Poverty and health

Temporal trends in the nutritional status of women and children under five years of age in sub-Saharan African countries: ecological study
Humbwavali J; Giugliani C; Silva I; Duncan B: Sao Paulo Medical Journal 136(5), 454-463, 2018

This paper seeks to describe obesity trends among women of childbearing age over recent decades, along with trends in over and under nutrition among children under five years of age, in sub-Saharan African countries. An ecological study with temporal trend analysis in 13 sub-Saharan African countries was carried out covering trends in nutritional status such as adult obesity, childhood overweight, low height-for-age, low weight-for-height, low weight-for-age and low birth weight. Publicly available data from repeated cross-sectional national surveys were used. The authors chose 13 sub-Saharan African countries from which at least four surveys conducted since 1993 were available. The authors investigated women aged 15-49 years and children under five years of age. In multilevel linear models, the prevalence of obesity increased by an estimated 6 percentage points over 20 years among women of childbearing age, while the prevalence of overweight among children under 5 years old was stable. A major decrease in stunting and, to a lesser extent, wasting accompanied these findings. The upward trend in obesity among women of childbearing age in the context of highly prevalent childhood undernutrition suggests that the focus of maternal and child health in sub-Saharan Africa needs to be expanded to consider both nutritional deficiencies and nutritional excess.

Receding Malawi lake lays bare cost of climate change
AFP: Times Live, South Africa, 2018

Just four months ago, the fishing harbour at Kachulu on the western shores of Lake Chilwa in Malawi was bustling with fishermen and traders haggling over the catch of the day. Today hundreds of fishing boats sit marooned on cracked, dry mud as vultures fly above the shores of the once productive fishing zone 30 kilometres (19 miles) east of the southern African country's old capital Zomba. Julius Nkhata, a local villager, says the increasingly dramatic seasonal dry-out of the lake -- blamed by experts on man-made climate change -- has displaced local people and increased joblessness. One-and-a-half million people live in the areas on the Lake Chilwa basin, which is one of the most densely populated areas in southern Africa. Nixon Masi, a government fishery official at Chilwa, said a women's fish-drying cooperative that depends on the lake had been devastated. "There is no fish. This has resulted in a big problem as the women from the cooperative have no source of income," he said. Of the initial 38 members, 21 have left to rebuild their lives elsewhere.

The problem or the solution? Early fertility and parenthood in the transition to adulthood in Khayelitsha, South Africa
Swartz A; Christopher C; Harrison A: Reproductive Health Matters 16(32), doi: https://doi.org/10.1080/09688080.2018.1537417, 2018

This article draws on ethnographic data collected between 2014 and early 2016 with young adults (17-25 years) in Town Two, Khayelitsha. Participant observation was the primary data collection method. Narratives and experiences of 15 young people are presented here. The authors argue that in addition to immediate fertility desires, young people’s contraceptive decision-making was significantly shaped by gendered ideals and social norms. Young women’s fertility operated as both an aspiration and a threat within partnerships. Some couples partially achieved relationship stability or longevity through having a child. Entering parenthood in the context of a seemingly stable relationship was perceived as a movement towards an accepted, albeit tenuous, form of social adulthood. Although living up to the ideal of good parent was challenging, it was partially achieved by young mothers who provided care and young fathers who provided financially for children. The authors argue that in the absence of other accepted markers of transition to adulthood and within a context of deprivation and exclusion, early fertility, though clearly a public health problem, can become a solution to social circumstances.

How do gender and disability influence the ability of the poor to benefit from pro-poor health financing policies in Kenya? An intersectional analysis
Kabia E; Mbau R; Muraya K; et al: International Journal for Equity in Health 17(149) 1-12, 2018

This study employed an intersectional approach to explore how gender disability and poverty interact to influence how poor women in Kenya benefit from pro-poor financing policies that target them. The authors applied a qualitative cross-sectional study approach in two purposively selected counties in Kenya. The authors collected data using in-depth interviews with women with disabilities living in poverty who were beneficiaries of the health insurance subsidy programme and those in the lowest wealth quintiles residing in the health and demographic surveillance system. Women with disabilities living in poverty often opted to forgo seeking free healthcare services because of their roles as the primary household providers and caregivers. Due to limited mobility, they needed someone to accompany them to health facilities, leading to greater transport costs. The absence of someone to accompany them and unaffordability of the high transport costs, for example, made some women forgo seeking antenatal and skilled delivery services despite the existence of a free maternity programme. The layout and equipment at health facilities offering care under pro-poor health financing policies were disability-unfriendly. The latter in addition to negative healthcare worker attitudes towards women with disabilities discouraged them from seeking care. Negative stereotypes against women with disabilities in the society led to their exclusion from public participation forums thereby limiting their awareness about health services. Intersections of gender, poverty, and disability influenced the experiences of women with disabilities living in poverty with pro-poor health financing policies in Kenya. Addressing the healthcare access barriers they face could entail ensuring availability of disability-friendly health facilities and public transport systems, building cultural competence in health service delivery, and empowering them to engage in public participation.

A longitudinal perspective on boys as victims of childhood sexual abuse in South Africa: Consequences for adult mental health
Richter L; Mathews S; Nonterah E; et al: Child Abuse & Neglect 84, 1-10, 2018

Childhood sexual abuse of boys was examined in a longitudinal cohort in South Africa, with data on abuse collected at six age points between 11 and 18 years. Potential personal and social vulnerability of male sexual abuse victims was explored and mental health outcomes of sexually abused boys were examined at age 22–23 years. Reports of all sexual activity – touching, oral and penetrative sex – increased with age and sexual coercion decreased with age. Almost all sexual activity at 11 years of age was coerced, with the highest rates of coercion occurring between 13 and 14 years of age; 45% of reports of coerced touching were reported at age 14, 41 percent of coerced oral sex at age 13, and 31% of coerced penetrative sex at age 14. Sexual coercion was perpetrated most frequently by similar aged peers and although gender of the assailant was less often reported, it can be presumed that perpetration is by males. Boys who experienced childhood sexual abuse tended to be smaller (shorter) and from poorer families. No relationships to measured childhood intelligence, pubertal stage, marital status of mother or presence of the father were found and there was no significant association between reports of childhood sexual abuse and mental health in adulthood.

Drinking water, sanitation and hygiene in schools, Global baseline report 2018
United Nations Children's Fund; World Health Organization: Geneva, 2018

Millions of children around the world do not have access to clean water or decent sanitation at school, putting their education – and those of girls in particular – at risk. The first ever global baseline report on drinking-water, sanitation and hygiene in schools – carried out by WHO and UNICEF – shows that 620 million children worldwide do not have access to decent toilets at school, and around 900 million children cannot wash their hands properly. Ensuring that children attend school and complete their education is crucial to a country’s social and economic development, yet a lack of decent hygiene facilities discourages children, particularly girls, from doing so. Nearly 570 million children lacked a basic drinking water service at their school. Nearly half of schools in sub-Saharan Africa had no safe drinking water and a third of schools in sub-Saharan Africa had no sanitation service.

The BRICS, climate catastrophe, resource plunder – and resistance
Maguwu F: Pambazuka News, August 2018

The heads of state from Brazil, Russia, India, China and South Africa (BRICS) met in August for a two-day annual BRICS summit, with one of the issues that of energy related investments and their impact. The author notes that China and India are investing billions of dollars in coal-fired thermal-power generation in Africa while winning global applause for increasing their solar and wind power at home and suggests that this points to a contradiction and policy inconsistency. China is funding coal projects in Ghana, Kenya, Tanzania, Malawi, Zambia and Zimbabwe, yet is a global powerhouse in renewable energy. He suggests that Chinese state energy companies losing business due to government slowing of carbon emissions in China are turning to Africa, even while they have first-hand knowledge on the effects of coal on the environment and human health. The Indian Government is also being praised globally for taking steps to halt carbon emissions, but it too has made investments in Africa in coal-based energy. He describes protest against harmful approaches with pickets by activists raising issues and demands to address exploitation, climate change, pollution and the looting of Africa resources with inequality and social harm.

Home is best: Why women in rural Zimbabwe deliver in the community
Dodzo M; Mhloyi M: PLOS One 12(8) e0181771, doi: 10.1371/journal.pone.0181771, 2017

Maternal mortality in Zimbabwe has unprecedentedly risen over the last two and half decades although a decline has been noted recently. Many reasons have been advanced for the rising trend, including deliveries without skilled care, in places without appropriate or adequate facilities to handle complications. The recent decline has been attributed to health systems strengthening. On the other hand, the proportion of community deliveries has also been growing steadily over the years and in this study the authors investigate why. Twelve focus group discussions with child-bearing women and eight key informant interviews (KIIs) were conducted. Four were traditional birth attendants and four were spiritual birth attendants. The study shows that women prefer community deliveries due to perceived low economic, social and opportunity costs involved; pliant and flexible services offered; and diminishing quality and appeal of institutional maternity services. The authors conclude that rural women are very economic, logical and rational in making choices on place of delivery. Delivering in the community offers financial, social and opportunity advantages to disenfranchised women, particularly in remote rural areas. The authors recommend increased awareness of the dangers of community deliveries; establishment of basic obstetric care facilities in the community and more efficient emergency referral systems. In the long-term, they argue that there should be a sustainable improvement of the public health delivery system to make it accessible, affordable and usable by the public.

"Poverty is the big thing”: exploring financial, transportation, and opportunity costs associated with fistula management and repair in Nigeria and Uganda
Keya K; Sripad P; Nwala E; et al: International Journal for Equity in Health 17(70) 1-10, 2018

This paper explored, through women’s, communities’, and providers’ perspectives, the financial, transport, and opportunity cost barriers and enabling factors for seeking services for fistula. A qualitative approach was applied in Kano and Ebonyi in Nigeria and Hoima and Masaka in Uganda. Between June and December 2015, the study team conducted in-depth interviews with women affected by fistula including those awaiting repair, living with fistula, and after repair, their spouses and other family members, and health service providers involved in fistula repair and counseling. Focus group discussions with male and female community stakeholders and post-repair clients were also conducted. Women’s experiences indicate the obstetric fistula results in a combined set of costs associated with delivery, repair, transportation, lost income, and companion expenses that are often limiting. Medical and non-medical ancillary costs such as food, medications, and water are not borne evenly among all fistula care centers or camps due to funding shortages. Women in Uganda spend Ugandan Shilling 10,000 to 90,000 for two people for a single trip to a camp. Factors that influence women’s and families’ ability to cover costs of fistula care access include education and vocational skills, community savings mechanisms, available resources in repair centers, client counseling, and subsidized care and transportation. The concentration of women in poverty and the perceived and actual out of pocket costs associated with fistula repair speak to an inability to prioritize accessing fistula treatment over household expenditures. Innovative approaches to financial assistance, transport, information of the available repair centers, rehabilitation, and reintegration in overcoming cost barriers were recommended.

No end to cholera without basic water, sanitation and hygiene
Montgomery M; Jones M; Kabole I; et al: Bulletin of the World Health Organisation 96(66), doi: http://dx.doi.org/10.2471/BLT.18.213678, 2018

Safe water, sanitation and hygiene are crucial in protecting people from cholera. The oral cholera vaccine is perceived as an interim solution that can be deployed in advance of, or together with, investments in water sanitation and hygiene. Oral cholera vaccine comes at a cost. Efforts to improve water sanitation and hygiene, on the other hand, have a relatively high return: US$ 4.30 for every dollar invested in water and sanitation, in addition to prevention of most waterborne diseases and time saved from not having to fetch water. Furthermore, several water sanitation and hygiene interventions can be implemented quickly and cheaply, such as point-of-use water treatment and safe storage, community action to end open defecation, provision of soap and promotion of handwashing. The authors argue that the reasonable alternative would be to pursue both oral cholera vaccine and water sanitation and hygiene efforts in parallel as done in, for example, Zanzibar, the United Republic of Tanzania and in Zambia. They argue that three main actions need to be taken to ensure that such investments are prioritized as part of the renewed efforts to end cholera. First, when countries request oral cholera vaccine, they should engage in water sanitation and hygiene efforts. Second, efforts should be made to ensure that initiatives to strengthen health systems and provide quality care devote sufficient resources for providing and sustaining water and sanitation services, especially in cholera treatment centres. Third, external funders and partners must align behind national multisectoral cholera control plans, not simply invest in stand-alone interventions. A shared vision and unanimous agreement among Member States, partners and funders to prioritize broader social and environmental determinants of health, including water, sanitation and hygiene, is needed to end cholera. A proposed World Health Assembly resolution seeks to promote this consensus, ensure effective multisectoral collaborations and address cholera in tandem with other diarrhoeal diseases.