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Background: Assistance during delivery by a skilled attendant is recommended as a means to reduce child and maternal mortality. Globally, higher levels of maternal education have been associated with better health behaviours at delivery. However, given that heads of households tend to be the decision makers regarding accessing healthcare, some educated mothers may find themselves prevented from accessing healthcare at the point of delivery.Methods: We examined the association between head of household education level and health seeking behaviours at delivery across a sample of 392 households. Chi-squared analysis and odds ratios were calculated to measure the strength of the relationship between no, some primary, or some secondary or higher education attained by the head of household and the presence or absence of a skilled birth attendant at that child’s birth, and whether the birth took place at a health facility.Results: Heads of household (n = 392) were predominantly male (93.4% [(90.9%, 95.8%), a = 0.05]). We found a significant difference in skilled birth attendance between heads of households with some primary education and heads of household with some secondary education or higher (χ2 (1) = 6.231, p <0.05) whereby those with secondary or higher education were significantly more likely to seek a skilled birth attendant (OR = 1.5,[1.1,2.1]). The difference in health centre delivery between heads of household with a primary education and heads of household with a secondary or higher education was also significant (χ2 (1) = 7.519, p <0.05). Those with secondary or higher education were significantly more likely to deliver in a health facility (OR = 1.6,[1.2,2.1]).Conclusions: The results of our analysis, which identified the vast majority of heads of households as men, suggests that education, or rather limited or a lack of education for the head of household, may be a barrier to women's use of health care in Uganda and therefore reinforces the need to increase educational access among male heads of households. Improving the rates of health centre deliveries and utilization of services provided by skilled health workers might lie, in part, in increasing overall education levels of heads of households, specifically the education of male heads of households. © 2013 Vallières et al.; licensee BioMed Central Ltd.
This paper first examines whether the education of the head of household (predominantly male and the key decision maker in Ugandan households) is associated with health seeking behaviours at time of delivery in Busia, Uganda. Where an association was found, we also further explore the strength of that association. The secondary data obtained for this paper were collected as part of a baseline assessment of maternal and child health in the sub-counties of Busitema, Sikuda, Lunyo, and Busiime, located in Uganda’s Busia District, during June and July of 2011. World Vision Ireland and World Vision Uganda conducted the baseline in preparation for the implementation of a community-based maternal and child health programme using community health workers to target changes in household health behaviour. Bordering Kenya to the east and Tanzania to the south and formally known as Tororo District, Busia District has an estimated population of approximately 287,800 inhabitants [30]. The baseline exercise employed a cross-sectional household survey, which was conducted across a sample of 400 households located in four sub-counties of Busia. A two-stage probability sampling method was used to obtain a sample of the population in each parameter. Village lists were obtained for the sub-counties of Busitema, Sikuda, Lunyo, and Busiime. The probability of a village being selected was set as proportional to the number of households within that village. All households therefore had an equal chance of being selected regardless of whether they contained the target population or not. In the second stage of sampling, village leaders led field teams to the village centre where a pen was spun to determine the field team’s walking direction. A random number generation table was subsequently used to decide which household was to be visited first. A total of 407 households, from 125 out of the possible 136 villages, were ultimately visited in the sample, 400 of which completed the questionnaire. Sample size was calculated assuming a confidence level of 95% (a = 0.05). The survey tool was adapted from the Ministry of Health’s (MOH) own village health team (VHT)/ICCM Register 2010 [31] and developed in consultation with the district health management team in Busia (Additional file 1). Though the questionnaire was printed in English, training was conducted in a mixture of English and Luganda. VHTs were permitted to conduct the interview in whichever language they felt best suited the household. The household was defined in terms of any people who were co-resident and shared common cooking arrangements, and were able to recognise one person as the head of household [32]. Participants in each household were asked to identify the HOH, and that individual’s most recently completed education level. Participants were then asked to identify all children under the age of 5 within that household and the child’s relation to the HOH. For each child, subsequent questions determined the location of their birth (at a health centre or elsewhere), as well as who was present at the time of birth: a skilled provider, unskilled provider such as a TBA, both, or neither. Aligned with Ugandan MOH policy, a skilled provider was defined as a “doctor, nurse, midwife, medical assistant, or clinical officer” [21]. To be considered for secondary analysis a household had to contain at least one child under the age of 60 months. Interviews were primarily conducted with the child’s primary caregiver. A primary caregiver was defined as the person who was, “primarily responsible for the health, safety and comfort of that child”. A total of 392 out of 400 de-identified households were included in the analysis. Informed written consent was obtained from all participants. If the participant was illiterate, signatures were obtained in the form of a fingerprint using an inkpad. Permission for the Centre for Global Health, Trinity College Dublin to use the de-identified baseline data for secondary analysis was obtained from both World Vision Ireland and World Vision Uganda and ethical approval was obtained from the Health Policy and Management/Centre for Global Health Research Ethics committee, Trinity College Dublin. Quantitative analysis was conducted using PASW Statistics 18 (Release Version 18.0.0) and SPSS Statistics 17 (Release Version 17.0.0). Delivery practices were statistically analyzed according to relevant demographic variables. Respondent’s level of education was recorded as the highest grade or year completed by that individual. For analysis, these were categorised as follows: no form of education; attained any level of primary education; or, attained any form of secondary or higher education. Both education levels and delivery practices were compared across age and gender to ensure comparability and to identify any possible confounders or effect modifiers. Descriptive tests and Chi-Square/Correlation analysis were used to demonstrate the effects of the independent variables on the probability of choosing a health centre facility for delivery, rather than remaining at home or outside a clinical setting for delivery. The effects of the independent variable on the probability of choosing assistance from a trained, skilled birth attendant versus opting for a traditional home delivery without trained assistance were also presented. Pearson Chi-Square tests were conducted to measure the significance of the relationship between the education level attained by the HOH and the presence of an SBA or TBA (or other unskilled birth attendant) at that child’s birth, as well as whether the birth took place at a health facility. Additional Chi-Square tests of independence were individually executed on each possible combination of the groups. Where a statistically significant relationship was found, odds ratios were calculated with the lower education level as reference. Analysis was first conducted for children who were labeled as biologically related to the HOH. Biologically related children included only sons and daughters of the HOH. This same analysis was subsequently conducted for all children who were either biologically linked or relatively linked to the HOH. Relative children included nieces, nephews, stepchildren, and grandchildren. All tests were conducted for 95% confidence with α = 0.05.
