Inequities in childhood anaemia at provincial borders in Mozambique: Cross-sectional study results from multilevel Bayesian analysis of 2018 National Malaria Indicator Survey

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Study Justification:
– The study aims to identify the determinants of anaemia among children in Mozambique and determine the inequities in anaemia prevalence across communities.
– Anaemia is a significant public health issue in Mozambique, particularly among children aged 6-59 months.
– Understanding the factors contributing to anaemia and its geographical distribution can inform targeted interventions and policies to reduce its prevalence.
Study Highlights:
– The study found that the mean prevalence of childhood anaemia in Mozambique was 77.7%, with Cabo Delgado province having the highest prevalence (86.2%) and Maputo province the lowest (70.2%).
– Children living in communities near provincial borders, such as the Niassa-Cabo Delgado-Nampula triprovincial border, Gaza-Inhambane border, Zambezia-Nampula border, as well as Manica and Inhambane provinces, had a higher risk of anaemia.
– Factors associated with anaemia included younger age, male gender, lack of mosquito net use, poverty, and living in female-headed households.
– The study highlights the importance of malaria prevention, income generation, community support for female-headed households, improved malaria control, capacity building for healthcare workers, and health education for mothers in reducing childhood anaemia.
Recommendations for Lay Readers:
– Implement interventions to prevent malaria, such as the use of bed nets, as it is a significant risk factor for anaemia.
– Support programs that generate income for households to alleviate poverty, which is associated with a higher risk of anaemia.
– Promote community support for households headed by women to address the vulnerability of children in these households.
– Strengthen malaria control efforts to reduce the burden of anaemia among children.
– Provide training and resources to healthcare workers to effectively manage severely anaemic children.
– Increase health education initiatives targeting mothers to improve their knowledge and practices related to anaemia prevention.
Recommendations for Policy Makers:
– Develop and implement policies that prioritize malaria prevention strategies, including the distribution of bed nets and other interventions.
– Allocate resources to programs that address poverty and income generation, as poverty is a significant determinant of childhood anaemia.
– Support initiatives that empower and provide resources to female-headed households to improve the health outcomes of children in these households.
– Strengthen malaria control programs through increased funding, capacity building, and improved coordination between relevant stakeholders.
– Invest in training and professional development opportunities for healthcare workers to enhance their ability to manage and treat severely anaemic children.
– Allocate resources for health education campaigns targeting mothers to raise awareness about anaemia prevention and management.
Key Role Players:
– Ministry of Health: Responsible for developing and implementing policies related to malaria prevention, poverty alleviation, and healthcare services.
– Non-governmental Organizations (NGOs): Involved in implementing interventions and programs related to malaria control, poverty reduction, and community support.
– Community Leaders: Engage in mobilizing communities, promoting health education, and facilitating the implementation of interventions.
– Healthcare Workers: Provide healthcare services, including diagnosis and treatment of anaemia, and play a crucial role in health education and capacity building.
Cost Items for Planning Recommendations:
– Procurement and distribution of bed nets for malaria prevention.
– Funding for income generation programs targeting households living in poverty.
– Resources for community support initiatives, such as training and capacity building for community leaders.
– Investment in malaria control programs, including surveillance, treatment, and prevention measures.
– Budget for training and professional development of healthcare workers.
– Allocation of funds for health education campaigns, including materials and outreach activities.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it presents the findings of a cross-sectional study conducted using a large sample size. The study used multilevel Bayesian analysis to identify determinants of childhood anaemia and determine the inequities in prevalence across communities in Mozambique. The study provides specific percentages and identifies key risk factors for anaemia. The abstract also suggests actionable steps to improve the situation, such as malaria prevention and interventions to generate income for households. To improve the evidence, it would be helpful to provide more details on the methodology used, including the sampling strategy and data collection procedures. Additionally, including information on the statistical significance of the findings would further strengthen the evidence.

Objectives This study aims to identify the child-level, maternal-level, household-level and community-level determinants of anaemia among children aged 6-59 months, and determine the inequities of anaemia prevalence across communities in Mozambique. Design Cross-sectional study. Setting Mozambique. Participants This study used data of a weighted population of 3946 children, 6-59 months, delivered by women between 15 and 49 years of age, from the 2018 Mozambique Malaria Indicator Survey. Primary outcome measure Child’s anaemic status, measured as altitude-adjusted haemoglobin concentration (in g/L); the severity of anaemia was categorised based on predefined threshold values. Multilevel Bayesian linear regressions identified key determinants of childhood anaemia. Based on data availability and policy implications, spatial analysis was used to determine geographical variation of anaemia at the community level and areas with higher risks. Results The mean prevalence of childhood anaemia was 77.7% (SD: 5.5%). Provincially, Cabo Delgado province (86.2%) had the highest prevalence, Maputo province (70.2%) the lowest. Children with excess risk were mostly found in communities that had proximity to provincial borders: Niassa-Cabo Delgado-Nampula triprovincial border, Gaza-Inhambane border, Zambezia-Nampula border and provinces of Manica and Inhambane. Children with anaemia tended to be younger, males and at risk of having malaria because they were not sleeping under mosquito nets. In addition, children from poor families relative to children from wealthier households and those living in female-headed households were prone to anaemia. Conclusion Findings from this study provide evidence that spatial inequities in childhood anaemia exist in Mozambique, mostly concentrated in the communities living close to the provincial borders. Anaemia among children could be effectively reduced through malaria prevention, for example, bed netting. Interventions are needed that generate income for households, increase community support for households headed by women, improve malaria control, build capacity of healthcare workers to manage severely anaemic children and health education for mothers.

Mozambique is a Southeastern African country that shares boundary with the Indian Ocean to the east, Tanzania to the north, Malawi and Zambia to the northwest, Zimbabwe to the west, and Eswatini and South Africa to the southwest. The country is divided into 10 provinces and a capital city (Maputo), which are further divided into 129 districts. The districts are subdivided into 405 administrative posts and then into local communities—the lowest geographical unit. According to 2017 census, Mozambique’s population was estimated at 29 million, with preponderance of young people—nearly half (46.6%) are under age 15 years.24 Almost 6 out of 10 Mozambicans reside in rural areas.25 According to the 2019 United Nations Development Programme Human Development report, Mozambique ranks 181 out of 189 countries in human development league table, and 72.5% of its population lives in poverty.26 This is a cross-sectional study that used child recode datafile and the global positioning system (GPS) dataset of the 2018 Mozambique MIS.27 The survey was conducted between March 2018 and June 2018 by the Moçambique Instituto Nacional de Saúde, in collaboration with ICF International Calverton, Maryland, USA, to provide national and subnational estimates of anaemia and malaria indicators for policy and programmatic purposes. The details of the methodology used for the survey has been published elsewhere.28 With a stratified two-stage sampling design, face-to-face standardised questionnaire interviews were conducted among women aged 15–49 years. Using probability proportional to size, the first stage of sampling involved selection of 224 clusters or enumeration areas (otherwise known as the primary sampling units (PSU)) from the 2007 General Population and Housing Census.28 Out of the 224 clusters, 58.9% were in rural areas, while the rest were in urban areas. The second stage involved systematic sampling of 6279 households. Each household was randomly selected from the household listing, with an average of 28 households per cluster. For this study, the clusters are referred to as the ‘communities’ because they are believed to comprise homogenous or kinship populations. Of the 6279 households, the response rate was 99%, while out of the 6290 eligible women identified, 6184 could be interviewed (response rate of 98.3%). With the consent of the parents/caregivers, blood samples were collected in a microcuvette from the heel (of children aged 6–11 months) or fingers (of the children aged 12–59 months) for Hb concentration estimation. After discarding the first drop of blood to avoid possible contamination, Hb concentration was estimated with the second drop, using an automatic haematology analyser (HemoCue 201+). For this study, a subpopulation of 3652 (weighted: 3946) singletons aged 6–59 months who were alive at the commencement of the survey and had Hb concentration results reported were analysed. This is a secondary analysis of data available online27 where the datasets are deidentified of the respondents’ personal information; hence, no ethical approval was required for this specific study. However, prior to the commencement of the primary survey, ethical clearances were obtained by the Demographic and Health Survey (DHS) team from National Committee for Bioethics in Health of Mozambique (Comité Nacional de Bioética para Saúde). Also, written informed consent was obtained from all mothers during the field work. Following registration and submission of research protocol, administrative access to the dataset was granted by the DHS team, USA. The survey data files were provided at no cost for academic research.28 Patient and public involvement was not possible in this study given it was based on an analysis of secondary data.

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

1. Mobile Health (mHealth) Solutions: Develop and implement mobile applications or SMS-based systems that provide pregnant women and new mothers with important health information, reminders for prenatal and postnatal care appointments, and access to teleconsultations with healthcare providers.

2. Community Health Workers: Train and deploy community health workers to provide education, support, and basic healthcare services to pregnant women and new mothers in remote or underserved areas. These workers can help identify and refer women at risk of anaemia for appropriate care.

3. Telemedicine: Establish telemedicine networks to connect healthcare providers in urban areas with pregnant women and new mothers in rural or remote areas. This would allow for remote consultations, diagnosis, and treatment, reducing the need for women to travel long distances for healthcare.

4. Maternal Health Vouchers: Implement a voucher system that provides pregnant women with access to essential maternal health services, such as antenatal care visits, skilled birth attendance, and postnatal care. This would help reduce financial barriers to accessing care.

5. Maternal Waiting Homes: Establish maternal waiting homes near healthcare facilities in rural areas. These homes would provide accommodation and support for pregnant women who need to travel long distances to reach a healthcare facility, ensuring they have a safe place to stay before giving birth.

6. Strengthening Health Systems: Invest in improving the overall healthcare infrastructure, including facilities, equipment, and healthcare workforce, to ensure that pregnant women have access to quality maternal health services.

7. Health Education and Awareness Campaigns: Develop and implement targeted health education campaigns to raise awareness about the importance of prenatal and postnatal care, proper nutrition, and malaria prevention among pregnant women and their families.

8. Integration of Services: Integrate maternal health services with other existing healthcare programs, such as malaria prevention and treatment, to provide comprehensive care for pregnant women and address multiple health needs simultaneously.

9. Public-Private Partnerships: Foster collaborations between the government, private sector, and non-profit organizations to leverage resources and expertise in improving access to maternal health services.

10. Data-driven Decision Making: Use data from surveys and research studies, such as the National Malaria Indicator Survey mentioned in the description, to inform evidence-based decision making and prioritize interventions to address inequities in maternal health access.

These innovations have the potential to improve access to maternal health services, reduce anaemia prevalence, and ultimately contribute to better maternal and child health outcomes in Mozambique.
AI Innovations Description
Based on the information provided, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Implement targeted interventions in communities near provincial borders: The study found that communities living close to provincial borders in Mozambique had higher prevalence of childhood anaemia. To address this inequity, innovative interventions can be developed and implemented specifically in these communities. These interventions can include targeted malaria prevention strategies, such as distributing bed nets and providing education on their proper use. Additionally, efforts can be made to increase access to healthcare services, including prenatal care and treatment for anaemia.

By focusing on communities near provincial borders, where the prevalence of childhood anaemia is highest, this innovation can help improve access to maternal health services and reduce the burden of anaemia among children. It is important to consider the specific needs and challenges of these communities in order to develop effective and sustainable interventions.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health in Mozambique:

1. Strengthen Malaria Prevention: Given the association between malaria and childhood anaemia, implementing effective malaria prevention strategies such as distributing insecticide-treated bed nets and promoting indoor residual spraying can help reduce the risk of anaemia among children.

2. Income Generation Programs: Introduce income generation programs targeted at poor households to alleviate poverty and improve access to healthcare services. These programs can include vocational training, microfinance initiatives, and support for small-scale entrepreneurship.

3. Support Female-Headed Households: Provide targeted support and resources to households headed by women, as they are more vulnerable to anaemia and face additional challenges in accessing healthcare. This can include financial assistance, skills training, and community support networks.

4. Strengthen Malaria Control: Enhance malaria control efforts through improved surveillance, early diagnosis, and prompt treatment of malaria cases. This can be achieved by training healthcare workers, ensuring the availability of antimalarial drugs, and promoting community awareness and engagement in malaria prevention and control.

5. Capacity Building for Healthcare Workers: Enhance the capacity of healthcare workers to effectively manage severely anaemic children. This can be achieved through training programs, workshops, and continuous professional development opportunities focused on anaemia management and related maternal health issues.

6. Health Education for Mothers: Implement health education programs targeting mothers and caregivers to raise awareness about the importance of proper nutrition, hygiene practices, and timely healthcare seeking for children. This can be done through community-based initiatives, mobile health clinics, and partnerships with local organizations.

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

1. Data Collection: Gather data on key indicators related to maternal health, such as maternal mortality rates, anaemia prevalence, healthcare utilization, and socio-economic factors. This data can be obtained from national surveys, health facilities, and other relevant sources.

2. Baseline Assessment: Conduct a baseline assessment to establish the current status of access to maternal health services and anaemia prevalence. This can involve analyzing existing data and conducting surveys or interviews with relevant stakeholders.

3. Modeling and Simulation: Develop a simulation model that incorporates the identified recommendations and their potential impact on access to maternal health. This can be done using statistical software or specialized simulation tools.

4. Parameter Estimation: Estimate the parameters of the simulation model based on available data and expert knowledge. This may involve conducting statistical analyses, literature reviews, and consultations with subject matter experts.

5. Scenario Analysis: Simulate different scenarios by varying the implementation levels of the recommendations. This can help assess the potential impact of each recommendation individually and in combination.

6. Impact Evaluation: Evaluate the simulated impact of the recommendations on improving access to maternal health by comparing the outcomes of different scenarios. This can include indicators such as maternal mortality rates, anaemia prevalence, healthcare utilization, and socio-economic indicators.

7. Sensitivity Analysis: Conduct sensitivity analysis to assess the robustness of the simulation results to changes in key parameters and assumptions. This can help identify the most influential factors and potential uncertainties in the simulation model.

8. Policy Recommendations: Based on the simulation results, provide evidence-based policy recommendations to stakeholders and decision-makers. These recommendations should prioritize the most effective and feasible interventions to improve access to maternal health in Mozambique.

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