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Title: An epidemiological study of morbidity, mortality and use of primary health care services among mothers and children in three demographic areas of Mozambique 
Author: Oliver, Charles Whitney Jr
Date: 1992
Abstract: Studies of morbidity, mortality, and use of primary health care (PHC) were conducted in Zambezia Province, Mozambique. Formerly a leading agricultural resource of the region, Zambezia was particularly traumatized by a generation of war in what remains one of the poorest countries of the developing world. Cross-sectional surveys were conducted during 1990-1991. Subjects were 3,232 mothers and children (under five years) from three areas: centros de acomodacao, camps for persons displaced by war [0], a rural town [R], and the periurban provincial capital [U]. Household interviews were complemented by medical examinations and laboratory analyses. Indices of socio-economic status (SES), knowledge and use of PHC services were calculated from composite scores. An estimated rate of cumulative child mortality (CCMR) was derived from birth histories in lieu of lack of accurate census data. Laboratory and anthropometric measures were used to determine prevalence rates and levels of intensity for P. falciparum malaria and helminthic infections, anemia, and low nutritional status. Morbidity scores were calculated from a composite of these findings. Results of the study delineate significant differences in levels of morbidity, child mortality, SES, and knowledge and use of PHC services among these groups. Aggregate and group data were further analyzed utilizing stepwise logistic regression models developed for all major variables. P falciparum malaria is holoendemic in the study areas, but was observed more often among women from [U] (OR=4.6, P < 0.001). Similar results were found for children. Malaria was associated with higher parity, and with hookworm among women and children. Hookworm infections were commonly found in all groups, although more prevalent among women from [U] and [0], and among women than children. Children from [U] had twice the prevalence of hookworm compared with the other groups. Hookworm was associated with anemia in women, and older age in children. Trichuriasis was more prevalent among women and children from [U], while strongyloidiasis more common in the rural groups. Anemia (Hb < 11.0 g dl-1 ) was commonly observed in all groups, sharing a similar, albeit higher, prevalence distribution with hookworm. Mean prevalence for children was below 8.0 g dr-1 , and below 10.0 g dl-1 for women. Among women, moderate anemia (Hb < 9.0 g dl^-1 ) was associated with hookworm, pregnancy, and low knowledge of PHC. It was associated with higher CCMR (≥ 200), age (< 2 years), lower nutritional status, and recent febrile episode among children. Prevalence of severe anemia (Hb < 7.0 g dl^-1 ) was very high (even for Sub-Saharan Africa), and was associated with malaria among children from [U]. Malaria, helminthic infection, and anemia were found to be associated between mothers and children suggesting common etiologies. Prevalence of wasting (weight-for-height Z scores < -2) did not differ among children from all groups. Wasting was found to be associated with anemia, age (< 2 years), and in the [U] group with low maternal Body Mass Index (<18.0) (OR=3.0S, P < 0.001). Growth stunting (height-for-age Z scores < -2) was more prevalent among rural children (OR=3.77, p < 0.001), associated with anemia, age ( > 2 years), and low SES. In [U] children underweight (weight-for-age Z scores < -2) or stunted were found associated with low birth weight (<2.5 kg), indicating failure in catch up growth during early childhood. The peak age for underweight and wasting among the urban children was a year later than the rural groups. Women and children from [U] had higher morbidity scores (OR = 2.52, P < 0.001) and (OR = 1.71, P < 0.001) respectively. A high morbidity score was associated with pregnancy, neonatal death, and low knowledge of PHC among women, while related to growth stunting, and age (> 2 years) in children. Women with higher CCMR ( ~ 200) were associated with low SES, low knowledge and use of PHC. Also, it was more likely that their child had severe anemia. The CCMR was lower in [U] than the rural groups, however interpretation remains limited since it could reflect a wide range of risk factors beyond the scope of this study, e.g. from exposure to the effects of war among older women in the rural groups to exposure to improved antenatal facilities among younger women in the urban group. Another unusual finding was that women from [U] had lower SES more often than group [R] (OR=1.97, P < 0.001). Lower SES scores were found associated with maternal anemia, a neonatal death, age (> 24 years), and low knowledge of PHC. Knowledge of PHC was low in all groups, although lower in [D] (OR=2.34, P < 0.001). A low score was found associated with anemic and underweight children, and low use of PHC services. Similarly, [D] had more women with lower use of PHC services. Low use of PHC was found associated with higher CCMR, growth stunting, and low knowledge of PHC. The finding that morbidity and SES levels were worse in [U] than [R] may be explained by the supposition that much of the urban area has become marginalized as a result of war-induced migration into the remains of an abandoned, formerly Portuguese urban enclave. Thus as a result of the capital's inability to cope with this massive influx, the situation in many periurban bairros more resembled that found in the accommodation camps than the traditional rural town. Results of logistic regression analyses revealed that individual morbidity indicators, e.g. moderate anemia, to be more informative than composite scores of morbidity or PHC. The development of sensitive measures of mortality in Mozambique are precluded until an accurate census can be undertaken, once peace is finally established throughout the country. The complex web of associations elucidated from morbidity indicators in comparison with PHC scores suggest that the inclusion of inexpensive morbidity studies in development of maternal and child care programs may be of greater utility than PHC interviews alone. The numerous correlations between maternal and child morbidity indicators suggest common etiologies, and may prove useful in community diagnosis if prospective studies prove confirmatory. Innovative and cost-effective triage protocol is needed to be employed at every opportunity for PHC intervention, e.g. when women attending antenatal clinics are found with anemia, hookworm, or malaria, her youngest child could be treated presumptively as well. The observation of higher prevalences of morbidity (both individual and composite indicators) and lower levels of SES among the periurban group merits further study of these phenomena in similar areas of the developing world. The cumulative impact of a generation of war and socioeconomic devastation continues to adversely affect the delivery of PHC services in rural Mozambique. However, the consequences of poverty and massive internal migration have exacerbated the precarious balance of health in periurban areas, and new strategies are needed to prevent large scale pandemics (e.g. AIDS and drug-resistant malaria) in the rapidly emerging periurban communities of the developing world in the future.
Description: Thesis (Ph. D.)--University of Hawaii at Manoa, 1992. Includes bibliographical references (leaves 200-215) Microfiche. xvii, 215 leaves, bound ill. 29 cm
URI: http://hdl.handle.net/10125/9445
Rights: All UHM dissertations and theses are protected by copyright. They may be viewed from this source for any purpose, but reproduction or distribution in any format is prohibited without written permission from the copyright owner.

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