to investigate the community- and individual-level determinants of knowledge of fertility period among women of childbearing age in Kenya.MethodsThe 2022 Kenyan Demography and Health Survey data was used for the current study. This study included 16,901 women of reproductive age. To account for the clustering effects of DHS data and the binary nature of the outcome variable, a multilevel binary logistic regression model was applied. An adjusted odds ratio with a 95% confidence interval was reported to declare the statistical significance. In addition, the model that had the lowest deviance was the one that best fit the data.ResultsThe overall prevalence of knowledge of the fertility period among Kenyan women was 38.1% (95%CI = 37.3, 38.9). Women’s age, women’s education status, heard FP, contraceptive use, media exposure, and distance from health facility significant individual factors while place of residence, and community-level education, were all of factors were found to be strongly associated with knowledge of fertility period.ConclusionAs per the findings of our study, Knowledge of the fertility period among reproductive women was low in Kenya. In the era of increasing refusal of hormone-based family planning, fertility-awareness-based family planning methods may be an option. Promoting the correct fertility period through education and media outreach may be helpful strategies for enhancing fertility decision-making.

Socioeconomic inequalities in the uptake of postpartum care at home across Dutch neighbourhoods.

Postpartum care focuses on prevention of health problems by performing medical check-ups and through enhancing maternal empowerment, the parent-infant interaction and knowledge about mother's own health and that of her newborn. We aimed to investigate whether there was significant clustering within neighbourhoods regarding the uptake of postpartum care and to what extent neighbourhood-level differences are explained by individual socio-demographic factors, pregnancy-related factors and neighbourhood-level determinants (i.e. deprivation and urbanization). A nationwide population-based observational study was carried out using linked routinely collected healthcare data from appropriate-for-gestational-age weight live-born term singleton deliveries (2015-18) in the Netherlands. We performed two-level multivariable logistic regression analyses, using three different models. Model 1 contained no explanatory variables and was used to assess clustering of postpartum care uptake within neighbourhoods. In model 2, individual-level determinants were added one by one and in model 3, neighbourhood-level determinants were added. About 520818 births were included. Multilevel modelling showed that 11% of the total variance in postpartum care uptake could be attributed to the neighbourhood of residence. Individual characteristics explained 38% of the neighbourhood variance, of which income and migration background were the most important contributors. An additional 6% of the variation could be explained by neighbourhood-level determinants. We found substantial neighbourhood differences in postpartum care uptake. These differences are influenced by a complex interplay between individual-level and neighbourhood-level determinants, highlighting the importance of addressing both individual and neighbourhood-level determinants to improve the uptake of postpartum care and therewith overall community health.

Assessing associations between individual-level social determinants of health and COVID-19 hospitalizations: investigating racial/ethnic disparities among people living with HIV in the U.S. National COVID Cohort Collaborative (N3C)

Assessing associations between individual-level social determinants of health and COVID-19 hospitalizations: investigating racial/ethnic disparities among people living with HIV in the U.S. National COVID Cohort Collaborative (N3C)

Colorectal cancer outcomes among Hispanic/Latino patients in the United States: a scoping review protocol.

This scoping review will identify the patterns of survival, treatment, and recurrence among Hispanic and/or Latino/a/x (H/L) patients with colorectal cancer (CRC) living in the United States (US) and Puerto Rico. Additionally, population- and individual-level determinants of cancer outcomes among H/L CRC patients will be mapped to highlight under-reported/under-investigated research areas. CRC is the third most common cancer excluding skin cancers in the US. Unlike non-Hispanic White populations, cancer is the number one cause of death in H/L populations and currently represents 21% of total deaths. Despite this, a lack of consensus exists on CRC outcomes for H/L patients. Most research on H/L individuals has examined incidence and screening of CRC, with fewer studies focusing on cancer outcomes. All epidemiological study designs and systematic reviews will be considered. The review will only include peer-reviewed studies that report on survival, treatment, and/or recurrence patterns for H/L patients with CRC residing in the US and Puerto Rico. A 3-step search with a 2-stage study selection process will be followed, as recommended by JBI and Arksey and O'Malley. Databases to be searched will include MEDLINE (PubMed), Embase (Ovid), and Scopus. A data extraction tool will be designed based on JBI recommendations. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRSIMA-ScR) will be used, with the results presented in a PRISMA diagram. Publications in English from database inception to the present will be considered.

What determines public attitudes toward immigration in the Middle East: an analysis at the individual level

PurposeSurveys in Europe show that immigration is more of a challenge than an opportunity for a significant number of people. However, little attention is given to attitudes toward immigration in the Middle East. This paper examines the effects of personal values and religiosity on the anti-immigration attitudes of citizens in the Middle East and North African countries.Design/methodology/approachUtilizing data from the World Values Survey, we analyze how personal values and religiosity affect anti-immigration attitudes in nine Middle Eastern countries. The data covers individual-level data of 9 MENA countries from the WVS Round 7 (2017–2022). Factor analysis is applied as a data reduction method. Afterward, an OLS regression analysis is conducted on the pooled data.FindingsAnti-immigration attitudes increase with age, education, and religiosity. Personal values such as national pride, support for nationals, and belongingness to one’s country significantly affect anti-immigration attitudes. Furthermore, the importance of religion as a measure of religiosity was found to be positively associated with anti-immigration attitudes.Originality/valueThis paper contributes to underexplored literature by investigating how individual-level determinants, such as demographic indicators, personal values, and religious factors, shape anti-immigration attitudes in the MENA context, distinct from European dynamics.

Associations among educators' beliefs, intervention fidelity, and student outcomes in school-wide positive behavior interventions, and supports: A school-level moderated mediation analysis.

Existing literature has established the effectiveness of school-wide positive behavioral interventions and supports (SWPBIS) for improving school-level student behavioral and academic outcomes. Implementation of SWPBIS in uncontrolled settings is often suboptimal, leading to lackluster outcomes. Researchers have developed and validated several implementation strategies to improve individual-level implementation determinants (e.g., educators' supportive beliefs) to promote the successful delivery of universal programs (e.g., SWPBIS). However, empirical studies are needed to explore the mechanisms of change through which school-level educators' beliefs influence their delivery of SWPBIS. This school-level quasi-experimental study tested a mediational mechanism of change where changes in educators' beliefs work through their intervention fidelity of SWPBIS to influence student outcomes. We delivered the Supportive Belief Intervention (a school-wide implementation strategy used before training to promote educators' supportive beliefs about SWPBIS) and then Tier 1 SWPBIS training to 81 elementary schools serving diverse student populations. At the start of the academic year, school-level educators' beliefs were assessed before the Supportive Belief Intervention. At the end of the academic year, educators' beliefs, intervention fidelity, and rates of student reading proficiency and suspension were assessed. Conditional process analyses with nonparametric bootstrapping (mediational and first stage moderated mediational models) revealed that, at the school level, a larger increase in educators' supportive beliefs was associated with enhanced SWPBIS fidelity and better corollary student outcomes (increased reading proficiency and reduced suspension), while student socioeconomic status moderated the size of the mediation effect. Implications for research and practices about the implementation of SWPBIS and school context were discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Assessing teachers' intervention-related expectations and self-efficacy: An examination of the factor structure of the implementation beliefs assessment.

Individual-level determinants are hypothesized to enable or prevent successful implementation of evidence-based practices, yet there are limited options for measuring theory-informed, individual-level determinants that influence teachers' and other implementers' delivery of school-based interventions. The goal of this study was to develop a self-report scale that measures variables that have been associated with initial and sustained behavior change related to school-based intervention implementation according to the health action process approach (HAPA). Participants were a nationally representative sample of kindergarten through Grade 12 public school teachers, stratified by grade level and geographical region. Item generation was based on a systematic review of the literature on outcome expectations and self-efficacy, the core constructs related to initiating and sustaining behavior change from the HAPA and in consultation with the theory developer. The sample was randomly split; half of the sample was used for exploratory factor analysis (EFA), and the other half was used for confirmatory factor analysis (CFA). The EFA resulted in a final factor structure of three dimensions of the Implementation Beliefs Assessment (IBA): (a) implementation self-efficacy, (b) positive outcome expectations, and (c) negative outcome expectations. This structure was supported in the other half of the sample using CFA. Additional analyses supported the reliability of IBA data. The IBA represents a step forward toward psychometrically sound measurement of factors associated with initial and sustained behavior change. Implications for future research are discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Relationships Among Determinants of Health, Cancer Screening Participation, and Sexual Minority Identity: A Systematic Review.

Purpose: To address cancer screening disparities and reduce cancer risk among sexual minority (SM) groups, this review identifies individual, interpersonal, and community/societal determinants of cancer screening (non)participation among differing SM identities. Methods: Seven scientific databases were searched. Inclusion criteria were as follows: (1) used quantitative methods; (2) English language; (3) cancer screening focus; and (4) at least one SM group identified. Articles were excluded if: (1) analysis was not disaggregated by SM identity (n = 29) and (2) quantitative analysis excluded determinants of cancer screening (n = 19). The Sexual and Gender Minority Health Disparities Research Framework guided literature synthesis. Results: Twelve studies addressed cervical (n = 4), breast (n = 3), breast/cervical (n = 3), or multiple cancers (n = 2). Other cancers were excluded due to inclusion/exclusion criteria. The total sample was 20,622 (mean 1525), including lesbian (n = 13,409), bisexual (n = 4442), gay (n = 1386), mostly heterosexual (n = 1302), and queer (n = 83) identities. Studies analyzing individual-level determinants (n = 8) found that socioeconomic status affected cervical, but not breast, cancer screening among lesbian and bisexual participants (n = 2). At the interpersonal level (n = 7), provider-patient relationship was a determinant of cervical cancer screening among lesbian participants (n = 4); a relationship not studied for other groups. Studies analyzing community/societal determinants (n = 5) found that rurality potentially affected cervical cancer screening among lesbian, but not bisexual people (n = 3). Conclusions: This review identified socioeconomic status, provider-patient relationship, and rurality as determinants affecting cancer screening among SM people. While literature addresses diverse SM groups, inclusion/exclusion criteria identified studies addressing cisgender women. Addressing disparities in the identified determinants of cervical cancer screening may improve participation among SM women. Further research is needed to understand determinants of cancer screening unique to other SM groups.

The social determinants of migrant domestic worker (MDW) health and well-being in the Western Pacific Region: A Scoping Review.

The health and well-being of transnational migrant domestic workers (MDWs) is a pressing but largely neglected public health concern. The Asia Pacific region is home to over 20% of the global MDW population. Living and working conditions, social contexts, political environments, and migration regimes are recognized as consequential to the health of this population, but currently no synthesis of available literature to prioritize research or policy agenda setting for MDW has yet been conducted. This scoping review screened 6,006 peer-reviewed articles and 1,217 gray literature sources, identifying 173 articles and 276 gray literature sources that reported key MDW health outcomes, social determinants of health, and related interventions. The majority of identified studies were observational and focused on the prevalence of common mental disorders and chronic physical conditions, with most studies lacking population representativeness. Identified social determinants of health were primarily concerned with personal social and financial resources, and health knowledge and behaviors, poor living and working conditions, community resources, experienced stigma and discrimination, poor healthcare access, exploitation within the MDW employment industry, and weak governance. Six interventional studies were identified that targeted individual-level health determinants such as financial and health knowledge with mixed effectiveness. Future population representative epidemiological and respondent driven sampling studies are needed to estimate population health burdens. In addition, randomized control trials and public health intervention studies are needed to improve women's health outcomes and address proximal health determinants to reduce health inequalities. Leveraging social networks and community facing non-governmental organizations (NGOs) are promising directions to overcome access to care for this population.

Partisanship with Rightist and Leftist Parties in Central America: A Test of Four Hypotheses

Abstract Although scholars have made substantial progress in the debate on party systems in Latin America, many questions about partisanship in the region remain unaddressed. This article explores how the determinants of partisanship identified in the literature navigate in Central America, a region commonly overlooked by scholars. We examine a decade of public opinion surveys by the Latin American Public Opinion Project (LAPOP) from 2008 to 2018 to explore the individual-level determinants of partisan attachments with sixty-six leftist and rightist parties in six Central American countries to test four hypotheses. While differences across countries exist, self-placement on the left-right ideological scale, engagement in societal organizations, and protest participation help portray partisan attachments.

Abstract P137: Patient Level Determinants of Glycemic Control Among Patients With Type 2 Diabetes Mellitus in Primary Health Facilities in Ghana

Background: Glycemic control among patients with type 2 diabetes mellitus (T2DM) has implications for the risk of complications. Despite the increasing burden of T2DM in sub-Saharan Africa, research on glycemic control remains scanty. Objective: To assess individual-level determinants of glycemic control among patients with T2DM who were on treatment. Methods: A retrospective review of medical records of patients with T2DM in four primary health clinics in the Bono Region of Ghana was conducted. Glycemic control was classified as controlled (fasting blood glucose [FBG] <7.0 mmol/l) and uncontrolled (FBG ≥7 mmol/l) using WHO guidelines for glycemic control. Patient-level characteristics were selected as predictors based on their potential association with glycemic outcomes. A multivariable logistic regression model was fitted to examine the association between patient-level characteristics and glycemic control. Results: Medical records of 637 patients were included, mean age of 61 (±12.2) years, 77% females and 59% farmers. Prevalent complications were Peripheral Neuropathy (17%) and Retinopathy (4%). The mean FBG was 9.7mmol/l (±3.9). Twenty-seven percent (27%) of the patients had glycemic control, with a higher proportion among middle-aged patients (36-65). Patients older than 65 years had higher odds of glycemic control compared to those between 20-35 (adjusted odds ratio OR = 1.83, [95% CI: (1.13 3.54)] p=0.049). Patients without any complications had higher odds of glycemic control compared with those with complications (adjusted OR (AOR) 1.80 [95% CI: 1.07 3.02] p=0.029) (Table) Conclusions: Age and diabetes-related complications were significantly associated with glycemic control. Intensive treatment strategies should be implemented to improve glycemic control among younger adults to reduce the risk of complications. Health system interventions for people with diabetes must recognize the age dimension of glycemic control in Ghana.

Abstract P482: Associations Between Determinates of Food Choice and Healthy Eating Index-2015 in Adults: An NHANES 2017 - 2018 Analysis

Introduction: Previous work in nationally representative US samples has focused on associations between single determinants of food choice and diet quality assessed by the Health Eating Index-2015 (HEI-2015). Limited research has examined the relationship between multiple domains of food choice and diet quality. A greater understanding of the association between individual-level determinants of food choice and diet quality may inform the development of interventions to improve diet quality. Aim: The aim was to examine the association between potentially modifiable factors known to affect individual-level food choice and HEI-2015. Methods: This cross-sectional analysis included adult participants in NHANES 2017 - 2018. Determinates of individual-level food choice were based on a previously proposed framework. Variables assessed in NHANES were mapped to the following four domains: 1) food-external factors (use of nutrition labels, hours worked weekly, typical work schedule); 2) personal-state factors (health status, consumption of food away from home); 3) cognitive factors (perceived diet quality, knowledge of MyPlate); 4) society-related features (monthly grocery expenditures, food security status, income to poverty ratio). Univariate regression assessed the relationship between food choice determinates and HEI-2015 score. Statistically significant variables were entered into multivariate regression models predicting HEI-2015 score. Significant variables from the final model were used in multivariate regression models predicting adequacy and moderation component sub scores of HEI-2015. All models were adjusted for non-modifiable determinates of food choice, including age, sex, race, BMI, education, and relationship status. All analyses were survey weighted. Results: The weighted mean HEI-2015 score for the sample (N=1467) was 51.69 points (95% CI 49.55, 53.84; weighted n=95.6 million). In the final model, perceived diet quality, food away from home, and use of nutrition labels were significant predictors of HEI-2015 (R 2 adj =0.25, p<0.001). Those with excellent/very good perceived diet quality had a 4.88-pt higher HEI-2015 score than those with fair/poor perceived diet quality (p<0.001). Consuming food away from home ≥5 times per week resulted in a 5.92-pt lower HEI-2015 score than 0 times per week (p=0.02). Always/most of the time using nutrition labels was associated with a 7.85-pt higher HEI-2015 score compared to rarely/never using labels (p<0.001). Variables accounted for a higher proportion of variance in adequacy score (R 2 adj =0.10, p<.001) than moderation score (R 2 adj =0.24, p<.001). Conclusion: Food-external, personal-state, cognitive, and socio-cultural factors are associated with diet quality. Future research should consider multiple individual-level food-choice determinates when developing interventions to improve diet quality.

Time to death explains the chronological decline of voter turnout among the older population

Age is possibly the strongest known individual-level socio-demographic determinant of participation in elections. Despite its substantial influence in shaping electoral outcomes, evidence-based understanding of the steep decline in turnout at older ages is scarce. We suggest that time-related proximity to death and the associated decline in cognitive and physical functioning may explain this relationship. With full population data on the participation of the 65+ year-old electorate in the 1999 parliamentary elections in Finland linked to a more than 21-year mortality follow-up, we demonstrate that the remaining lifetime is a more powerful predictor of voting than age, often by an order of magnitude. These results offer a novel theoretical principle into understanding the fundamental age-related decline in electoral participation at older ages: It is not the time from the cradle, but the time to the grave, that counts more.

Technocratic beliefs and delegative democratic attitudes in states of emergency: evidence from a cross-national analysis

ABSTRACT Previous research on delegative democracy has predominantly emphasized its structural aspects, leaving the individual-level determinants of support for this governance relatively unexplored. While some studies have investigated the association between trust in the president and delegative democratic attitudes (DDA), the connection between technocratic beliefs, DDA, and the context of national emergencies has been minimally addressed. This study aims to fill this research gap by examining the correlation between technocratic beliefs and DDA, specifically focusing on how emergencies influence this relationship. Analysing data from the Asian Barometer Survey and the World Values Survey, the results indicate a robust connection between individuals’ technocratic beliefs and DDA. Moreover, this correlation exhibits greater strength as a country’s level of emergency escalates. These results may provide valuable insights into our understanding of both individual and structural factors associated with public support for delegative democracy.

Abstract WMP99: A Novel Network Analysis of County- and Individual-Level Factors Associated With Functional Outcomes After Stroke

Background: Social circumstances may contribute to health disparities in patients with stroke through indirect and interdependent mechanisms that are not well understood. Objective: This study used complexity science methodology to examine the interplay between county- and individual-level social and clinical factors influencing stroke functional outcomes. Methods: As part of the Get With the Guidelines-Stroke (GWTG-S) Data Challenge, the GWTG-S Registry was merged with county-level Institute for Health Metrics and Evaluation data. Patients diagnosed with stroke (ischemic, subarachnoid, or intracerebral hemorrhage) were included. Multilayer networks were constructed by estimating mixed graphical models of 32 nodes across four layers, including social (county- and patient-level) and clinical (comorbidities and encounter) factors. Social determinant networks were estimated for patients with less favorable (ie., functional dependence or death, modified Rankin Score [mRS] 3-6) versus favorable outcomes (ie., functional independence, mRS 0-2). Network structure and node centrality were compared between mRS groups using bootstrap permutation analyses. Hub nodes were defined by betweenness centrality and facilitate effects across the network. Results: From 2013-2019, 990 721 (62.3%) stroke patients had mRS of 3-6 and 597 477 (37.6%) had mRS 0-2 at discharge. Compared to the mRS 0-2 group, the mRS 3-6 group’s social determinants network had greater global connectivity (p<0.001), and homelessness (p<0.001) and Black race (p<0.001) were hub nodes. Unique to the mRS 3-6 group, younger patients were more likely to identify as homeless (p=0.031), uninsured (p=0.001), and live in a county with lower per capita income (p<0.001). Conclusions: The effects of social determinants were significantly greater in patients with less favorable functional outcomes. Homelessness and race play critical roles in mediating the impacts of county- and individual-level social determinants on downstream disparities in stroke outcomes. Particularly among younger patients, housing, insurance status, and income may serve as a critical leverage point for county-level interventions to improve function after stroke.

Individual-level social determinants of health and allostatic load/chronic toxic stress in men with prostate cancer.

Individual-level social determinants of health and allostatic load/chronic toxic stress in men with prostate cancer.

Coverage and determinants of infant postnatal care in Nigeria: A population-based cross-sectional study.

In 2019, Nigeria had the largest number of under-5 child deaths globally and many of these deaths occurred within the first week of life. The World Health Organization recommends infant postnatal care (PNC) attendance to support newborn survival; however, utilization of PNC is known to be low in many contexts. This study examined coverage and individual-level determinants of infant PNC attendance in Nigeria. Nigeria Demographic Health Survey (NDHS) 2018 data were used to evaluate infant PNC coverage and determinants. Infant PNC was defined as receipt of care within 2 days of birth. Children delivered up to 2 years before the 2018 NDHS were included. We examined predictors of infant PNC with modified Poisson regression models to estimate relative risks (RRs). The national coverage of infant PNC was 37.3% (95% confidence interval [CI]: 35.8%-38.7%). Significant heterogeneity in PNC attendance existed at state and regional levels. Facility delivery was strongly associated with the uptake of PNC (RR: 6.07; 95% CI: 5.60-6.58). Greater maternal education, maternal employment, urban residence, female head of household, and greater wealth were also associated with an increased likelihood of PNC visits. The uptake of infant PNC is low and interventions are urgently needed to promote equity in access and increase demand for PNC in Nigeria.

Individual and community level determinants of delayed antenatal care initiation in Ethiopia: A multilevel analysis of the 2019 Ethiopian Mini Demographic Health Survey.

Antenatal care (ANC) is essential health care and medical support provided to pregnant women, with the aim of promoting optimal health for both the mother and the developing baby. Pregnant women should initiate ANC within the first trimester of pregnancy to access a wide range of crucial services. Early initiation of ANC significantly reduces adverse pregnancy outcomes, yet many women in Sub-Saharan Africa delay its initiation. The aim of this study was to assess prevalence and determinants of delayed ANC initiation in Ethiopia. We conducted a secondary data analysis of the 2019 Ethiopian Mini Demographic and Health Survey (EMDHS). The study involved women of reproductive age who had given birth within the five years prior to the survey and had attended ANC for their most recent child. A total weighted sample of 2,895 pregnant women were included in the analysis. Due to the hierarchical nature of the data, we employed a multi-level logistic regression model to examine both individual and community level factors associated with delayed ANC initiation. The findings of the regressions were presented with odds ratios (OR), 95% confidence intervals (CI), and p-values. All the statistical analysis were performed using STATA-14 software. This study showed that 62.3% (95% CI: 60.5, 64.1) of pregnant women in Ethiopia delayed ANC initiation. Participants, on average, began their ANC at 4 months gestational age. Women with no education (AOR = 2.1; 95% CI: 1.4, 3.0), poorest wealth status (AOR = 1.9; 95% CI: 1.3, 2.8), from the Southern Nations, Nationalities, and Peoples (SNNP) region (AOR = 2.1; 95% CI: 1.3, 3.3), and those who gave birth at home (AOR = 1.4; 95% CI: 1.1, 1.7) were more likely to delay ANC initiation. The prevalence of delayed ANC initiation in Ethiopia was high. Enhancing mothers' education, empowering them through economic initiatives, improving their health-seeking behavior towards facility delivery, and universally reinforcing standardized ANC, along with collaborating with the existing local community structure to disseminate health information, are recommended measures to reduce delayed ANC initiation.

Social disparities and inequalities in healthcare access and expenditures among Iranians exposed to sulfur mustard: a national study using spatio-temporal analysis

Background Sulfur Mustard (SM) is a chemical warfare agent that has serious short-term and long-term effects on health. Thousands of Iranians were exposed to SM during the eight-year Iran-Iraq conflict and permanently injured while the socioeconomic imbalance in their healthcare utilization (HCU) and health expenditures remains. This study aims to describe the HCU of SM-exposed survivors in Iran from 2018 to 2021; identify high-risk areas; and apply an inequality analysis of utilization regarding the socioeconomic groups to reduce the gap by controlling crucial determinants.Methods From Oct 2018 to June 2021, the Veterans and Martyrs Affairs Foundation (VMAF) recorded 58,888 living war survivors with eye, lung, and skin ailments. After cleaning the dataset and removing junk codes, we defined 11 HCU-related variables and predicted the HCU for the upcoming years using Bayesian spatio-temporal models. We explored the association of individual-level HCU and determinants using a Zero-inflated Poisson (ZIP) model and also investigated the provincial hotspots using Local Moran’s I.ResultsWith ≥ 90% confidence, we discovered eleven HCU clusters in Iran. We discovered that the expected number of HCU 1) rises with increasing age, severity of complications in survivors' eyes and lungs, wealth index (WI), life expectancy (LE), and hospital beds ratio; and 2) decreases with growing skin complications, years of schooling (YOS), urbanization, number of hospital beds, length of stay (LOS) in bed, and bed occupancy rate (BOR). The concentration index (CInd) of HCU and associated costs in age and wealth groups were all positive, however, the signs of CInd values for HCU and total cost in YOS, urbanization, LOS, and Hospital beds ratio groups were not identical.ConclusionsWe observed a tendency of pro-rich inequity and also higher HCU and expenditures for the elderly population. Finally, health policies should tackle potential socioeconomic inequities to reduce HCU gaps in the SM-exposed population. Also, policymakers should allocate the resources according to the hotspots of HCU.