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Socioeconomic and geographical inequalities in health care coverage in Mozambique: a repeated cross-sectional study of the 2015 and 2018 national surveys
Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Directorate of Planning and Cooperation, Ministry of Health, Maputo, Mozambique; Centre for African Studies, Universidade Eduardo Mondlane, Maputo, Mozambique.
Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.ORCID iD: 0000-0001-7234-3510
Centre for African Studies, Universidade Eduardo Mondlane, Maputo, Mozambique.
Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden.ORCID iD: 0000-0002-9722-0370
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2023 (English)In: BMC Public Health, E-ISSN 1471-2458, Vol. 23, no 1, article id 1007Article in journal (Refereed) Published
Abstract [en]

Background: Over the past years, Mozambique has implemented several initiatives to ensure equitable coverage to health care services. While there have been some achievements in health care coverage at the population level, the effects of these initiatives on social inequalities have not been analysed.

Objective: The present study aimed to assess changes in socioeconomic and geographical inequalities (education, wealth, region, place of residence) in health care coverage between 2015 and 2018 in Mozambique.

Methods: The study was based on repeated cross-sectional surveys from nationally representative samples: the Survey of Indicators on Immunisation, Malaria and HIV/AIDS in Mozambique (IMASIDA) 2015 and the 2018 Malaria Indicator survey. Data from women of reproductive age (15 to 49 years) were analysed to evaluate health care coverage of three indicators: insecticide-treated net use, fever treatment of children, and use of Fansidar malaria prophylaxis for pregnant women. Absolute risk differences and the slope index of inequality (SII) were calculated for the 2015 survey period and the 2018 survey period, respectively. An interaction term between the socioeconomic and geographical variables and the period was included to assess inequality changes between 2015 and 2018.

Results: The non-use of insecticide-treated nets dropped, whereas the proportion of women with children who were not treated for fever and the prevalence of women who did not take the full Fansidar dose during pregnancy decreased between 2015 and 2018. Significant reductions in the inequality related to insecticide-treated net use were observed for all socioeconomic variables. Concerning fever treatment, some reductions in socioeconomic inequalities were observed, though not statistically significant. For malaria prophylaxis, the SII was significant for education, wealth, and residence in both periods, but no significant inequality reductions were observed in any of these variables over time.

Conclusions: We observed significant reductions of socioeconomic inequalities in insecticide-treated net use, but not in fever treatment of children and Fansidar prophylaxis for pregnant women. Decision-makers should target underserved populations, specifically the non-educated, poor, and rural women, to address inequalities in health care coverage.

Place, publisher, year, edition, pages
BioMed Central (BMC), 2023. Vol. 23, no 1, article id 1007
Keywords [en]
Health care coverage, Health inequality, Mozambique, National surveys, Socioeconomic inequalities
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-209540DOI: 10.1186/s12889-023-15988-yPubMedID: 37254141Scopus ID: 2-s2.0-85160627630OAI: oai:DiVA.org:umu-209540DiVA, id: diva2:1766571
Funder
Sida - Swedish International Development Cooperation AgencyAvailable from: 2023-06-13 Created: 2023-06-13 Last updated: 2024-05-20Bibliographically approved
In thesis
1. Making the connections: understanding inequalities in reproductive and child health in Mozambique
Open this publication in new window or tab >>Making the connections: understanding inequalities in reproductive and child health in Mozambique
2024 (English)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[sv]
Att förstå ojämlikheter i reproduktiv och barns hälsa i Moçambique
Abstract [en]

Background: In Mozambique, despite significant socio-economic and health system challenges, there has been progress in reproductive and child health in recent years. However, there is still a lack of comprehensive studies that thoroughly unravel the socio-economic determinants of health and health inequalities in the country.

The overall aim of this thesis was to understand the socio-economic and geographic inequalities in reproductive and child health with the intention of informing and optimizing the implementation of targeted health programmes in Mozambique.

Methods: This thesis is based on three sub-studies that used data obtained from population-based health surveys. In sub-study I, prevalence ratios (PRs) with 95% confidence intervals (95% CI) were calculated by log binomial regression to assess the relationship of socio-economic, demographic, and geographic characteristics with three outcomes of interest: insecticide-treated bed nets (ITNs), child immunization coverage and modern contraceptive use. Sub-study II used the concentration index (Cindex) and decomposition analysis to assess the socio-economic and regional contributions to the wealth inequality in health preventive care. Sub-study III estimated absolute risk differences and the slope index of inequality (SII) as the measures of association between the socio-economic variables and the outcomes (ITN use, fever treatment and Fansidar prophylaxis) for the 2015 and 2018 surveys, as well as for the differences between the two time points.

Results: The proportion of mothers with at least one child aged under five years that did not use an ITN was 51.01%, while 46.25% of women had children aged one to four years who were not fully immunized and 74.28% of women did not use modern contraceptives. Non-educated mothers and residents of the southern region were more likely to report not using an ITN (PR = 1.36; 95% CI: 1.17–1.59), while those in the lowest wealth quintile had a higher chance of having children who were not fully immunized (PR = 1.34; 95% CI: 1.04–1.71). Similarly, non-educated mothers (PR = 1.17; 95% CI: 1.10–1.25), non-working women (PR = 1.09; 95% CI: 1.04–1.16) and those in the poorest wealth quintile (PR = 1.13; 95% CI: 1.04–1.24) were more likely to not use modern contraception (sub-study I). Sub-study II found a Cindex of -0.081 for non-ITN, -0.189 for a lack of vaccination coverage and -0.284 for non-contraceptive use, showing a worse health outcome among the poorest population. The study revealed that 88.41% of the wealth gap for ITNs was explained by socio-economic factors, with education and wealth playing the largest roles. With regard to the lack of full vaccination, socio-economic factors (47.74%), particularly the wealth quintile (35.79%), emerged as the predominant contributor to the inequality. Similarly, socio-economic factors (39.39%) were also the main explanatory factors for the lack of contraceptive use, but to a lesser degree than for the other two outcomes (sub-study II). Access to health preventive activities increased in all of the three studied outcomes between 2015 and 2018. Significant reductions in ITN inequality were observed for all socio-economic variables, but no decrease of inequalities in fever treatment and Fansidar prophylaxis was found over time (sub-study III).

Conclusion: This thesis revealed that bed net use and immunization coverage among children, and modern contraceptive use among women, were notably low. There was inequality, concentrated among the poor, in reproductive and child preventive measures. The greater part of this inequality could be attributed to low wealth and education, as well as to residence in rural areas. Reductions in socio-economic inequalities between 2015 and 2018 were observed for ITN use but not for fever treatment or malaria prophylaxis. Based on these findings, achieving universal health coverage in Mozambique will require an equitable resource distribution among rural regions, increased community education on health preventative measures and health service expansion to socio-economically disadvantaged households.

Place, publisher, year, edition, pages
Umeå: Umeå University, 2024. p. 66
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2306
Keywords
reproductive health, child health, malaria, demographic, geographic, socio-economic inequalities, vaccination, Mozambique
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
health services research
Identifiers
urn:nbn:se:umu:diva-224497 (URN)9789180704014 (ISBN)9789180704021 (ISBN)
Public defence
2024-06-10, Alicante, Norrlands universitetssjukhus, plan 3, byggnad 5B, Umeå, 13:00 (English)
Opponent
Supervisors
Available from: 2024-05-20 Created: 2024-05-20 Last updated: 2024-05-20Bibliographically approved

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Daca, Chanvo S. L.San Sebastian, MiguelSchumann, BarbaraNamatovu, Fredinah

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