Volume 96, Issue 2
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Globally, approximately 5.9 million children under 5 years of age died in 2015, a reduction of over 50% since 1990. Millennium Development Goal 4 established the goal of reducing child mortality by two-thirds by 2015. Multiple countries have surpassed this goal; however, regional and within-country inequities exist. We sought to study determinants of health-care utilization among children 6–59 months of age with fever, diarrhea, and respiratory symptoms in Zambézia Province, Mozambique. We conducted a population-based cross-sectional survey of female heads of household between April and May 2014. Mobile teams conducted interviews in 262 enumeration areas, with three distinct districts being oversampled for improved precision. Descriptive statistics and logistic regression using Stata 13.1 and R 3.2.2 were used to examine factors associated with health-care utilization. A total of 2,317 children were evaluated in this study. Mothers' median age was 26 years, whereas child median age was 24 months. The proportion of children reporting fever, diarrhea, or respiratory illness in the prior 30 days was 44%, 22%, and 22%, respectively. Health-care utilization varied with 65% seeking health care for fever, compared with 57% for diarrhea and 25% for respiratory illness. In multivariable logistic regression, the characteristics most associated with health-care utilization across illnesses were delivery of last child at a facility, higher maternal education, and household ownership of a radio. The decision or ability to use health care is a multifaceted behavior swayed by societal norms, values, socioeconomics, and perceived need. Recognizing the predictors of a particular population may offer useful information to increase uptake in health-care services.

[open-access] This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


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  1. United Nations Children's Emergency Fund (UNICEF), 2015. Committing to Child Survival: A Promise Renewed Progress Report. Available at: http://www.apromiserenewed.org/wp-content/uploads/2015/09/APR_2015_8_Sep_15.pdf. Accessed March 19, 2016.
  2. United Nations Inter-agency Group for Child Mortality Estimation (UN IGME), 2014. Levels and Trends in Child Mortality. Available at: http://www.unicef.org/media/files/Levels_and_Trends_in_Child_Mortality_2014.pdf. Accessed March 19, 2016.
  3. United Nations, 2015. The Millennium Development Goals Report 2015. Available at: http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG2015rev(July1).pdf. Accessed March 19, 2016.
  4. United Nations Economic Commission for Africa, 2015. Assessing Progress in Africa toward the Millennium Development Goals. Available at: http://www.uneca.org/sites/default/files/PublicationFiles/mdg-2015_eng_16sep_rev2.pdf. Accessed March 19, 2016.
  5. United Nations Development Program, 2015. Human Development Report 2015. Available at: http://hdr.undp.org/sites/all/themes/hdr_theme/country-notes/MOZ.pdf. Accessed March 19, 2016.
  6. World Bank–Working for a World Free of Poverty, 2015. Mortality Rate, Under-5 (per 1,000). Available at: http://data.worldbank.org/indicator/SH.DYN.MORT. Accessed March 19, 2016.
  7. United Nations Children's Emergency Fund (UNICEF), 2008. Multiple Indicator Cluster Surveys (MICS)–2008, Mozambique. Available at: http://www.childinfo.org/files/MICS3_Mozambique_FinalReport_2008.pdf. Accessed March 19, 2016.
  8. Ministry of Health, Mozambique, 2009. National Child Mortality Survey–2009, Mozambique. Available at: http://citeseerx.ist.psu.edu/viewdoc/download;jsessionid=8D22E59A605917E725DC7C8F77017B91?doi= Accessed March 19, 2016.
  9. Macassa G, Ghilagaber G, Charsmar H, Walander A, Sundin Ö, Soares J, , 2012. Geographic differentials in mortality of children in Mozambique: their implications for achievement of Millennium Development Goal 4. J Health Popul Nutr 30: 331.[Crossref]
  10. Fernandes QF, Wagenaar BH, Anselmi L, Pfeiffer J, Gloyd S, Sherr K, , 2014. Effects of health-system strengthening on under-5, infant, and neonatal mortality: 11-year provincial-level time-series analyses in Mozambique. Lancet Glob Health 2: e468e477.[Crossref]
  11. United Nations Children's Emergency Fund (UNICEF), 2010. Child Poverty and Disparities in Mozambique. Available at: http://www.unicef.org.mz/cpd/documents/Child-Poverty-2010.pdf. Accessed March 19, 2016.
  12. World Health Organization, 2013. Mozambique: Neonatal and Child Health Profile. Available at: http://www.who.int/maternal_child_adolescent/epidemiology/profiles/neonatal_child/moz.pdf. Accessed March 19, 2016.
  13. Victor B, Blevins M, Green AF, Ndatimana E, Gonzalez-Calvo L, Fischer EF, Vergara AE, Vermund SH, Olupona O, Moon TD, , 2014. Multidimensional poverty in rural Mozambique: a new metric for evaluating public health interventions. PLoS One 9: e108654.[Crossref]
  14. Nhampossa T, Mandomando I, Acacio S, Nhalungo D, Sacoor C, Nhacolo A, Macete E, Nhabanga A, Quintó L, Kotloff K, Levine MM, Nasrin D, Farag T, Bassat Q, Alonso P, , 2013. Health care utilization and attitudes survey in cases of moderate-to-severe diarrhea among children ages 0–59 months in the District of Manhica, southern Mozambique. Am J Trop Med Hyg 89: 41.[Crossref]
  15. Moshabela M, Schneider H, Silal SP, Cleary SM, , 2012. Factors associated with patterns of plural healthcare utilization among patients taking antiretroviral therapy in rural and urban South Africa: a cross-sectional study. BMC Health Serv Res 12: 182.[Crossref]
  16. Peterson S, Pariyo G, Rutebemberwa E, Tomson G, Kallander K, , 2009. Utilization of public or private health care providers by febrile children after user fee removal in Uganda. Malar J 8: 45.[Crossref]
  17. Leclere FB, Jensen L, Biddlecom AE, , 1994. Health care utilization, family context, and adaptation among immigrants to the United States. J Health Soc Behav 35: 370384.[Crossref]
  18. Marmot M, , 2005. Social determinants of health inequalities. Lancet 365: 10991104.[Crossref]
  19. Osaki K, Kosen S, Indriasih E, Pritasari K, Hattori T, , 2015. Factors affecting the utilisation of maternal, newborn, and child health services in Indonesia: the role of the Maternal and Child Health Handbook. Public Health 129: 582586.[Crossref]
  20. World Health Organization, 2004. Family and Community Practices That Promote Child Survival, Growth and Development: A Review of the Evidence. Available at: http://apps.who.int/iris/bitstream/10665/42924/1/9241591501.pdf. Accessed March 19, 2016.
  21. United Nations, 2012. United Nations System Task Team on the Post-2015 UN Development Agenda. Addressing Inequalities: The Heart of the Post-2015 Agenda and the Future We Want for All. Available at: http://www.un.org/millenniumgoals/pdf/ThinkPieces/10_inequalities.pdf. Accessed March 19, 2016.
  22. Berkley S, Chan M, Dybul M, Hansen K, Lake A, Osotimehin B, Sidibé M, , 2013. A healthy perspective: the post-2015 development agenda. Lancet 381: 1076.[Crossref]
  23. Gwatkin DR, , 2005. How much would poor people gain from faster progress towards the Millennium Development Goals for health? Lancet 365: 813817.[Crossref]
  24. Agadjanian V, Hayford SR, Luz L, Yao J, , 2015. Bridging user and provider perspectives: family planning access and utilization in rural Mozambique. Int J Gynaecol Obstet 130: E47E51.[Crossref]
  25. United Nations, 2014. Open Working Group Proposal for Sustainable Development Goals. Available at: https://sustainabledevelopment.un.org/content/documents/1579SDGsProposal.pdf. Accessed March 19, 2016.
  26. The Lancet, 2015. Health and the post-2015 development agenda. Lancet 381: 699.
  27. Presern C, , 2013. Placing populations' health at the heart of the post-2015 agenda. Bull World Health Organ 7: 467467A.[Crossref]
  28. Reidpath DD, Morel CM, Mecaskey JW, Allotey P, , 2009. The Millennium Development Goals fail poor children: the case for equity-adjusted measures. PLoS Med 6: e1000062.[Crossref]
  29. Amouzou A, Kozuki N, Gwatkin DR, , 2014. Where is the gap?: the contribution of disparities within developing countries to global inequalities in under-five mortality. BMC Public Health 14: 216.[Crossref]
  30. Carrera C, Azrack A, Begkoyian G, Pfaffmann J, Ribaira E, O'Connell T, Doughty P, Aung KM, Prieto L, Rasanathan K, Sharkey A, Chopra M, Knippenberg R, , 2012. The comparative cost-effectiveness of an equity-focused approach to child survival, health, and nutrition: a modelling approach. Lancet 380: 13411351.[Crossref]
  31. Gandhi G, , 2015. Charting the evolution of approaches employed by the Global Alliance for Vaccines and Immunizations (GAVI) to address inequities in access to immunization: a systematic qualitative review of GAVI policies, strategies and resource allocation mechanisms through an equity lens (1999–2014). BMC Public Health 15: 1198.[Crossref]
  32. Vergara A, Blevins M, Vaz LME, Manders EJ, Gonzalez-Calvo L, Arregui C, Green A, Olupona O, , 2011. Baseline Survey Report, SCIP–Ogumaniha: Improving Health and Livelihoods of Children, Women and Families in the Province of Zambézia, Republic of Mozambique—Phase I and II: Zambézia-wide. Available at: http://globalhealth.vanderbilt.edu/manage/wp-content/uploads/phase1and2_report.pdf. Accessed March 19, 2016.
  33. Harrell F, , 2015. Regression Modeling Strategies: With Applications to Linear Models, Logistic and Ordinal Regression, and Survival Analysis. New York: Springer.
  34. R Core Team, 2013. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing. Available at: http://www.R-project.org/. Accessed October 19, 2016.
  35. StataCorp, 2013. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP.
  36. Binka FN, Morris S, Ross D, Arthur P, Aryeetey M, , 1994. Patterns of malaria morbidity and mortality in children in northern Ghana. Trans R Soc Trop Med Hyg 88: 381385.[Crossref]
  37. Brewster DR, Greenwood BM, , 1993. Seasonal variation of paediatric diseases in The Gambia, west Africa. Ann Trop Paediatr 13: 133146.[Crossref]
  38. Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H, , 2008. Epidemiology and etiology of childhood pneumonia. Bull World Health Organ 86: 408.[Crossref]
  39. Pierce H, Heaton TB, Hoffmann J, , 2014. Increasing maternal healthcare use in Rwanda: implications for child nutrition and survival. Soc Sci Med 107: 61.[Crossref]
  40. Thind A, Andersen R, , 2003. Respiratory illness in the Dominican Republic: what are the predictors for health services utilization of young children? Soc Sci Med 56: 11731182.[Crossref]
  41. Thind A, Cruz AM, , 2003. Determinants of children's health services utilization in the Philippines. J Trop Pediatr 49: 269273.[Crossref]
  42. Tinuade O, Iyabo RA, Durotoye O, , 2010. Health-care-seeking behaviour for childhood illnesses in a resource-poor setting. J Paediatr Child Health 46: 238242.[Crossref]
  43. Lindelow M, , 2005. The utilisation of curative healthcare in Mozambique: does income matter? J Afr Econ 14: 435482.[Crossref]
  44. Filmer D, Pritchett LH, , 2001. Estimating wealth effects without expenditure data—or tears: an application to educational enrollments in states of India. Demography 38: 115132.
  45. Fosu GB, , 1989. Access to health care in urban areas of developing societies. J Health Soc Behav 30: 398411.[Crossref]
  46. Vosti S, , 1995. Choosing between public and private health-care: a case study of malaria treatment in Brazil. J Health Econ 14: 191.[Crossref]
  47. Buor D, , 2003. Mothers' education and childhood mortality in Ghana. Health Policy 64: 297309.[Crossref]
  48. Caldwell JC, , 1994. How is greater maternal education translated into lower child mortality? Health Transit Rev 4: 224229.
  49. Chakrabarti A, , 2012. Determinants of child morbidity and factors governing utilization of child health care: evidence from rural India. Appl Econ 44: 27.[Crossref]
  50. National Institute of Statistics, 2008. Inquérito de Indicadores Múltiplos 2008. Summary, Government of Mozambique, Maputo. Available at: http://www.ine.gov.mz/. Accessed March 19, 2016.
  51. Broeck JVD, Eeckels R, Massa GUY, , 1996. Maternal determinants of child survival in a rural African community. Int J Epidemiol 25: 9981004.[Crossref]
  52. Macassa G, Ghilagaber G, Bernhardt E, Diderichsen F, Burström B, , 2003. Inequalities in child mortality in Mozambique: differentials by parental socio-economic position. Soc Sci Med 57: 22552264.[Crossref]
  53. Yabiku ST, Agadjanian V, Cau B, , 2012. Labor migration and child mortality in Mozambique. Soc Sci Med 75: 25302538.[Crossref]

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  • Received : 23 Mar 2016
  • Accepted : 23 Sep 2016

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