Health interventions among mobile pastoralists: a systematic review to guide health service design

Evaluation of mobile clinics by MSF in pastoralist community in Doolo Zone, Somali region, Ethiopia

BACKGROUND

The Somali region in Ethiopia has poor health infrastructure, coupled with the adversity experienced by the largely pastoralist population through frequent droughts, disease outbreaks and conflict. From January 2019, MSF strategically focused on improving access to primary healthcare in the Doolo zone of the Somali region by providing 15-20 mobile clinics covering a wide geographical area. We aimed to evaluate the extent to which mobile clinics were an appropriate and effective modality to deliver healthcare for populations living in the region.

METHODS

In this mixed-methods study, we conducted a descriptive analysis of 24 months of routine mobile clinic data (February 2019 to January 2021) to evaluate the appropriateness and effectiveness of mobile clinics. We conducted a patient satisfaction survey to assess perceived benefits and challenges, as well as seven interviews with MSF medical staff and four focus group discussions with community members from mobile clinic sites to explore the appropriateness, effectiveness, and connectedness of mobile clinics.

RESULTS

MSF mobile clinics conducted 90,542 outpatient consultations, across 30 mobile clinic sites during the two-year period. However, there were gaps in continuity of care. The ratio of follow-up-to-first antenatal care visits was 0.82, and the ratio of third-to-first dose of DTP/Hib/HepB vaccine was 0.39. The current mobile clinic strategy is generally well perceived by the community in terms of the quality of services provided. However, MSF staff and community members expressed that its appropriateness and effectiveness are limited by mobile clinic opening hours, large patient volumes, referral policies, staffing, and drug supply issues.

CONCLUSIONS

Limited opening hours, large patient volumes, weak referral processes and supply issues impacted the appropriateness and effectiveness of healthcare provision by mobile clinics to this pastoralist population. These challenges are consistent with those faced by mobile clinics in other contexts. To enhance the effectiveness and appropriateness of mobile clinics for pastoralist populations requires collaboration with both community members and local authorities to design and regularly review the locations, frequency, healthcare service package and referral policies of mobile clinics.

Vaccination strategies to identify and reach zero-dose and under-immunized children in crisis-affected states in Sudan: a qualitative study

BACKGROUND

Globally, 21 million children were un- or under-vaccinated with Diphtheria-Tetanus-Pertussis (DTP)-containing vaccines in 2023. Around 20% of zero-dose children, those who had not received any DTP doses, live in conflict-affected settings in low and middle-income countries. There is insufficient evidence on vaccination interventions to identify and reach zero-dose children in these settings. This study aimed to map and assess current vaccination strategies to identify and reach zero-dose and under-vaccinated children in the crisis-affected states of South Kordofan, South Darfur and Blue Nile in Sudan.

METHODS

We conducted a cross-sectional qualitative study guided by the (Identify-Reach-Monitor-Measure-Advocate (IRMMA) framework, developed by Gavi, the Vaccine Alliance. We conducted 20 individual semi-structured interviews during November and December 2022. We interviewed governmental and non-governmental vaccination stakeholders at federal, state and locality levels. We used the IRMMA framework to analyze the interview transcripts.

RESULTS

Zero-dose and under-immunized children in the study sites were concentrated in opposition-controlled areas, nomadic communities, and remote rural areas. Zero-dose and under-immunized children in accessible areas were identified through routine vaccination strategies and surveillance reports. Various strategies were used in inaccessible areas. This includes tasking local institutions and individuals trusted by communities to identify and reach children, and infrequent integration and co-delivery of routine vaccines with other health interventions such as COVID-19 vaccination and insecticidal net distribution. There are inaccurate population estimates and a lack of guidance from ministries of health for measuring and monitoring zero-dose and under-immunized children. Respondents conflated advocacy with mobilization, and advocacy was broadly characterized as an ad hoc activity mostly connected to immunization campaigns.

CONCLUSIONS

Our study underscored the complexity of vaccinating zero-dose and under-immunized children in crisis-affected states of Sudan. Further research is needed to evaluate these practices and the role of non-governmental organizations (NGOs) and community engagement in improving vaccination coverage. Furthermore, exploring alternative funding methods and using geographic information systems (GIS) could enhance vaccination data and address funding limitations.

A One Health approach to pastoral (im)mobility, health, and disease: A qualitative participatory study in Plateau State, Nigeria

In Plateau State, pastoralism has historically been a cost effective and resilient economic system well-suited to the ecological context. However, changes in land use and conflict have increasingly changed patterns of mobility. Pastoralist movement is now often associated with zoonotic disease transmission, environmental degradation and conflict, increasingly resulting in forced sedentarisation. Rather than a direct outcome of population movement however, animal, human and zoonotic disease drivers are complex and influenced by a range of socio-economic and environmental factors. The interlinkages of (im)mobility and health requires better understanding of underlying vulnerabilities to disease, which we aim to address in this study. Using a multisite case study methodology we investigated pastoralists' animal and human health concerns and priorities in Plateau State, Nigeria. We deployed participatory tools, including open-ended Focus Group Discussions, transect walks, mapping exercises, calendars and matrices. Data were analysed using a One Health conceptual framework. We interviewed 105 participants, from transhumance, migratory and sedentary households, dependent on livestock and small-scale crops. While transhumance was often preferred, participants had become sedentary as a result of insecurity, loss in livestock, and household characteristics. Humans and animals suffered from several endemic diseases, including zoonoses, however veterinary and human health services are only available in larger towns, and people mostly rely on community (animal) health workers and self-medication. Both transhumance and sedentary livestock keepers face challenges around forage grazing, regularly blocked by landowners, sometimes escalating into conflict. While conflict and changes in land use affected animal and human disease patterns, underlying political, social and economic risk factors were important determinants of health. There is a need for more inclusive, transdisciplinary, multilevel approaches to address animal and human disease, based on better contextualization of the challenges, through the participation of affected communities.

Transmission of SARS-CoV-2 among underserved pastoralist communities in Kajiado County, Kenya: 2020-2022

Initial transmission of severe acute respiratory syndrome virus-2 (SARS-CoV-2) was highest in densely populated regions of Kenya. Transmission gradually trickled down to the less densely populated, remote and underserved regions such as the pastoral regions of Kajiado County which are characterized by poor healthcare systems. Molecular assays that were pivotal for COVID-19 diagnosis were not available in these regions. Serology is an alternative method for retrospectively tracking the transmission of SARS-CoV-2 in such populations. Dry blood spots (DBS) were prepared from consenting patients attending six health facilities in Kajiado County from March 2020 to March 2022. Upon elution, we conducted an enzyme-linked immunosorbent assay (ELISA) for the detection of SARS-Cov-2 IgG antibodies. Of the 908 DBSs we analyzed, 706 (78%) were from female participants. The overall seropositivity to SARS-Cov-2 antibodies was 7.3% (95% CI 5.7-9.1). The elderly (over 60 years) and male participants had a high likelihood of testing positive for SAR-CoV-2 infections. Mashuru (15.6%, 14/90) and Meto (15%, 19/127) health facilities registered the highest proportion of seropositive participants. Evidence of SARS-CoV-2 transmission among pastoralists in the remote and underserved regions of Kajiado County was established by DBS sampling and serologic testing.

Roles of health system leadership under emergency in drought-affected districts in northeast Uganda: a mixed-method study

OBJECTIVE

Health system leadership plays a critical role in sustaining healthcare delivery during emergencies. Thus, we aimed to assess the contribution of health system leadership in sustaining healthcare delivery under emergency conditions based on adaptive leadership theoretical framework.

DESIGN

We employed a concurrent mixed-methods study approach to assess health system leadership roles during emergency. This involved a quantitative survey administered to 150 health facilities managers/service focal persons selected via multistage sampling method from 15 districts, and qualitative interviews with 48 key informants who purposively selected.

PARTICIPANTS

We interviewed health facility managers, services focal persons, district health officers and residential district commissioners. We also reviewed weekly emergency situation reports and other relevant documents related to the emergency response. We used structured questionnaire, observation checklist and semistructured questionnaire to collect data. We employed descriptive statistics to analyse quantitative data and thematic analysis for qualitative data.

MAIN OUTCOME

Health system leadership contributions in sustaining healthcare delivery during emergencies.

RESULTS

Health system leadership was effective in leading emergency response and ensuring the continuity of health service during emergencies. Community engagement, partners coordination and intersectoral collaboration were effectively used in the emergency response and ensuring continuity of healthcare delivery. Deployment of experienced personnel and essential medical and non-medical supplies played a critical role in the continuity of health service. Availability of incidence management teams across health system significantly contributed to health system leadership. Participation of village health teams in community engagement and information communication helped in the success of health system leadership under emergency.

CONCLUSION

Adaptive health system leadership played a crucial role in managing health services delivery under emergency conditions. Effective partnership coordination and collaboration across sectors, frequent information communication, building local actor capacity and implementing scheduled supportive supervisions emerged as key strategies for sustaining health services during emergencies.

Perceived barriers of access to health and nutrition services under drought and food insecurity emergency in north-east Uganda: a qualitative study

BACKGROUND

In the face of drought and food insecurity emergency, evidence on access to health and nutrition services is important. Karamoja is one of the regions that have experienced extreme drought and food insecurity emergency in Uganda. As a part of the drought and food insecurity emergency response, World Health Organization (WHO) with Ministry of Health (MoH) has designed and implemented a qualitative study in 15 districts that have experienced drought and food insecurity emergency in north-east Uganda. Thus, we aimed to explore the barriers of access to health and nutrition services in drought and food insecurity emergency affected districts in north-east Uganda.

METHODS

We employed a descriptive qualitative study design. We interviewed 30 patients and 20 Village Health Teams (VHT) from 15 districts. We employed an in-depth interview with semi-structured questions to collect data until information saturation reached. We used thematic data analysis approach by ATLAS.ti version 7.5.1.8 software.

RESULTS

Of the 30 interviewed subjects, 15 were female, and the median age of the subjects was 29 years with interquartile range (IQR) of 23 to 37 years. Majority (68.8%) of subjects reported that access to health and nutrition services was harder to them. Four themes: sociocultural and economic; environmental; health system, and individual related factors were identified as the barriers of access to health and nutrition services.

CONCLUSION

The present study identified several modifiable barriers that hinder access to health and nutrition services in drought and food insecurity affected districts. Comprehensive interventions aimed at addressing sociocultural, economic, environmental, health system and subject related challenges are required to improve access to health and nutrition services in drought and food insecurity affected setups.

Identifying target areas for risk-based surveillance and control of transboundary animal diseases: a seasonal analysis of slaughter and live-trade cattle movements in Uganda

Animal movements are a major driver for the spread of Transboundary Animal Diseases (TADs). These movements link populations that would otherwise be isolated and hence create opportunities for susceptible and infected individuals to meet. We used social network analysis to describe the seasonal network structure of cattle movements in Uganda and unravel critical network features that identify districts or sub-regions for targeted risk-based surveillance and intervention. We constructed weighted, directed networks based on 2019 between-district cattle movements using official livestock mobility data; the purpose of the movement ('slaughter' vs. 'live trade') was used to subset the network and capture the risks more reliably. Our results show that cattle trade can result in local and long-distance disease spread in Uganda. Seasonal variability appears to impact the structure of the network, with high heterogeneity of node and edge activity identified throughout the seasons. These observations mean that the structure of the live trade network can be exploited to target influential district hubs within the cattle corridor and peripheral areas in the south and west, which would result in rapid network fragmentation, reducing the contact structure-related trade risks. Similar exploitable features were observed for the slaughter network, where cattle traffic serves mainly slaughter hubs close to urban centres along the cattle corridor. Critically, analyses that target the complex livestock supply value chain offer a unique framework for understanding and quantifying risks for TADs such as Foot-and-Mouth disease in a land-locked country like Uganda. These findings can be used to inform the development of risk-based surveillance strategies and decision making on resource allocation. For instance, vaccine deployment, biosecurity enforcement and capacity building for stakeholders at the local community and across animal health services with the potential to limit the socio-economic impact of outbreaks, or indeed reduce their frequency.

Constraints to maternal healthcare access among pastoral communities in the Darussalam area of Mudug region, Somalia "a qualitative study"

Background

While countries embrace efforts to achieve Sustainable Development Goals (SDG) goal 3.1 (to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030 and end preventable deaths of new-borns and children), an estimated 2.5 million pastoralists in Somalia are struggling to access maternal and child healthcare services. Institutional delivery and access to antenatal care remained to be a challenge in Somalia, where pastoralism is a common means of livelihood. The aim of this study is to explore the maternal health services available for settled pastoralists (transhumant) and their families who still practice nomadic pastoralism in the Mudug region of Somalia.

Methods

A qualitative study, including 14 interviews and one FGD, was conducted in Darussalam village (a transhumant village along the border between Somalia and Ethiopia), Puntland State, from December 2022 to January 2023. The study participants were community members who support the maternal and child health clinic (MCH), village administration, and health providers.

Results

We found that the efficiency of the health facilities that serve for pastoralist women and children are hampered by staff-related, supply-related, patients-related and referral-related constraints. This study highlights that the absence of essential supplies, the unmet need for training among the staff as well as the absence of important facilities in the MCH such as ambulance and blood bags.

Conclusion

Numerous strides could be made in the provision of affordable maternal healthcare to pastoralist communities in Darussalam areas of the Mudug region when organizations that support health care in Somalia and the Ministry of Health include pastoralists' healthcare in their priorities.