Socioeconomic development,medical care,and nutrition as determinants of infant mortality in less‐developed countries

Abstract

Using data for sixty less‐developed countries, we constructed a causal model in which medical care, nutrition, status of women, and socioeconomic development are examined as determinants of infant mortality. Social and economic development are treated as exogenous variables; medical care, nutrition, and status of women are viewed as variables endogenous to the model. The model is tested by maximum likelihood methods. Results indicate that good nutrition and the presence of informally trained health care personnel, i.e., midwives, are more significantly related to low rates of infant mortality than are the employment status of women and the presence of formally trained health care personnel such as physicians and nurses. The general level of social and economic development conditions these relationships.     

Investigating associations between COVID-19 mortality and population-level health and socioeconomic indicators in the United States: A modeling study

BackgroundWith the availability of multiple Coronavirus Disease 2019 (COVID-19) vaccines and the predicted shortages in supply for the near future, it is necessary to allocate vaccines in a manner that minimizes severe outcomes, particularly deaths. To date, vaccination strategies in the United States have focused on individual characteristics such as age and occupation. Here, we assess the utility of population-level health and socioeconomic indicators as additional criteria for geographical allocation of vaccines.Methods and findingsCounty-level estimates of 14 indicators associated with COVID-19 mortality were extracted from public data sources. Effect estimates of the individual indicators were calculated with univariate models. Presence of spatial autocorrelation was established using Moran’s I statistic. Spatial simultaneous autoregressive (SAR) models that account for spatial autocorrelation in response and predictors were used to assess (i) the proportion of variance in county-level COVID-19 mortality that can explained by identified health/socioeconomic indicators (R²); and (ii) effect estimates of each predictor.Adjusting for case rates, the selected indicators individually explain 24%–29% of the variability in mortality. Prevalence of chronic kidney disease and proportion of population residing in nursing homes have the highest R². Mortality is estimated to increase by 43 per thousand residents (95% CI: 37–49; p < 0.001) with a 1% increase in the prevalence of chronic kidney disease and by 39 deaths per thousand (95% CI: 34–44; p < 0.001) with 1% increase in population living in nursing homes. SAR models using multiple health/socioeconomic indicators explain 43% of the variability in COVID-19 mortality in US counties, adjusting for case rates. R² was found to be not sensitive to the choice of SAR model form. Study limitations include the use of mortality rates that are not age standardized, a spatial adjacency matrix that does not capture human flows among counties, and insufficient accounting for interaction among predictors.ConclusionsSignificant spatial autocorrelation exists in COVID-19 mortality in the US, and population health/socioeconomic indicators account for a considerable variability in county-level mortality. In the context of vaccine rollout in the US and globally, national and subnational estimates of burden of disease could inform optimal geographical allocation of vaccines.

Sasikiran Kandula and Jeffrey Shaman study population health and COVID-19 mortality in the United States.     

A Review of “Maritime Power and the Law of the Sea: Expeditionary Operations in World Politics”

Abstract

The purpose of the London Dumping Convention (LDC) is the protection of the marine environment including its seabed and subsoil. The preamble, articles, and annexes of the LDC make clear that the Convention must be interpreted in a manner which ensures that this responsibility is met. As a partial response to that mandate, the LDC prohibits the dumping at sea of certain wastes, including high‐level radioactive wastes. Disposal of high‐level wastes in seabed sediments is the subject of ongoing technical, environmental, and engineering feasibility studies by several countries. In the LDC's definition of dumping, the phrase “disposal at sea”; could be interpreted narrowly to mean the final resting place of wastes—with seabed disposal excluded from coverage because those wastes are not in direct contact with “marine waters.”; Given the LDC's object and purpose, though, the only harmonious and reasonable interpretation is that which defines “disposal at sea”; to mean the place where the dumping activities occur. Other international agreements also support this object and purpose‐based interpretation which concludes that seabed disposal is covered and prohibited. In addition, this approach is preferred because it contributes to the continued effectiveness of the LDC.     

Development and childlessness in the states and territories of Brazil

Abstract

This article provides an analytical account of the variability in and correlates of Brazil's childlessness rates. Following from the socioeconomic development model, which suggests that involuntary childlessness predominates among developing countries and voluntary childlessness among developed countries, this paper examines the extent to which levels of development are related to age‐specific rates of childlessness in the states and territories of Brazil. We find both variation within the age‐specific childlessness rates and important associations between measures of economic development in 1970 and the rates of childlessness in 1980. Moreover, childlessness in Brazil tends to be more voluntary than involuntary, particularly among the younger women in the more modernized subregions of the country.     

Testing and clarifying a macro model of socioeconomic change and fertility

This study examines human reproduction and its causal links to the socioeconomic conditions of society within the framework of the demographic transition. A theoretical fertility model for 100 countries -- 28 more developed countries (MDCs) and 72 less developed countries (LDCs) -- is subjected to path analysis. Findings for the 100 countries were mainly a function of the LDCs. Stronger support was found in the LDCs for the indirect fertility-inhibiting effect of economic development than for its fertility-promoting effect. This indirect effect was by far the most important cause of fertility decline, although there were smaller positive direct effects of economic development and government attitudes towards family planning. When education/literacy was controlled, economic development became a negative, but insignificant, influence on fertility, and the effect of government attitudes toward family planning exhibited no effect on fertility. These findings suggest strongly that improvement of education and literacy may be an answer to fertility control. Changes in health service and infant mortality seem natural results of the betterment of education and literacy. This study reconciles the 2 distinct views as to whether fertility increases or remains stable and high while mortality declines during early demographic transition. Both offer valid explanations for the transition in LDCs. Results for the LDCs are compared with those for the MDCs, and policy implications are discussed.     

Structural determinants of child mortality in sub‐Saharan Africa: A cross‐national study of economic and social influences from 1970 to 1997

Abstract

This cross‐national study seeks to understand the lagging child mortality declines in sub‐Saharan Africa by using World Bank data to investigate social and economic factors at three points in time: 1970, 1985, and 1997. Women's education, foreign debt‐to‐export ratio, and GNP per capita are among the strongest correlates of under five mortality over time. Cross‐sectional and longitudinal results suggest that female education is the best overall predictor of child mortality. Average national income does not emerge as a strong predictor, particularly since 1985. Increasing levels of foreign debt are associated with a substantial excess mortality burden. In 1997, the effect of adult HIV prevalence on child mortality was moderate and statistically significant. The study concludes that, although future gains in social factors such as female education will likely be beneficial, without simultaneously addressing high levels of foreign debt and high HIV prevalence, it may be difficult to improve child mortality rates across sub‐Saharan Africa.     

Life expectancy in less developed countries: socioeconomic development or public health?

Various studies have enquired into the influence of socioeconomic development or public health measures on life expectancies in less developed countries. Analysis of the effect of these two groups of factors upon life expectancy, using data for 95 less developed countries, indicates that mortality is primarily influenced by such socioeconomic development measures as urbanization, industrialization, and education, and secondarily by such public health measures as access to safe water, physicians, and adequate nutrition.     

The relationship between socioeconomic status and infant mortality in metropolitan Ohio, 1999–2001

Abstract

Empirical evidence has consistently documented the direct relationship between infant mortality and socioeconomic inequality in the United States and numerous other countries. While the majority of these studies reveal an inverse relationship between socioeconomic level and infant mortality, not even this finding is free from disagreement. Furthermore, the specific nature and magnitude of this relationship has varied over time.

This study will examine the relationship between socioeconomic status and infant mortality in metropolitan Ohio by using birth and infant death data centered on the 2000 Census. The analyses presented herein will describe and analyze the relationship between infant mortality and socioeconomic status in metropolitan Ohio in the year 2000. The key finding is that in spite of remarkable declines in infant mortality during the past several decades, most notably in neonatal mortality, there continues to be a pronounced inverse association between the infant death rate and the economic status of a population.     

The influence of early conditions on health status among elderly Puerto Ricans

Abstract

The demographic origins of aging in Puerto Rican and other Latin American and Caribbean (LAC) countries may have important implications for the profile of health status and mortality of elderly people. For this article we tested a general conjecture about the relation between early childhood conditions and adult health status among Puerto Rican elderly using a rich data set recently collected through an island‐wide survey (N=4,293). We examined the association between markers of early nutritional status, self‐reports of health and on socioeconomic conditions during early childhood, and the prevalence of 3 conditions during adult ages: obesity, diabetes, and cardiovascular diseases. Although we found that obesity and diabetes are associated with markers of early malnutrition, that heart disease is associated with early deprivations and selected early childhood conditions, the evidence we were able to tease out from the data provides only fragile support for the conjecture.     

Stagnant Neonatal Mortality and Persistent Health Inequality in Middle-Income Countries: A Case Study of the Philippines

Background

The probability of survival through childhood continues to be unequal in middle-income countries. This study uses data from the Philippines to assess trends in the prevalence and distribution of child mortality and to evaluate the country’s socioeconomic-related child health inequality.

Methodology

Using data from four Demographic and Health Surveys we estimated levels and trends of neonatal, infant, and under-five mortality from 1990 to 2007. Mortality estimates at national and subnational levels were produced using both direct and indirect methods. Concentration indices were computed to measure child health inequality by wealth status. Multivariate regression analyses were used to assess the contribution of interventions and socioeconomic factors to wealth-related inequality.

Findings

Despite substantial reductions in national under-five and infant mortality rates in the early 1990s, the rates of declines have slowed in recent years and neonatal mortality rates remain stubbornly high. Substantial variations across urban-rural, regional, and wealth equity-markers are evident, and suggest that the gaps between the best and worst performing sub-populations will either be maintained or widen in the future. Of the variables tested, recent wealth-related inequalities are found to be strongly associated with social factors (e.g. maternal education), regional location, and access to health services, such as facility-based delivery.

Conclusion

The Philippines has achieved substantial progress towards Millennium Development Goal 4, but this success masks substantial inequalities and stagnating neonatal mortality trends. This analysis supports a focus on health interventions of high quality – that is, not just facility-based delivery, but delivery by trained staff at well-functioning facilities and supported by a strong referral system – to re-start the long term decline in neonatal mortality and to reduce persistent within-country inequalities in child health.     

Assessing Progress towards Public Health,Human Rights,and International Development Goals Using Frontier Analysis

Indicators to measure progress towards achieving public health, human rights, and international development targets, such as 100% access to improved drinking water or zero maternal mortality ratio, generally focus on status (i.e., level of attainment or coverage) or trends in status (i.e., rates of change). However, these indicators do not account for different levels of development that countries experience, thus making it difficult to compare progress between countries. We describe a recently developed new use of frontier analysis and apply this method to calculate country performance indices in three areas: maternal mortality ratio, poverty headcount ratio, and primary school completion rate. Frontier analysis is used to identify the maximum achievable rates of change, defined by the historically best-performing countries, as a function of coverage level. Performance indices are calculated by comparing a country’s rate of change against the maximum achievable rate at the same coverage level. A country’s performance can be positive or negative, corresponding to progression or regression, respectively. The calculated performance indices allow countries to be compared against each other regardless of whether they have only begun to make progress or whether they have almost achieved the target. This paper is the first to use frontier analysis to determine the maximum achievable rates as a function of coverage level and to calculate performance indices for public health, human rights, and international development indicators. The method can be applied to multiple fields and settings, for example health targets such as cessation in smoking or specific vaccine immunizations, and offers both a new approach to analyze existing data and a new data source for consideration when assessing progress achieved.     

Narrowing sex differentials in life expectancy in the industrialized world: Early 1970's to early 1990's

Abstract

Between the early 1970's and 1990's, twelve industrialized nations experienced for the first time a narrowing of their sex differences in life expectancy at age zero. In another set of countries, the differential has not yet reached a stage of convergence, although in some of these nations the female advantage appears to be increasing at a slower pace than ever before. We discuss the demographic and epidemiologic conditions for this new and largely unanticipated trend, as well as its applied and theoretical implications in the context of the following questions: (1) Is the observed change a function of males’ faster pace of gains in life expectancy since the early 1970s? (2) What is the relationship between country differences in socioeconomic development (as measured by GNP) and the degree of convergence in the sex gap in average length of life? (3) What is the degree of association between temporal change in age‐sex specific death rates and change in the sex gap in life expectancy over the twenty‐year interval between the early 1970s and early 1990s? Our results indicate that where some convergence has taken place, in relation to women, men have experienced more rapid gains in survival; the higher a nation's level of social and economic development, the greater the amount of convergence in male and female life expectancies. The most pronounced age‐specific association with the changing sex gap in longevity is that of ages 25–59, where the greater reductions in male mortality, as compared to that for females, contributed to a significant portion of the observed convergence in life expectancy across industrialized nations.     

The Link between Inequality and Population Health in Low and Middle Income Countries: Policy Myth or Social Reality?

An influential policy idea states that reducing inequality is beneficial for improving health in the low and middle income countries (LMICs). Our study provides an empirical test of this idea: we utilized data collected by the Demographic and Health Surveys between 2000 and 2011 in as much as 52 LMICs, and we examined the relationship between household wealth inequality and two health outcomes: anemia status (of the children and their mothers) and the women'' experience of child mortality. Based on multi-level analyses, we found that higher levels of household wealth inequality related to worse health, but this effect was strongly reduced when we took into account the level of individuals'' wealth. However, even after accounting for the differences between individuals in terms of household wealth and other characteristics, in those LMICs with higher household wealth inequality more women experienced child mortality and more children were tested with anemia. This effect was partially mediated by the country''s level and coverage of the health services and infrastructure. Furthermore, we found higher inequality to be related to a larger health gap between the poor and the rich in only one of the three examined samples. We conclude that an effective way to improve the health in the LMICs is to increase the wealth among the poor, which in turn also would lead to lower overall inequality and potential investments in public health infrastructure and services.     

The Matthew effect in health development.

A study was conducted examining the paradox that populations with a poor standard of health seem to achieve only meagre improvements over time, whereas those with a good standard of health seem to show continual, substantial improvement. The health states of 122 nations were measured by reference to their infant mortality in 1965 and the changes that occurred over the next 20 years. Countries with low infant mortality in 1965 (for example, Japan and East Germany) achieved substantial, further declines over the 20 years, whereas in countries such as Rwanda and Ethiopia infant mortality hardly declined at all or even increased (Ethiopia 165/1000 to 168/1000). In 48 countries for which data were available there was a close link between the change in health state of a people and the ratio of government expenditure on health and defence. As the ratio increased in favour of defence, so the improvement in health state of a people declined; the reverse was also true. At the primary care level disparity in uptake of care both among and within communities was associated with literacy and socioeconomic state, services inadvertently being aimed at those sections most likely to benefit. The forces that act to produce this setting of unequal care must be checked at both national and primary levels if we are to have "Health for All by the Year 2000."     

Profile of cancer in the Eastern Mediterranean region: The need for action

BackgroundMany countries in the Eastern Mediterranean region (EMR) are undergoing marked demographic and socioeconomic transitions that are increasing the cancer burden in region. We sought to examine the national cancer incidence and mortality profiles as a support to regional cancer control planning in the EMR.MethodsGLOBOCAN 2012 data were used to estimate cancer incidence and mortality by country, cancer type, sex and age in 22 EMR countries. We calculated age-standardized incidence and mortality rates (per 100,000) using direct method of standardization.ResultsThe cancer incidence and mortality rates vary considerably between countries in the EMR. Incidence rates were highest in Lebanon (204 and 193 per 100,000 in males and females, respectively). Mortality rates were highest in Lebanon (119) and Egypt (121) among males and in Somalia (117) among females. The profile of common cancers differs substantially by sex. For females, breast cancer is the most common cancer in all 22 countries, followed by cervical cancer, which ranks high only in the lower-income countries in the region. For males, lung, prostate, and colorectal cancer in combination represent almost 30% of the cancer burden in countries that have attained very high levels of human development.ConclusionsThe most common cancers are largely amenable to preventive strategies by primary and/or secondary prevention, hence a need for effective interventions tackling lifestyle risk factors and infections. The high mortality observed from breast and cervical cancer highlights the need to break the stigmas and improve awareness surrounding these cancers.     

Radwaste at sea: A new era of polarization or a new basis for consensus?

Abstract

A coalition of third world nations, led by the Pacific island countries and those European nations who have developed land‐based disposal programs for their radioactive wastes, seek to amend the London Convention on Dumping (the international treaty controlling ocean disposal of radioactive and other wastes) in order to ban ocean disposal of low‐level radioactive wastes. Pro‐dumping nations maintain that the treaty may only be amended based on science and that current scientific research indicates that low‐level waste represents neither a threat to the integrity of the marine environment nor human health. Anti‐dumping nations, on the other hand, argue that the same science, particularly the models used to predict the fate and the effects of these wastes, exhibits sufficient uncertainty to preclude judgments about the absence of harm from future disposal activities. These differing conclusions mirror differing assessments of risk. These assessments build on the differing social, political, and economic values placed on use of the ocean and on conflicting conceptions of the fundamental rights and obligations of nations whose use of the ocean may impinge on the resources of others. Each side's continued intransigence may result in unilateral ocean disposal activities with serious consequences for the London Convention on Dumping (LDC) and its control over other wastes transported to sea for disposal. Initiatives of anti‐dumping nations to expand the LDC's decision‐making framework to examine the social, economic, and political issues underlying each side's interpretation of scientific evidence offer hope to address the underlying non‐scientific issues and perhaps to strengthen decision‐making within the LDC.     

Healthcare utilization and maternal and child mortality during the COVID-19 pandemic in 18 low- and middle-income countries: An interrupted time-series analysis with mathematical modeling of administrative data

BackgroundThe Coronavirus Disease 2019 (COVID-19) pandemic has had wide-reaching direct and indirect impacts on population health. In low- and middle-income countries, these impacts can halt progress toward reducing maternal and child mortality. This study estimates changes in health services utilization during the pandemic and the associated consequences for maternal, neonatal, and child mortality.Methods and findingsData on service utilization from January 2018 to June 2021 were extracted from health management information systems of 18 low- and lower-middle-income countries (Afghanistan, Bangladesh, Cameroon, Democratic Republic of the Congo (DRC), Ethiopia, Ghana, Guinea, Haiti, Kenya, Liberia, Madagascar, Malawi, Mali, Nigeria, Senegal, Sierra Leone, Somalia, and Uganda). An interrupted time-series design was used to estimate the percent change in the volumes of outpatient consultations and maternal and child health services delivered during the pandemic compared to projected volumes based on prepandemic trends. The Lives Saved Tool mathematical model was used to project the impact of the service utilization disruptions on child and maternal mortality. In addition, the estimated monthly disruptions were also correlated to the monthly number of COVID-19 deaths officially reported, time since the start of the pandemic, and relative severity of mobility restrictions. Across the 18 countries, we estimate an average decline in OPD volume of 13.1% and average declines of 2.6% to 4.6% for maternal and child services. We projected that decreases in essential health service utilization between March 2020 and June 2021 were associated with 113,962 excess deaths (110,686 children under 5, and 3,276 mothers), representing 3.6% and 1.5% increases in child and maternal mortality, respectively. This excess mortality is associated with the decline in utilization of the essential health services included in the analysis, but the utilization shortfalls vary substantially between countries, health services, and over time. The largest disruptions, associated with 27.5% of the excess deaths, occurred during the second quarter of 2020, regardless of whether countries reported the highest rate of COVID-19-related mortality during the same months. There is a significant relationship between the magnitude of service disruptions and the stringency of mobility restrictions. The study is limited by the extent to which administrative data, which varies in quality across countries, can accurately capture the changes in service coverage in the population.ConclusionsDeclines in healthcare utilization during the COVID-19 pandemic amplified the pandemic’s harmful impacts on health outcomes and threaten to reverse gains in reducing maternal and child mortality. As efforts and resource allocation toward prevention and treatment of COVID-19 continue, essential health services must be maintained, particularly in low- and middle-income countries.

Tashrik Ahmed and co-workers study health-care use and maternal and child health outcomes across low- and lower-middle-income countries during the COVID-19 pandemic.     

Macroanalytic study of development and fertility: Consideration of transition models

Abstract

Macroanalytic studies of the relationship of fertility and development have been applied in the past based mostly on cross‐sectional aggregate data from various countries. Because these countries belong to different models of the epidemiologic transition, variation in the dynamic relationship among these models should be allowed for. In this paper, various techniques (including linear and quadratic regression, a minimum‐maximum method of plotting the relationship, a special approach of stepwise regression) were applied to a data set from 85 countries. The crude birth rate was used as the dependent variable with several demographic, economic, social health, and family planning indicators as independent variables, measures over the period 1950–75. The results confirm the existence of submodels of countries with varying relationships between fertility and its correlates. The results disallow direct transferability of the experience of one group of countries (such as Europe) to another group belonging to another model (such as the less developed countries). The study also found the strength of the family planning effort to be a significant factor and one to be singled out as a major contributor in the fertility decline between 1965–75 in the developing countries. Its effect, however, stands to be enhanced in various degrees by concurrent social and economic development.     

Snake Envenoming: A Disease of Poverty

Background

Most epidemiological and clinical reports on snake envenoming focus on a single country and describe rural communities as being at greatest risk. Reports linking snakebite vulnerability to socioeconomic status are usually limited to anecdotal statements. The few reports with a global perspective have identified the tropical regions of Asia and Africa as suffering the highest levels of snakebite-induced mortality. Our analysis examined the association between globally available data on snakebite-induced mortality and socioeconomic indicators of poverty.

Methodology/Principal Findings

We acquired data on (i) the Human Development Index, (ii) the Per Capita Government Expenditure on Health, (iii) the Percentage Labour Force in Agriculture and (iv) Gross Domestic Product Per Capita from publicly available databases on the 138 countries for which snakebite-induced mortality rates have recently been estimated. The socioeconomic datasets were then plotted against the snakebite-induced mortality estimates (where both datasets were available) and the relationship determined. Each analysis illustrated a strong association between snakebite-induced mortality and poverty.

Conclusions/Significance

This study, the first of its kind, unequivocally demonstrates that snake envenoming is a disease of the poor. The negative association between snakebite deaths and government expenditure on health confirms that the burden of mortality is highest in those countries least able to deal with the considerable financial cost of snakebite.