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British Journal of Pharmacology KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY COLLEGE OF HEALTH SCIENCES SCHOOL OF MEDICAL SCIENCES DEPARTMENT OF COMMUNITY HEALTH DISTRICT INEQUITIES IN HOUSEHOLD CHILD SURVIVAL PRACTICES IN THE UPPER WEST REGION OF GHANA EASMON OTUPIRI FEBRUARY 2012 DISTRICT INEQUITIES IN HOUSEHOLD CHILD SURVIVAL PRACTICES IN THE UPPER WEST REGION OF GHANA By Easmon Otupiri A thesis submitted to the Department of Community Health, Kwame Nkrumah University of Science and Technology in partial fulfillment of the requirements for the award of the degree DOCTOR OF PHILOSOPHY (COMMUNITY HEALTH) School of Medical Sciences College of Health Sciences FEBRUARY 2012 i DECLARATION The work described in this thesis was carried out at the Department of Community Health, KNUST-School of Medical Sciences. I declare that, except for references to other people’s work, which I have duly acknowledged, this thesis is original to me. This work has not been submitted either completely or in part for the award of any other degree in this or any other university. ……………………….. …………………………………. Easmon Otupiri Date …………………………. ……………………………….. Prof. Michelle J Hindin Date (Supervisor) …………………………… ………………………………. Rev. (Dr.) ENL Browne Date (Supervisor) ………………………….. ……………………………… Dr P Agyei-Baaffour Date (Head of Department) ii DEDICATION I dedicate this thesis to my parents (Mr William Otupiri and Mrs Comfort Otupiri), my wife (Joana) and children (Kwabena, Abena and Akosua) for all the encouragement you gave me to get this thesis completed. I love you very much. iii ACKNOWLEDEMENT I am very grateful to the Lord God Almighty who through His abundant mercy, endless grace and everlasting love made this work possible. My sincere thanks go to my supervisors: Prof. MJ Hindin (Johns Hopkins School of Public Health) and Rev. (Dr.) ENL Browne (Tamale); without you it would have been impossible to complete this work. Michelle I am particularly grateful for your diligence and encouragement. I will not forget the coaching in statistics that you and Prof. Joe Coresh (your husband) provided during my stay at Johns Hopkins. To the field staff and study participants in rural Upper West Region, I say a big thank you; your contribution may contribute to the ensuring that these life-saving interventions reach universal coverage in the Upper West Region and Ghana. The data entry clerks (Jane Ansere and Mavis Amankwah) and the data manager (Samuel Boateng) deserve my gratitude for all the hard work they put into data management process. This study was funded by UNICEF-Ghana and I duly acknowledge the support I received from the child health department (Dr. M Aliu and Dr. V Ankrah). To my colleagues at the Department of Community Health I say thanks for your support. I am equally thankful to The Bill and Melinda Gates Institute for Population and Reproductive Health at Johns Hopkins School of Public Health (JHSPH) for funding my stay in Baltimore. To God be the glory!!! iv ABSTRACT Worldwide, too many children under-five die needlessly but the greatest burden is in sub- Saharan Africa where in 2008, one-in-seven children died before the fifth birthday. Evidence shows that a set of 23 effective interventions could reduce child mortality by 66% if delivered at universal coverage (99%). Four of these interventions are capable of reducing the burden remarkably at universal coverage; three of these interventions do not require contact with the formal health sector. The children who are in greatest need of these life-saving practices do not get them. In Ghana, the worst place to live as a child under-five for the last two decades has been the Upper west Region; the 2008 GDHS reported a burden of 191 per 1000 live births for the region. Even though data on coverage of household practices for child survival growth and development are available at the regional level, the same cannot be said for data at the district and sub-district levels. Data at lower levels are poor, inconsistent and unreliable. National and regional data mask significant inequities within regions. We sought to determine whether the then eight districts in the Upper West Region differ in terms of the uptake of the four core household practices evidenced to be capable of reducing the under-five mortality burden by up to 41% even in resource-constrained settings such as the Upper West Region; the region is one of the poorest in Ghana. Additionally, we were interested in differences across the districts with reference to specific cofactors. We collected data from 2400 households (300 per district) using the methodology described by UNICEF in the 2005 Multiple-indicator Cluster Survey manual. The outcome variables were the four core household practices – exclusive breastfeeding, appropriate complementary feeding, insecticide bed net use and oral rehydration salt for v diarrhoea management – which together at universal coverage could considerably reduce under-five deaths. The cofactors we studied included: child characteristics (age, sex); maternal characteristics (age, level of education, ability to read and write English); husband characteristics (age, level of education, ability to read and write English) and household wealth. In the Upper West Region, the overall prevalence of the four-core household practices was: exclusive breastfeeding (23%), appropriate complementary feeding (22%), insecticide bed net use (68%) and oral rehydration salt (47%). Even after multivariate adjustment, statistically significant district differentials were observed for all outcome variables (p≤0.05). With reference to the cofactors studied the following relationships were observed even after multivariate adjustment: wealthy mothers were significantly less likely to have initiated breastfeeding within an hour of delivery (AOR=0.85, p-value≤0.001, 95%CI: 0.77-0.93); a mother’s ability to read and write English and her husband’s age were significantly associated with appropriate complementary feeding (AOR=2.22, p-value ≤0.01, 95%CI: 1.35-3.56 and AOR=1.31, p- value≤0.01, 95%CI:1.09-1.57 respectively); children under-five from wealthy homes were less likely to have slept under an insecticide-treated bed net the night preceding the survey (AOR=0.78, p-value ≤0.001, 95%CI: 0.72-0.85) and a mother’s age, her husband’s age and ability to read and write English, and household wealth were significant predictors of a mother’s ability to correctly prepare ORS. The study indicates important district inequities across the Upper West Region. Interventions should be evidence-based emphasizing district level differentials and recognizing the paradoxical effect of wealth. Further research could emphasize the cofactors studied, cultural practices, access to and utilization of health care facilities and family planning. vi TABLE OF CONTENTS DECLARATION ....................................................................................................................... II DEDICATION......................................................................................................................... III ACKNOWLEDEMENT .......................................................................................................... IV ABSTRACT............................................................................................................................... V LIST OF TABLES..................................................................................................................... X LIST OF FIGURES ................................................................................................................ XII ABBREVIATIONS/ACRONYMS ....................................................................................... XIII CHAPTER 1 1.0 INTRODUCTION ....................................................................................... 1 1.1 GENERAL INTRODUCTION .............................................................................................................. 1 1.2 PREAMBLE ................................................................................................................................... 1 1.2.1 Global efforts at improving child health ............................................................................... 9 1.2.2 Child survival in Ghana ..................................................................................................... 20 1.3 PROBLEM STATEMENT ................................................................................................................. 29 1.4 RATIONALE FOR THE STUDY ........................................................................................................ 33 1.5 CONCEPTUAL FRAMEWORK ......................................................................................................... 35 1.6 RESEARCH QUESTIONS ................................................................................................................ 43 1.7 AIMS, OBJECTIVES AND HYPOTHESES ............................................................................................ 44 1.7.1 Specific objectives and hypotheses ..................................................................................... 44 1.8 HEALTH PROFILE OF STUDY AREA ................................................................................................ 45 1.8.1 Regional health profile ...................................................................................................... 45 1.8.2 Location ..........................................................................................................................
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