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Reproductive and Overall Health Outcomes and Their Economic Consequences for
Households in Accra, Ghana
Allan Hill and Günther FinkHarvard Center for Population & Development Studies
Ernest Aryeetey and Isaac Osei-AkotoInstitute for Statistical, Social and Economic Research
Third Annual Research Conference on Population, Reproductive Health and Economic Development
Dublin, Jan 16-18, 2009
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Research Questions
Broad question:
What are the economic consequences of ill health?
Original Research Questions:
a. How do spells of ill health affect household income and consumption in urban Sub-Saharan Africa?
b. How does household composition affect the coping mechanisms chosen by the household in the short run?
c. How does ill health affect household composition in the short and medium run?
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Empirical challenges…
• Identifying the causal effect of ill health on economic outcomes in the presence of unobserved heterogeneity
• Distinguishing “reproductive” morbidity from general ill-health
• Measuring the indirect effects of women’s RH morbidity– Childhood illness and women’s work– Other adult illnesses in the household– “Openness” of household support (e.g. Ga non-residence of
spouses; extended family transfers; national health insurance)
• Capturing the co-incidence of a set of individually “minor” RH conditions which are nonetheless additive….
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Baseline Sample
Women’s Health Study of Accra 2003:
• Representative sample of 3200 women aged 18+ from the Accra Metropolitan Area
• Over-sampling of elderly
• Stratification by social class based on census data
• Detailed home interview with focus on general and reproductive health
• Blood tests and hospital visit for a sub-sample of the women (Korle Bu Teaching Hospital)
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Original Sampling Framework
SES of EASurvey Age groups
Total18-24 25-34 35-54 55+
Low class259 299 219 199 976
Low middle class207 169 203 164 743
Upper middle class189 182 187 184 742
High class189 167 176 179 711
Total844 817 785 726 3172
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Findings from 2003
• Heavy burden of non-communicable diseases – strong association with age– Obesity– Cholesterol levels– Diabetes– Depression and mental illness
• Women of reproductive age in good general health– TFR=2.1– Clustering of minor reproductive health conditions (co-
morbidities c.f. Giza Study)– RH conditions additive…
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Health topics covered in the home interview
Topic Questions Topic Questions General Health 11 SF36 topics Affect 2
Self-care 2 Physical activity 9 Pain and discomfort 2 Food security 3
Cognition 3 Reproductive health 4 Community interactions 2 Sexual behaviour 4
Vision 3 STIs 10 Hearing 3 Breastfeeding 3
Breathing 2 Family planning 7 Energy and sleep 2
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Physical examination
– Measurement of height, weight and girth
– Measurement of visual acuity
– Measurement of blood pressure, heart rate
and temperature
– Complete physical examination: head to
toe
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Self-report health changes by age
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
Age groups
%
Health Transition -somewhat+much worseGeneral Health Index<70Overall health - fair +poor
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Age group
Self-reported
obesity % N
Measured with
BMI>30 % N
18-24 0.7 852 11.0 191
25-34 1.5 817 29.1 189
35-44 2.8 469 40.0 210
45-54 6.0 317 44.7 206
55-64 4.6 368 43.0 230
65 & over 6.4 359 36.4 228
All 2.8 3182 34.6 1254
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Reported and measured blood pressure
0102030405060708090
18-24 25-34 35-44 45-54 55-64 65 &over
Age groups
% e
leva
ted Measured
Reported
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Microeconomic Study 2008/2009
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Study Design
• Sub-sample of 1000 households indexed to women interviewed both in 2003 and 2008 (in progress)
• Each households is followed over 12 weeks with at least one visit per week
• Rolling sample to guarantee regional coverage of all four socioeconomic residence types in each season
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Accra Metropolitan Area- Total population estimate 1.6-2.9 Millions (about 10% of total population)
- 1741 enumeration areas (EA) in 6 sub-metros – 200 randomly selected
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Rolling Sample Time Line
IV 1 round 1Week 1Week 2Week 3
October 08 December 09
IV 2 round 1IV 3 round 1
12 weeks
IV 11: round 4IV 12: round 4
IV 13: round 4Week 52
Each “cohort” consists of
- 20-25 households
- 3-5 different EAs
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Background Information Collected
• Household structure and arrangements (week 1)
• Detailed schooling information for all children in the houshold (week 7)
• Detailed job information for all adult household members (week 10)
• Detailed health history of index woman and her family (WHSA II)
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Main Health Information Collected
• Health Module: During each of the 12 weekly visits, a log about sickness spells in the household is kept. If any acute sickness occurred in previous 6 days, the following information is collected:uration of sickness
• Health facility name and location • Medication used• Direct cost to the household: prescriptions & doctor fees• Indirect private cost: number of hours/days not able to work• Indirect HH cost: number of hours other HH members stayed
home to take care of sick person
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Additional Health Information Collected
• Daily time use and health diaries: selected household members are trained to fill out daily diaries containing:
– Principal activity for each 30 minute time block
– Overall self-health assessment each day
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Daily Diary Example
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Discussion Diary Data
Main benefits:
• allows to verify household response from health modules: how does daily routine change for individuals during health problems of any HH member?
• Provides interesting picture of everyday life in an modern African urban environment – how do individuals spend their time?
• Allows limited risk factor analysis: work distance, commuting and health; work/leisure balance and health
Concerns:
• Large potential error in self-reports
• Major sample selection problem: literacy!
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Data Collection: Status and Projection
Currently collected Total projected
Number of Households 93 1,000
Number of Individuals 347 4,000
Number of Health Modules 213 2,130
Number of Diaries 255 5,840
More coming soon…
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Thank you!