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Ghosh R, Kayentao K, Beckerman J, Traore B, Rozenshteyn S, Johnson A, Treleaven E, Liu JX. Qualified, skilled or trained delivery care provider: a conundrum of who, where and when. BMJ Glob Health 2024; 9:e015624. [PMID: 39299777 PMCID: PMC11418470 DOI: 10.1136/bmjgh-2024-015624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 08/23/2024] [Indexed: 09/22/2024] Open
Affiliation(s)
- Rakesh Ghosh
- Institute for Health and Aging, University of California San Francisco, San Francisco, California, USA
| | - Kassoum Kayentao
- Malaria Research and Training Centre, University of Sciences Techniques and Technologies of Bamako, Bamako, Mali
- Muso, Route de 501 Lodgements SEMA, Bamako, Mali
| | | | | | - Sasha Rozenshteyn
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Ari Johnson
- Muso, Route de 501 Lodgements SEMA, Bamako, Mali
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Emily Treleaven
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Jenny X Liu
- Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
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Whidden C, Cissé AB, Cole F, Doumbia S, Guindo A, Karambé Y, Treleaven E, Liu J, Tolo O, Guindo L, Togola B, Chiu C, Tembely A, Keita Y, Greenwood B, Chandramohan D, Johnson A, Kayentao K, Webster J. Community case management to accelerate access to healthcare in Mali: a realist process evaluation nested within a cluster randomized trial. Health Policy Plan 2024; 39:864-877. [PMID: 39058651 PMCID: PMC11384120 DOI: 10.1093/heapol/czae066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 05/30/2024] [Accepted: 07/25/2024] [Indexed: 07/28/2024] Open
Abstract
The Proactive Community Case Management (ProCCM) trial in Mali reinforced the health system across both arms with user fee removal, professional community health workers (CHWs) and upgraded primary health centres (PHCs)-and randomized village-clusters to receive proactive home visits by CHWs (intervention) or fixed site-based services by passive CHWs (control). Across both arms, sick children's 24-hour treatment and pregnant women's four or more antenatal visits doubled, and under-5 mortality halved, over 3 years compared with baseline. In the intervention arm, proactive CHW home visits had modest effects on children's curative and women's antenatal care utilization, but no effect on under-5 mortality, compared with the control arm. We aimed to explain these results by examining implementation, mechanisms and context in both arms We conducted a process evaluation with a mixed method convergent design that included 79 in-depth interviews with providers and participants over two time-points, surveys with 195 providers and secondary analyses of clinical data. We embedded realist approaches in novel ways to test, refine and consolidate theories about how ProCCM worked, generating three context-intervention-actor-mechanism-outcome nodes that unfolded in a cascade. First, removing user fees and deploying professional CHWs in every cluster enabled participants to seek health sector care promptly and created a context of facilitated access. Second, health systems support to all CHWs and PHCs enabled equitable, respectful, quality healthcare, which motivated increased, rapid utilization. Third, proactive CHW home visits facilitated CHWs and participants to deliver and seek care, and build relationships, trust and expectations, but these mechanisms were also activated in both arms. Addressing multiple structural barriers to care, user fee removal, professional CHWs and upgraded clinics interacted with providers' and patients' agency to achieve rapid care and child survival in both arms. Proactive home visits expedited or compounded mechanisms that were activated and changed the context across arms.
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Affiliation(s)
- Caroline Whidden
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
- Department of Research, Monitoring & Evaluation, Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
| | | | - Faith Cole
- Department of Anthropology, University of California, 375 Portola Plaza, Los Angeles, CA 90095, United States
- Institute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, MI 48103, United States
| | - Saibou Doumbia
- Department of Research, Monitoring & Evaluation, Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
| | - Abdoulaye Guindo
- Faculté des Sciences de l'Éducation et des Sciences Humaines, Université des Lettres et des Sciences Humaines de Bamako, Rue 627 Porte 83, Bamako BP E 2528, Mali
| | - Youssouf Karambé
- Institut National de la Jeunesse et des Sports, Bamako J35J+CJF, Mali
| | - Emily Treleaven
- Institute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, MI 48103, United States
| | - Jenny Liu
- Institute for Health & Aging, University of California, 490 Illinois Street, San Francisco, CA 94158, United States
| | - Oumar Tolo
- Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
| | - Lamine Guindo
- Department of Research, Monitoring & Evaluation, Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
| | - Bréhima Togola
- Department of Research, Monitoring & Evaluation, Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
| | - Calvin Chiu
- School of Public Health, University of California, 2121 Berkeley Way, Berkeley, CA 94704, United States
| | - Aly Tembely
- Ministère de la Santé et du Développement Social, Cité Administrative, Bamako JXGR+R48, Mali
| | - Youssouf Keita
- Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
| | - Brian Greenwood
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - Daniel Chandramohan
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - Ari Johnson
- Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
- Institute for Global Health Sciences, University of California, 550 16th Street, San Francisco, CA 94110, United States
| | - Kassoum Kayentao
- Department of Research, Monitoring & Evaluation, Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
- Malaria Research & Training Centre, Université des Sciences, des Techniques et des Technologies de Bamako, Bamako PO Box 1805, Mali
| | - Jayne Webster
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
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Liu J, Treleaven E, Whidden C, Doumbia S, Kone N, Cisse AB, Diop A, Berthé M, Guindo M, Koné BM, Fay MP, Johnson AD, Kayentao K. Home visits versus fixed-site care by community health workers and child survival: a cluster-randomized trial, Mali. Bull World Health Organ 2024; 102:639-649. [PMID: 39219760 PMCID: PMC11362699 DOI: 10.2471/blt.23.290975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 03/31/2024] [Accepted: 05/28/2024] [Indexed: 09/04/2024] Open
Abstract
Objective To test the effect of proactive home visits by trained community health workers (CHWs) on child survival. Methods We conducted a two arm, parallel, unmasked cluster-randomized trial in 137 village-clusters in rural Mali. From February 2017 to January 2020, 31 761 children enrolled at the trial start or at birth. Village-clusters received either primary care services by CHWs providing regular home visits (intervention) or by CHWs providing care at a fixed site (control). In both arms, user fees were removed and primary health centres received staffing and infrastructure improvements before trial start. Using lifetime birth histories from women aged 15-49 years surveyed annually, we estimated incidence rate ratios (IRR) for intention-to-treat and per-protocol effects on under-five mortality using Poisson regression models. Findings Over three years, we observed 52 970 person-years (27 332 in intervention arm; 25 638 in control arm). During the trial, 909 children in the intervention arm and 827 children in the control arm died. The under-five mortality rate declined from 142.8 (95% CI: 133.3-152.9) to 56.7 (95% CI: 48.5-66.4) deaths per 1000 live births in the intervention arm; and from 154.3 (95% CI: 144.3-164.9) to 54.9 (95% CI: 45.2-64.5) deaths per 1000 live births in the control arm. Intention-to-treat (IRR: 1.02; 95% CI: 0.88-1.19) and per-protocol estimates (IRR: 1.01; 95% CI: 0.87-1.18) showed no difference between study arms. Conclusion Though proactive home visits did not reduce under-five mortality, system-strengthening measures may have contributed to the decline in under-five mortality in both arms.
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Affiliation(s)
- Jenny Liu
- Institute for Health and Aging, University of California, San Francisco, United States of America (USA)
| | - Emily Treleaven
- Institute for Social Research, 426 Thompson Street, University of Michigan, Ann Arbor, MI48103, USA
| | | | | | | | | | - Aly Diop
- Ministère de la Santé et du Développement Social, Bamako, Mali
| | - Mohamed Berthé
- Ministère de la Santé et du Développement Social, Bamako, Mali
| | | | | | - Michael P Fay
- National Institute of Allergy and Infectious Disease, Rockville, USA
| | - Ari D Johnson
- Department of Medicine, University of California, San Francisco, USA
| | - Kassoum Kayentao
- Malaria Research and Training Centre, University of Science, Technic and Technologies of Bamako, Bamako, Mali
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Ghosh R, Konipo AN, Treleaven E, Rozenshteyn S, Beckerman J, Whidden C, Johnson A, Kayentao K, Liu J. Factors influencing pregnancy care and institutional delivery in rural Mali: a secondary baseline analysis of a cluster-randomised trial. BMJ Open 2024; 14:e084315. [PMID: 38594181 PMCID: PMC11015193 DOI: 10.1136/bmjopen-2024-084315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/14/2024] [Indexed: 04/11/2024] Open
Abstract
OBJECTIVE The vast majority of the 300 000 pregnancy-related deaths every year occur in South Asia and sub-Saharan Africa. Increased access to quality antepartum and intrapartum care can reduce pregnancy-related morbidity and mortality worldwide. We used a population-based cross-sectional cohort design to: (1) examine the sociodemographic risk factors and structural barriers associated with pregnancy care-seeking and institutional delivery, and (2) investigate the influence of residential distance to the nearest primary health facility in a rural population in Mali. METHODS A baseline household survey of Malian women aged 15-49 years was conducted between December 2016 and January 2017, and those who delivereda baby in the 5 years preceding the survey were included. This study leverages the baseline survey data from a cluster-randomised controlled trial to conduct a secondary analysis. The outcomes were percentage of women who received any antenatal care (ANC) and institutional delivery; total number of ANC visits; four or more ANC visits; first ANC visit in the first trimester. RESULTS Of the 8575 women in the study, two-thirds received any ANC in their last pregnancy, one in 10 had four or more ANC visits and among those that received any ANC, about one-quarter received it in the first trimester. For every kilometre increase in distance to the nearest facility, the likelihood of the outcomes reduced by 5 percentage points (0.95; 95% CI 0.91 to 0.98) for any ANC; 4 percentage points (0.96; 95% CI 0.94 to 0.98) for an additional ANC visit; 10 percentage points (0.90; 95% CI 0.86 to 0.95) for four or more ANC visits; 6 percentage points (0.94; 95% CI 0.94 to 0.98) for first ANC in the first trimester. In addition, there was a 35 percentage points (0.65; 95% CI 0.56 to 0.76) decrease in likelihood of institutional delivery if the residence was within 6.5 km to the nearest facility, beyond which there was no association with the place of delivery. We also found evidence of increase in likelihood of receiving any ANC care and its intensity increased with having some education or owning a business. CONCLUSION The findings suggest that education, occupation and distance are important determinants of pregnancy and delivery care in a rural Malian context. TRIAL REGISTRATION NUMBER NCT02694055.
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Affiliation(s)
- Rakesh Ghosh
- Institute for Health & Aging, University of California San Francisco, San Francisco, California, USA
| | | | - Emily Treleaven
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Sasha Rozenshteyn
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Caroline Whidden
- MUSO, Route de 501 Lodgements SEMA, Bamako, Mali
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Ari Johnson
- MUSO, Route de 501 Lodgements SEMA, Bamako, Mali
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Kassoum Kayentao
- MUSO, Route de 501 Lodgements SEMA, Bamako, Mali
- Malaria Research & Training Centre, University of Sciences Techniques and Technologies of Bamako, Bamako, Mali
| | - Jenny Liu
- Institute for Health & Aging, Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
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Whidden C, Kayentao K, Koné N, Liu J, Traoré MB, Diakité D, Coumaré M, Berthé M, Guindo M, Greenwood B, Chandramohan D, Leyrat C, Treleaven E, Johnson A. Effects of proactive vs fixed community health care delivery on child health and access to care: a cluster randomised trial secondary endpoint analysis. J Glob Health 2023; 13:04047. [PMID: 37083317 PMCID: PMC10122537 DOI: 10.7189/jogh.13.04047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Abstract
Background Professional community health workers (CHWs) can help achieve universal health coverage, although evidence gaps remain on how to optimise CHW service delivery. We conducted an unblinded, parallel, cluster randomised trial in rural Mali to determine whether proactive CHW delivery reduced mortality and improved access to health care among children under five years, compared to passive delivery. Here we report the secondary access endpoints. Methods Beginning from 26-28 February 2017, 137 village-clusters were offered care by CHWs embedded in communities who were trained, paid, supervised, and integrated into a reinforced public-sector health system that did not charge user fees. Clusters were randomised (stratified on primary health centre catchment and distance) to care during CHWs during door-to-door home visits (intervention) or based at a fixed village site (control). We measured outcomes at baseline, 12-, 24-, and 36-month time points with surveys administered to all resident women aged 15-49 years. We used logistic regression with cluster-level random effects to estimate intention-to-treat and per-protocol effects over time on prompt (24-hour) treatment within the health sector. Results Follow-up surveys between February 2018 and April 2020 generated 20 105 child-year observations. Across arms, prompt health sector treatment more than doubled compared to baseline. At 12 months, children in intervention clusters had 22% higher odds of receiving prompt health sector treatment than those in control (cluster-specific adjusted odds ratio (aOR) = 1.22; 95% confidence interval (CI) = 1.06, 1.41, P = 0.005), or 4.7 percentage points higher (adjusted risk difference (aRD) = 0.047; 95% CI = 0.014, 0.080). We found no evidence of an effect at 24 or 36 months. Conclusions CHW-led health system redesign likely drove the 2-fold increase in rapid child access to care. In this context, proactive home visits further improved early access during the first year but waned afterwards. Registration ClinicalTrials.gov NCT02694055.
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Affiliation(s)
- Caroline Whidden
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
- Department of Research, Monitoring & Evaluation, Muso, Bamako, Mali
| | - Kassoum Kayentao
- Department of Research, Monitoring & Evaluation, Muso, Bamako, Mali
- Malaria Research & Training Centre, Université des Sciences, des Techniques et des Technologies de Bamako, Bamako, Mali
| | - Naimatou Koné
- Department of Research, Monitoring & Evaluation, Muso, Bamako, Mali
| | - Jenny Liu
- Institute for Health & Aging, University of California, San Francisco, San Francisco, California, USA
| | | | | | - Mama Coumaré
- Ministère de la Santé et du Développement Social, Mali
| | | | | | - Brian Greenwood
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Daniel Chandramohan
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Clémence Leyrat
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Emily Treleaven
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Ari Johnson
- Muso, Bamako, Mali
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, USA
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Ratovoson R, Garchitorena A, Kassie D, Ravelonarivo JA, Andrianaranjaka V, Razanatsiorimalala S, Razafimandimby A, Rakotomanana F, Ohlstein L, Mangahasimbola R, Randrianirisoa SAN, Razafindrakoto J, Dentinger CM, Williamson J, Kapesa L, Piola P, Randrianarivelojosia M, Thwing J, Steinhardt LC, Baril L. Proactive community case management decreased malaria prevalence in rural Madagascar: results from a cluster randomized trial. BMC Med 2022; 20:322. [PMID: 36192774 PMCID: PMC9531497 DOI: 10.1186/s12916-022-02530-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 08/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malaria remains a leading cause of morbidity and mortality worldwide, with progress in malaria control stalling in recent years. Proactive community case management (pro-CCM) has been shown to increase access to diagnosis and treatment and reduce malaria burden. However, lack of experimental evidence may hinder the wider adoption of this intervention. We conducted a cluster randomized community intervention trial to assess the efficacy of pro-CCM at decreasing malaria prevalence in rural endemic areas of Madagascar. METHODS Twenty-two fokontany (smallest administrative unit) of the Mananjary district in southeast Madagascar were selected and randomized 1:1 to pro-CCM (intervention) or conventional integrated community case management (iCCM). Residents of all ages in the intervention arm were visited by a community health worker every 2 weeks from March to October 2017 and screened for fever; those with fever were tested by a rapid diagnostic test (RDT) and treated if positive. Malaria prevalence was assessed using RDTs on all consenting study area residents prior to and following the intervention. Hemoglobin was measured among women of reproductive age. Intervention impact was assessed via difference-in-differences analyses using logistic regressions in generalized estimating equations. RESULTS A total of 27,087 and 20,475 individuals participated at baseline and endline, respectively. Malaria prevalence decreased from 8.0 to 5.4% in the intervention arm for individuals of all ages and from 6.8 to 5.7% in the control arm. Pro-CCM was associated with a significant reduction in the odds of malaria positivity in children less than 15 years (OR = 0.59; 95% CI [0.38-0.91]), but not in older age groups. There was no impact on anemia among women of reproductive age. CONCLUSION This trial suggests that pro-CCM approaches could help reduce malaria burden in rural endemic areas of low- and middle-income countries, but their impact may be limited to younger age groups with the highest malaria burden. TRIAL REGISTRATION NCT05223933. Registered on February 4, 2022.
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Affiliation(s)
- Rila Ratovoson
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar.
| | - Andres Garchitorena
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
- MIVEGEC, Univ. Montpellier, IRD, CNRS, Montpellier, France
| | - Daouda Kassie
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
- Centre de Coopération International en Recherche Agronomique pour le Développement (CIRAD), Montpellier, France
| | - Jemima A Ravelonarivo
- Malaria Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
- Present address: Humanity & inclusion, Toliara, Madagascar
| | - Voahangy Andrianaranjaka
- Malaria Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
- Present address: Mention Biochimie Fondamentale et Appliquée, Domaine Sciences et Technologie, Faculté des Sciences, Université d'Antananarivo, Antananarivo, Madagascar
| | | | - Avotra Razafimandimby
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | - Fanjasoa Rakotomanana
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | | | - Reziky Mangahasimbola
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | | | | | - Catherine M Dentinger
- U.S. President's Malaria Initiative, Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, USA
- U.S. President's Malaria Initiative, US Centers for Disease Control and Prevention, Antananarivo, Madagascar
| | - John Williamson
- U.S. President's Malaria Initiative, Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Laurent Kapesa
- U.S. President's Malaria Initiative, USAID, Antananarivo, Madagascar
| | - Patrice Piola
- Epidemiology Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Milijaona Randrianarivelojosia
- Malaria Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
- Faculté des Sciences, Université de Toliara, Toliara, Madagascar
| | - Julie Thwing
- U.S. President's Malaria Initiative, Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Laura C Steinhardt
- U.S. President's Malaria Initiative, Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Laurence Baril
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
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Yang JE, Lassala D, Liu JX, Whidden C, Holeman I, Keita Y, Djiguiba Y, N'Diaye SI, Fall F, Kayentao K, Johnson AD. Effect of mobile application user interface improvements on minimum expected home visit coverage by community health workers in Mali: a randomised controlled trial. BMJ Glob Health 2021; 6:bmjgh-2021-007205. [PMID: 34815242 PMCID: PMC8609935 DOI: 10.1136/bmjgh-2021-007205] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/18/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Proactive community case management (ProCCM) has shown promise to advance goals of universal health coverage (UHC). ProCCM community health workers (CHWs) face operational challenges when pursuing their goal of visiting every household in their service area at least twice monthly to proactively find sick patients. We developed a software extension (UHC Mode) to an existing CHW mobile application featuring user interface design improvements to support CHWs in planning daily home visits. We evaluated the effect of UHC Mode on minimum expected home visit coverage. METHODS We conducted a parallel-group, two-arm randomised controlled trial of ProCCM CHWs in two separate regions in Mali. CHWs were randomly assigned to UHC Mode or the standard mobile application (control) with a 1:1 allocation. Randomisation was stratified by health catchment area. CHWs and other programme personnel were not masked to arm allocation. CHWs used their assigned intervention for 4 months. Using a difference-in-differences analysis, we estimated the mean change in minimum expected home visit coverage from preintervention to postintervention between arms. RESULTS Enrolment occurred in January 2019. Of 199 eligible CHWs randomised to the intervention or control arm, 196 were enrolled and 195 were included in the analysis. Households whose CHW used UHC Mode had 2.41 times higher odds of minimum expected home visit coverage compared with households whose CHW used the control (95% CI 1.68 to 3.47; p<0.0005). Minimum expected home visit coverage in the UHC Mode arm increased 13.6 percentage points (95% CI 8.1 to 19.0) compared with the control arm. CONCLUSION Our findings suggest UHC Mode is an effective tool that can improve home visit coverage and promote progress towards UHC when implemented in the ProCCM context. User interface design of health information systems that supports health workers' daily practices and meets their requirements can have a positive impact on health worker performance and home visit coverage. TRIAL REGISTRATION NUMBER NCT04106921.
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Affiliation(s)
| | | | - Jenny X Liu
- Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, California, USA
| | | | - Isaac Holeman
- Medic, San Francisco, California, USA.,Department of Human Centered Design & Engineering, University of Washington, Seattle, Washington, USA.,Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | | | | | | | - Kassoum Kayentao
- Muso, Bamako, Mali.,Malaria Research & Training Centre, University of Sciences Techniques and Technologies, Bamako, Mali
| | - Ari D Johnson
- Muso, San Francisco, California, USA.,Department of Medicine, Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
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Kirk K, McClair TL, Dakouo SP, Abuya T, Sripad P. Introduction of digital reporting platform to integrate community-level data into health information systems is feasible and acceptable among various community health stakeholders: A mixed-methods pilot study in Mopti, Mali. J Glob Health 2021; 11:07003. [PMID: 33791098 PMCID: PMC7956070 DOI: 10.7189/jogh.11.07003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Integration of community-level health data within Mali's web-based District Health Information System (DHIS2) is underexplored. This study conducted in Mopti, Mali examined challenges and enablers affecting integration and investigated how digital technology optimizes data quality, availability, and use. METHODS This pre-post mixed-methods study compared community health workers' (CHWs') experiences reporting routine community-level data using the DHIS2 digital application on tablets and paper forms. 141 CHWs participated in quantitative surveys and focus group discussions at baseline and endline. In-depth interviews were conducted with 18 and eight CHW supervisors and 12 and 11 other stakeholders at baseline and endline, respectively. We calculated changes in CHW performance, and job satisfaction among intervention and comparison groups using the difference-in-difference (DID) estimator controlling for baseline characteristics. Routine longitudinal DHIS2 data described timeliness and completeness of CHW reporting. Thematic analysis of qualitative data explained implementation challenges and enablers, and considerations for data use. RESULTS The median number of health talks and household visits among intervention group CHWs increased from baseline to endline compared to the comparison group (DID estimator; P < 0.05 for both), as did aspects of job satisfaction (satisfaction with opportunities to contribute ideas to improve services and coordination with supervisors and stakeholders, P < 0.1). CHWs reported high levels of comfort and confidence navigating the tablet for data collection and on-time reporting. While CHWs experienced challenges -tablet quality, limited network connection and increased workload, they preferred the digital to paper system. Stakeholder, supervisor and CHW roles in data review and decision-making appear unchanged from baseline to endline, though some supervisors found the tablets improved data timeliness and completeness. Routine longitudinal DHIS2 data confirm high rates of data timeliness and completeness before and after the intervention, with little or no change over time. CONCLUSIONS CHW tablet use for data collection and reporting is feasible and desirable, however, program and policy changes are needed for this to be a fully-functional system. Future efforts need to consider how to ensure site-level network connectivity; quality, compatibility and functionality of digital technology; and routine supportive systems for CHWs and community health actors on data use.
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Affiliation(s)
- Karen Kirk
- Population Council, New York, New York, USA
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Whidden C, Keita Y, Treleaven E, Beckerman J, Johnson A, Cissé A, Liu J, Kayentao K. Women's empowerment, intrahousehold influences, and health system design on modern contraceptive use in rural Mali: a multilevel analysis of cross-sectional survey data. Reprod Health 2021; 18:55. [PMID: 33658054 PMCID: PMC7931535 DOI: 10.1186/s12978-020-01061-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Persistent challenges in meeting reproductive health and family planning goals underscore the value in determining what factors can be leveraged to facilitate modern contraceptive use, especially in poor access settings. In Mali, where only 15% of reproductive-aged women use modern contraception, understanding how women's realities and health system design influence contraceptive use helps to inform strategies to achieve the nation's target of 30% by 2023. METHODS Using household survey data from the baseline round of a cluster-randomized trial, including precise geolocation data from all households and public sector primary health facilities, we used a multilevel model to assess influences at the individual, household, community, and health system levels on women's modern contraceptive use. In a three-level, mixed-effects logistic regression, we included measures of women's decision-making and mobility, as well as socio-economic sources of empowerment (education, paid labor), intrahousehold influences in the form of a co-residing user, and structural factors related to the health system, including distance to facility. RESULTS Less than 5% of the 14,032 women of reproductive age in our study used a modern method of contraception at the time of the survey. Women who played any role in decision-making, who had any formal education and participated in any paid labor, were more likely to use modern contraception. Women had three times the odds of using modern contraception if they lived in a household with another woman, typically a co-wife, who also used a modern method. Compared to women closest to a primary health center, those who lived between 2 and 5 km were half as likely to use modern contraception, and those between 5 and 10 were a third as likely. CONCLUSIONS Despite chronically poor service availability across our entire study area, some women-even pairings of women in single households-transcended barriers to use modern contraception. When planning and implementing strategies to expand access to contraception, policymakers and practitioners should consider women's empowerment, social networks, and health system design. Accessible and effective health systems should reconsider the conventional approach to community-based service delivery, including distance as a barrier only beyond 5 km.
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Affiliation(s)
- Caroline Whidden
- Muso, Route de 501 Lodgements SEMA, Bamako, Mali.
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK.
| | | | - Emily Treleaven
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | | | - Ari Johnson
- Muso, Route de 501 Lodgements SEMA, Bamako, Mali
- Institude for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Aminata Cissé
- Sub-Direction of Reproductive Health, General Directorate of Health and Public Hygiene, Bamako, Mali
| | - Jenny Liu
- Institute for Health & Aging, University of California, San Francisco, San Francisco, CA, USA
| | - Kassoum Kayentao
- Muso, Route de 501 Lodgements SEMA, Bamako, Mali
- Malaria Research & Training Centre, University of Sciences Techniques and Technologies of Bamako, Bamako, Mali
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Oliphant NP, Manda S, Daniels K, Odendaal WA, Besada D, Kinney M, White Johansson E, Doherty T. Integrated community case management of childhood illness in low- and middle-income countries. Cochrane Database Syst Rev 2021; 2:CD012882. [PMID: 33565123 PMCID: PMC8094443 DOI: 10.1002/14651858.cd012882.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The leading causes of mortality globally in children younger than five years of age (under-fives), and particularly in the regions of sub-Saharan Africa (SSA) and Southern Asia, in 2018 were infectious diseases, including pneumonia (15%), diarrhoea (8%), malaria (5%) and newborn sepsis (7%) (UNICEF 2019). Nutrition-related factors contributed to 45% of under-five deaths (UNICEF 2019). World Health Organization (WHO) and United Nations Children's Fund (UNICEF), in collaboration with other development partners, have developed an approach - now known as integrated community case management (iCCM) - to bring treatment services for children 'closer to home'. The iCCM approach provides integrated case management services for two or more illnesses - including diarrhoea, pneumonia, malaria, severe acute malnutrition or neonatal sepsis - among under-fives at community level (i.e. outside of healthcare facilities) by lay health workers where there is limited access to health facility-based case management services (WHO/UNICEF 2012). OBJECTIVES To assess the effects of the integrated community case management (iCCM) strategy on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for children younger than five years of age in low- and middle-income countries. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and CINAHL on 7 November 2019, Virtual Health Library on 8 November 2019, and Popline on 5 December 2018, three other databases on 22 March 2019 and two trial registers on 8 November 2019. We performed reference checking, and citation searching, and contacted study authors to identify additional studies. SELECTION CRITERIA Randomized controlled trials (RCTs), cluster-RCTs, controlled before-after studies (CBAs), interrupted time series (ITS) studies and repeated measures studies comparing generic WHO/UNICEF iCCM (or local adaptation thereof) for at least two iCCM diseases with usual facility services (facility treatment services) with or without single disease community case management (CCM). We included studies reporting on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for under-fives in low- and middle-income countries. DATA COLLECTION AND ANALYSIS At least two review authors independently screened abstracts, screened full texts and extracted data using a standardised data collection form adapted from the EPOC Good Practice Data Collection Form. We resolved any disagreements through discussion or, if required, we consulted a third review author not involved in the original screening. We contacted study authors for clarification or additional details when necessary. We reported risk ratios (RR) for dichotomous outcomes and hazard ratios (HR) for time to event outcomes, with 95% confidence intervals (CI), adjusted for clustering, where possible. We used estimates of effect from the primary analysis reported by the investigators, where possible. We analysed the effects of randomized trials and other study types separately. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included seven studies, of which three were cluster RCTs and four were CBAs. Six of the seven studies were in SSA and one study was in Southern Asia. The iCCM components and inputs were fairly consistent across the seven studies with notable variation for the training and deployment component (e.g. on payment of iCCM providers) and the system component (e.g. on improving information systems). When compared to usual facility services, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (RR 0.96, 95% CI 0.77 to 1.19; 2 CBA studies, 5898 children; very low-certainty evidence). iCCM may have little to no effect on neonatal mortality (HR 1.01, 95% 0.73 to 1.28; 2 trials, 65,209 children; low-certainty evidence). We are uncertain of the effect of iCCM on infant mortality (HR 1.02, 95% CI 0.83 to 1.26; 2 trials, 60,480 children; very low-certainty evidence) and under-five mortality (HR 1.18, 95% CI 1.01 to 1.37; 1 trial, 4729 children; very low-certainty evidence). iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness by 68% (RR 1.68, 95% CI 1.24 to 2.27; 2 trials, 9853 children; moderate-certainty evidence). None of the studies reported quality of care, severity of illness or adverse events for this comparison. When compared to usual facility services plus CCM for malaria, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (very low-certainty evidence) and iCCM may have little or no effect on careseeking to an appropriate provider for any iCCM illness (RR 1.06, 95% CI 0.97 to 1.17; 1 trial, 811 children; low-certainty evidence). None of the studies reported quality of care, case load or severity of illness at health facilities, mortality or adverse events for this comparison. AUTHORS' CONCLUSIONS iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness. However, the evidence presented here underscores the importance of moving beyond training and deployment to valuing iCCM providers, strengthening health systems and engaging community systems.
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Affiliation(s)
- Nicholas P Oliphant
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland
- School of Public Health, University of the Western Cape, Belleville, South Africa
| | - Samuel Manda
- Biostatistics Unit, South African Medical Research Council, Hatfield, South Africa
- Department of Statistics, University of Pretoria, Hatfield, South Africa
| | - Karen Daniels
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Willem A Odendaal
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
| | - Donela Besada
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
| | - Mary Kinney
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland
| | - Emily White Johansson
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Tanya Doherty
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
- School of Public Health, University of the Western Cape, Belleville, South Africa
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Boettiger DC, Treleaven E, Kayentao K, Guindo M, Coumaré M, Johnson AD, Whidden C, Koné N, Cissé AB, Padian N, Liu J. Household factors and under-five mortality in Bankass, Mali: results from a cross-sectional survey. BMC Public Health 2021; 21:244. [PMID: 33514345 PMCID: PMC7845123 DOI: 10.1186/s12889-021-10242-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 01/14/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Rural parts of Mali carry a disproportionate burden of the country's high under-five mortality rate. A range of household factors are associated with poor under-five health in resource-limited settings. However, it is unknown which most influence the under-five mortality rate in rural Mali. We aimed to describe household factors associated with under-five mortality in Bankass, a remote region in central Mali. METHODS We analysed baseline household survey data from a trial being conducted in Bankass. The survey was administered to households between December 2016 and January 2017. Under-five deaths in the five years prior to baseline were documented along with detailed information on household factors and women's birth histories. Factors associated with under-five mortality were analysed using Cox regression. RESULTS Our study population comprised of 17,408 under-five children from 8322 households. In the five years prior to baseline, the under-five mortality rate was 152.6 per 1000 live births (158.8 and 146.0 per 1000 live births for males and females, respectively). Living a greater distance from a primary health center was associated with a higher probability of under-five mortality for both males (adjusted hazard ratio [aHR] 1.53 for ≥10 km versus < 2 km, 95% confidence interval [CI] 1.25-1.88) and females (aHR 1.59 for ≥10 km versus < 2 km, 95% CI 1.27-1.99). Under-five male mortality was additionally associated with lower household wealth quintile (aHR 1.47 for poorest versus wealthiest, 95%CI 1.21-1.78), lower reading ability among women of reproductive age in the household (aHR 1.73 for cannot read versus can read, 95%CI 1.04-2.86), and living in a household with access to electricity (aHR 1.16 for access versus no access, 95%CI 1.00-1.34). CONCLUSIONS U5 mortality is very high in Bankass and is associated with living a greater distance from healthcare and several other household factors that may be amenable to intervention or facilitate program targeting.
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Affiliation(s)
- David C Boettiger
- Kirby Institute, University of New South Wales, Sydney, 2252, Australia.
| | - Emily Treleaven
- Population Studies Center, University of Michigan, Ann Arbor, USA
| | - Kassoum Kayentao
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | | | - Mama Coumaré
- Ministère de la Santé et des Affaires Sociales, Bamako, Mali
| | - Ari D Johnson
- Department of Medicine, University of California, San Francisco, USA
| | | | | | | | - Nancy Padian
- School of Public Health, University of California, Berkeley, USA
| | - Jenny Liu
- Institute for Health and Aging, University of California, San Francisco, USA
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