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Madera-Garcia V, Coalson JE, Subelj M, Bell ML, Hayden MH, Agawo M, Munga S, Ernst KC. Self-Reported Symptoms at Last Febrile Illness as a Predictor of Treatment-Seeking in Western Kenya: A Cross-Sectional Study. Am J Trop Med Hyg 2023; 108:212-220. [PMID: 36410323 PMCID: PMC9833091 DOI: 10.4269/ajtmh.21-0447] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/25/2022] [Indexed: 11/23/2022] Open
Abstract
Timely treatment-seeking behavior can reduce morbidity and mortality due to infectious diseases. Patterns of treatment-seeking behavior can differ by access to health care, and perceptions of disease severity and symptoms. We evaluated the association between self-reported symptoms at last illness and the level of treatment-seeking behaviors. We analyzed cross-sectional data from 1,037 participants from the lowlands and highlands of Western Kenya from 2015 using logistic regression models. There was considerable heterogeneity in the symptoms and treatment-seeking behaviors reported among individuals who were febrile at their last illness. A greater number of self-reported categories of symptoms tended to be associated with a higher likelihood of treatment-seeking in both sites. Participants were significantly more likely to seek treatment if they reported fever, aches, and digestive symptoms at last illness than just fever and aches or fever alone, but the frequency of treatment-seeking for fever in combination with aches and respiratory symptoms did not follow a consistent pattern. Among those who sought treatment, most used a formal source, but the patterns were inconsistent across sites and by the number of symptoms categories. Understanding the drivers of treatment-seeking behavior after febrile illness is important to control and treat infectious diseases in Kenya.
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Affiliation(s)
| | - Jenna E. Coalson
- Eck Institute for Global Health, University of Notre Dame, Notre Dame, Indiana
| | - Maja Subelj
- National Institute of Public Health, University of Ljubljana, Ljubljana, Slovenia
| | - Melanie L. Bell
- College of Public Health, University of Arizona, Tucson, Arizona
| | - Mary H. Hayden
- Lyda Hill Institute for Human Resilience, University of Colorado, Colorado Springs, Colorado
| | - Maurice Agawo
- Kenya Medical Research Institute, Kisian Research Station, Kenya
| | - Stephen Munga
- Kenya Medical Research Institute, Kisian Research Station, Kenya
| | - Kacey C. Ernst
- College of Public Health, University of Arizona, Tucson, Arizona
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Kaplowitz ET, Fiori KP, Lauria ME, Gbeleou S, Miziou A, Sowu E, Schechter J, Jones HE. Sexual Relationship Power and Socio-demographic Factors Predicting Contraceptive Use, Antenatal Visits and Sick Child Health Service Use in Northern Togo. Matern Child Health J 2020. [PMID: 32347439 DOI: 10.1007/s10995-020-02948-w.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Implementation of community-based healthcare services offering effective contraception, antenatal care (ANC), and treatment for symptomatic children under five has reduced maternal and child mortality in Togo. However, understanding if women are utilizing these services differentially based on social or demographic factors is important. This study identifies whether sexual relationship and socio-demographic factors are associated with healthcare utilization in four health facility catchment areas. METHODS We conducted a cross-sectional household survey of women aged 15-49 in four health facility catchment areas in 2016 (three rural sites, one urban site). We used multivariable Poisson regression to test whether socio-demographic factors and a validated sexual relationship power scale were associated with contraceptive use, ANC visits, and seeking treatment for symptomatic children under five. RESULTS Among women not pregnant or desiring pregnancy, older age, lower education, and single relationship status were associated with lower use of effective contraception. Among women who gave birth in two years preceding survey, low relationship power and low wealth quintile were associated with being less likely to attend at least four ANC visits. Women in rural sites were slightly more likely than women in the urban site to report seeking treatment for child under five with malaria, pneumonia, and/or diarrhea symptoms in last 2 weeks. DISCUSSION Interventions in low-resource settings should explore ways to reach women with low health-service utilization to improve contraceptive use, ANC visits, and treatment for sick children. Furthermore, age, education, marital status, wealth status and sexual relationship power must be considered when targeting maternal health behaviors. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03773913; Date of registration: 12 Dec. 2018.
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Affiliation(s)
- Elianna T Kaplowitz
- Department of Epidemiology and Biostatistics, City University of New York (CUNY) School of Public Health, New York, USA
| | - Kevin P Fiori
- Department of Family & Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA. .,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA. .,Community Health Systems Lab, Integrate Health/Santé Intégrée, Kara, Togo. .,Community Health Systems Lab, Integrate Health/Santé Intégrée, New York, NY, USA.
| | - Molly E Lauria
- Community Health Systems Lab, Integrate Health/Santé Intégrée, Kara, Togo.,Community Health Systems Lab, Integrate Health/Santé Intégrée, New York, NY, USA
| | | | | | | | | | - Heidi E Jones
- Department of Epidemiology and Biostatistics, City University of New York (CUNY) School of Public Health, New York, USA.,Community Health Systems Lab, Integrate Health/Santé Intégrée, Kara, Togo
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Kaplowitz ET, Fiori KP, Lauria ME, Gbeleou S, Miziou A, Sowu E, Schechter J, Jones HE. Sexual Relationship Power and Socio-demographic Factors Predicting Contraceptive Use, Antenatal Visits and Sick Child Health Service Use in Northern Togo. Matern Child Health J 2020; 24:845-855. [PMID: 32347439 DOI: 10.1007/s10995-020-02948-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Implementation of community-based healthcare services offering effective contraception, antenatal care (ANC), and treatment for symptomatic children under five has reduced maternal and child mortality in Togo. However, understanding if women are utilizing these services differentially based on social or demographic factors is important. This study identifies whether sexual relationship and socio-demographic factors are associated with healthcare utilization in four health facility catchment areas. METHODS We conducted a cross-sectional household survey of women aged 15-49 in four health facility catchment areas in 2016 (three rural sites, one urban site). We used multivariable Poisson regression to test whether socio-demographic factors and a validated sexual relationship power scale were associated with contraceptive use, ANC visits, and seeking treatment for symptomatic children under five. RESULTS Among women not pregnant or desiring pregnancy, older age, lower education, and single relationship status were associated with lower use of effective contraception. Among women who gave birth in two years preceding survey, low relationship power and low wealth quintile were associated with being less likely to attend at least four ANC visits. Women in rural sites were slightly more likely than women in the urban site to report seeking treatment for child under five with malaria, pneumonia, and/or diarrhea symptoms in last 2 weeks. DISCUSSION Interventions in low-resource settings should explore ways to reach women with low health-service utilization to improve contraceptive use, ANC visits, and treatment for sick children. Furthermore, age, education, marital status, wealth status and sexual relationship power must be considered when targeting maternal health behaviors. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03773913; Date of registration: 12 Dec. 2018.
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Affiliation(s)
- Elianna T Kaplowitz
- Department of Epidemiology and Biostatistics, City University of New York (CUNY) School of Public Health, New York, USA
| | - Kevin P Fiori
- Department of Family & Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA. .,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA. .,Community Health Systems Lab, Integrate Health/Santé Intégrée, Kara, Togo. .,Community Health Systems Lab, Integrate Health/Santé Intégrée, New York, NY, USA.
| | - Molly E Lauria
- Community Health Systems Lab, Integrate Health/Santé Intégrée, Kara, Togo.,Community Health Systems Lab, Integrate Health/Santé Intégrée, New York, NY, USA
| | | | | | | | | | - Heidi E Jones
- Department of Epidemiology and Biostatistics, City University of New York (CUNY) School of Public Health, New York, USA.,Community Health Systems Lab, Integrate Health/Santé Intégrée, Kara, Togo
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Alegana VA, Khazenzi C, Akech SO, Snow RW. Estimating hospital catchments from in-patient admission records: a spatial statistical approach applied to malaria. Sci Rep 2020; 10:1324. [PMID: 31992809 PMCID: PMC6987150 DOI: 10.1038/s41598-020-58284-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 01/07/2020] [Indexed: 01/20/2023] Open
Abstract
Admission records are seldom used in sub-Saharan Africa to delineate hospital catchments for the spatial description of hospitalised disease events. We set out to investigate spatial hospital accessibility for severe malarial anaemia (SMA) and cerebral malaria (CM). Malaria admissions for children between 1 month and 14 years old were identified from prospective clinical surveillance data recorded routinely at four referral hospitals covering two complete years between December 2015 to November 2016 and November 2017 to October 2018. These were linked to census enumeration areas (EAs) with an age-structured population. A novel mathematical-statistical framework that included EAs with zero observations was used to predict hospital catchment for malaria admissions adjusting for spatial distance. From 5766 malaria admissions, 5486 (95.14%) were linked to specific EA address, of which 272 (5%) were classified as cerebral malaria while 1001 (10%) were severe malaria anaemia. Further, results suggest a marked geographic catchment of malaria admission around the four sentinel hospitals although the extent varied. The relative rate-ratio of hospitalisation was highest at <1-hour travel time for SMA and CM although this was lower outside the predicted hospital catchments. Delineation of catchments is important for planning emergency care delivery and in the use of hospital data to define epidemiological disease burdens. Further hospital and community-based studies on treatment-seeking pathways to hospitals for severe disease would improve our understanding of catchments.
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Affiliation(s)
- Victor A Alegana
- Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box, 43640-00100, Nairobi, Kenya.
- Geography and Environmental Science, University of Southampton, SO17 1BJ, Southampton, UK.
- Faculty of Science and Technology, Lancaster University, LA1 4YR, Lancaster, UK.
| | - Cynthia Khazenzi
- Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box, 43640-00100, Nairobi, Kenya
| | - Samuel O Akech
- Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box, 43640-00100, Nairobi, Kenya
| | - Robert W Snow
- Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box, 43640-00100, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, OX3 7LJ, Oxford, UK
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Ilinca S, Di Giorgio L, Salari P, Chuma J. Socio-economic inequality and inequity in use of health care services in Kenya: evidence from the fourth Kenya household health expenditure and utilization survey. Int J Equity Health 2019; 18:196. [PMID: 31849334 PMCID: PMC6918604 DOI: 10.1186/s12939-019-1106-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 12/09/2019] [Indexed: 11/27/2022] Open
Abstract
Background Kenya is experiencing persistently high levels of inequity in health and access to care services. In 2018, decades of sustained policy efforts to promote equitable, affordable and quality health services have culminated in the launch of a universal health coverage scheme, initially piloted in four Kenyan counties and planned for national rollout by 2022. Our study aims to contribute to monitoring and evaluation efforts alongside policy implementation, by establishing a detailed, baseline assessment of socio-economic inequality and inequity in health care utilization in Kenya shortly before the policy launch. Methods We use concentration curves and corrected concentration indexes to measure socio-economic inequality in care use and the horizontal inequity index as a measure of inequity in care utilization for three types of care services: outpatient care, inpatient care and preventive and promotive care. Further insights into the individual and household level characteristics that determine observed inequality are derived through decomposition analysis. Results We find significant inequality and inequity in the use of all types of care services favouring richer population groups, with particularly pronounced levels for preventive and inpatient care services. These are driven primarily by differences in living standards and educational achievement, while the region of residence is a key driver for inequality in preventive care use only. Pro-rich inequalities are particularly pronounced for care provided in privately owned facilities, while public providers serve a much larger share of individuals from lower socio-economic groups. Conclusions Through its focus on increasing affordability of care for all Kenyans, the newly launched universal health coverage scheme represents a crucial step towards reducing disparities in health care utilization. However in order to achieve equity in health and access to care such efforts must be paralleled by multi-sectoral approaches to address all key drivers of inequity: persistent poverty, disparities in living standards and educational achievement, as well as regional differences in availability and accessibility of care.
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Affiliation(s)
- Stefania Ilinca
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland. .,European Centre for Social Welfare Policy and Research, Vienna, Austria.
| | | | - Paola Salari
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
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Achoki T, Miller-Petrie MK, Glenn SD, Kalra N, Lesego A, Gathecha GK, Alam U, Kiarie HW, Maina IW, Adetifa IMO, Barsosio HC, Degfie TT, Keiyoro PN, Kiirithio DN, Kinfu Y, Kinyoki DK, Kisia JM, Krish VS, Lagat AK, Mooney MD, Moturi WN, Newton CRJ, Ngunjiri JW, Nixon MR, Soti DO, Van De Vijver S, Yonga G, Hay SI, Murray CJL, Naghavi M. Health disparities across the counties of Kenya and implications for policy makers, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. LANCET GLOBAL HEALTH 2018; 7:e81-e95. [PMID: 30482677 PMCID: PMC6293072 DOI: 10.1016/s2214-109x(18)30472-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 08/03/2018] [Accepted: 10/03/2018] [Indexed: 12/21/2022]
Abstract
Background The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 provided comprehensive estimates of health loss globally. Decision makers in Kenya can use GBD subnational data to target health interventions and address county-level variation in the burden of disease. Methods We used GBD 2016 estimates of life expectancy at birth, healthy life expectancy, all-cause and cause-specific mortality, years of life lost, years lived with disability, disability-adjusted life-years, and risk factors to analyse health by age and sex at the national and county levels in Kenya from 1990 to 2016. Findings The national all-cause mortality rate decreased from 850·3 (95% uncertainty interval [UI] 829·8–871·1) deaths per 100 000 in 1990 to 579·0 (562·1–596·0) deaths per 100 000 in 2016. Under-5 mortality declined from 95·4 (95% UI 90·1–101·3) deaths per 1000 livebirths in 1990 to 43·4 (36·9–51·2) deaths per 1000 livebirths in 2016, and maternal mortality fell from 315·7 (242·9–399·4) deaths per 100 000 in 1990 to 257·6 (195·1–335·3) deaths per 100 000 in 2016, with steeper declines after 2006 and heterogeneously across counties. Life expectancy at birth increased by 5·4 (95% UI 3·7–7·2) years, with higher gains in females than males in all but ten counties. Unsafe water, sanitation, and handwashing, unsafe sex, and malnutrition were the leading national risk factors in 2016. Interpretation Health outcomes have improved in Kenya since 2006. The burden of communicable diseases decreased but continues to predominate the total disease burden in 2016, whereas the non-communicable disease burden increased. Health gains varied strikingly across counties, indicating targeted approaches for health policy are necessary. Funding Bill & Melinda Gates Foundation.
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Affiliation(s)
- Tom Achoki
- Sloan Management, Massachusetts Institute of Technology, Cambridge, MA, USA; Center for Pharmaceutical Policy and Regulation, Utrecht University, Utrecht, Netherlands
| | - Molly K Miller-Petrie
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Scott D Glenn
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Nikhila Kalra
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Abaleng Lesego
- Strategic Information and Learning, University of Research Company, Gaborone, Botswana
| | | | - Uzma Alam
- International Center for Humanitarian Affairs, Nairobi, Kenya
| | | | - Isabella Wanjiku Maina
- Policy, Planning, and Healthcare Financing Department, Nairobi, Kenya; Institute of Tropical Medicine, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Ifedayo M O Adetifa
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; Epidemiology and Demography Department, Kilifi, Kenya
| | - Hellen C Barsosio
- Malaria Branch, Kilifi, Kenya; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | | | - Yohannes Kinfu
- Faculty of Health, University of Canberra, Canberra, ACT, Australia; Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Vic, Australia
| | - Damaris K Kinyoki
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - James M Kisia
- East Africa Center, Humanitarian Leadership Academy, Nairobi, Kenya
| | - Varsha Sarah Krish
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Abraham K Lagat
- Department of Health Systems and Research Ethics, KEMRI-Wellcome Research Programme, Nairobi, Kenya
| | - Meghan D Mooney
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | | | - Charles Richard James Newton
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Collaborative Programme, Kilifi, Kenya; Department of Psychiatry, University of Oxford, Oxford, UK
| | | | - Molly R Nixon
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - David O Soti
- Eastern Africa Regional Collaborating Centre, African Centre for Disease Control and Prevention, Nairobi, Kenya
| | | | - Gerald Yonga
- School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Christopher J L Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Mohsen Naghavi
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA.
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Neighborhood Violence Impacts Disease Control and Surveillance: Case Study of Cali, Colombia from 2014 to 2016. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15102144. [PMID: 30274270 PMCID: PMC6211120 DOI: 10.3390/ijerph15102144] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 01/02/2023]
Abstract
Arboviruses are responsible for a large burden of disease globally and are thus subject to intense epidemiological scrutiny. However, a variable notably absent from most epidemiological analyses has been the impact of violence on arboviral transmission and surveillance. Violence impedes surveillance and delivery of health and preventative services and affects an individual’s health-related behaviors when survival takes priority. Moreover, low and middle-income countries bear a disproportionately high burden of violence and related health outcomes, including vector borne diseases. To better understand the epidemiology of arboviral outbreaks in Cali, Colombia, we georeferenced chikungunya (CHIKV), dengue (DENV), and Zika (ZIKV) viral cases from The National System of Surveillance in Public Health between October 2014 and April 2016. We extracted homicide data from the municipal monthly reports and kernel density of homicide distribution from IdeasPaz. Crucially, an overall higher risk of homicide is associated with increased risk of reported DENV, lower rates of acute testing, and higher rates of lab versus clinical discordance. In the context of high violence as a potential barrier to access to preventive health services, a community approach to improve health and peace should be considered.
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Dennis ML, Benova L, Owolabi OO, Campbell OMR. Meeting need vs. sharing the market: a systematic review of methods to measure the use of private sector family planning and childbirth services in sub-Saharan Africa. BMC Health Serv Res 2018; 18:699. [PMID: 30200964 PMCID: PMC6131793 DOI: 10.1186/s12913-018-3514-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 08/30/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ensuring universal access to maternal and reproductive health services is critical to the success of global efforts to reduce poverty and inequality. Engaging private providers has been proposed as a strategy for increasing access to healthcare in low- and middle-income countries; however, little consensus exists on how to estimate the extent of private sector use. Using research from sub-Saharan Africa, this study systematically compares and critiques quantitative measures of private sector family planning and childbirth service use and synthesizes evidence on the role of the private sector in the region. METHODS We conducted a systematic review of the Medline, Global Health, and Popline databases. All studies that estimated use of private sector of family planning or childbirth services in one or more sub-Saharan African countries were included in this review. For each study, we extracted data on the key study outcomes and information on the methods used to estimate private sector use. RESULTS Fifty-three papers met our inclusion criteria; 31 provided outcomes on family planning, and 26 provided childbirth service outcomes. We found substantial methodological variation between studies; for instance, while some reported on service use from any private sector source, others distinguished private sector providers either by their profit orientation or position within or outside the formal medical sector. Additionally, studies measured the use of private sector services differently, with some estimating the proportion of need met by the private sector and others examining the sector's share among the market of service users. Overall, the estimates suggest that the private sector makes up a considerable portion (> 20%) of the market for family planning and childbirth care, but its role in meeting women's need for these services is fairly low (< 10%). CONCLUSIONS Many studies have examined the extent of private sector family planning and childbirth service provision; however, inconsistent methodologies make it difficult to compare results across studies and contexts. Policymakers should consider the implications of both private market share and coverage estimates, and be cautious in interpreting data on the scale of private sector health service provision without a clear understanding of the methodology.
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Affiliation(s)
- Mardieh L. Dennis
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Lenka Benova
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | | | - Oona M. R. Campbell
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
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Prudhomme O’Meara W, Menya D, Laktabai J, Platt A, Saran I, Maffioli E, Kipkoech J, Mohanan M, Turner EL. Improving rational use of ACTs through diagnosis-dependent subsidies: Evidence from a cluster-randomized controlled trial in western Kenya. PLoS Med 2018; 15:e1002607. [PMID: 30016316 PMCID: PMC6049880 DOI: 10.1371/journal.pmed.1002607] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 06/08/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND More than half of artemisinin combination therapies (ACTs) consumed globally are dispensed in the retail sector, where diagnostic testing is uncommon, leading to overconsumption and poor targeting. In many malaria-endemic countries, ACTs sold over the counter are available at heavily subsidized prices, further contributing to their misuse. Inappropriate use of ACTs can have serious implications for the spread of drug resistance and leads to poor outcomes for nonmalaria patients treated with incorrect drugs. We evaluated the public health impact of an innovative strategy that targets ACT subsidies to confirmed malaria cases by coupling free diagnostic testing with a diagnosis-dependent ACT subsidy. METHODS AND FINDINGS We conducted a cluster-randomized controlled trial in 32 community clusters in western Kenya (population approximately 160,000). Eligible clusters had retail outlets selling ACTs and existing community health worker (CHW) programs and were randomly assigned 1:1 to control and intervention arms. In intervention areas, CHWs were available in their villages to perform malaria rapid diagnostic tests (RDTs) on demand for any individual >1 year of age experiencing a malaria-like illness. Malaria RDT-positive individuals received a voucher for a discount on a quality-assured ACT, redeemable at a participating retail medicine outlet. In control areas, CHWs offered a standard package of health education, prevention, and referral services. We conducted 4 population-based surveys-at baseline, 6 months, 12 months, and 18 months-of a random sample of households with fever in the last 4 weeks to evaluate predefined, individual-level outcomes. The primary outcome was uptake of malaria diagnostic testing at 12 months. The main secondary outcome was rational ACT use, defined as the proportion of ACTs used by test-positive individuals. Analyses followed the intention-to-treat principle using generalized estimating equations (GEEs) to account for clustering with prespecified adjustment for gender, age, education, and wealth. All descriptive statistics and regressions were weighted to account for sampling design. Between July 2015 and May 2017, 32,404 participants were tested for malaria, and 10,870 vouchers were issued. A total of 7,416 randomly selected participants with recent fever from all 32 clusters were surveyed. The majority of recent fevers were in children under 18 years (62.9%, n = 4,653). The gender of enrolled participants was balanced in children (49.8%, n = 2,318 boys versus 50.2%, n = 2,335 girls), but more adult women were enrolled than men (78.0%, n = 2,139 versus 22.0%, n = 604). At baseline, 67.6% (n = 1,362) of participants took an ACT for their illness, and 40.3% (n = 810) of all participants took an ACT purchased from a retail outlet. At 12 months, 50.5% (n = 454) in the intervention arm and 43.4% (n = 389) in the control arm had a malaria diagnostic test for their recent fever (adjusted risk difference [RD] = 9 percentage points [pp]; 95% CI 2-15 pp; p = 0.015; adjusted risk ratio [RR] = 1.20; 95% CI 1.05-1.38; p = 0.015). By 18 months, the ARR had increased to 1.25 (95% CI 1.09-1.44; p = 0.005). Rational use of ACTs in the intervention area increased from 41.7% (n = 279) at baseline to 59.6% (n = 403) and was 40% higher in the intervention arm at 18 months (ARR 1.40; 95% CI 1.19-1.64; p < 0.001). While intervention effects increased between 12 and 18 months, we were not able to estimate longer-term impact of the intervention and could not independently evaluate the effects of the free testing and the voucher on uptake of testing. CONCLUSIONS Diagnosis-dependent ACT subsidies and community-based interventions that include the private sector can have an important impact on diagnostic testing and population-wide rational use of ACTs. Targeting of the ACT subsidy itself to those with a positive malaria diagnostic test may also improve sustainability and reduce the cost of retail-sector ACT subsidies. TRIAL REGISTRATION ClinicalTrials.gov NCT02461628.
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Affiliation(s)
- Wendy Prudhomme O’Meara
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Moi University School of Public Health, College of Health Sciences, Eldoret, Kenya
| | - Diana Menya
- Moi University School of Public Health, College of Health Sciences, Eldoret, Kenya
| | - Jeremiah Laktabai
- Moi University School of Medicine, College of Health Sciences, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Alyssa Platt
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, United States of America
| | - Indrani Saran
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Elisa Maffioli
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Economics, Duke University, Durham, North Carolina, United States of America
| | - Joseph Kipkoech
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Manoj Mohanan
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Economics, Duke University, Durham, North Carolina, United States of America
- Sanford School of Public Policy, Duke University, Durham, North Carolina, United States of America
| | - Elizabeth L. Turner
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, United States of America
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Escamilla V, Calhoun L, Winston J, Speizer IS. The Role of Distance and Quality on Facility Selection for Maternal and Child Health Services in Urban Kenya. J Urban Health 2018; 95:1-12. [PMID: 29270709 PMCID: PMC5862698 DOI: 10.1007/s11524-017-0212-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Universal access to health care requires service availability and accessibility for those most in need of maternal and child health services. Women often bypass facilities closest to home due to poor quality. Few studies have directly linked individuals to facilities where they sought maternal and child health services and examined the role of distance and quality on this facility choice. Using endline data from a longitudinal survey from a sample of women in five cities in Kenya, we examine the role of distance and quality on facility selection for women using delivery, facility-based contraceptives, and child health services. A survey of public and private facilities offering reproductive health services was also conducted. Distances were measured between household cluster location and both the nearest facility and facility where women sought care. A quality index score representing facility infrastructure, staff, and supply characteristics was assigned to each facility. We use descriptive statistics to compare distance and quality between the nearest available facility and visited facility among women who bypassed the nearest facility. Facility distance and quality comparisons were also stratified by poverty status. Logistic regression models were used to measure associations between the quality and distance to the nearest facility and bypassing for each outcome. The majority of women bypassed the nearest facility regardless of service sought. Women bypassing for delivery traveled the furthest and had the fewest facility options near their residential cluster. Poor women bypassing for delivery traveled 4.5 km further than non-poor women. Among women who bypassed, two thirds seeking delivery and approximately 46% seeking facility-based contraception or child health services bypassed to a public hospital. Both poor and non-poor women bypassed to higher quality facilities. Our findings suggest that women in five cities in Kenya prefer public hospitals and are willing to travel further to obtain services at public hospitals, possibly related to free service availability. Over time, it will be important to examine service quality and availability in public sector facilities with reduced or eliminated user fees, and whether it lends itself to a continuum of care where women can visit one facility for multiple services reducing travel burden.
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Affiliation(s)
- Veronica Escamilla
- Carolina Population Center, University of North Carolina (UNC), Chapel Hill, NC, USA.
| | - Lisa Calhoun
- Carolina Population Center, University of North Carolina (UNC), Chapel Hill, NC, USA
| | - Jennifer Winston
- Department of Obstetrics and Gynecology - Division of Global Women's Health, UNC, Chapel Hill, NC, USA
| | - Ilene S Speizer
- Carolina Population Center, University of North Carolina (UNC), Chapel Hill, NC, USA
- Gillings School of Public Health, Department of Maternal and Child Health, UNC, Chapel Hill, NC, USA
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People living with HIV travel farther to access healthcare: a population-based geographic analysis from rural Uganda. J Int AIDS Soc 2016; 19:20171. [PMID: 26869359 PMCID: PMC4751409 DOI: 10.7448/ias.19.1.20171] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 12/09/2015] [Accepted: 01/07/2016] [Indexed: 11/21/2022] Open
Abstract
Introduction The availability of specialized HIV services is limited in rural areas of sub-Saharan Africa where the need is the greatest. Where HIV services are available, people living with HIV (PLHIV) must overcome large geographic, economic and social barriers to access healthcare. The objective of this study was to understand the unique barriers PLHIV face when accessing healthcare compared with those not living with HIV in a rural area of sub-Saharan Africa with limited availability of healthcare infrastructure. Methods We conducted a population-based cross-sectional study of 447 heads of household on Bugala Island, Uganda. Multiple linear regression models were used to compare travel time, cost and distance to access healthcare, and log binomial models were used to test for associations between HIV status and access to nearby health services. Results PLHIV travelled an additional 1.9 km (95% CI (0.6, 3.2 km), p=0.004) to access healthcare compared with those not living with HIV, and they were 56% less likely to access healthcare at the nearest health facility to their residence, so long as that facility lacked antiretroviral therapy (ART) services (aRR=0.44, 95% CI (0.24 to 0.83), p=0.011). We found no evidence that PLHIV travelled further for care if the nearest facility supplies ART services (aRR=0.95, 95% CI (0.86 to 1.05), p=0.328). Among those who reported uptake of care at one of two facilities on the island that provides ART (81% of PLHIV and 68% of HIV-negative individuals), PLHIV tended to seek care at a higher tiered facility that provides ART, even when this facility was not their closest facility (30% of PLHIV travelled further than the closest ART facility compared with 16% of HIV-negative individuals), and travelled an additional 2.2 km (p=0.001) to access that facility, relative to HIV-negative individuals (aRR=1.91, 95% CI (1.00 to 3.65), p=0.05). Among PLHIV, residential distance was associated with access to facilities providing ART (RR=0.78, 95% CI (0.61 to 0.99), p=0.044, comparing residential distances of 3–5 km to 0–2 km; RR=0.71, 95% CI (0.58 to 0.87), p=0.001, comparing residential distances of 6–10 km to 0–2 km). Conclusions PLHIV travel longer distances for care, a phenomenon that may be driven by both the limited availability of specialized HIV services and preference for higher tiered facilities.
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