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Wealth inequalities in reproductive and child health preventive care in Mozambique: a decomposition analysis
Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Cooperation, Ministry of Health, Directorate of Planning and Cooperation, Maputo, Mozambique.
Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.ORCID iD: 0000-0002-9722-0370
Universidade Eduardo Mondlane, Maputo, Mozambique.
Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.ORCID iD: 0000-0001-7234-3510
2022 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 15, no 1, article id 2040150Article in journal (Refereed) Published
Abstract [en]

Background: Assessing the gap between rich and poor is important to monitor inequalities in health. Identifying the contribution to that gap can help policymakers to develop interventions towards decreasing that difference.

Objective: To quantify the wealth inequalities in health preventive measures (bed net use, vaccination, and contraceptive use) to determine the demographic and socioeconomic contribution factors to that inequality using a decomposition analysis.

Methods: Data from the 2015 Immunisation, Malaria and AIDs Indicators Survey were used. The total sample included 6946 women aged 15–49 years. Outcomes were use of insecticide-treated nets (ITN), child vaccination, and modern contraception use. Wealth Index was the exposure variable and age, marital status, place of residence, region, education, occupation, and household wealth index were the explanatory variables. Wealth inequalities were assessed using concentration indexes (Cindex). Wagstaff-decomposition analysis was conducted to assess the determinants of the wealth inequality.

Results: The Cindex was −0.081 for non-ITN, −0.189 for lack of vaccination coverage and −0.284 for non-contraceptive use, indicating a pro-poor inequality. The results revealed that 88.41% of wealth gap for ITN was explained by socioeconomic factors, with education and wealth playing the largest roles. Lack of full vaccination, socioeconomic factors made the largest contribution, through the wealth variable, whereas geographic factors came next. Finally, the lack of contraceptive use, socioeconomic factors were the main explanatory factors, but to a lesser degree than the other two outcomes, with wealth and education contributing most to explaining the gap.

Conclusion: There was a pro-poor inequality in reproductive and child preventive measures in Mozambique. The greater part of this inequality could be attributed to wealth, education, and residence in rural areas. Resources should be channeled into poor and non-educated rural communities to tackle these persistent inequities in preventive care.

Place, publisher, year, edition, pages
Taylor & Francis Group, 2022. Vol. 15, no 1, article id 2040150
Keywords [en]
decomposition analysis, health preventive care, Mozambique, Socioeconomic inequality
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-193395DOI: 10.1080/16549716.2022.2040150ISI: 000769311900001PubMedID: 35290171Scopus ID: 2-s2.0-85126650585OAI: oai:DiVA.org:umu-193395DiVA, id: diva2:1651552
Available from: 2022-04-12 Created: 2022-04-12 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, ChanvoSchumann, BarbaraSan Sebastian, Miguel

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