Intermediary determinants are the most immediate mechanisms through which socioeconomic position shapes health inequities. This study examines the effect of community socioeconomic context on different indicators representing intermediary determinants of child health. In the context of Colombia, a developing country with a clear economic expansion, but one of the most unequal countries in the world, two categories of intermediary determinants, namely behavioural and psychosocial factors and the health system, are analysed. Using data from the 2010 Colombian Demographic and Health Survey (DHS), the results suggest that whilst the community context can exert a greater influence on factors linked directly to health, in the case of psychosocial factors and parent's behaviours, the family context can be more important. In addition, the results from multilevel analysis indicate that a significant percentage of the variability in the overall index of intermediary determinants of child health is explained by the community context, even after controlling for individual, family and community characteristics. These findings underline the importance of distinguishing between community and family intervention programmes in order to reduce place-based health inequities in Colombia.

Cognitive abilities of children in Costa Rica and Austria were compared using three age groups (N=385/366). Cognitive ability tests (mental speed, culture reduced/fluid intelligence, literacy/crystallized intelligence) were applied that differed in the extent to which they refer to school-related knowledge. Preschool children (kindergarten, 5–6 years old, NCR=80, NAu=51) were assessed with the Coloured Progressive Matrices (CPM), primary school children (4th grade, 9–11 years old, NCR=71, NAu=71) with ZVT (a trail-making test), Standard Progressive Matrices (SPM) and items from PIRLS-Reading and TIMSS-Mathematics, and secondary school students (15–16 years old, NCR=48, NAu=48) with ZVT, Advanced Progressive Matrices (APM) and items from PISA-Reading and PISA-Mathematics. Additionally, parents and pupils were given questionnaires covering family characteristics and instruction. Average cognitive abilities were higher in Austria (Greenwich-IQ MCR=87 and MAu=99, dIQ=12 points) and differences were smaller in preschool than in secondary school (dIQ=7 vs 20 points). Differences in crystallized intelligence were larger than in fluid intelligence (mental speed: dIQ=12, Raven: dIQ=10, student achievement tests: dIQ=17 IQ points). Differences were larger in comparisons at the level of g-factors. Austrian children were also taller (6.80 cm, d=1.07 SD), but had lower body mass index (BMICR=19.35 vs BMIAu=17.59, d=−0.89 SD). Different causal hypotheses explaining these differences are compared.

This study uses three key anthropometric measures of nutritional status among children (stunting, wasting and underweight) to explore the dual effects of household composition and dependency on nutritional outcomes of under-five children in Ghana. The objective is to examine changes in household living arrangements of under-five children to explore the interaction of dependency and nucleation on child health outcomes. The concept of nucleation refers to the changing structure and composition of household living arrangements, from highly extended with its associated socioeconomic system of production and reproduction, social behaviour and values, towards single-family households – especially the nuclear family, containing a husband and wife and their children alone. A negative relationship between levels of dependency, as measured by the number of children in the household, and child health outcomes is premised on the grounds that high dependency depletes resources, both tangible and intangible, to the disadvantage of young children. Data were drawn from the last four rounds of the Ghana Demographic and Health Surveys (GDHSs), from 1993 to 2008, for the first objective – to explore changes in household composition. For the second objective, the study used data from the 2008 GDHS. The results show that, over time, households in Ghana have been changing towards nucleation. The main finding is that in households with the same number of dependent children, in nucleated households children under age 5 have better health outcomes compared with children under age 5 in non-nucleated households. The results also indicate that the effect of dependency on child health outcomes is mediated by household nucleation and wealth status and that, as such, high levels of dependency do not necessarily translate into negative health outcomes for children under age 5, based on anthropometric measures.

A growing body of research suggests that orphanhood and fostering might be (independently) associated with educational disadvantage in sub-Saharan Africa. However, literature on the impacts of orphanhood and fostering on school enrolment, attendance and progress produces equivocal, and often conflicting, results. This paper reports on quantitative and qualitative data from sixteen field-sites in Ghana and Malawi, highlighting the importance of historical and social context in shaping schooling outcomes for fostered and orphaned children. In Malawi, which has been particularly badly affected by AIDS, orphans were less likely to be enrolled in and attending school than other children. By contrast, in Ghana, with its long tradition of ‘kinship fostering’, orphans were not significantly educationally disadvantaged; instead, non-orphaned, purposively fostered children had lower school enrolment and attendance than their peers. Understanding the context of orphanhood and fostering in relation to schooling is crucial in achieving ‘Education for All’.

This study seeks to explore and explain the socio-cultural factors responsible for the incidence of infant malnutrition in Cameroon with particular emphasis on northern Cameroon where it is most accentuated. It combines quantitative data drawn from the 1991, 1998, 2004 and 2011 Cameroon Demographic and Health Surveys, as well as a literature review of publications by the WHO and UNICEF. This is further complemented with qualitative data from various regions of Cameroon, partly from a national ethnographic study on the ethno-medical causes of infertility in Cameroon conducted between 1999 and 2000. Whereas socio-cultural factors related to child feeding and maternal health (breast-feeding, food taboos and representations of the colostrum as dangerous for infants) are widespread throughout Cameroon, poverty-related factors (lack of education for mothers, natural disaster, unprecedented influx of refugees, inaccessibility and inequity in the distribution of health care services) are pervasive in northern Cameroon. This conjunction of factors accounts for the higher incidence of infant malnutrition and mortality in northern Cameroon. The study suggests the need for women's empowerment and for health care personnel in transcultural situations to understand local cultural beliefs, practices and sentiments before initiating change efforts in infant feeding practices and maternal health. Biomedical services should be tailored to the social and cultural needs of the target population – particularly women – since beliefs and practices underpin therapeutic recourse. Whereas infant diarrhoea might be believed to be the result of sexual contact, in reality, it is caused by unhygienic conditions. Similarly, weaning foods aimed at transmitting ethnic identity might not meet a child's age-specific food needs and might instead give rise to malnutrition.

The objective of the study was to explore the survival trends of centenarians in Japan. A cohort of centenarians born between 1881 and 1900 was analysed based on national census data, and the average life expectancy at 100 years of age, risk of death and maximum age were estimated. An analysis of covariance and a Cox regression analysis were performed to explore the factors associated with life expectancy and risk of death. The death rates in centenarians tended to decrease with birth year, and the average life expectancy from the age of 100 slightly increased at a rate of 0.013 years (95% CI: 0.007–0.019) by birth year in men and 0.026 in women. Women had a longer life expectancy than men, with a difference of 0.174 years (95% CI: 0.071–0.277) at birth year 1881 and increasing by 0.013 years per year thereafter. The risk of death in both sexes decreased significantly by birth year over the course of the period analysed, and the risk of death in men was 1.16 (95% CI: 1.14–1.19) times that of women. In women, death rates at every age significantly decreased with birth year over the course of the period analysed until age 104. However, this trend did not hold true for ages 105 and older. The average life expectancy of centenarians at the age of 100 in Japan increased by birth year in the 1881–1900 birth cohort. In addition, Japanese centenarians had the lowest death rates among several countries.

Analyses of historical or modern populations indicate a strong relationship between mortality level and standard of living, measured, among other factors, by degree of urbanization. The aim of this study was to assess mortality rates in children of up to 5 years of age in two populations living under different conditions in central modern Poland at the end of the 19th century: the rural parish of Kowal, under Russian partition, and Toruń, an industrial and urbanized centre under Prussian partition. Data on births and deaths were taken from birth certificate registries and from the Prussian statistics yearbooks for 1876–1894. Death rates of children aged 0–5 years were calculated, and also for annual age ranges. The urban population had lower birth rates (37.19‰), natural increase rates (8.0‰), population dynamics rates (1.26‰), which provide information about the relation between two components of a natural increase, i.e. births and deaths, and an over-mortality of boys in relation to girls. In the rural population these values were all higher: 53.67‰, 18.11‰ and 1.59‰ respectively. No impact was found of social stratification on child mortality in the wide age group of 0–5 years. However, for subsequent one-year age groups significant relationships between mortality level and size and industrialization level of the population centres were noted. The living conditions of infants in Toruń, although being in a better position as an area annexed by Prussia, were markedly worse than those of rural Kowal Parish. In the urban centre infant mortality was slightly over 269 for 1000 live born, and in Kowal Parish it was 163 for 1000 live born. The high infant mortality was balanced in Toruń by the higher mortality levels of children aged 2–5 years compared with Kowal Parish. Natural selection in the city had the greatest impact on infants, who did not have the protective influence of breast-feeding because women had to return to work shortly after giving birth. The lower infant mortality of mothers in the countryside due to longer breast-feeding led to larger family sizes. In 1871–1890 in the villages the number of children per women was about 7.42, whereas in Toruń it ranged from 4.4 to 5.2. The probability of death among children who survived the first year of life was higher in the countryside than the town. In the rural parish, perhaps because of cultural factors such as breast-feeding or working practices making full-time baby-sitting possible, children who did not reach the age of 1 year were not subjected to such intensive natural selection. Overall, differences in child mortality in the two centres in 19th central Poland resulted from ecological and cultural conditions, rather than from social and economical reasons (living under different partitions).

The role of religion in contraceptive use is an issue of significant debate. This study employed the 1990 and 2008 Nigeria Demographic and Health Survey data to examine differences and similarities in the influence of religious affiliation on non-use of modern contraceptives in Nigeria over the last two decades. The results suggest that a significant increase has occurred in the level of awareness of modern contraceptives in Nigeria over the last two decades, but that non-use remains very high. Religion could not independently predict non-use of modern contraceptives in 1990. Women of Islam and Traditional religions were more likely to have never used or not to be using modern contraceptives compared with Catholics and Protestants in 2008 (p<0.05). This can be explained by their poorer socioeconomic status relative to Catholics and Protestants. Therefore, improving women's socioeconomic status is an imperative in the promotion of modern contraception in Nigeria. Education and employment are critical in this regard and adherents of Islam and Traditional religions require special attention.

Cross-sectional surveys with carers, health workers, community drug distributors (CDDs) and neighbourhood health committees were conducted to identify factors associated with utilization of community-directed treatment (ComDT) of soil-transmitted helminths in children aged 12–59 months in Mazabuka district, Zambia. The surveys took place in December 2006 and December 2007. In addition child treatment records were reviewed. The factors that were found to be significantly associated (p<0.05) with treatment of children by the CDDs were: (1) the perception of soil-transmitted helminth infections as having significant health importance, (2) the community-based decision to launch and subsequently implement ComDT, (3) the use of the door-to-door method of drug distribution, (4) CDDs being visited by a supervisor, (5) CDDs receiving assistance in mobilizing community members for treatment, (6) CDDs having access to a bicycle and (7) CDDs having received assistance in collecting drugs from the health centre. Despite the effectiveness of ComDT in raising treatment coverage there are factors in the implementation process that will still affect whether children and their carers utilize the ComDT approach. Identification and understanding of these factors is paramount to achieving the desired levels of utilization of such interventions.

Consanguineous unions are a deeply rooted social practice among traditional societies. Despite their presumed social advantages, they can result in several health conditions. The aim of this study was: i) to compare consanguinity levels between Tunisian patients affected with autosomal recessive disorders (ARDs) and those with a chromosomal abnormality; and ii) to gain more insight into the mutational status of patients affected with ARDs. Data were collected from 290 files of patients affected by one of five ARDs confirmed by molecular analysis and 248 files of patients with confirmed Down syndrome. Information on the disease, mutation defining the disease, parents' relatedness and geographical origin was gathered. Consanguinity was found among 58% of the ARD patients and among 22% of Down syndrome patients, and a homozygous status was found in 90% of the patients born to related parents and in 70% of patients born to unrelated parents. Also, children from unrelated parents from the same geographical background were found to be more frequently affected by homozygous mutations than those from unrelated parents from different geographical backgrounds. The present study shows how marriage practices affect patterns of genetic variations and how they can lead to homogenization in the genetic pool.

This paper investigates whether community-level wealth inequality predicts HIV serostatus using DHS household survey and HIV biomarker data for men and women ages 15–59 pooled from six sub-Saharan African countries with HIV prevalence rates exceeding 5%. The analysis relates the binary dependent variable HIV-positive serostatus and two weighted aggregate predictors generated from the DHS Wealth Index: the Gini coefficient, and the ratio of the wealth of households in the top 20% wealth quintile to that of those in the bottom 20%. In separate multilevel logistic regression models, wealth inequality is used to predict HIV prevalence within each statistical enumeration area, controlling for known individual-level demographic predictors of HIV serostatus. Potential individual-level sexual behaviour mediating variables are added to assess attenuation, and ordered logit models investigate whether the effect is mediated through extramarital sexual partnerships. Both the cluster-level wealth Gini coefficient and wealth ratio significantly predict positive HIV serostatus: a 1 point increase in the cluster-level Gini coefficient and in the cluster-level wealth ratio is associated with a 2.35 and 1.3 times increased likelihood of being HIV positive, respectively, controlling for individual-level demographic predictors, and associations are stronger in models including only males. Adding sexual behaviour variables attenuates the effects of both inequality measures. Reporting eleven plus lifetime sexual partners increases the odds of being HIV positive over five-fold. The likelihood of having more extramarital partners is significantly higher in clusters with greater wealth inequality measured by the wealth ratio. Disaggregating logit models by sex indicates important risk behaviour differences. Household wealth inequality within DHS clusters predicts HIV serostatus, and the relationship is partially mediated by more extramarital partners. These results emphasize the importance of incorporating higher-level contextual factors, investigating behavioural mediators, and disaggregating by sex in assessing HIV risk in order to uncover potential mechanisms of action and points of preventive intervention.

There are substantial regional disparities in under-five mortality in Nigeria, and evidence suggests that both individual- and community-level characteristics have an influence on health outcomes. Using 2008 Nigeria Demographic and Health Survey data, this study (1) examines the effects of individual- and community-level characteristics on infant/child mortality in Nigeria and (2) determines the extent to which characteristics at these levels influence regional variations in infant/child mortality in the country. Multilevel Cox proportional hazard analysis was performed on a nationally representative sample of 28,647 children nested within 18,028 mothers of reproductive age, who were also nested within 886 communities. The results indicate that community-level variables (such as region, place of residence, community infrastructure, community hospital delivery and community poverty level) and individual-level factors (including child's sex, birth order, birth interval, maternal education, maternal age and wealth index) are important determinants of infant/child mortality in Nigeria. For instance, the results show a lower risk of death in infancy for children of mothers residing in communities with a high proportion of hospital delivery (HR: 0.70, p<0.05) and for children whose mothers had secondary or higher education (HR: 0.84, p<0.05). Although community factors appear to influence the association between individual-level factors and death during infancy and childhood, the findings consistently indicate that community-level characteristics are more important in explaining regional variations in child mortality, while individual-level factors are more important for regional variations in infant mortality. The results of this study underscore the need to look beyond the influence of individual-level factors in addressing regional variations in infant and child mortality in Nigeria.

In this study the construct of a ‘good life’ was explored among upper secondary school senior pupils and their parents and teachers by applying cultural consensus model analysis. A total of 469 students, 474 parents and 158 teachers from four Croatian cities participated in the study, which was conducted in 2011/2012. The information collected through interviewing and free-listing during the first phase of the study was used to create a set of structured questionnaire questions as a part of the survey in the second phase of data collection. The results are reported on two good-life sub-domains: ‘health & well-being’ and ‘migration & socioeconomic milieu’. The results indicate heterogeneity of the sample groups, incomplete inter-generational transmission of cultural values and examples of two sub-groups that resist cultural norms and do not comply with the dominant ‘competence-as-sharing’ paradigm. The value of testing the cultural consensus model based on the emic approach and locally significant phenomena is demonstrated for planning and conducting holistic anthropological research.

The disease burden in both developed and developing countries is moving towards higher proportions of chronic diseases, and diseases such as cancers are now considered to be of public health concern. In sub-Saharan Africa, healthy behaviours such as fruit and vegetable consumption are recommended to reduce the chances of onset of chronic diseases. This paper examines the determinants of fruit and vegetable consumption in Ghana with particular emphasis on consumption by ecological zone. Data were from the 2008 Ghana Demographic and Health Survey (n=4916 females; n=4568 males). Univariate and multivariate analyses were performed using basic descriptive and Poisson regression. The main independent variable was ecological zone and the dependent variables were levels of fruit and vegetable consumption. The mean number of fruits and vegetables consumed in a week was higher among females (fruits: 7.5, 95% CI=7.3–7.7; vegetables: 8.1, 95% CI=7.8–8.3) than males (fruits: 6.2, 95% CI=6.0–6.4; vegetables: 7.9, 95% CI=7.7–8.2). There were significant differences in consumption by ecological zone. Respondents in the Savannah zone consumed less fruit than those in the Coastal and Forest zones, but the differences in fruit and vegetable consumption between the Coastal and Savannah zones were not consistent, especially for vegetable consumption. The findings suggest that one of the key interventions to improve fruit and vegetable consumption could lie in improving distribution systems since their consumption is significantly higher in the Forest zone, where the production of fruit and vegetables is more developed than in the Savannah and Coastal zones. The findings relating to household wealth challenge conventional knowledge on fruit and vegetable consumption, and rather argue for equal consideration of spatial differences in critical health outcomes.

The practice of dowry is widespread in India and refers to the payment of cash/gifts by the bride's family to the bridegroom's family before marriage. Though prohibited by law, dowry is widely practised, and often contributes to severe injuries and even death of young brides. This study examined the prevalence and risk factors for dowry demand and dowry harassment and its psychosocial correlates across different social strata in India, and also by husband and mother-in-law characteristics. In a cross-sectional survey of 9938 women in rural, urban and urban non-slum sites across India conducted in 1998–99, dowry demand was found to be significantly higher (p<0.001) in the urban non-slum and rural areas (26% and 23% respectively) than in urban slum areas (18%). Overall, 17% of groom's families were not satisfied with the dowry, this being higher in rural areas (21%) than in urban slum and non-slum areas (about 14% in both). The overall prevalence of dowry harassment among this group of women was 13.3%. Mothers-in-law who had themselves experienced dowry demand were 14 (95% CI 5.0–40.4) and 5 (95% CI 1.3–18.9) times more likely to demand and harass daughters-in-law over dowry, respectively. Another significant risk factor for dowry-related harassment was mother-in law's status in the family. Interventions related to modifiable risk factors, such as increased social support at the community level, should help reduce dowry harassment.

Childhood adversity has been associated with accelerated menarcheal and reproductive timing in females. The relationship between family- and neighbourhood-level measures of childhood adversity, menarcheal timing and intended reproductive timing was investigated in a sample of 354 English adolescent girls. The data were collected from March to June 2012. In total 90 of the participants had reached menarche. Frequent residential relocations increased the likelihood of reaching menarche (HR 1.11; 95%CI 1.02–1.22). Girls who had moved house one to four times or five or more times, were respectively, more than twice (HR 2.14; 95%CI 1.23–3.73) and more than three times (HR 3.20; 95%CI 1.44–7.10) as likely to have reached menarche than girls who had never moved house. Frequent residential relocations were associated with stepfather co-residence, increased number of half/stepsiblings and reduced feelings of family support. Menarche was also accelerated by the presence of half/stepsisters. There was no relationship between menarcheal timing and intended reproductive timing. Frequent residential relocations may indicate instability in a young person's life, which is often outside of their control. Extending childhood adversity measures to include residential relocations could be important in better understanding the role early life events play in accelerating menarche.

Female genital cutting (FGC) is widely practised in Kenya. However, its prevalence has declined over the last two decades (38.0% in 1998 KDHS, 32.2% in 2003 KDHS and 27.1% in 2008–09 KDHS), implying changes in behaviours and attitudes of Kenyans towards FGC. This study provides an overview of changing attitudes of women towards FGC in Kenya. An extensive literature review was undertaken and 2008–09 Kenya Demographic and Health Survey data were used to focus on the present scenario. Analyses were based on a national sample of 2284 circumcised women. About 68% of these women wanted to discontinue FGC, and attitudes towards discontinuation were found to vary with women's background characteristics. Surprisingly, 92.5% of circumcised women of the North-Eastern province still wished to continue FGC, and for Muslims the percentage was 72.2%. About 36% of circumcised women responded that their daughters were already circumcised. Only 13% of circumcised mothers intended their daughters to be circumcised in the future. The study shows that the attitude of Kenyan women, irrespective of their circumcision status, has been changing gradually towards the discontinuation of circumcision of their daughters.

It is difficult to gauge the success of programmatic efforts to reduce unmet need for contraception without knowing whether individual women have had their need met and adopted contraception. However, the number of true longitudinal datasets tracking the transition of panels of individual women in and out of states of contraceptive use is limited. This study analyses changes in contraceptive use states using Demographic and Health Survey data for 22 sub-Saharan African countries. A cohort approach, tracking representative samples of five-year age groups longitudinally across surveys, as well as period-based techniques, are applied to indicate whether new users of contraception have been drawn from women who previously had no need and/or those who had unmet need for family planning. The results suggest that a greater proportion of increases in contraceptive use in recent years can be attributed to decreases in the percentage of women with no need, especially among younger women, than to decreases in the proportion with unmet need.

This paper assesses the reproductive and abortion patterns of women living in Plaza de la Revolución, a municipality of Havana, Cuba, by studying the factors influencing birth and abortion rates. Socio-demographic data and female reproductive histories were collected in a survey of 1200 post-menopausal women living in the municipality. Average ages at menarche and at menopause were 12.71 and 48.39 years, respectively, thus yielding a potential long reproductive period of 35.68 years, indicating high fertility. Although the mean pregnancy rate was 3.81 pregnancies per woman, the live birth rate at time of delivery was only 1.89 due to the high rate of abortions: 40% of all pregnancies were voluntarily interrupted. Among the biological and socio-cultural variables that were found to influence the rate of live births were those related marriage pattern, especially age at first union. Demographic variables such as pregnancy order, maternal age and marital status were the main determinants of the abortion pattern, with abortion being used as a method of birth control in order to obtain the desired family size, and most women (75.2%) using contraceptives.

Both objective and, more recently, subjective measures of low social status have been linked to poor health outcomes. It is unclear, however, through which precise physiological mechanisms such standing may influence health, although it has been proposed that those of lower status may have biomarker profiles that are more dysregulated (and hence pose a greater risk for poorer health). The main objective of this study was to investigate whether lower subjective social standing is associated with riskier neuroendocrine biomarker profiles. Data were from the Social Environment and Biomarkers of Aging Study (SEBAS), a nationally representative survey of Taiwanese men and women (ages 54–91) conducted in Taiwan in 2000. Five neuroendocrine markers (cortisol, dehydroepiandrosterone sulphate (DHEAS), adrenaline, noradrenaline and dopamine) were analysed both separately and collectively in an index termed neuroendocrine allostatic load (NAL) in relation to status – both self-reported and as measured through objective socioeconomic status (SES) indicators. For the biomarker DHEAS, some connection was found between its levels and the measures of status, but for the other markers and the NAL index almost no connection was found. The overall negative finding of this paper would be further supported with more and different measures of neuroendocrine system function and a reordering of the subjective social status questions in the survey such that the one probing about status in the community (that has no prompt) was asked before the one probing about status in all of Taiwan (which has a SES prompt).