Determinants of maternal healthcare utilization among married adolescents: Evidence from 13 Sub-Saharan African countries

F. Iacoella; N. Tirivayi

doi:10.1016/j.puhe.2019.07.002

Determinants of maternal healthcare utilization among married adolescents: Evidence from 13 Sub-Saharan African countries

F. Iacoella^*, N. Tirivayi

^*Corresponding author for this work

Research output: Contribution to journal › Article › Academic › peer-review

8 Citations (Web of Science)

Abstract

Objectives: Child and adolescent marriage are widely prevalent in some developing countries, and yet evidence on the maternal healthcare utilization of married adolescents is sparse. This study sought to identify the determinants of maternal healthcare utilization among married adolescents in 13 countries with the highest adolescent marriage rates in Sub-Saharan Africa. Study design: This is a multicountry cross-sectional analysis. Methods: Demographic and Health Survey data on 4288 married adolescents were used. Multivariable logistic regressions were used to identify the individual- and household-level predictors of the utilization of antenatal care, safe delivery and postnatal care. Results: Wealth and access to media were positively associated with the utilization of all types of maternal healthcare services. Female education and partner education were positively associated with antenatal care. Predictors of safe delivery included urban residence (odds ratio [OR] = 1.87; 95% confidence interval [CI] = 1.15–3.03), female education (OR = 1.37; 95% CI = 1.16–1.60) and number of living children (OR = 1.25; 95% CI = 1.01,1.54), whereas positive correlates of postnatal care were urban residence (OR = 1.35; 95% CI = 1.00–1.82), partner education (OR = 1.32; 95% CI = 1.12–1.56) and employment (OR = 1.43; 95% CI = 1.07,1.89). Full antenatal care and safe delivery utilization were associated with increased postnatal care utilization. Second or third birth order and associated birth intervals were strong barriers to maternal healthcare utilization. Although autonomy in decision-making over financial spending and relationships were positively associated with full antenatal care (OR = 1.09; 95% CI = 1.03–1.14), the results suggest that autonomy over personal healthcare decisions had an opposite relationship (OR = 0.76; 95% CI = 0.58–1.01). Conclusions: Living conditions and autonomy in decision-making over resources and relationships are facilitators of maternal healthcare utilization among married adolescents. Determinants observed in this multicountry study can help shape maternal healthcare interventions in context with high child and teenage marriage rates.

Original language	English
Pages (from-to)	1-9
Number of pages	9
Journal	Public Health
Volume	177
DOIs	https://doi.org/10.1016/j.puhe.2019.07.002
Publication status	Published - Dec 2019

JEL classifications

i15 - Health and Economic Development

Keywords

Adolescent
Africa South of the Sahara
Africa south of the Sahara
Cross-Sectional Studies
Decision Making
Demography
Female
Humans
Marriage
Married adolescents
Maternal Health Services
Maternal health care
Multi-country analysis
Patient Acceptance of Health Care
Personal Autonomy
Pregnancy
Social Conditions
Sub-Saharan Africa
accessibility
adolescence
adolescent
article
autonomy
birth order
child
controlled study
cross-sectional study
decision making
demography
developing world
education
employment
family planning
female
health care
health care utilization
health policy
health survey
household
human
human experiment
major clinical study
male
marriage
married person
maternal care
maternal health
maternal health service
patient attitude
personal autonomy
policy approach
postnatal care
pregnancy
prenatal care
social status
young population
SERVICES
MOTHERS
CHILD
WOMEN
MORTALITY
ANTENATAL CARE

Access to Document

10.1016/j.puhe.2019.07.002

Cite this

@article{4b3b7dd010dd413987c0520c580d036d,

title = "Determinants of maternal healthcare utilization among married adolescents: Evidence from 13 Sub-Saharan African countries",

abstract = "Objectives: Child and adolescent marriage are widely prevalent in some developing countries, and yet evidence on the maternal healthcare utilization of married adolescents is sparse. This study sought to identify the determinants of maternal healthcare utilization among married adolescents in 13 countries with the highest adolescent marriage rates in Sub-Saharan Africa. Study design: This is a multicountry cross-sectional analysis. Methods: Demographic and Health Survey data on 4288 married adolescents were used. Multivariable logistic regressions were used to identify the individual- and household-level predictors of the utilization of antenatal care, safe delivery and postnatal care. Results: Wealth and access to media were positively associated with the utilization of all types of maternal healthcare services. Female education and partner education were positively associated with antenatal care. Predictors of safe delivery included urban residence (odds ratio [OR] = 1.87; 95% confidence interval [CI] = 1.15–3.03), female education (OR = 1.37; 95% CI = 1.16–1.60) and number of living children (OR = 1.25; 95% CI = 1.01,1.54), whereas positive correlates of postnatal care were urban residence (OR = 1.35; 95% CI = 1.00–1.82), partner education (OR = 1.32; 95% CI = 1.12–1.56) and employment (OR = 1.43; 95% CI = 1.07,1.89). Full antenatal care and safe delivery utilization were associated with increased postnatal care utilization. Second or third birth order and associated birth intervals were strong barriers to maternal healthcare utilization. Although autonomy in decision-making over financial spending and relationships were positively associated with full antenatal care (OR = 1.09; 95% CI = 1.03–1.14), the results suggest that autonomy over personal healthcare decisions had an opposite relationship (OR = 0.76; 95% CI = 0.58–1.01). Conclusions: Living conditions and autonomy in decision-making over resources and relationships are facilitators of maternal healthcare utilization among married adolescents. Determinants observed in this multicountry study can help shape maternal healthcare interventions in context with high child and teenage marriage rates.",

keywords = "Adolescent, Africa South of the Sahara, Africa south of the Sahara, Cross-Sectional Studies, Decision Making, Demography, Female, Humans, Marriage, Married adolescents, Maternal Health Services, Maternal health care, Multi-country analysis, Patient Acceptance of Health Care, Personal Autonomy, Pregnancy, Social Conditions, Sub-Saharan Africa, accessibility, adolescence, adolescent, article, autonomy, birth order, child, controlled study, cross-sectional study, decision making, demography, developing world, education, employment, family planning, female, health care, health care utilization, health policy, health survey, household, human, human experiment, major clinical study, male, marriage, married person, maternal care, maternal health, maternal health service, patient attitude, personal autonomy, policy approach, postnatal care, pregnancy, prenatal care, social status, young population, SERVICES, MOTHERS, CHILD, WOMEN, MORTALITY, ANTENATAL CARE",

author = "F. Iacoella and N. Tirivayi",

note = "Correspondence Address: Iacoella, F.; Unu-Merit (United Nations University), Boschstraat 24, Netherlands; email: iacoella@merit.unu.edu References: United Nations, TRANSFORMING OUR WORLD: the 2030 agenda for sustainable development goals [Internet]. Geneva (2015), pp. 1-41. , https://sustainabledevelopment.un.org/content/documents/21252030 Agenda for Sustainable Development web.pdf, [cited 2018 Apr 27]; WHO, Trends in maternal mortality: 1990 to 2015 [Internet]. Geneva (2015), www.who.int/about/licensing/, [cited 2018 Feb 19]. Available from:; Ayiga, N., Rampagane, V., Determinants of age at first marriage in sub-Saharan Africa : a comparative study of Uganda and South Africa (2013) J Soc Dev Afr, 28 (1); Palamuleni, M.E., Socioeconomic determinants of age at marriage in Malawi (2011) Int J Sociol Anthropol, 3 (July), pp. 224-235; Morgan, J., Family honour and shattered dreams: girl brides in Mali, Niger and Senegal [Internet] (2016), https://www.girlsnotbrides.org/wp-content/uploads/2017/08/Plan_Family-honour-and-shattered-dreams_Web.pdf, Dakar [cited 2019 May 22]. Available from:; Walker, J.-A., Mapping early marriage in West Africa [Internet] (2013), https://www.girlsnotbrides.org/wp-content/uploads/2013/10/Ford-Foundation-CM-West-Africa-2013_09.pdf, [cited 2019 May 22]. Available from:; Lake, I.R.C., Chad basin crisis: an analysis of violence against women, children and displaced populations in the region [Internet] (2017), https://www.rescue-uk.org/sites/default/files/document/1328/reportoslo-analysisofviolenceagainstwomenchildrenanddisplacedpopulations-17march2017.pdf, [cited 2019 May 22]. Available from:; Why does child marriage happen? [Internet] (2018), https://www.girlsnotbrides.org/why-does-it-happen/, Available from:; Clark, S., Bruce, J., Dude, A., Protecting young women from HIV/AIDS: the case against child and adolescent marriage (2006) Int Fam Plan Perspect, 32 (2); Glynn, J., Carael, M., Auvert, B., Kahindo, M., Chege, J., Musonda, R., Why do young women have a much higher prevalence of HIV than young men? A study in Kisumu, Kenya and Ndola, Zambia (2001), AIDS; The State if the World's Children: Maternal and Newborn Health (2009), UNICEF, 3 United Nations Plaza New York, NY 10017, USA; Santhya, K., Erulkar, A., Supporting married girls: calling attention to a neglected group [Internet] (2011), http://www.popcouncil.org/uploads/pdfs/TABriefs/03_MarriedGirls.pdf, [cited 2018 Jul 2]. Available from:; Gavin, L., Galavotti, C., Dube, H., Mcnaghten, A.D., Murwirwa, M., Khan, R., Factors associated with HIV infection in adolescent females in Zimbabwe (2006) J Adolesc Heal [Internet], 39 (596), pp. 11-596. , https://ac.els-cdn.com/S1054139X06000826/1-s2.0-S1054139X06000826-main.pdf?_tid=597f2d27-0976-4dba-b252-91fbd345450b&acdnat=1530610592_8ccda7c929f52065d0b491e699f484ce, [cited 2018 Jul 3]; WHO, Early marriages, adolescent and young pregnancies [Internet]. New York (2011), http://apps.who.int/gb/ebwha/pdf_files/EB130/B130_12-en.pdf, [cited 2018 Feb 6]. 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Available from:; Temin, M., Levine, R., START with a girl a new agenda for global health a girls count report ON adolescent girls [Internet] (2009), https://www.cgdev.org/files/1422899_file_Start_with_a_Girl_FINAL.pdf, [cited 2018 Jul 2]. Available from:; Canning, D., Finlay, J., Ozaltin, E., Adolescent girls health agenda: study on Intergenerational health Impacts (2009), Harvard Sch Public Heal Unpubl; Prakash, R., Singh, A., Pathak, P., Parasuraman, S., Early marriage, poor reproductive health status of mother and child well-being in India (2011) J Fam Plan Reprod Health Care, 37 (3); Finlay, J.E., Zaltin, E., Canning, D., The association of maternal age with infant mortality, child anthropometric failure, diarrhoea and anaemia for first births: evidence from 55 low-and middle-income countries (2011) Br Med J [Internet], , https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3191600/pdf/bmjopen-2011-000226.pdf, [cited 2018 Jul 1];1(2); Available from:; Sawyer, S., Afifi, R., Bearinger, L., Blakemore, S., Dick, B., Ezeh, A., Adolescence: a foundation for future health (2012) Lancet, 279 (9826), pp. 1630-1640; Bhutta, Z.A., Darmstadt, G.L., Hasan, B.S., Haws, R.A., Community-based interventions for improving Perinatal and neonatal health outcomes in developing countries: a review of the evidence (2005) Pediatrics [Internet], , http://pediatrics.aappublications.org/, [cited 2018 Apr 27];115(519). 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year = "2019",

month = dec,

doi = "10.1016/j.puhe.2019.07.002",

language = "English",

volume = "177",

pages = "1--9",

journal = "Public Health",

issn = "0033-3506",

publisher = "Elsevier Saunders",

}

TY - JOUR

T1 - Determinants of maternal healthcare utilization among married adolescents: Evidence from 13 Sub-Saharan African countries

AU - Iacoella, F.

AU - Tirivayi, N.

N1 - Correspondence Address: Iacoella, F.; Unu-Merit (United Nations University), Boschstraat 24, Netherlands; email: iacoella@merit.unu.edu References: United Nations, TRANSFORMING OUR WORLD: the 2030 agenda for sustainable development goals [Internet]. Geneva (2015), pp. 1-41. , https://sustainabledevelopment.un.org/content/documents/21252030 Agenda for Sustainable Development web.pdf, [cited 2018 Apr 27]; WHO, Trends in maternal mortality: 1990 to 2015 [Internet]. Geneva (2015), www.who.int/about/licensing/, [cited 2018 Feb 19]. Available from:; Ayiga, N., Rampagane, V., Determinants of age at first marriage in sub-Saharan Africa : a comparative study of Uganda and South Africa (2013) J Soc Dev Afr, 28 (1); Palamuleni, M.E., Socioeconomic determinants of age at marriage in Malawi (2011) Int J Sociol Anthropol, 3 (July), pp. 224-235; Morgan, J., Family honour and shattered dreams: girl brides in Mali, Niger and Senegal [Internet] (2016), https://www.girlsnotbrides.org/wp-content/uploads/2017/08/Plan_Family-honour-and-shattered-dreams_Web.pdf, Dakar [cited 2019 May 22]. Available from:; Walker, J.-A., Mapping early marriage in West Africa [Internet] (2013), https://www.girlsnotbrides.org/wp-content/uploads/2013/10/Ford-Foundation-CM-West-Africa-2013_09.pdf, [cited 2019 May 22]. Available from:; Lake, I.R.C., Chad basin crisis: an analysis of violence against women, children and displaced populations in the region [Internet] (2017), https://www.rescue-uk.org/sites/default/files/document/1328/reportoslo-analysisofviolenceagainstwomenchildrenanddisplacedpopulations-17march2017.pdf, [cited 2019 May 22]. Available from:; Why does child marriage happen? [Internet] (2018), https://www.girlsnotbrides.org/why-does-it-happen/, Available from:; Clark, S., Bruce, J., Dude, A., Protecting young women from HIV/AIDS: the case against child and adolescent marriage (2006) Int Fam Plan Perspect, 32 (2); Glynn, J., Carael, M., Auvert, B., Kahindo, M., Chege, J., Musonda, R., Why do young women have a much higher prevalence of HIV than young men? A study in Kisumu, Kenya and Ndola, Zambia (2001), AIDS; The State if the World's Children: Maternal and Newborn Health (2009), UNICEF, 3 United Nations Plaza New York, NY 10017, USA; Santhya, K., Erulkar, A., Supporting married girls: calling attention to a neglected group [Internet] (2011), http://www.popcouncil.org/uploads/pdfs/TABriefs/03_MarriedGirls.pdf, [cited 2018 Jul 2]. Available from:; Gavin, L., Galavotti, C., Dube, H., Mcnaghten, A.D., Murwirwa, M., Khan, R., Factors associated with HIV infection in adolescent females in Zimbabwe (2006) J Adolesc Heal [Internet], 39 (596), pp. 11-596. , https://ac.els-cdn.com/S1054139X06000826/1-s2.0-S1054139X06000826-main.pdf?_tid=597f2d27-0976-4dba-b252-91fbd345450b&acdnat=1530610592_8ccda7c929f52065d0b491e699f484ce, [cited 2018 Jul 3]; WHO, Early marriages, adolescent and young pregnancies [Internet]. New York (2011), http://apps.who.int/gb/ebwha/pdf_files/EB130/B130_12-en.pdf, [cited 2018 Feb 6]. Available from:; Graft, A., Haverland, N., Goldber, R., Married adolescents: a review of programmes, paper presented at the WHO/UNFPA/Population Council Technical Consultation on married adolescents (2003), Geneva; Reynolds, H.W., Wong, E.L., Tucker, H., Adolescents' use of maternal and child health services in developing countries (2006) Int Fam Plan Perspect [Internet], 32 (1), pp. 6-16. , https://www.guttmacher.org/sites/default/files/article_files/3200606.pdf, [cited 2018 Feb 6];; Chopra, M., Daviaud, E., Pattinson, R., Fonn, S., Lawn, J.E., Saving the lives of South Africa's mothers, babies, and children: can the health system deliver? (2009) Lancet [Internet], , https://ac.els-cdn.com/S0140673609611235/1-s2.0-S0140673609611235-main.pdf?_tid=1c48b3a2-0361-452e-bd6f-49e90e93fba9&acdnat=1524820905_a21bef6d45d1f58a6490cb66851fb4ef, [cited 2018 Apr 27];374:835–46. Available from:; Temin, M., Levine, R., START with a girl a new agenda for global health a girls count report ON adolescent girls [Internet] (2009), https://www.cgdev.org/files/1422899_file_Start_with_a_Girl_FINAL.pdf, [cited 2018 Jul 2]. Available from:; Canning, D., Finlay, J., Ozaltin, E., Adolescent girls health agenda: study on Intergenerational health Impacts (2009), Harvard Sch Public Heal Unpubl; Prakash, R., Singh, A., Pathak, P., Parasuraman, S., Early marriage, poor reproductive health status of mother and child well-being in India (2011) J Fam Plan Reprod Health Care, 37 (3); Finlay, J.E., Zaltin, E., Canning, D., The association of maternal age with infant mortality, child anthropometric failure, diarrhoea and anaemia for first births: evidence from 55 low-and middle-income countries (2011) Br Med J [Internet], , https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3191600/pdf/bmjopen-2011-000226.pdf, [cited 2018 Jul 1];1(2); Available from:; Sawyer, S., Afifi, R., Bearinger, L., Blakemore, S., Dick, B., Ezeh, A., Adolescence: a foundation for future health (2012) Lancet, 279 (9826), pp. 1630-1640; Bhutta, Z.A., Darmstadt, G.L., Hasan, B.S., Haws, R.A., Community-based interventions for improving Perinatal and neonatal health outcomes in developing countries: a review of the evidence (2005) Pediatrics [Internet], , http://pediatrics.aappublications.org/, [cited 2018 Apr 27];115(519). Available from:; Tura, G., Fantahun, M., Worku, A., The effect of health facility delivery on neonatal mortality: systematic review and meta-analysis (2013) BMC Pregnancy Childbirth [Internet], , https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584809/pdf/1471-2393-13-18.pdf, [cited 2018 Feb 28];13:1:1–9. Available from:; Adolescent girls task force terms of reference [Internet] (2010), http://unesco.org.pk/education/documents/UNAGTF/UN_Adolescent_Girls_Task_Force.pdf; THE global strategy for WOMEN'S, CHILDREN'S and adolescents’ health (2016-2030) [Internet] (2016), https://data.unicef.org/wp-content/uploads/2017/02/EWEC_globalstrategyreport_200915_FINAL_WEB.pdf, [cited 2018 Feb 19]. Available from:; Rai, R.K., Singh, P.K., Kumar, C., Parasuraman, S., Teenage childbearing: a growing public health concern in need of urgent policy and program action (2013) J Public Health (Bangkok) [Internet], , https://link.springer.com/content/pdf/10.1007/s10389-012-0551-6.pdf, [cited 2018 Feb 28];21(4):379–84. Available from:; Patton, G.C., Coff, C., Cappa, C., Currie, D., Riley, L., Gore, F., Health of the world's adolescents: a synthesis of internationally comparable data (2012) Lancet [Internet], , https://ac.els-cdn.com/S0140673612602037/1-s2.0-S0140673612602037-main.pdf?_tid=8776daff-5097-4977-bfb6-f2d1384f28b7&acdnat=1530798457_f688c429cfe2d58dd3d9cf3ecb23eef3, [cited 2018 Jul 5];379(9826):1665–75. Available from:; WHO, Standards for maternal and neonatal care [Internet]. Geneva (2007), http://apps.who.int/iris/bitstream/10665/69735/1/a91272.pdf, [cited 2018 Feb 6]. 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PY - 2019/12

Y1 - 2019/12

N2 - Objectives: Child and adolescent marriage are widely prevalent in some developing countries, and yet evidence on the maternal healthcare utilization of married adolescents is sparse. This study sought to identify the determinants of maternal healthcare utilization among married adolescents in 13 countries with the highest adolescent marriage rates in Sub-Saharan Africa. Study design: This is a multicountry cross-sectional analysis. Methods: Demographic and Health Survey data on 4288 married adolescents were used. Multivariable logistic regressions were used to identify the individual- and household-level predictors of the utilization of antenatal care, safe delivery and postnatal care. Results: Wealth and access to media were positively associated with the utilization of all types of maternal healthcare services. Female education and partner education were positively associated with antenatal care. Predictors of safe delivery included urban residence (odds ratio [OR] = 1.87; 95% confidence interval [CI] = 1.15–3.03), female education (OR = 1.37; 95% CI = 1.16–1.60) and number of living children (OR = 1.25; 95% CI = 1.01,1.54), whereas positive correlates of postnatal care were urban residence (OR = 1.35; 95% CI = 1.00–1.82), partner education (OR = 1.32; 95% CI = 1.12–1.56) and employment (OR = 1.43; 95% CI = 1.07,1.89). Full antenatal care and safe delivery utilization were associated with increased postnatal care utilization. Second or third birth order and associated birth intervals were strong barriers to maternal healthcare utilization. Although autonomy in decision-making over financial spending and relationships were positively associated with full antenatal care (OR = 1.09; 95% CI = 1.03–1.14), the results suggest that autonomy over personal healthcare decisions had an opposite relationship (OR = 0.76; 95% CI = 0.58–1.01). Conclusions: Living conditions and autonomy in decision-making over resources and relationships are facilitators of maternal healthcare utilization among married adolescents. Determinants observed in this multicountry study can help shape maternal healthcare interventions in context with high child and teenage marriage rates.

AB - Objectives: Child and adolescent marriage are widely prevalent in some developing countries, and yet evidence on the maternal healthcare utilization of married adolescents is sparse. This study sought to identify the determinants of maternal healthcare utilization among married adolescents in 13 countries with the highest adolescent marriage rates in Sub-Saharan Africa. Study design: This is a multicountry cross-sectional analysis. Methods: Demographic and Health Survey data on 4288 married adolescents were used. Multivariable logistic regressions were used to identify the individual- and household-level predictors of the utilization of antenatal care, safe delivery and postnatal care. Results: Wealth and access to media were positively associated with the utilization of all types of maternal healthcare services. Female education and partner education were positively associated with antenatal care. Predictors of safe delivery included urban residence (odds ratio [OR] = 1.87; 95% confidence interval [CI] = 1.15–3.03), female education (OR = 1.37; 95% CI = 1.16–1.60) and number of living children (OR = 1.25; 95% CI = 1.01,1.54), whereas positive correlates of postnatal care were urban residence (OR = 1.35; 95% CI = 1.00–1.82), partner education (OR = 1.32; 95% CI = 1.12–1.56) and employment (OR = 1.43; 95% CI = 1.07,1.89). Full antenatal care and safe delivery utilization were associated with increased postnatal care utilization. Second or third birth order and associated birth intervals were strong barriers to maternal healthcare utilization. Although autonomy in decision-making over financial spending and relationships were positively associated with full antenatal care (OR = 1.09; 95% CI = 1.03–1.14), the results suggest that autonomy over personal healthcare decisions had an opposite relationship (OR = 0.76; 95% CI = 0.58–1.01). Conclusions: Living conditions and autonomy in decision-making over resources and relationships are facilitators of maternal healthcare utilization among married adolescents. Determinants observed in this multicountry study can help shape maternal healthcare interventions in context with high child and teenage marriage rates.

KW - Adolescent

KW - Africa South of the Sahara

KW - Africa south of the Sahara

KW - Cross-Sectional Studies

KW - Decision Making

KW - Demography

KW - Female

KW - Humans

KW - Marriage

KW - Married adolescents

KW - Maternal Health Services

KW - Maternal health care

KW - Multi-country analysis

KW - Patient Acceptance of Health Care

KW - Personal Autonomy

KW - Pregnancy

KW - Social Conditions

KW - Sub-Saharan Africa

KW - accessibility

KW - adolescence

KW - adolescent

KW - article

KW - autonomy

KW - birth order

KW - child

KW - controlled study

KW - cross-sectional study

KW - decision making

KW - demography

KW - developing world

KW - education

KW - employment

KW - family planning

KW - female

KW - health care

KW - health care utilization

KW - health policy

KW - health survey

KW - household

KW - human

KW - human experiment

KW - major clinical study

KW - male

KW - marriage

KW - married person

KW - maternal care

KW - maternal health

KW - maternal health service

KW - patient attitude

KW - personal autonomy

KW - policy approach

KW - postnatal care

KW - pregnancy

KW - prenatal care

KW - social status

KW - young population

KW - SERVICES

KW - MOTHERS

KW - CHILD

KW - WOMEN

KW - MORTALITY

KW - ANTENATAL CARE

U2 - 10.1016/j.puhe.2019.07.002

DO - 10.1016/j.puhe.2019.07.002

M3 - Article

C2 - 31470265

VL - 177

SP - 1

EP - 9

JO - Public Health

JF - Public Health

SN - 0033-3506

ER -