Association of socioeconomic and behavioral factors with adult mortality: Analysis of data from verbal autopsy in Addis Ababa, Ethiopia

BMC Public Health, Volume 13, No. 1, Year 2013

Interprétation

Background: Changes in socioeconomic status, lifestyle and behavioral factors among the urban population in Ethiopia is resulting in a shift in the causes of mortality.We used verbal autopsy data from 2006 to 2009 to measure the association of socioeconomic and behavioral factors with causes of mortality in Addis Ababa, Ethiopia. Methods. A total of 49,309 deaths from burial surveillance were eligible for verbal autopsy for the years 2006 to 2009. Among these, 10% (4,931) were drawn randomly for verbal autopsy of which 91% (4,494) were adults of age ≥15 years. Verbal autopsies, used to identify causes of death and frequency of risk factors, were completed for 3,709 (83%) of the drawn sample. Results: According to the results of the verbal autopsy, non-communicable diseases caused 1,915 (51%) of the total adult deaths, while communicable diseases and injuries caused 1,566 (42%) and 233 (6%) of the deaths respectively.Overall, frequent alcohol (12%) and tobacco consumption (7%) were highly prevalent among the deceased individuals; both because of communicable diseases (HIV/AIDS and tuberculosis) as well as due to non-communicable diseases (malignancy, cardiovascular and chronic liver diseases). HIV/AIDS (AOR = 2.14, 95% CI [1.52-3.00], p < 0.001) and chronic liver diseases (AOR = 3.09, 95% CI [1.95-4.89], p < 0.001) were significantly associated with frequent alcohol consumption, while tuberculosis was associated with both frequent alcohol (AOR = 1.61, 95% CI [1.15-2.24], p = 0.005) and tobacco consumption (AOR = 1.67, 95% CI [1.13-2.47], p < 0.010). Having low educational status, being female and being within the age range of 25 to 44 years were positively associated with HIV/AIDS related mortality. Individuals aged 45 years and above were 3 to 6 times more likely to have died due to cardiovascular diseases compared with those within the 15 to 24 years age group. Conclusion: The findings from the analysis suggest that public health interventions targeting HIV/AIDS, tuberculosis, as well as non-communicable diseases need to consider behavioral factors related to alcohol, tobacco and khat consumption. We also recommend large scale national level studies to further assess the specific contributions of these risk factors to the burden of mortality in the country. © 2013 Misganaw et al.; licensee BioMed Central Ltd. This study is part of the Addis Ababa Mortality Surveillance Program (AAMSP) that uses the verbal autopsy method on adult mortality. As usable mortality data are lacking in Ethiopia to measure the impact of socioeconomic and behavioral factors on causes of mortality, it has been necessary to apply the verbal autopsy method on data from burial surveillance for such analysis. The AAMSP analyzes data from surveillance of burials in Addis Ababa to capture causes of adult deaths. The burial surveillance has been conducted since 2001 in all cemeteries under the city limit of Addis Ababa. Addis Ababa harbors 89 cemeteries (670 are church based, 9 are mosque based, while 10 are municipality owned cemeteries) [14]. The data used are for the period of September, 2006 to December, 2009. The burial surveillance is used as a sampling frame for the verbal autopsy procedure [15]. As cremation is not practiced in Addis Ababa, all burials of deaths are conducted at the above mentioned religious or municipality based cemeteries. Thus, in principle, the burial surveillance captures all deceased residents of Addis Ababa, although biases exist because residents may die and/or be buried outside the capital just as non-residents may be buried inside Addis Ababa. Some of these biases are mostly identified and corrected while others inevitably go unnoticed. The burials are registered by cemetery clerks who are well trained and regularly given annual refresher trainings. They report all deaths (n ≈ 18,000 per year) from cemeteries using structured forms. They collect the information from relatives or close friends during burial ceremonies. The information include: date of burial, age, name, sex, address, marital status, region of birth, ethnicity, religion, and a lay reported cause of death [15]. Adult deaths aged 15 years and above that were captured by the burial surveillance in 2007 were 18,013, making age specific death rate of 8.9 per 1000 for Addis Ababa. This figure is very close to the results of the census by the Ethiopian Statistical Authority for the same year (18,686 total deaths of aged 15 years with age specific death rate of 9.2 per 1000) [16]. Adult deaths captured by the burial surveillance in 2008 and 2009 were 17,984 and 18,154 respectively. Overall, the burial surveillance has identified 58,010 deaths during September 2006 to December 2009. Among these, 49,309 (85%) deaths were eligible for verbal autopsy procedures while the remaining could not be subject to such procedures because the burials were conducted without close relatives or friends who could provide information for the verbal autopsy interviews. Verbal Autopsy is interviewing the relatives or caregivers about the signs, symptoms, lifestyle behaviors and other characteristics experienced by the deceased before their death and the circumstances surrounding their death [17]. The verbal autopsy questionnaire was piloted and adapted to local situation from a standardized WHO and International Network of field sites with continuous Demographic Evaluation of Populations and their Health in developing countries (INDEPTH Network) verbal autopsy questionnaires [17,18]. Some modifications were made on the questionnaire for the purpose of enhancing local comprehension and ensuring cultural acceptability. This helped the program to obtain internationally comparable verbal autopsy data with the burial surveillance approach. The questionnaire consists of identification of respondents and care givers, identification of the deceased, death related information, signs and symptoms during illness and list of possible risk factors. Three data collectors, who are high school graduates with similar previous experiences, are deployed to visit each of the sampled households on average of two months after the death occurred. Data collectors are given extensive training on the objective of the program, on the questionnaire and on skills of interview. To maintain the quality of the data, annual refresher trainings, monthly supervisions and weekly meetings are conducted. After data entry and cleaning, 10% (4,931) of the deaths were randomly drawn using the Visual Basic Computer Program for verbal autopsy. Among the drawn sample, 91% (4,494) were adults of age 15 years and above, and 9% (437) were under 15 years of age. Verbal autopsies were completed among 3,709 (83%) of the adult deaths, while care givers were not willing to participate or not available with repeated visits for the rest of the cases. All completed verbal autopsies also underwent physician review before assigning underlying causes of death. Initially, two physicians reviewed every completed verbal autopsy interview blindly to assign possible cause/s of death. Any inconsistent case within the initial review is referred to a third physician. If the results of the three physicians are inconsistent, it would be referred to a panel discussion. In the few cases where it is difficult to arrive at a probable cause of death even after panel discussion, the cause of death will be labeled as “undetermined”. Finally, the International Classification of Diseases Version 10 (ICD-10) is used for standardization and for comparison with other studies. The adult verbal autopsy questionnaire for this study contains similar questions to that of the internationally standard verbal autopsy questionnaire on consumption of tobacco and alcohol [17]. In addition, khat chewing has been included as a locally important behavioral risk factors [19] with the globally identified risk factors of tobacco and alcohol consumption [1]. Since a system for surveillance of behavioral risk factors is lacking in Ethiopia, the verbal autopsy with burial surveillance can be considered as one alternative approach to examine the prevalence of behavioral risk factors and their associations with mortality. The questionnaire elicited information on the duration and frequency of tobacco and alcohol consumption as well as khat chewing. Alcohol consumption and khat chewing were categorized into: frequently in a week (at least four times a week) and occasionally; while tobacco use was categorized as frequently (at least once per day) and occasionally. Furthermore, there were categories for getting drunk with alcohol as frequently, once in a week and occasionally. The causes of deaths were analyzed in relation to demographic (age, sex and marital status) and socioeconomic (religion, educational and occupation) factors. The age of the deceased (in completed years) is categorized as: 15 to 24, 25 to 44, 45 to 54, 55 to 64, and 75 and older. Educational status is categorized as: no education, primary education, and secondary education, above secondary and others (traditional). Occupation is categorized as: professional (technical/managerial/sales/clerical/self-employed), manual labor (skilled/unskilled), housewives, unemployed, retired, and others (students, farmers). Double data entry has been implemented with Microsoft Access program followed by a thorough data cleaning using STATA driven .do files. For this analysis the age group 15 years and above was selected due to the fact that this group is economically productive and is highly affected by over-consumption of the substances at issue [20]. Using this age group for analysis is also considered appropriate since the burial surveillance method is prone to under-reporting child deaths [14,15,21]. Further analysis focused on identified leading causes of diseases in the study area such as cardiovascular diseases, malignancy, chronic liver diseases, HIV/AIDS and tuberculosis and presented meaningful findings [13]. The 2006 Global Burden of Diseases classification was adapted to classify causes of death in this study. The classification categorized diseases into: Group I (communicable diseases, maternal conditions and nutritional deficiencies); Group II (non-communicable causes); and Group III (injuries) [22]. Statistics such as frequencies and cross tabulations are applied to examine the distribution of each demographic, socio economic and behavioural risk factors. To compare proportions of behavioural risk factors by causes of death, the chi-squared test is used. Further, binary logistic regression was applied to examine the relationship between demographic, socioeconomic and behavioural risk factors with selected causes of death using the STATA software (Stata Corp LP, College Station, Texas). The protocol for the Addis Ababa Mortality Surveillance Program has been approved by the Institutional Review Board (IRB) of the College of Health Sciences, Addis Ababa University as well as the Ethics Committee of the Ethiopian Ministry of Science and Technology. Permission for conducting the study within the burial sites has also been obtained from the local authorities. Individual interviews are conducted after getting verbal informed consent from the immediate kin and caregivers of the deceased. At the program office, individual information is accessible only to the research team and is kept strictly confidential.

Résumé de l’IA

Study Justification:

– The study aims to measure the association of socioeconomic and behavioral factors with causes of mortality in Addis Ababa, Ethiopia.
– Changes in socioeconomic status, lifestyle, and behavioral factors among the urban population in Ethiopia are resulting in a shift in the causes of mortality.
– Usable mortality data are lacking in Ethiopia to measure the impact of socioeconomic and behavioral factors on causes of mortality.
– The study uses the verbal autopsy method on data from burial surveillance to capture causes of adult deaths.

Study Highlights:

– Non-communicable diseases caused 51% of total adult deaths, while communicable diseases and injuries caused 42% and 6% of deaths respectively.
– Frequent alcohol and tobacco consumption were highly prevalent among deceased individuals, contributing to both communicable and non-communicable diseases.
– HIV/AIDS and chronic liver diseases were significantly associated with frequent alcohol consumption, while tuberculosis was associated with both frequent alcohol and tobacco consumption.
– Low educational status, being female, and being within the age range of 25 to 44 years were positively associated with HIV/AIDS related mortality.
– Individuals aged 45 years and above were 3 to 6 times more likely to have died due to cardiovascular diseases compared to those within the 15 to 24 years age group.

Recommendations for Lay Reader and Policy Maker:

– Public health interventions should target HIV/AIDS, tuberculosis, and non-communicable diseases, taking into consideration behavioral factors related to alcohol, tobacco, and khat consumption.
– Large-scale national level studies are recommended to further assess the specific contributions of these risk factors to the burden of mortality in the country.

Key Role Players:

– Researchers and scientists in the field of public health and epidemiology.
– Government officials and policymakers in Ethiopia.
– Healthcare professionals and organizations involved in public health interventions.
– Community leaders and organizations working on health promotion and education.

Cost Items for Planning Recommendations:

– Research funding for large-scale national level studies.
– Budget for public health interventions targeting HIV/AIDS, tuberculosis, and non-communicable diseases.
– Resources for health promotion and education campaigns.
– Training and capacity building for healthcare professionals and community leaders.
– Monitoring and evaluation costs for assessing the impact of interventions.

Force de la preuve

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study used verbal autopsy data from a large sample size and analyzed the association of socioeconomic and behavioral factors with causes of mortality in Addis Ababa, Ethiopia. The study found significant associations between frequent alcohol and tobacco consumption and certain diseases. However, the study is limited to a specific population and may not be generalizable to other settings. To improve the strength of the evidence, future studies could include a more diverse population and use a combination of verbal autopsy and other data collection methods.

Abstrait

This study is part of the Addis Ababa Mortality Surveillance Program (AAMSP) that uses the verbal autopsy method on adult mortality. As usable mortality data are lacking in Ethiopia to measure the impact of socioeconomic and behavioral factors on causes of mortality, it has been necessary to apply the verbal autopsy method on data from burial surveillance for such analysis. The AAMSP analyzes data from surveillance of burials in Addis Ababa to capture causes of adult deaths. The burial surveillance has been conducted since 2001 in all cemeteries under the city limit of Addis Ababa. Addis Ababa harbors 89 cemeteries (670 are church based, 9 are mosque based, while 10 are municipality owned cemeteries) [14]. The data used are for the period of September, 2006 to December, 2009. The burial surveillance is used as a sampling frame for the verbal autopsy procedure [15]. As cremation is not practiced in Addis Ababa, all burials of deaths are conducted at the above mentioned religious or municipality based cemeteries. Thus, in principle, the burial surveillance captures all deceased residents of Addis Ababa, although biases exist because residents may die and/or be buried outside the capital just as non-residents may be buried inside Addis Ababa. Some of these biases are mostly identified and corrected while others inevitably go unnoticed. The burials are registered by cemetery clerks who are well trained and regularly given annual refresher trainings. They report all deaths (n ≈ 18,000 per year) from cemeteries using structured forms. They collect the information from relatives or close friends during burial ceremonies. The information include: date of burial, age, name, sex, address, marital status, region of birth, ethnicity, religion, and a lay reported cause of death [15]. Adult deaths aged 15 years and above that were captured by the burial surveillance in 2007 were 18,013, making age specific death rate of 8.9 per 1000 for Addis Ababa. This figure is very close to the results of the census by the Ethiopian Statistical Authority for the same year (18,686 total deaths of aged 15 years with age specific death rate of 9.2 per 1000) [16]. Adult deaths captured by the burial surveillance in 2008 and 2009 were 17,984 and 18,154 respectively. Overall, the burial surveillance has identified 58,010 deaths during September 2006 to December 2009. Among these, 49,309 (85%) deaths were eligible for verbal autopsy procedures while the remaining could not be subject to such procedures because the burials were conducted without close relatives or friends who could provide information for the verbal autopsy interviews. Verbal Autopsy is interviewing the relatives or caregivers about the signs, symptoms, lifestyle behaviors and other characteristics experienced by the deceased before their death and the circumstances surrounding their death [17]. The verbal autopsy questionnaire was piloted and adapted to local situation from a standardized WHO and International Network of field sites with continuous Demographic Evaluation of Populations and their Health in developing countries (INDEPTH Network) verbal autopsy questionnaires [17,18]. Some modifications were made on the questionnaire for the purpose of enhancing local comprehension and ensuring cultural acceptability. This helped the program to obtain internationally comparable verbal autopsy data with the burial surveillance approach. The questionnaire consists of identification of respondents and care givers, identification of the deceased, death related information, signs and symptoms during illness and list of possible risk factors. Three data collectors, who are high school graduates with similar previous experiences, are deployed to visit each of the sampled households on average of two months after the death occurred. Data collectors are given extensive training on the objective of the program, on the questionnaire and on skills of interview. To maintain the quality of the data, annual refresher trainings, monthly supervisions and weekly meetings are conducted. After data entry and cleaning, 10% (4,931) of the deaths were randomly drawn using the Visual Basic Computer Program for verbal autopsy. Among the drawn sample, 91% (4,494) were adults of age 15 years and above, and 9% (437) were under 15 years of age. Verbal autopsies were completed among 3,709 (83%) of the adult deaths, while care givers were not willing to participate or not available with repeated visits for the rest of the cases. All completed verbal autopsies also underwent physician review before assigning underlying causes of death. Initially, two physicians reviewed every completed verbal autopsy interview blindly to assign possible cause/s of death. Any inconsistent case within the initial review is referred to a third physician. If the results of the three physicians are inconsistent, it would be referred to a panel discussion. In the few cases where it is difficult to arrive at a probable cause of death even after panel discussion, the cause of death will be labeled as “undetermined”. Finally, the International Classification of Diseases Version 10 (ICD-10) is used for standardization and for comparison with other studies. The adult verbal autopsy questionnaire for this study contains similar questions to that of the internationally standard verbal autopsy questionnaire on consumption of tobacco and alcohol [17]. In addition, khat chewing has been included as a locally important behavioral risk factors [19] with the globally identified risk factors of tobacco and alcohol consumption [1]. Since a system for surveillance of behavioral risk factors is lacking in Ethiopia, the verbal autopsy with burial surveillance can be considered as one alternative approach to examine the prevalence of behavioral risk factors and their associations with mortality. The questionnaire elicited information on the duration and frequency of tobacco and alcohol consumption as well as khat chewing. Alcohol consumption and khat chewing were categorized into: frequently in a week (at least four times a week) and occasionally; while tobacco use was categorized as frequently (at least once per day) and occasionally. Furthermore, there were categories for getting drunk with alcohol as frequently, once in a week and occasionally. The causes of deaths were analyzed in relation to demographic (age, sex and marital status) and socioeconomic (religion, educational and occupation) factors. The age of the deceased (in completed years) is categorized as: 15 to 24, 25 to 44, 45 to 54, 55 to 64, and 75 and older. Educational status is categorized as: no education, primary education, and secondary education, above secondary and others (traditional). Occupation is categorized as: professional (technical/managerial/sales/clerical/self-employed), manual labor (skilled/unskilled), housewives, unemployed, retired, and others (students, farmers). Double data entry has been implemented with Microsoft Access program followed by a thorough data cleaning using STATA driven .do files. For this analysis the age group 15 years and above was selected due to the fact that this group is economically productive and is highly affected by over-consumption of the substances at issue [20]. Using this age group for analysis is also considered appropriate since the burial surveillance method is prone to under-reporting child deaths [14,15,21]. Further analysis focused on identified leading causes of diseases in the study area such as cardiovascular diseases, malignancy, chronic liver diseases, HIV/AIDS and tuberculosis and presented meaningful findings [13]. The 2006 Global Burden of Diseases classification was adapted to classify causes of death in this study. The classification categorized diseases into: Group I (communicable diseases, maternal conditions and nutritional deficiencies); Group II (non-communicable causes); and Group III (injuries) [22]. Statistics such as frequencies and cross tabulations are applied to examine the distribution of each demographic, socio economic and behavioural risk factors. To compare proportions of behavioural risk factors by causes of death, the chi-squared test is used. Further, binary logistic regression was applied to examine the relationship between demographic, socioeconomic and behavioural risk factors with selected causes of death using the STATA software (Stata Corp LP, College Station, Texas). The protocol for the Addis Ababa Mortality Surveillance Program has been approved by the Institutional Review Board (IRB) of the College of Health Sciences, Addis Ababa University as well as the Ethics Committee of the Ethiopian Ministry of Science and Technology. Permission for conducting the study within the burial sites has also been obtained from the local authorities. Individual interviews are conducted after getting verbal informed consent from the immediate kin and caregivers of the deceased. At the program office, individual information is accessible only to the research team and is kept strictly confidential.

Matériaux

N/A

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide pregnant women with access to information about prenatal care, nutrition, and common pregnancy complications. These apps can also send reminders for prenatal appointments and provide access to telemedicine consultations.

2. Community Health Workers: Train and deploy community health workers to provide education and support to pregnant women in rural areas. These workers can conduct home visits, provide basic prenatal care, and refer women to healthcare facilities for more specialized care.

3. Telemedicine: Establish telemedicine networks to connect pregnant women in remote areas with healthcare providers. This allows women to receive prenatal consultations and advice without having to travel long distances to a healthcare facility.

4. Maternal Health Vouchers: Implement a voucher system that provides pregnant women with access to essential maternal health services, such as prenatal care, delivery, and postnatal care. These vouchers can be distributed to women in low-income communities to ensure they can afford and access quality care.

5. Maternal Waiting Homes: Establish maternal waiting homes near healthcare facilities in rural areas. These homes provide a safe and comfortable place for pregnant women to stay during the final weeks of pregnancy, ensuring they are close to a healthcare facility when it is time to give birth.

6. Transportation Support: Develop transportation programs that provide pregnant women with affordable and reliable transportation to healthcare facilities for prenatal care and delivery. This can include subsidized transportation services or partnerships with local transportation providers.

7. Maternal Health Education Campaigns: Launch targeted education campaigns to raise awareness about the importance of prenatal care, nutrition, and safe delivery practices. These campaigns can use various media channels, including radio, television, and community outreach programs.

8. Maternal Health Hotlines: Establish toll-free hotlines staffed by trained healthcare professionals who can provide information and support to pregnant women. These hotlines can address common concerns, provide guidance on prenatal care, and connect women with healthcare services.

9. Maternal Health Clinics: Set up dedicated maternal health clinics in underserved areas to provide comprehensive prenatal care, delivery services, and postnatal care. These clinics can be staffed by skilled healthcare providers and equipped with necessary medical equipment.

10. Partnerships with Traditional Birth Attendants: Collaborate with traditional birth attendants to improve their skills and knowledge on safe delivery practices. This partnership can help ensure that women who choose to deliver at home have access to trained attendants who can provide safe and hygienic care.

It is important to note that these recommendations are based on the information provided and may need to be adapted to the specific context and resources available in Ethiopia.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health would be to integrate maternal health services with the existing Addis Ababa Mortality Surveillance Program (AAMSP). This integration would allow for the collection of data on maternal deaths and causes of maternal mortality, which can help identify areas for improvement and inform targeted interventions.

Specifically, the integration could involve the following steps:

1. Adapt the verbal autopsy questionnaire used in the AAMSP to include questions specifically related to maternal health, such as antenatal care utilization, delivery practices, and postnatal care.

2. Train data collectors in the AAMSP to conduct interviews with relatives or caregivers of deceased women of reproductive age to gather information on maternal deaths and associated factors.

3. Include maternal health experts in the physician review process to accurately assign underlying causes of maternal deaths.

4. Analyze the collected data to identify patterns and trends in maternal mortality, as well as the socioeconomic and behavioral factors associated with maternal deaths.

5. Use the findings to inform the development and implementation of targeted interventions to improve access to maternal health services, address behavioral risk factors, and reduce maternal mortality.

By integrating maternal health services into the existing AAMSP, policymakers and healthcare providers can gain valuable insights into the factors contributing to maternal mortality in Addis Ababa. This information can guide evidence-based interventions to improve access to maternal health services and ultimately reduce maternal deaths in the region.

AI Innovations Methodology

Based on the information provided, here are some potential recommendations for improving access to maternal health:

1. Increase awareness and education: Implement comprehensive education programs to raise awareness about maternal health issues, including the importance of prenatal care, safe delivery practices, and postnatal care. This can be done through community health workers, schools, and media campaigns.

2. Strengthen healthcare infrastructure: Invest in improving healthcare facilities, particularly in rural areas where access to maternal health services is limited. This includes building and equipping health centers, training healthcare providers, and ensuring the availability of essential medical supplies and equipment.

3. Expand access to skilled birth attendants: Train and deploy more skilled birth attendants, such as midwives and nurses, especially in underserved areas. This can be done through scholarships and incentives to encourage healthcare professionals to work in remote areas.

4. Improve transportation and referral systems: Develop and strengthen transportation networks to ensure that pregnant women can easily access healthcare facilities. This may involve providing ambulances or other means of transportation for emergency cases and establishing referral systems to ensure timely access to specialized care.

5. Enhance community engagement: Involve communities in the planning and implementation of maternal health programs. This can be done through community health committees, which can help identify barriers to access and develop strategies to overcome them.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define indicators: Identify key indicators to measure the impact of the recommendations, such as the number of women receiving prenatal care, the percentage of deliveries attended by skilled birth attendants, and maternal mortality rates.

2. Collect baseline data: Gather data on the current status of maternal health access, including the number of healthcare facilities, the availability of skilled birth attendants, and the utilization of maternal health services.

3. Develop a simulation model: Create a simulation model that incorporates the recommendations and their potential impact on the identified indicators. This model should consider factors such as population size, geographical distribution, and existing healthcare infrastructure.

4. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to estimate the potential impact of the recommendations. This can be done by adjusting the parameters related to the recommendations, such as the number of healthcare facilities or the availability of skilled birth attendants.

5. Analyze results: Analyze the simulation results to assess the potential impact of the recommendations on improving access to maternal health. This may involve comparing the simulated outcomes with the baseline data and identifying areas of improvement.

6. Refine and validate the model: Refine the simulation model based on the analysis of the results and validate it using additional data or expert input. This will help ensure the accuracy and reliability of the simulation.

7. Communicate findings and make recommendations: Present the findings of the simulation study, including the estimated impact of the recommendations, to relevant stakeholders and decision-makers. Use this information to inform policy and programmatic decisions aimed at improving access to maternal health.

Auteur

Dima Health

Statistics:

Citations: 10

Identifiers:

DOI: 10.1186/1471-2458-13-634

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Social Determinants, Substance Abuse, Technology and Innovations, Violence and Injury

Study Countries:

Ethiopia

Study Design:

Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female

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