Using geographical analysis to identify child health inequality in sub-Saharan Africa

PLoS One
[Accessed 1 Sep 2018]

Research Article
Using geographical analysis to identify child health inequality in sub-Saharan Africa
Jennifer Yourkavitch, Clara Burgert-Brucker, Shireen Assaf, Stephen Delgado
Research Article | published 29 Aug 2018 PLOS ONE
One challenge to achieving Millennium Development Goals was inequitable access to quality health services. In order to achieve the Sustainable Development Goals, interventions need to reach underserved populations. Analyzing health indicators in small geographic units aids the identification of hotspots where coverage lags behind neighboring areas. The purpose of these analyses is to identify areas of low coverage or high need in order to inform effective resource allocation to reduce child health inequity between and within countries. Using data from The Demographic and Health Survey Program surveys conducted in 27 selected African countries between 2010 and 2014, we computed estimates for six child health indicators for subnational regions. We calculated Global Moran’s I statistics and used Local Indicator of Spatial Association analysis to produce a spatial layer showing spatial associations. We created maps to visualize sub-national autocorrelation and spatial clusters. The Global Moran’s I statistic was positive for each indicator (range: 0.41 to 0.68), and statistically significant (p <0.05), suggesting spatial autocorrelation across national borders, and highlighting the need to examine health indicators both across countries and within them. Patterns of substantial differences among contiguous subareas were apparent; the average intra-country difference for each indicator exceeded 20 percentage points. Clusters of cross-border associations were also apparent, facilitating the identification of hotspots and informing the allocation of resources to reduce child health inequity between and within countries. This study exposes differences in health indicators in contiguous geographic areas, indicating that specific regional and subnational, in addition to national, strategies to improve health and reduce health inequalities are warranted
[Article Excerpt]
Geographic context of child health inequity for six key indicators
…Measles and Diphtheria, pertussis, and tetanus (DPT-3) immunizations.
Although preventable with immunization, measles is still a leading cause of death for children under 5, and is highly contagious [19]. Diphtheria, pertussis, and tetanus are also vaccine-preventable diseases that contribute to substantial global disease burden among children. In addition to measuring coverage of full protection against these diseases, DPT-3 can be a measure of health system strength because it requires individual follow-up on three occasions.
There is high variability of immunization coverage between and within African countries [20]. Identifying geographic areas of low coverage in order to focus immunization efforts was recommended decades ago [21]. Geographic isolation (remoteness) is a key barrier to equitable vaccine coverage for measles and countries with lower coverage have greater inequity [22]. Vaccination rates correlated with distance to a health center in Niger, where distance was affected by geo-temporal conditions hindering access [11]. That spatial analysis pinpointed optimal locations for new health facilities to improve access for hundreds of thousands of people [11] and exemplifies the utility of subnational spatial analysis of immunization and other child health indicators. No research to date has examined the spatial distribution of immunization coverage across and within a large proportion of African countries…