| 1. |
- Collinson, Mark A, 1964-
(författare)
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Striving against adversity. : the dynamics of migration, health and poverty in rural South Africa
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The study is based in post-apartheid South Africa and looks at the health and well being of households in the rural northeast. Temporary migration remains important in South Africa because it functions as a mainstay for income and even survival of rural communities. The economic base of rural South Africans is surprisingly low because there is high inequity at a national level, within and between racial groups. There has now been a democratic system in place for 15 years and there is no longer restriction of mobility, but there remain high levels of poverty in rural areas and rising mortality rates. Migration patterns did not change after apartheid in the manner expected. We need to examine consequences of migration and learn how to offset negative impacts with targeted policies. Aims: To determine a relevant typology of migration in a typical rural sending community, namely the Agincourt sub-district of Mpumalanga, South Africa, and relate it to the urban transition at a national level – Paper (I) . To evaluate the dynamics of socio-economic status in this rural community and examine the relationship with migration – Paper (II). To explore, using longitudinal methods, the impact of migration on key dimensions of health, including adult and child mortality, and sexual partnerships, over a period of an emerging HIV/AIDS epidemic – Papers (III), (IV) and (V). Methods: The health and socio-demographic surveillance system (HDSS) is a large open cohort where the migration dynamics are monitored as they unfold. They are recorded as temporary or permanent migration. Settled refugees are captured using nationality on entry into the HDSS. Longitudinal methods, namely a household panel and two discrete time event history analyses, are used to examine consequences of migration. Results: Migration features prominently and different types have different age and sex profiles. Temporary migration impacts the most on socio-economic status (SES) and health, but permanent migration and the settlement of former refugees are also important. Remittances from migrants make a significant difference to SES. For the poorest households the key factors improving SES are government grants and female temporary migration, while for less poor it is male temporary migration and local employment. Migration has been associated with HIV. Migrants that return more frequently may be less exposed to outside partners and therefore less implicated in the HIV epidemic. There are links between migration and mortality including a higher risk of dying for returnee migrants compared to permanent residents. A mother’s migration can impact on child survival after accounting for other factors. There remains a higher mortality risk for children of Mozambican former refugee parents. Interpretation: Migration changes the risks and resources for health with positive and negative implications. Measures such as improved transportation and roads should be seen as a positive, not a negative intervention, even though it will create more migration. Health services need to adapt to a reality of high levels of circular migration ranging from budget allocation to referral systems. Data should be enhanced at a national level by accounting for temporary migration in national censuses and surveys. At individual level we can offset negative consequences by treating migrants as persons striving against adversity, instead of unwelcome visitors in our better-off communities.
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| 2. |
- Emmelin, Anders, 1950-
(författare)
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Counted - and then? : trends in child mortality within an Ethiopian demographic surveillance site
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background Knowledge of the state of health of a population is necessary for planning for health services for that population. It is a paradox that the health of populations is most commonly measured by mortality and cause of death patterns, but the absence of medical services available to a majority of the world population has made it unavoidable to equate “state of health” with “cause of death pattern”. In the absence of population registration, mortality and causes of death must be studied in samples from the population. The research presented in this thesis mainly has been done within such a sample in a collaborative project between Umeå university and the Addis Ababa university in Ethiopia. This research started 1986 and has run continuously since then. The thesis attempts to measure the effect that social and geographical inequalities has had on the mortality of the children in the study population. Population and Methods The population that is included in the demographic surveillance is the children under five years of age in nine rural and one urban community in central Ethiopia. Mortality and causes of death among the children have been followed since 1987. Results The mortality of the children in the study is high by international comparisons. The most important reason for mortality differences within the population is the difference in living conditions and societal services between the rural and urban areas. Approximately 45% of the child deaths could have been prevented if living conditions and services had been equal to rural and urban children. Conclusions Information concerning mortality and cause of death patterns are essential to planning. In order to empower the population, knowledge of the mortality and most common causes of death must be known to them.
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| 3. |
- Fantahun, Mesganaw, 1958-
(författare)
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Mortality and survival from childhood to old age in rural Ethiopia
- 2008
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This thesis examines ways of establishing cause of death, assessing trends in mortality, and identifying factors that affect mortality and survival among the different population groups in rural and semi-urban Ethiopia. These data are important for health care planning; however, such vital data are unavailable in many developing countries. The study was conducted in Butajira Rural Health Program Demographic Surveillance Site, Ethiopia, where data collection on vital events and related research has been conducted for the last 20 years. This thesis used a cohort and a case referent study preceded by Focus Group Discussion. It also employed a verbal autopsy procedure to identify causes of death. The cohort component used 18 years of surveillance data (1987-2004). The prospective case referent study, carried out in the years 2003-2005, was used to complement the mortality analysis and focused particularly on issues related to household decision making, social capital, and economic status. The main subgroups included were children under-five years old, adults 15-64, and the elderly 65 years and above. Cause of death was ascertained using the Physicians’ Review and InterVA methods. Food shortage and epidemics affected the modest downward trend of mortality. There was a general similarity between the Physicians’ Review and InterVA methods in identifying the major causes of death. About 60% of the deaths were due to pneumonia/sepsis, pulmonary tuberculosis, malaria, and diarrhoea disease/malnutrition. The InterVA method was cheaper and more consistent. Higher rates of HIV/AIDS (11%), tuberculosis (18%), and cardiovascular (9%) mortality were noted in urban areas compared to rural areas. Consistent higher mortality was found in rural areas. Women were disadvantaged by residence and advanced age. Place of residence, illiteracy, widowhood, and not owning a house affected men and women differently, indicating a possible need for gender-specific interventions. Children and women survival is affected by household decision-making; this means efforts to improve women’s involvement in household decision-making (women empowerment) might improve child and women survival in poor settings. Many factors that significantly affect mortality can only be controlled by concerted efforts to improve health and overall development.
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| 4. |
- Fottrell, Edward F, 1980-
(författare)
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Dying to count : mortality surveillance methods in resource-poor settings
- 2008
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background Mortality data are critical to understanding and monitoring changes in population health status over time. Nevertheless, the majority of people living in the world’s poorest countries, where the burden of disease is highest, remain outside any kind of systematic health surveillance. This lack of routine registration of vital events, such as births and deaths, constitutes a major and longstanding constraint on the understanding of patterns of health and disease and the effectiveness of interventions. Localised sentinel demographic and health surveillance strategies are a useful surrogate for more widespread surveillance in such settings, but rigorous, evidence-based methodologies for sample-based surveillance are weak and by no means standardised. This thesis aims to describe, evaluate and refine methodological approaches to mortality measurement in resource-poor settings. Methods Through close collaboration with existing community surveillance operations in a range of settings, this work uses existing data from demographic surveillance sites and community-based surveys using various innovative approaches in order to evaluate and refine methodological approaches to mortality measurement and cause-of-death determination. In doing so, this work explores the application of innovative techniques and procedures for mortality surveillance in relation to the differing needs of those who use mortality data, ranging from global health organisations to local health planners. Results Empirical modelling of sampling procedures in community-based surveys in rural Africa and of random errors in longitudinal data collection sheds light on the effects of various data-capture and quality-control procedures and demonstrates the representativeness and robustness of population surveillance datasets. The development, application and refinement of a probabilistic approach to determining causes of death at the population level in developing countries has shown promise in overcoming the longstanding limitations and issues of standardisation of existing methods. Further adaptation and application of this approach to measure maternal deaths has also been successful. Application of international guidelines on humanitarian crisis detection to mortality surveillance in Ethiopia demonstrates that simple procedures can and, from an ethical perspective, should be applied to sentinel surveillance methods for the prospective detection of important mortality changes in vulnerable populations. Conclusion Mortality surveillance in sentinel surveillance systems in resource-poor settings is a valuable and worthwhile task. This work contributes to the understanding of the effects of different methods of surveillance and demonstrates that, ultimately, the choice of methods for collecting data, assuring data quality and determining causes of death depends on the specific needs and requirements of end users. Surveillance systems have the potential to contribute substantially to developing health care systems in resource-poor countries and should not only be considered as research-oriented enterprises.
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| 5. |
- Godefay Debeb, Hagos, 1972-
(författare)
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Maternal Mortality Then, Now, and Tomorrow : The Experience of Tigray Region, Northern Ethiopia
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- AbstractBackground: Maternal mortality is one of the most sensitive indicators of the health disparities between poorer and richer nations. It is also one of the most difficult health outcomes to measure reliably. In many settings, major challenges remain in terms of both measuring and reducing maternal mortality effectively. This thesis aims to quantify overall levels, identify specific causes, and evaluate local interventions in relation to efforts to reduce maternal mortality in Tigray Region, Northern Ethiopia, thereby providing a strong empirical basis for decision making by the Tigray Regional Health Bureau using methods that can be scaled at national level. Methods: This study employed a combination of community-based study designs to investigate the level and determinants of maternal mortality in six randomly selected rural districts of Tigray Region. A census of all households in the six districts was conducted to identify all live births and all deaths to women of reproductive age occurring between May 2012 and September 2013. Pregnancy-related deaths were screened through verbal autopsy with the data processed using the InterVA-4 model, which was used to estimate Maternal Mortality Ratio. To identify independent determinants of maternal mortality, a case-control study using multiple logistic regression analysis was done, taking all pregnancy-related deaths as cases and a random sample of geographical and age matched mothers as controls. Uptake of ambulance services in the six districts was determined retrospectively from ambulance logbooks, and the trends in pregnancy-related death were analyzed against ambulance utilization, distance from nearest health center, and mobile network coverage at local area level. Lastly, implementation of the Family Folder paper health register, and its potential for accurately capturing demographic and health events, were evaluated using a capture-recapture assessment. Results: A total of 181 deaths to women of reproductive age and 19,179 live births were documented from May 2012 to April2013. Of the deaths, 51 were pregnancy-related. The maternal mortality ratio for Tigray region was calculated at 266 deaths per 100,000 live births (95% CI 198-350), which is consistently lower than previous “top down” MMR estimates. District–level MMRs showed strong inverse correlation with population density (r2 = 0.86). Direct obstetric causes accounted for 61% of all pregnancy–related deaths, with hemorrhage accounting for 34%. Non-membership in the voluntary Women’s Development Army (AOR 2.07, 95% CI 1.04-4.11), low husband or partner involvement during pregnancy (AOR 2.19, 95% CI 1.14-4.18), pre-existing history of other illness (AOR 5.58, 95% CI 2.17-14.30), and never having used contraceptives (AOR 2.58, 95% CI 1.37-4.85) were associated with increased risk of maternal death in a multivariable regression model. In addition, utilization of free ambulance transportation service was strongly associated with reduced MMR at district level. Districts with above-average ambulance utilization had an MMR of 149 per 100,000 LB (95% CI: 77-260) compared with 350 per 100,000 (95% CI: 249-479) in districts with below average utilization. The Family Folder implementation assessment revealed some inconsistencies in the way Health Extension Workers utilize the Family Folders to record demographic and health events. Conclusion: This work contributes to understanding the status of and factors affecting maternal mortality in Tigray Region. It introduces a locally feasible approach to MMR estimation and gives important insights in to the effectiveness of various interventions that have been targeted at reducing maternal mortality in recent years.
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| 6. |
- Huong, Dao Lan, 1974-
(författare)
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Mortality in transitional Vietnam
- 2006
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Understanding mortality patterns is an essential pre-requisite for guiding public health action and for supporting development of evidence-based policy. However, such information is not sufficiently available in Vietnam. Mortality statistics and causes of death are solely collected from health facilities while most deaths occur at home without the presence of health professionals. Facility-based data cannot represent what happened in the wider community. This thesis studies the patterns and burdens of mortality as well as their relationships with socio-economic status in rural Vietnam. The overall aim is to contribute to the improvement of the current system of mortality data collection in the country for the purposes of public health planning and priority setting. The study was carried out within the framework of an ongoing Demographic Surveillance System (DSS) in Bavi district, Hatay province, northern rural Vietnam. This study used a verbal autopsy (VA) approach to identify cause of death in a cohort of approximately 250,000 person- years over a five-year period from 1999 to 2003. During the five year study, a total of 1,240 deaths were recorded and VA was successfully completed for 1,220 cases. Results revealed that VA was an appropriate and useful method for ascertaining cause of death in this rural Vietnamese community where specific data were otherwise scarce. The mortality pattern reflected a transitional pattern of disease in which the leading cause of death was cardiovascular diseases (CVD), followed by neoplasms, infectious and parasitic diseases, and external causes, accounting for 28.9%, 14.5%, 11.2%, and 9.8%, respectively. In terms of premature mortality, there were 85 and 55 Years of Life Lost (YLL) per 1,000 population for males and females respectively. The largest contributions to YLL were CVDs, malignant neoplasms, unintentional injuries, and perinatal and neonatal causes. In general, men had higher mortality rates than women for all mortality categories. In adults of 20 years and above, mortality rates increased substantially with age, and showed similar age effects for all mortality categories with the strongest association for non-communicable diseases (NCD). Education was an important factor for survival in general, and high economic status seemed to benefit men more than women. Compared with cancer and other NCD causes, higher CVD rates were observed among males, the elderly, and those without formal education, using a Cox proportional hazards model. This study is an initial effort to provide information on mortality patterns in a community using longitudinal follow-up of a dynamic cohort. Continuing the study using the VA approach as part of routine data collection in the setting will help to show trends in mortality patterns for the community over time, which may be useful for priority setting and health planning purposes, not only locally but also at the national level. Further analyses are needed to understand mortality inequality across all ages to have a comprehensive picture of mortality burdens in the setting. Validation studies and further standardization of VA methods should be carried out whenever possible to improve the performance and extension of the technique.
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| 7. |
- Krishnan, Anand, 1964-
(författare)
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Gender inequity in child survival : travails of the girl child in rural north India
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: While substantial progress has been made globally towards achieving United Nations Millennium Development Goal 4 (MDG 4) on child mortality, the decline is not sufficient to reach the targets set for 2015. The South Asian region, which includes India, was to achieve the MDG 4 target of 39 deaths per 1000 live births by 2015 but was estimated to have reached only 61 by 2011. A part of this under-achievement is due to the gender-differentials in child mortality in South-Asia. The inherent biological advantage of girls, reflected inlower mortality rates as compared to boys globally, is neutralized by their sociocultural disadvantage in India. The availability of technology for prenatal sex determination has promoted sex-linked abortions. Current government efforts include a law that regulates the use of ultrasound and other diagnostic techniquesfor prenatal testing of sex and a conditional cash transfer (CCT) scheme thatinvests a certain amount of funds at the birth of a girl child to attain maturity when the girl turns 18 years of age. This thesis describes the trends in genderspecific mortality during the period 1992-2011 and gender differentials in causes of death among children (paper I), compares gender differentials in child survivalby socio-economic status of the family (paper II), explores the contribution of non-specific effects of diphtheria-tetanus-pertussis (DTP) vaccination to the excess mortality among girls (paper III), and evaluates the impact of CCT schemes of the government and explores community attitudes and practices related to discrimination of girls (paper IV).Methods and Results: This study is set in Ballabgarh Health and DemographicSurveillance System (HDSS) of Haryana State in North India that covered a population of 88,861 across 28 villages in 2011. This study uses the electronic database that houses all individuals enumerated in the HDSS for the period 1992-2011 along with other demographic, socio-economic and health utilization variables. Sex ratio at birth (SRB) was adverse for girls throughout the study period, varying between 821 to 866 girls per 1000 boys. Overall, under-five mortality rates during the period 1992-2011 remained stagnant due to the increasing neonatal mortality rate and decreasing mortality in subsequent age groups. Mortality rates among girls were 1.6 to 2 times higher than boys during the post-neonatal period (1-11 months) as well as in the 1-4 year age group. Girls reported significantly higher mortality rates due to prematurity (relative risk of 1.52; 95% CI = 1.01-2.29); diarrhoea (2.29;1.59-3.29), and malnutrition (3.37; 2.05-5.53) during 2002-2007. The SRB and neonatal mortality rate were consistently adverse for girls in the advantaged groups. In the 1-36 month age group, girl children had higher mortality than boys in all SES groups. The age at vaccination for and coverage with ivabstractBacillus Calmette–Guérin, DTP, polio and measles vaccines did not differ by sex. There was significant excess mortality among girls as compared to boys in the period after immunization with DTP, for both primary (hazard ratio of 1.65; 95% CI 1.17-2.32) and DTPb (2.21; 1.24-3.93) vaccinations until the receipt of the next vaccine. No significant excess mortality among girls was noted after exposure to BCG (1.06; 0.67-1.67) or measles (1.34; 0.85-2.12) vaccine. A community survey showed poor awareness of specific government schemes for girl children. Four-fifths of the community wanted government to help families with girl children financially. In-depth interviews of government programme implementers revealed the themes of “conspiracy of silence” that was being maintained by general population, underplaying of the pervasiveness of the problem coupled with a passive implementation of the programme and “a clash between politicians trying to cash in on the public sentiment of need for subsidies for girl children and a bureaucratic approachof accountability which imposed lot of conditionalities and documentations to access these benefits”. While there has been some improvement in investment in girl children for immunization and education during the period 1992 to 2010, these were also seen among boys of the same houses and daughters in-laws who come from outside the state where such schemes are not in place.Conclusions: In the study area, girl children continue to be disadvantaged a tall periods in their childhood including in utero. In the short run, empowerment of individuals by education and increasing wealth without a concomitant change in culture of son-preference is harmful as it promotes the use of sex determination technology and female feticide to achieve desired family size and composition. There is a need to carefully review the use of health-enhancing technologies including vaccines so that they do not cause more harm to society. Current government efforts to address the gender imbalance are not working, as these are not rooted in a larger social context.
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| 8. |
- Mee, Paul, 1966-
(författare)
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Who died, where, when and why? : an investigation of HIV-related mortality in rural South Africa
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundSouth Africa has experienced the most severe consequences of the HIV/AIDS pandemic. Every community has been affected in some way, many experiencing huge increases in mortality,particularly before antiretroviral therapies (ART) were readily available. However, the micro-level understanding of the HIV epidemic in South Africa is weak, because of a lack of detailed data for most of the population. This thesis is based on detailed individual follow-up in the Agincourt Health and Demographic Surveillance Site (HDSS) located in the Agincourt subdistrict of Mpumalanga Province and investigates micro-level determinants of HIV epidemiology and the impact of treatment provided.MethodsThe Agincourt HDSS has followed a geographically defined population since 1992,approximately the time when the HIV/AIDS epidemic first became apparent. This population based surveillance has included capturing details of all deaths, with cause of death determined by verbal autopsy, as well as the geographical location of individual households within the overall Agincourt area. Background information on the roll-out of ART over time was also recorded.ResultsA comparison immediately before and after the major roll-out of ART showed a substantial decrease in HIV-related mortality, greater in some local communities within the area than others. Individual determinants associated with a decreased risk of HIV/AIDS mortality included proximity to ART services, as well as being female, younger, and in higher socioeconomic and educational strata. There was a decrease in the use of traditional healthcare sources and an increase in the use of biomedical healthcare amongst those dying of HIV/AIDS between periods before and after the roll-out of ART.ConclusionsUnderstanding micro-level determinants of HIV/AIDS infection and mortality was very important in terms of characterising the overall epidemic in this community. This approach will enable public health interventions to be more effectively targeted towards those who need them most in the continuing evolution of the HIV/AIDS epidemic.
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| 9. |
- Minh, Hoang Van, 1971-
(författare)
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Epidemiology of cardiovascular disease in rural Vietnam
- 2006
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- In the context of transitional Vietnam, although cardiovascular disease (CVD) has been shown to cause a large burden of mortality and morbidity in hospitals, little is known about the magnitude of its burden, risk factor levels and its relationship with socio-demographic status in the overall population. This thesis provides a preliminary insight into population-based knowledge of the CVD epidemiology in rural Vietnam and contributes to the development of methodologies for monitoring it. The ultimate goal of the work is to facilitate the formulation of evidence-based health interventions for reducing the burden of the CVD epidemic in Vietnam and elsewhere. This work was located in Bavi district, a rural community in the north of Vietnam. Studies on cause-specific mortality and risk factors were conducted within the framework of an ongoing Demographic Surveillance System (DSS) (called FilaBavi). The cause-specific mortality study used a verbal autopsy (VA) approach to identify causes of death in FilaBavi during 1999-2003. The risk factor study, conducted in 2002, employed the WHO STEPwise approach to surveillance of non-communicable disease (NCD) risk factors (WHO STEPS). Findings indicated that Bavi district, as an example of rural Vietnam, was already experiencing high rates of CVD mortality and associated risk factors. Mortality results indicated a substantial proportion of deaths due to CVD, which was the leading cause of death (20% and 25.7% of total mortality in 1999 and 2000, respectively and 32% of adult deaths during 1999-2003), exceeding infectious diseases. Hypertension was found to be a serious problem in terms both of its magnitude (14% of the population) and widespread unawareness (82% of the hypertensives). Smoking prevalence was very high among men (58% current daily smokers) and might be expected to cause a considerable number of future deaths without urgent action. CVD mortality and some risk factors seemed to be rising among disadvantaged groups (women, less educated people and the poor). The combination of DSS and WHO STEPS methodologies was shown to have potential for addressing basic epidemiological questions as to how NCD and CVD mortality and associated risk factors are distributed in populations. Given this evidence, actions to prevent CVD in Bavi and similar settings are clearly urgent. Interventions should be comprehensive and integrated, including both primary and secondary approaches, as well as policy-level involvement. Further studies, continuing on similar lines, plus qualitative approaches and deeper cross-site comparisons, are also needed to give further insights into CVD epidemiology in this type of setting.
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| 10. |
- Nguyen, Quang Ngoc, 1976-
(författare)
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Understanding and managing cardiovascular disease risk factors in Vietnam : integrating clinical and public health perspectives
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Vietnam, like other low-income countries, is facing an epidemic burden of cardiovascular disease risk factors (CVDRFs). The magnitude and directions of CVDRF progression are matters of uncertainty. Objectives: To describe the epidemiological progression of CVDRFs and the preventive effects of community lifestyle interventions, with reference to the differences in progression of CVDRF patterns between men and women. Methods: The study was conducted during 2001-2009 in nationally representative samples and in a local setting of rural areas of Ba-Vi district, Ha-Tay province. Both epidemiological and interventional approaches were applied: (i) a population-based cross-sectional survey of 2,130 people aged ≥25 years in Thai-Binh and Hanoi; (ii) an individual participant-level meta analysis of 23,563 people aged 24-74 years from multiple similar surveys in 9 provinces around Vietnam; (iii) a 17-month cohort study of 497 patients in a hypertension management programme; (iv) a quasi-experimental trial on community lifestyle promotion integrated with a hypertension management programme, evaluated by surveys of 4,645 people in both intervention and reference communes before and after a 3-year intervention. Main findings: (i) in the general adult population ≥25 years, CVDRFs were common, often clustered within individuals, and increased with age; (ii) the Vietnamese population is facing a growing epidemic of CVDRFs, which are generally not well managed; (iii) it is possible to launch a community intervention in low-resource settings within the scope of a commune-based patient-targeted programme on hypertension management; (iv) community health intervention with comprehensive healthy lifestyle promotion improves blood pressure and some behavioural CVDRFs. Conclusion: Alarming increases in CVDRFs in the general population need comprehensive multi-level prevention strategies, which combine both individual high-risk and population health approaches. The commune-based hypertension-centred management programmes integrated with community health promotion are the initial but essential steps towards comprehensive and effective management of CVDRFs and should be part of an integrated and co-ordinated national program on the prevention and control of chronic diseases in low-resource settings like Vietnam.
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