Poverty and health

Concurrence of water and food insecurities, 25 low- and middle-income countries
Young SL, Bethancourt HJ, Frongillo EA et al: Bulletin of the World Health Organisation 101:2;90–101, 2023

This study investigated how water and food insecurity were associated in nationally representative samples of individuals from 25 low- and middle-income countries, using data from the Individual Water Insecurity Experiences Scale and the Food Insecurity Experience Scale administered to 31 755 respondents, measuring insecurity in the previous 12 months. The likelihood of experiencing moderate-to-severe food insecurity was higher among respondents also experiencing water insecurity, including in sub-Saharan Africa. The results suggest that water insecurity should be considered when developing food and nutrition policies and interventions and the authors propose research to understand the paths between these insecurities.

Drivers of child marriage in specific settings of Ethiopia, Indonesia, Kenya, Malawi, Mozambique and Zambia – findings from the Yes I Do baseline study
Kok M C, Kakal T, Kassegne AB, et al: BMC Public Health 23:794; 1-16, 2023

This study explored the drivers of child marriage in specific contexts in Ethiopia, Indonesia, Kenya, Malawi, Mozambique and Zambia, combining a household survey among youth with focus group discussions and interviews conducted with youth, parents and community stakeholders. A lack of education was associated with the occurrence of child marriage in Ethiopia, Kenya and Zambia. In all countries, teenage pregnancy was associated with child marriage. In Ethiopia, Kenya and Mozambique, fathers’ education seemed a protective factor for child marriage. In all countries, child marriage was driven by difficult economic circumstances, which were often intertwined with disapproved social circumstances, in particular teenage pregnancy, in case of Kenya, Malawi, Mozambique and Zambia. These circumstances made child marriage an ‘acceptable practice’. The authors found that child marriage is a manifestation of social norms, particularly related to girls’ sexuality, which are intersecting with other factors at individual, social, material, and institutional level – most prominently poverty or economic constraints. The authors argue that efforts to prevent child marriage need to take these realities of girls and their families into account.

Limited handwashing facility and associated factors in sub-Saharan Africa: pooled prevalence and multilevel analysis of 29 sub-Saharan Africa countries from demographic health survey data
Endalew M; Belay D G; Tsega N T; et al: BMC Public Health 22(1969), 1-12, 2022

This study determined the prevalence of limited handwashing facility and its associated factors in sub-Saharan Africa. Data was obtained from the Demographic and Health Surveys in 29 sub-Saharan African countries since January 1, 2010. The pooled prevalence of limited handwashing facilities was found to be 66%. Having a limited handwashing facility was associated with having a household head aged between 35 and 60, having a mobile type of hand washing facility, unimproved sanitation facility, water access requiring more than a 30 min round trip, living in an urban residential area, having low media exposure, low educational level, low income level and being in a lower middle-income level and having more than three children.

A qualitative assessment of gender roles in child nutrition in Central Malawi
Mkandawire E; Bisai C; Dyke E; Dressel A; et al: BMC Public Health 22(1392), 1-13, doi: https://doi.org/10.1186/s12889-022-13749-x, 2022

This study was implemented in central Malawi in 2017 to understand the different roles that Malawian men and women play in child nutrition. It involved interviews (76), focus group discussions and in-depth interviews. The authors found that women carried a disproportionate workload in supporting child nutrition compared to men, and that their heavier workloads in other areas often prevented them from being able to meet children’s food needs. There were some shifts in gender roles with men taking up responsibilities typically associated with women, but this did not necessarily increase women’s power within the household. Women continued to be primarily responsible for the food, care, and health of the household. The authors suggest that improving gender equality and child nutrition will require efforts to redistribute gendered work and encourage men to move towards shared power with women over household decision-making and control over income.

COVID-19 Crisis and the Informal Economy
WIEGO: Study Report, 2022

Women in Informal Employment: Globalizing and Organizing (WIEGO) is a global network focused on empowering the working poor, especially women, in the informal economy to secure their livelihoods. WIEGO implemented this study in two rounds to capture changes across the different stages of the crisis during the second and third quarters of 2020, and how workers adapted by the first quarter of 2021. The study was implemented in 12 cities, including Dar es Salaam in Tanzania and Durban in South Africa. The work provides a platform to give visibility to the experience and voices of informal workers in policy. The organizations of informal workers involved in the study called for continuing relief, inclusive recovery and longer-term reforms for informal workers going forward. These demands, with concrete examples, were categorized into a common framework. a “Summary of Demands” to support these and other organizations of informal workers in their on-going advocacy and negotiations for a full and just recovery and for a “better deal” in the future for informal workers.

Application of community dialogue approach to prevent adolescent pregnancy, early marriage and school dropout in Zambia: a case study
Zulu I; Zulu J; Svanemyr J; Michelo C; et al: Reproductive Health 19(30), 1-9, 2022

This paper presents parents’ perspectives on the application of the community dialogue approach in addressing adolescents’ early pregnancy and school dropout in a 2018 cluster randomized controlled trial in rural Zambia. The guardians/parents perceived the community dialogue to be a relevant approach for addressing social and cultural norms regarding early pregnancy, marriage and school dropout. It was embraced for its value in initiating individual and collective change. The facilitators’ interactive approach and dialogue in the community meetings coupled with the use of films and role plays with the parents, lead to active participation and open discussions about sexual and reproductive health topics during the community dialogue meetings. Group interactions and sharing of experiences helped parents clarify their sexual and reproductive health values and subsequently made them feel able to communicate about sexual and reproductive health issues with their children. However, cultural and religious beliefs among the parents regarding some topics, like the use of condoms and contraceptives, complicated the delivery of reproductive health messages from the parents to their children.

Does disability increase households’ health financial risk: evidence from the Uganda demographic and health survey
Guets W and Behera D K: Global Health Research and Policy 7(2), 1-8, 2022

The authors examined the influence of disability and socio-demographic factors on households’ health financial risks in Uganda, using nationally representative cross-sectional data for 19305 households from the 2016 Uganda Demographic and Health Survey. Financial risk was measured by money paid for health care services. Almost 32% of households paid money for health care services access, among which 32% paid through out-of-pocket. Almost 41% of household heads were affected by disability. The majority of families went to the public sector for health care services. The mean age was 45 years. The findings indicated that disability is significantly associated with the household financial risk, as is a choice to use private sector health care services. The authors recommend identifying families with disability and those experiencing difficult living conditions for health authorities to enhance health coverage progress.

The potential of school-based WASH programming to support children as agents of change in rural Zambian households
Winter J C; Darmstadt G L; Lee S J; Davis J: BMC Public Health 21:1812, 1-13, 2021

Water, sanitation, and hygiene (WASH) interventions frequently assume that students who learn positive WASH behaviours will disseminate this information to their families. School-based programs rely on students to act as “agents of change” to translate impact from school to home. The authors conducted a quasi-experimental, prospective cohort study in 12 schools in rural, southern Zambia to assess this with students in grades 1–4, using in-person interviews with students, their teachers and caregivers. Student knowledge increased significantly, but primarily among students in grade 1. Students reporting sharing messages from the intervention with caregivers rose from 7% to 23%, particularly in students in grade 4. The authors propose that future work should prioritize developing curricula that reflect the variability in needs, capabilities and support in the home and community among primary school students rather than applying a single approach for a wide range of ages and contexts.

Access to water, sanitation and hygiene services in health facilities in sub-Saharan Africa 2013–2018: Results of health facility surveys and implications for COVID-19 transmission
Kanyangarara M; Allen S; Jiwani S S; et al: BMC Health Services Research 21(601), 1-11, 2021

The authors assessed the availability of water, sanitation and hygiene and standard precautions for infection prevention in 16456 health facilities across 18 countries in sub-Saharan Africa, as well as inequalities by location and managing authority, using data from health facility surveys conducted between 2013 and 2018 in 18 sub-Saharan African countries. Across countries, an estimated 88% had an improved water source, 94% had an improved toilet, 74% had soap and running water or alcohol-based hand rub, and 17% had standard precautions for infection prevention available. There was wide variability in access to water, sanitation and hygiene services between rural and urban health facilities and between public and private facilities, with consistently lower access in both rural and public facilities. In both rural and urban areas, access to water, sanitation and hygiene services was better at health facilities than households. Availability of water, sanitation and hygiene services in health facilities in sub-Saharan Africa has improved but remains below the global target of 80 % in many countries, with improvement essential to minimize the risk of COVID-19 transmission.

Burnt by the scorching sun: climate-induced livelihood transformations, reproductive health, and fertility trajectories in drought-affected communities of Zambia
Rosen J G; Mulenga D; Phiri L; et al: BMC Public Health 21(1501), 1-14, 2021

The authors explored the impact of severe and prolonged droughts on gendered livelihood transitions, women’s social and financial wellbeing, and sexual and reproductive health (SRH) outcomes in two Zambian provinces through in-depth interviews and focus group discussions with 165 adult women and men in five drought-affected districts, and key informant interviews with civic leaders and healthcare providers. Across districts, participants emphasized the toll drought had taken on their livelihoods and communities, leaving farming households with reduced income and food, with many turning to alternative income sources. Female-headed households were perceived as particularly vulnerable to drought, as women’s breadwinning and caregiving responsibilities increased, especially in households where women’s partners out-migrated in search of employment. As household incomes declined, women and girls’ vulnerabilities increased: young children increasingly entered the workforce, and young girls were married when families could not afford school fees and struggled to support them financially. With less income due to drought, many participants could not afford travel to health facilities or resorted to purchasing health commodities, including for family planning, from private retail pharmacies when unavailable from government facilities. Women expressed desires for smaller families, fearing drought would constrain their capacity to support larger families. While participants cited some ongoing activities in their communities to support climate change adaptation, most acknowledged current interventions were insufficient.