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ObjectiveHealthcare utilisation (HU) is key to improving the health of residents in urban informal settlements. This study aimed to explore household-level factors influencing HU among informal settlement households in Freetown, Sierra Leone.DesignCross-sectional survey.SettingThree informal settlements (Cockle Bay, Dwarzark and Moyiba) in Freetown, Sierra Leone.ParticipantsPrimary data from 4871 households were collected during the Health and Wellbeing survey conducted between April and May 2023, targeting households with adults aged 18 years and older.Primary outcome measuresThe primary outcomes were households HU both within and outside informal settlements. Household-level predisposing and enabling explanatory variables were derived from Andersen’s Behavioural Model of HU.ResultsDisability in households increases HU within settlements (especially in Dwarzark, 13% and Moyiba, 10%) but is less likely outside. Households engaged in income-generating activities are more likely to seek healthcare within settlements, but 12% less likely outside in Cockle Bay and Dwarzark. Food insecurity decreases HU within Dwarzark (9%) and increases HU outside by 174% in Moyiba. Longer water fetching times and water shortages were associated with higher HU (between 6% and 16%) within settlements, especially in Cockle Bay and Dwarzark. Clean water sources (eg, piped dwelling, bowser, surface, bottled) were consistently associated with higher HU both within and outside settlements. Shared sanitation facilities (such as shared toilets) were positively associated with HU both within and outside settlements, particularly in Dwarzark and Moyiba. Households with income from fishing, informal salaried work and bike riding showed higher HU both within and outside settlements, especially in Dwarzark and Moyiba.ConclusionsWe identified strong settlement-specific patterns of household-level factors that influence HU both within and outside Freetown’s informal settlements. These findings provide a foundation for developing targeted policies such as strengthening local services, addressing affordability and accessibility barriers and supporting vulnerable occupation groups.

Introduction Residents of informal settlements face significant intersectional inequalities, due to the overlapping and compounding effects of multiple social factors. This study aims to explore how these intersecting social factors, identified by community members, combine to shape household-level inequalities healthcare utilisation (HU) among residents of informal settlements in Freetown, Sierra Leone. Methods This study employed participatory action research to collaboratively identify key social determinants affecting healthcare utilisation in Freetown’s informal settlements. A cross-sectional health and wellbeing survey was implemented in April-May 2023 and collected data from 4,871 households in Cockle Bay, Dwazark, and Moyiba informal settlements. The survey questions were codesigned by researchers and community fieldworkers, informed by prior qualitative research. Two outcomes were analysed: HU within the settlement ( n  = 4,821), and outside the settlement ( n  = 4,616). A multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) was conducted, nesting households within 122 intersectional strata. These strata were defined by six social factors: head of household gender, marital composition, engagement in income-generating activity, food security, disability and the household’s settlement. Intersectional measures included variance partition coefficient (VPC), the proportional change in variance (PCV), and residual intersectional effects. Results VPCs of 0.9% (PCV, of 92.8%) for HU within the settlements and of 3.9% (PCV, 81.7%) for HU outside the informal settlements suggest moderate but meaningful intersectional effects in shaping HU inequalities. The lowest levels of HU within informal settlements were observed among single, male, disabled individuals in Moyiba who lacked income-generating activities and experienced food insecurity. For HU outside the settlement, the lowest levels were found among female-headed households in Moyiba who were married, cohabiting, or engaged with a disabled household member, experienced food insecurity, and were engaged in income-generating activities. Conclusion This study identifies and quantifies inequalities in HU at the household level across three informal settlements in Freetown, driven by intersecting social factors. Addressing these inequalities requires policies that are universally accessible but implemented with an intensity proportionate to the level of vulnerability, ensuring that support is targeted to those most in need. Highlights The findings identify and quantify intersectional inequalities in healthcare utilisation (HU), particularly among the most vulnerable groups. Single women without income and single men with disabilities and no income in Moyiba were less likely to utilise healthcare. Households with protective factors against illness showed higher HU than those exposed to illness-enabling conditions. Stakeholders are encouraged to address HU inequalities through social security and health insurance, proportionately targeted by level of need.

Background Sensitization to aeroallergens increases the risk of developing asthma or allergic rhinitis. Data on sensitization to airborne allergens in the general population in sub-Saharan Africa are lacking. The aim of this study was to determine the prevalence and determinants of sensitization to common aeroallergens in a population of young adults. Methods A cross-sectional study was conducted among students of the Faculty of Medicine and Pharmaceutical Sciences of the University of Douala between 1st February and 30th April 2014. We consecutively recruited all the students present in class or in hospital during our visit. They filled an anonymous questionnaire and underwent skin prick tests with common aeroallergens. A logistic regression model of the SPSS.20 software was used to investigate factors associated with sensitization to common aeroallergens. Results Of the 600 students included in the study, 305 (50.8 %) were female. The mean age of participants was 22.6 ± 2.7 years. The prevalence of sensitization to aeroallergens was 42.8 % (95 % CI 38.8–46.8). Dermatophagoides pteronyssimus (24.2 %), Dermatophagoides farinae (22.8 %), Blomia tropicalis (23.3 %) and Blatella germanica (15.2 %) were the most common allergens found. Allergic rhinitis, asthma symptoms and family atopy were independently associated to sensitization to common aeroallergens. Conclusion A significant proportion of young adults are sensitized to common aeroallergens. Dust mites and cockroach should be included in the panel of aeroallergens in Cameroon.

Background Although the high burden of both active smoking and human immunodeficiency virus (HIV) is clearly known, the relationship between them is still not well characterized. Therefore, we estimated the global prevalence of active smoking in people living with HIV (PLHIV) on antiretroviral therapy (ART) and investigated the association between exposure to active smoking and risk for suboptimal adherence to ART. Main text: We searched PubMed, Embase, and Web of Science to identify articles published until September 19, 2019. Eligible studies reported the prevalence of active smoking in PLHIV on ART or investigated the association between active smoking and ART adherence; or enough data to compute these estimates. We used a random-effects model to pool data and quantified heterogeneity ( I 2 ). The global prevalence of active smoking was 36.1% (95% CI : 33.7–37.2; 329 prevalence data; 462 104 participants) with substantial heterogeneity. The prevalence increased with level of country income; from 10.1% (95% CI : 6.8–14.1) in low-income to 45.2% (95% CI : 42.7–47.7) in high-income countries; P  < 0.0001. With regards to the Joint United Nations Programme on HIV/AIDS (UNAIDS) regions, the prevalence was higher in West and Central Europe and North America 45.4% (42.7–48.1) and lowest in the two UNAIDS regions of sub-Saharan Africa: Eastern and Southern Africa 10.7% (95% CI : 7.8–14.0) and West and Central Africa 4.4% (2.9–6.3); P  < 0.0001. Globally, we estimated that there were 4 110 669 PLHIV on ART who were active smokers, among which the highest number was from Eastern and Southern Africa (35.9%) followed by Asia and the Pacific (25.9%). Active smoking was significantly associated with suboptimal ART adherence: pooled odds ratio 1.57 (95% CI : 1.37–1.80; I 2  = 56.8%; 19 studies; 48 450 participants); even after considering adjusted estimates: 1.67 (95% CI : 1.39–2.01; I 2  = 53.0%; 14 studies). Conclusions This study suggests a high prevalence of active smoking in PLHIV on ART and an association between active smoking and ART suboptimal adherence. As such, healthcare providers and policy makers should focus on adopting and implementing tobacco harm reduction strategies in HIV care, especially in sub-Saharan Africa known as epicenter of HIV pandemic with highest number of active tobacco smoking among PLHIV on ART.

Because of the unfortunate synergistic effects ofclimate change (including drought, heat and extreme precipitation), combined with the conditions of extreme poverty, malnutrition, and social unrest, there is little doubt climate change will worsen the common health problems we already experience in Africa. [...]without any greenhouse gases from natural processes in our atmosphere, our planet would be very cold. Hurricanes and floods, such as those experienced during Hurricanes Katrina and Sandy, result in human displacement and loss of healthcare access and infrastructure and foster the spread of infection, including diarrheal illness and pneumonia. Because of the myriad consequences for health, the Lancet Commission on Climate Change and Health concluded that \"tackling climate change could be the greatest global public health opportunity of the 21st century\" (4). [...]heat wave warnings are reserved for extremely hot summer days and therefore only address a small fraction of the days that are hot enough to increase deaths.

The goal of asthma treatment is to obtain and maintain a good control of symptoms. Investigating factors associated with inadequately control asthma could help in strategies to improve asthma control. This study aimed to determine the prevalence and factors associated with inadequately controlled asthma in asthma patients under chest specialist care. A cross-sectional study was conducted from November 2012 to May 2013. Physician-diagnosed asthma patients aged 12 years and above were included. A questionnaire was used to collect demographic data, comorbidities, and medical history of asthma. Asthma control was assessed using the Asthma Control Test (ACT), with a score less than 20 for inadequately controlled asthma and a score greater or equal to 20 for controlled asthma. A multivariate analysis was used to identify factors associated with inadequately controlled asthma. Overall, 243 patients were included in this study. Asthma was controlled in 141 patients (58%) and inadequately controlled in 102 (42%). The mean duration of asthma was 8 years with an interquartile range of 4 and 18 years. Forty-three participants (17.7%) were not under any controller medication while the mean ACT score was 19.3 ± 4.6. Independent associations were found between inadequately controlled asthma and female gender (OR 1.91; 95% CI 1.06-3.47) and obesity (OR 1.81; 1.01-3.27). Asthma remains poorly controlled in a large proportion of asthma patients under specialist care in Cameroon. Educational programs for asthma patients targeting women and based on weight loss for obese patients may help in improving the control of asthma.

ObjectiveTo determine the prevalence and determinants of excessive daytime sleepiness (EDS) among a group of sub-Saharan Africans living with hypertension.DesignA cross-sectional study.SettingCardiology outpatient unit of the Douala General Hospital in Cameroon.ParticipantsPatients aged 15 years and over, being followed for hypertension between 1st January and 31st July 2013. Patients with unstable heart failure, stroke and head trauma were excluded.Main outcome measureEDS was the outcome of interest. It was defined as an Epworth sleeping scale greater or equal to 10. Logistic regression was used to identify factors associated with EDS.ResultsA total of 411 patients participated in this study, with a sex ratio (male/female) of 0.58 and a mean age of 55.56 years. No patient was underweight and the mean body mass index was 30 kg/m2. Controlled blood pressure was found in 92 (22.4%) patients. The prevalence of EDS was 62.78% (95% CI 58.08 to 67.47). The factors independently associated with EDS were: type 2 diabetes (OR 2.51; 95% CI 1 to 6.29), obesity (OR 2.75; 95% CI 1.52 to 4.97), snoring (OR 7.92; 95% CI 4.43 to 14.15) and uncontrolled blood pressure (OR 4.34; 95% CI 2.24 to 8.40).ConclusionsA significant proportion of hypertensive patients suffer from EDS and present a high risk of sleep apnoea. Preventive measures targeted on weight loss, type 2 diabetes and snoring should be considered among these patients.

The fragile health system in Sierra Leone undermines healthcare, leading to substantial patient costs. We aimed to estimate the economic burden and inequalities in healthcare in urban informal settlements in Freetown, Sierra Leone. A cross-sectional survey was conducted in three informal settlements in Freetown in April and May 2023 to collect data on healthcare usage within and outside the boundaries of the informal settlements. Catastrophic expenditures were estimated using the payer's household budget. Logistic regression explored socioeconomic characteristics associated with catastrophic expenditures. Inequalities in healthcare expenditures were assessed through concentration curves and indices. A total of 2575 participants reported healthcare utilization. Dwarzark (US$6.9) and Moyiba (US$7.1) had higher costs than Cockle Bay (US$5.5) when utilizing healthcare within the communities. Households incurred higher costs when seeking healthcare outside their informal settlements than within (US$14 vs US$ 7). Over half of the households across the settlements incurred catastrophic expenditures when seeking care outside the communities (57%), with the poorest wealth quintile (poorest, 89%; wealthier, 12%) incurring in higher incidence. Attending informal healthcare had a protective effect against catastrophic expenditure for healthcare within the communities. Age + 35, residence in Dwarzark and Moyiba, and length of residence + 4 years were associated with catastrophic expenditures. Healthcare expenditure was progressive in Dwarzark and equally distributed across wealth quintiles in the other communities. Our findings indicate the need to provide accessible, affordable, and good-quality healthcare within communities to alleviate the catastrophic costs of healthcare utilization. The regulation of informal health providers and their integration into the formal health system should be considered.

The fragile health system in Sierra Leone undermines healthcare, leading to substantial patient costs. We aimed to estimate the economic burden and inequalities in healthcare in urban informal settlements in Freetown, Sierra Leone. A cross-sectional survey was conducted in three informal settlements in Freetown in April and May 2023 to collect data on healthcare usage within and outside the boundaries of the informal settlements. Catastrophic expenditures were estimated using the payer’s household budget. Logistic regression explored socioeconomic characteristics associated with catastrophic expenditures. Inequalities in healthcare expenditures were assessed through concentration curves and indices. A total of 2575 participants reported healthcare utilization. Dwarzark (US$6.9) and Moyiba (US$7.1) had higher costs than Cockle Bay (US$5.5) when utilizing healthcare within the communities. Households incurred higher costs when seeking healthcare outside their informal settlements than within (US$14 vs US$ 7). Over half of the households across the settlements incurred catastrophic expenditures when seeking care outside the communities (57%), with the poorest wealth quintile (poorest, 89%; wealthier, 12%) incurring in higher incidence. Attending informal healthcare had a protective effect against catastrophic expenditure for healthcare within the communities. Age + 35, residence in Dwarzark and Moyiba, and length of residence + 4 years were associated with catastrophic expenditures. Healthcare expenditure was progressive in Dwarzark and equally distributed across wealth quintiles in the other communities. Our findings indicate the need to provide accessible, affordable, and good-quality healthcare within communities to alleviate the catastrophic costs of healthcare utilization. The regulation of informal health providers and their integration into the formal health system should be considered.