scholarly journals Linking household surveys and facility assessments: a comparison of geospatial methods using nationally representative data from Malawi

2020 ◽  
Vol 18 (1) ◽  
Author(s):  
Michael A. Peters ◽  
Diwakar Mohan ◽  
Patrick Naphini ◽  
Emily Carter ◽  
Melissa A. Marx
Keyword(s):  
Family Planning ◽  
Population Health ◽  
Health Survey ◽  
Catchment Area ◽  
National Level ◽  
Health Facilities ◽  
Modern Contraceptive ◽  
Household Surveys ◽  
Area Method ◽  
Administrative Boundary

Abstract Background Linking facility and household surveys through geographic methods is a popular technique to draw conclusions about the relationship between health services and population health outcomes at local levels. These methods are useful tools for measuring effective coverage and tracking progress towards Universal Health Coverage, but are understudied. This paper compares the appropriateness of several geospatial methods used for linking individuals (within displaced survey cluster locations) to their source of family planning (at undisplaced health facilities) at a national level. Methods In Malawi, geographic methods linked a population health survey, rural clusters from the Woman’s Questionnaire of the 2015 Malawi Demographic and Health Survey (MDHS 2015), to Malawi’s national health facility census to understand the service environment where women receive family planning services. Individuals from MDHS 2015 clusters were linked to health facilities through four geographic methods: (i) closest facility, (ii) buffer (5 km), (iii) administrative boundary, and (iv) a newly described theoretical catchment area method. Results were compared across metrics to assess the number of unlinked clusters (data lost), the number of linkages per cluster (precision of linkage), and the number of women linked to their last source of modern contraceptive (appropriateness of linkage). Results The closest facility and administrative boundary methods linked every cluster to at least one facility, while the 5-km buffer method left 288 clusters (35.3%) unlinked. The theoretical catchment area method linked all but one cluster to at least one facility (99.9% linked). Closest facility, 5-km buffer, administrative boundary, and catchment methods linked clusters to 1.0, 1.4, 21.1, and 3.3 facilities on average, respectively. Overall, the closest facility, 5-km buffer, administrative boundary, and catchment methods appropriately linked 64.8%, 51.9%, 97.5%, and 88.9% of women to their last source of modern contraceptive, respectively. Conclusions Of the methods studied, the theoretical catchment area linking method loses a marginal amount of population data, links clusters to a relatively low number of facilities, and maintains a high level of appropriate linkages. This linking method is demonstrated at scale and can be used to link individuals to qualities of their service environments and better understand the pathways through which interventions impact health.

scholarly journals Association between media exposure and family planning in Myanmar and Philippines: evidence from nationally representative survey data

2021 ◽  
Vol 6 (1) ◽  
Author(s):  
Pranta Das ◽  
Nandeeta Samad ◽  
Hasan Al Banna ◽  
Temitayo Eniola Sodunke ◽  
John Elvis Hagan ◽  
...  
Keyword(s):  
Family Planning ◽  
Mass Media ◽  
Health Survey ◽  
Unmet Need ◽  
Media Exposure ◽  
The Philippines ◽  
Education Level ◽  
Demographic And Health Survey ◽  
Modern Contraceptive ◽  
Mass Media Exposure

Abstract Background Although women in South Asia and South-east Asia have developed their knowledge regarding modern contraceptive and other family planning techniques, limited information exists on the influence of mass media exposure on the utilization of contraceptives and family planning. The current study examined the association between media exposure and family planning in Myanmar and Philippines. Methods The study analyzed data from the 2017 Philippines National Demographic and Health Survey (NDHS) and 2015–16 Myanmar Demographic and Health Survey (MDHS). Three family planning indicators were considered in this study (i.e., contraceptive use, demand satisfied regarding family planning and unmet need for family planning). A binary logistic regression model was fitted to see the effect of media exposure on each family planning indicator in the presence of covariates such as age group, residence, education level, partner education level, socio-economic status, number of living children, age at first marriage, and working status. Results The prevalence of contraception use was 57.2% in the Philippines and 55.7% in Myanmar. The prevalence of demand satisfied regarding family planning was 70.5 and 67.1% in the Philippines and Myanmar respectively. Unmet need regarding family planning was 16.6% and 19.9% in the Philippines and Myanmar respectively. After adjusting for the covariates, the results showed that women who were exposed to media were more likely to use contraception in Philippines (aOR = 2.24, 95% CI = 1.42–3.54) and Myanmar (aOR 1.39, 95% CI = 1.15–1.67). Media exposure also had a significant positive effect on demand satisfaction regarding family planning in the Philippines (aOR = 2.19, 95% CI = 1.42–3.37) and Myanmar (aOR = 1.34, 95% CI = 1.09–1.64). However, there was no significant association between media exposure and unmet need in both countries. Conclusions The study established a strong association between mass media exposure and the use and demand satisfaction for family planning among married and cohabiting women in Philippines and Myanmar. Using mass media exposure (e.g., local radio, television- electronic; newspapers) to increase both access and usage of contraceptives as well as other family planning methods in these countries could be pivotal towards the attainment of United Nations Sustainable Development Goal 3 (SDG 3) of improving maternal health.

scholarly journals Determinants Associated with Discontinuation of Modern Contraceptive in East Kalimantan: a Further Analysis of Indonesia Demographic and Health Survey 2017

2020 ◽  
Vol 8 (2) ◽  
Author(s):  
Ike Anggraeni ◽  
Annisa Nurrachmawati ◽  
Winardi Winardi ◽  
Hasmawati Hasmawati ◽  
Dewi Endah Ramadhani
Keyword(s):  
Family Planning ◽  
Health Survey ◽  
Urban Areas ◽  
Demographic And Health Survey ◽  
Modern Contraceptive ◽  
Entertainment Education ◽  
Childbearing Age ◽  
Cross Sectional ◽  
East Kalimantan ◽  
Modern Contraceptives

The national family planning program in East Kalimantan needs to achieve a larger target on modern contraceptives. Despite the fertility decline, this program still facing increasing discontinuation rates. A better understanding of the factors behind the discontinuation of a modern method would help in improving programs. This study aims to analyze the determinants of discontinuation of modern contraceptive use. This was a cross-sectional study, the dataset came from Indonesia Demographic and Health Survey 2017 of East Kalimantan Province. The sample is all couples of childbearing age between 10–49 years with marital status who have used and are still using contraception (408 samples). Descriptive analyses were used to assess the reasons for discontinuation. Multiple logistic regression was used to estimate the likelihood of discontinuation by demographic characteristics and others. The proportion of respondents who continue using modern contraceptives was 51%, against 49% discontinuation. The reasons for discontinuation were the husband’s disapproval (31%) and health problems related to side effects (26.5%). In the multivariate analysis showed maternal age, women who live in urban areas, and women with birth planning near the future will have an opportunity to discontinue in modern contraceptives. It concluded that there is still high modern contraceptive discontinuation in East Kalimantan, therefore it needed for disseminating information through entertainment-education in social media, health workers better counseling services from also better tools, and include the male participation in family planning counseling. DETERMINAN YANG BERHUBUNGAN DENGAN PUTUS PAKAI KONTRASEPSI MODERN DI KALIMANTAN TIMUR: ANALISIS LANJUT SURVEI DEMOGRAFI DAN KESEHATAN INDONESIA 2017Program keluarga berencana nasional di Kalimantan Timur perlu mencapai target yang lebih baik dalam penggunaan kontrasepsi modern. Meskipun terdapat penurunan fertilitas, namun program keluarga berencana masih menghadapi peningkatan angka putus pakai. Pemahaman yang lebih baik tentang faktor-faktor di balik putus pakai metode kontrasepsi modern akan membantu meningkatkan program. Penelitian ini bertujuan menganalisis faktor-faktor penentu putus pakai penggunaan kontrasepsi modern. Desain penelitian ini adalah cross-sectional, set data berasal dari Survei Demografi Kesehatan Indonesia 2017 untuk Provinsi Kalimantan Timur. Sampel adalah semua pasangan usia subur berusia 10–49 tahun dengan status perkawinan baik bagi yang pernah menggunakan dan masih menggunakan kontrasepsi, yaitu 408 sampel. Analisis deskriptif digunakan untuk menilai alasan putus pakai. Regresi logistik berganda digunakan untuk memperkirakan kemungkinan putus pakai berdasar atas karakteristik demografis dan lainnya. Proporsi responden yang masih terus menggunakan kontrasepsi modern adalah 51% dibanding dengan 49% putus pakai. Alasan penghentian adalah ketidaksetujuan suami (31%) dan masalah kesehatan yang berkaitan dengan efek samping (26,5%). Dalam analisis multivariat menunjukkan usia ibu, wanita yang tinggal di daerah perkotaan, dan wanita dengan perencanaan kelahiran dalam waktu dekat akan memiliki kesempatan untuk berhenti menggunakan kontrasepsi modern. Dapat disimpulkan bahwa kejadian putus pakai kontrasepsi modern masih tinggi di Kalimantan Timur, oleh karena itu diperlukan diseminasi informasi melalui entertainment-education dalam sosial media, layanan konseling dari petugas kesehatan, serta alat bantu konseling yang lebih baik dan juga keikutsertaan pria dalam proses konseling.

scholarly journals Experiences of women, men and healthcare workers accessing family planning services in Malawi: A grounded theory

2020 ◽  
Vol 62 (1) ◽  
Author(s):  
Idesi T. Chilinda ◽  
Alison Cooke ◽  
Dame T. Lavender
Keyword(s):  
Grounded Theory ◽  
Family Planning ◽  
Healthcare Workers ◽  
Contraceptive Use ◽  
National Level ◽  
Modern Contraceptive ◽  
Core Category ◽  
Unwanted Pregnancies ◽  
Planning Methods ◽  
Family Planning Methods

Background: The importance of modern contraceptive methods in averting unwanted pregnancies has been acknowledged in Malawi. Currently, the country has registered the highest rates of unsafe abortions, unmet needs for contraception and a low contraceptive prevalence rate. Understanding why these rates exist is important. However, women’s views and experiences regarding uptake of family planning methods in Malawi have not been explored.Methods: A grounded theory methodology was used. Data were gathered through in-depth interviews with women (n = 18), men (n = 10), healthcare workers (n = 10) and non-participant observations of family planning clinic consultations (n = 10). Data were analysed using constant comparative technique. Methods of open, axial and selective coding enabled subsequent conceptualisations until theoretical saturation occurred.Results: The core category ‘disenabling environment prevents women’s family planning needs from being met’ provides an understanding of women’s, men’s and healthcare workers’ experiences of contraceptive use and non-use. The disenabling environment contributed to shaping women’s family planning experiences. This was supported by three main categories: navigating the processes, disempowerment of women and learning by chance.Conclusion: Findings from this study illuminate contextual issues into how women, men and healthcare workers experience family planning use and non-use in Malawi. A multifaceted strategy is required to support a woman’s family planning needs. At community level, awareness and education of family planning methods is required to actively inform all people in society so that they support a woman’s family planning needs. At national level, laws that would empower women with decision-making ought to be developed and enforced.

scholarly journals Family Planning Knowledge, Attitudes, and Practices among Married Men and Women in Rural Areas of Pakistan: Findings from a Qualitative Need Assessment Study

2015 ◽  
Vol 2015 ◽  
pp. 1-8 ◽  
Author(s):  
Ghulam Mustafa ◽  
Syed Khurram Azmat ◽  
Waqas Hameed ◽  
Safdar Ali ◽  
Muhammad Ishaque ◽  
...  
Keyword(s):  
Family Planning ◽  
Rural Areas ◽  
Healthcare Providers ◽  
Health Facilities ◽  
Qualitative Assessment ◽  
Modern Contraceptive ◽  
Modern Contraception ◽  
Attitudes And Practices ◽  
The Government ◽  
Knowledge Attitudes And Practices

This paper presents the findings of a qualitative assessment aimed at exploring knowledge, attitudes, and practices regarding family planning and factors that influence the need for and use of modern contraceptives. A descriptive exploratory study was conducted with married women and men aged between 15 and 40. Overall, 24 focus group discussions were conducted with male and female participants in three provinces of Pakistan. The findings reveal that the majority knew about some modern contraceptive methods, but the overall contraceptive use was very low. Knowledge and use of any contraceptive method were particularly low. Reasons for not using family planning and modern contraception included incomplete family size, negative perceptions, in-laws’ disapproval, religious concerns, side-effects, and lack of access to quality services. The majority preferred private facilities over the government health facilities as the later were cited as derided. The study concluded the need for qualified female healthcare providers, especially for long term family planning services at health facilities instead of camps arranged occasionally. Addressing issues around access, affordability, availability, and sociocultural barriers about modern contraception as well as involving men will help to meet the needs and ensure that the women and couples fulfill their childbearing and reproductive health goals.

scholarly journals Understanding the relationship between family planning method choices and modern contraceptive use: an analysis of geographically linked population and health facilities data in Haiti

2019 ◽  
Vol 4 (Suppl 5) ◽  
pp. e000765 ◽  
Author(s):  
Wenjuan Wang ◽  
Lindsay Mallick
Keyword(s):  
Family Planning ◽  
Rural Areas ◽  
Contraceptive Use ◽  
Urban Women ◽  
Buffer Zone ◽  
Health Facilities ◽  
Modern Contraceptive ◽  
Contraceptive Methods ◽  
Multiple Methods ◽  
Modern Contraceptive Use

IntroductionThis study linked data from the 2012 Haiti Demographic and Health Survey (DHS) and the 2013 Haiti Service Provision Assessment (SPA) to estimate the extent to which women’s contraceptive use is associated with the method choices available in Haiti’s health facilities.MethodsUsing Global Positioning System (GPS) data for DHS clusters and for health facilities, we linked each DHS cluster to all of the family planning facilities located within a specified distance, and then measured the cluster’s level of contraceptive method choice based on the number of facilities within the buffer zone that offered three or more modern contraceptive methods. Random intercept logistic regressions were used to model the variation in individual modern contraceptive use and the availability of multiple method choices at the cluster level.ResultsLimited number of family planning facilities in Haiti offered at least three modern contraceptive methods (51% in urban and 23% in rural). Seventeen percent of both rural and urban women lived in an area with low availability of multiple methods—meaning that no facility in the specified buffer zone offered three or more contraceptive methods. Another 29% of rural women and 41% of urban women had medium availability—that is, only one facility in the buffer zone offered three or more methods. In rural areas, compared with women living in a cluster with low availability of multiple methods, the odds of using a modern method are 73% higher for women living in a cluster with medium availability, and over twice as high for women living in a cluster with high availability. A similar positive relationship was also found in urban areas.ConclusionsWomen in Haiti have only limited proximity to a health facility offering a variety of contraceptive methods. Improving access to a range of methods available at health facilities near where people live is critical for increasing contraceptive use in both urban and rural areas of Haiti.

Risk Factors for Serious Falls Among Community-Based Seniors: Results from the National Population Health Survey

2002 ◽  
Vol 21 (1) ◽  
pp. 103-116 ◽  
Author(s):  
Paula C. Fletcher ◽  
John P. Hirdes
Keyword(s):  
Risk Factors ◽  
Population Health ◽  
Health Survey ◽  
Temporal Order ◽  
National Level ◽  
National Population Health Survey ◽  
Community Based ◽  
National Population ◽  
Definitive Evidence ◽  
Risk Factors For Falls

ABSTRACTThis paper examines factors associated with falling among approximately 3,100 individuals aged 65 and older who were participants in the 1994 National Population Health Survey (NPHS). The intent of the NPHS is to monitor the health of Canadians and risk factors that affect their health. Several factors were identified as increasing the risk of falling, such as advanced age, being female, certain medical conditions, medication use and impaired mobility. The results from this survey, conducted on a national level, confirm the findings of many studies utilizing smaller samples within individual communities. Continuation of the NPHS will aid in offering longitudinal data with respect to falls, and allow for establishing a temporal order prior to the fall event, in order to provide more definitive evidence with respect to risk factors for falls.

scholarly journals The aggregate effect of implementation strength of family planning programs on modern contraceptive use at the health systems level in rural Malawi

PLoS ONE ◽  
2021 ◽  
Vol 16 (11) ◽  
pp. e0232504
Author(s):  
Anooj Pattnaik ◽  
Diwakar Mohan ◽  
Amy Tsui ◽  
Sam Chipokosa ◽  
Hans Katengeza ◽  
...  
Keyword(s):  
Family Planning ◽  
Health Facility ◽  
Catchment Area ◽  
Contraceptive Use ◽  
Modern Contraceptive ◽  
Summary Measure ◽  
Modern Contraceptives ◽  
Family Planning Programs ◽  
Modern Contraceptive Use ◽  
Combined Impact

To explore the association between the strength of implementation of family planning (FP) programs on the use of modern contraceptives. Specifically, how strongly these programs are being implemented across a health facility’s catchment area in Malawi and the odds of a woman in that catchment area is using modern contraceptives. This information can be used to assess whether the combined impact of multiple large-scale FP programs is leading to change in the health outcomes they aim to improve. We used data from the 2017 Implementation Strength Assessment (ISA) that quantified how much of family planning programs at the health facility and community health worker levels were being implemented across every district of Malawi. We used a summary measure developed in a previous study that employs quantitative methods to combine data across FP domains and health system levels. We tested the association of this summary measure for implementation strength with household data from the 2015 Malawi Demographic Health Survey (DHS). We found that areas with stronger implementation of FP programs had higher odds of women using modern contraceptives compared with areas with weaker implementation. The association of ISA with use of modern contraception was different by education, marital status, and geography. After controlling for these factors, we found that the adjusted odds of using a modern contraceptive was three times higher in catchment areas with high implementation strength compared to those with lower strength. Metrics that summarize how strongly FP programs are being implemented were used to show a statistically significantly positive relationship between increasing implementation strength and higher rates of modern contraceptive use. Decisionmakers at the various levels of health authority can use this type of summary measure to better understand the combined impact of their diverse FP programming and inform future programmatic and policy decisions. The findings also reinforce the idea that having a well-supported and supplied cadre of community health workers supplementing FP provision at the health facility can be an important health systems mechanism, especially in rural settings and to target youth populations.

scholarly journals Experiences of women accessing family planning services in Malawi: A Grounded Theory Study

2019 ◽  
Author(s):  
Idesi Temwa Chilinda ◽  
Alison Cooke ◽  
Dame Tina Lavender
Keyword(s):  
Grounded Theory ◽  
Family Planning ◽  
Healthcare Workers ◽  
Contraceptive Use ◽  
Health Centre ◽  
National Level ◽  
Modern Contraceptive ◽  
Contraception Use ◽  
Planning Methods ◽  
Family Planning Methods

Abstract Background The importance of modern contraceptive methods in averting unwanted pregnancies has been acknowledged in Malawi. Currently, the country has registered highest rates of unsafe abortions, slow decline in maternal mortality, unmet needs for contraception and a low contraceptive prevalence rate. Understanding why these rates exist is important. However, women’s views and experiences regarding uptake of family planning methods in Malawi have not been explored.Methods A grounded theory methodology was used. Data were gathered through in-depth interviews with women (n=18), men (n=10), healthcare workers (n=10); and non-participant observations of family planning clinic consultations (n=10) at three health centre settings in Malawi. Interviews, field notes and memos were analysed using constant comparative technique. Methods of open, axial and selective coding enabled subsequent conceptualisations until theoretical saturation occurred.Results The core category “disenabling environment prevents women’s family planning needs from being met” provides an understanding of women’s, men’s and healthcare workers’ experiences of contraceptive use and non-use. The disenabling environment contributed to shaping women’s family planning experiences. This was supported by three main categories: navigating the processes, disempowerment of women and learning by chance. Access to contraception use was influenced by personal beliefs and motivations, procedures to follow and inadequate resources. Women were disempowered from using contraception due to societal demands and cultural influences.Conclusion Findings from this study illuminate contextual issues into how women, men and healthcare workers experience family planning use and non-use in Malawi. A multifaceted strategy is required to support a woman’s family planning needs. At community level, awareness and education of family planning methods is required to actively inform all people in society so that they support a woman’s family planning needs. At national level, laws that would empower women with decision-making ought to be developed and enforced.

scholarly journals The aggregate effect of implementation strength of family planning programs on modern contraceptive use at the health systems level in rural Malawi

2020 ◽  
Author(s):  
Anooj Pattnaik ◽  
Diwakar Mohan ◽  
Amy Tsui ◽  
Sam Chipokosa ◽  
Hans Katengeza ◽  
...  
Keyword(s):  
Family Planning ◽  
Health Facility ◽  
Catchment Area ◽  
Contraceptive Use ◽  
Modern Contraceptive ◽  
Summary Measure ◽  
Modern Contraceptives ◽  
Family Planning Programs ◽  
Modern Contraceptive Use ◽  
Combined Impact

AbstractBackgroundTo explore the association between the strength of implementation of family planning (FP) programs on the use of modern contraceptives. Specifically, how strongly these programs are being implemented across a health facility’s catchment area in Malawi and the odds of a woman in that catchment area is using modern contraceptives. This information can be used to assess whether the combined impact of multiple large-scale FP programs is leading to change in the health outcomes they aim to improve.Methods and findingsWe used data from the 2017 Implementation Strength Assessment (ISA) that quantified how much of family planning programs at the health facility and community health worker levels were being implemented across every district of Malawi. We used a summary measure developed in a previous study that employs quantitative methods to combine data across FP domains and health system levels. We tested the association of this summary measure for implementation strength with household data from the 2015 Malawi Demographic Health Survey (DHS). We found that areas with stronger implementation of FP programs had higher odds of women using modern contraceptives compared with areas with weaker implementation. The association of ISA with use of modern contraception was different by education, marital status, and geography. After controlling for these factors, we found that the adjusted odds of using a modern contraceptive was three times higher in catchment areas with high implementation strength compared to those with lower strength.ConclusionMetrics that summarize how strongly FP programs are being implemented were used to show a statistically significantly positive relationship between increasing implementation strength and higher rates of modern contraceptive use. Decisionmakers at the various levels of health authority can use this type of summary measure to better understand the combined impact of their diverse FP programming and inform future programmatic and policy decisions. The findings also reinforce the idea that having a well-supported and supplied cadre of community health workers supplementing FP provision at the health facility can be an important health systems mechanism, especially in rural settings and to target youth populations.

scholarly journals Prevalence and associated factors of caesarian section in Ethiopia: a multilevel analysis of the 2019 Ethiopia Mini Demographic Health Survey

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Samuel Hailegebreal ◽  
Girma Gilano ◽  
Binyam Tariku Seboka ◽  
Mohammedjud Hassen Ahmed ◽  
Atsedu Endale Simegn ◽  
...  
Keyword(s):  
Health Survey ◽  
Associated Factors ◽  
National Level ◽  
Educational Status ◽  
Caesarian Section ◽  
Modern Contraceptive ◽  
Age Group ◽  
Individual Level ◽  
Country Level ◽  
Level Data

Abstract Background Caesarian section is a vital emergency obstetric intervention for saving the lives of mothers and newborns. However, factors which are responsible for caesarian section (CS) were not well established in the country level data. Therefore, this study aimed to assess the prevalence and associated factors of caesarian section in Ethiopia. Methods Data from the Ethiopian Mini Demographic and Health survey 2019 were used to identify factors associated with the caesarian section in Ethiopia. We applied multi-level logistic regression and a p-value of <0.25 to include variables before modeling and a p-value<0.05 with 95% confidence interval (CI) for final results. Result The prevalence of caesarian section in Ethiopia was 5.44% (95% CI; 0.048-0.06) in2019. Women in age group of 30-39 and 40-49 years had a higher odd of caesarian section (AOR = 2.14, 95%CI = 1.55-2.94) and (AOR = 2, 95%CI = 1.20-3.97) respectively compared to women in age group of 15-29 years. Women with secondary and higher educational level had higher odds of caesarian section (AOR = 2.15, 95%CI = 1.38-3.34) and (AOR = 2.8, 95%CI = 1.73-4.53) compared to those in no education category. Compared to Orthodox, Muslims and Protestant religions had lower odds of caesarian section with AOR of 0.50 (0.34-0.73) and 0.53 (0.34-0.85). Having <2 births was also associated with the low caesarian section 0.61(0.52-1.22). Using modern contraceptive methods, having ANC visits of 1-3, 4th, 5 plus, and urban residence were associated with higher odds of caesarian section as 1.4 (1.05-1.80]), 2.2 (1.51-3.12), 1.7 (1.12-2.46), and 2.4 (1.65-3.44) 1.6(1.04-2.57) respectively. Conclusion Although evidence indicates that the caesarian deliveries increased both in developed and underdeveloped countries, the current magnitude of this service was very low in Ethiopia which might indicate missing opportunities that might costing lives of mothers and newborns. Women’s age, religion, educational status, parity, contraceptive method, and ANC visit were individual level factors influenced caesarian section. whereas, region and place of residence were community level factors affected caesarian section in the country. Depending on these factors, the country needs policy decisions for further national level interventions.

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