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Berhane M, Girma T, Tesfaye W, Jibat N, Abera M, Abrahim S, Aboubaker S, Nisar YB, Ahmad Qazi S, Bahl R, Abdissa A. Implementation research on management of sick young infants with possible serious bacterial infection when referral is not possible in Jimma Zone, Ethiopia: Challenges and solutions. PLoS One 2021; 16:e0255210. [PMID: 34370744 PMCID: PMC8351942 DOI: 10.1371/journal.pone.0255210] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 07/09/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Of 2.5 million newborn deaths each year, serious neonatal infections are a leading cause of neonatal death for which inpatient treatment is recommended. However, manysick newborns in sub-Saharan Africa and south Asia do not have access to inpatientcare. A World Health Organization (WHO) guideline recommends simplified antibiotic treatment atan outpatient level for young infants up to two months of age with possible serious bacterial infection (PSBI), when referral is not feasible.We implemented this guidelinein Ethiopia to increase coverage of treatment and to learn about potential facilitating factors and barriers for implementation. Methods We conducted implementation research in two districts (Tiro Afata and Gera) in Jimma Zone, Ethiopia, to learn about the feasibility of implementing the WHO PSBI guideline within a programme setting using the existing health care structure. We conducted orientation meetings and policy dialogue with key stakeholders and trained health extension workers and health centre staff to identify and manage sick young infants with PSBI signs at a primary health care unit. We established a Technical Support Unit (TSU) to facilitate programme learning, built health workers’ capacity and provided support for quality control, monitoring and data collection.We sensitized the community to appropriate care-seeking and supported the health care system in implementation. The research team collected data using structured case recording forms. Results From September 2016 to August 2017, 6185 live births and 601 sick young infants 0–59 days of age with signs of PSBI were identified. Assuming that 25% of births were missed (total births 7731) and 10% of births had an episode of PSBI in the first two months of life, the coverage of appropriate treatment for PSBI was 77.7% (601/773). Of 601 infants with PSBI, fast breathing only (pneumonia) was recorded in 432 (71.9%) infants 7–59 days of age; signs of clinical severe infection (CSI) in 155 (25.8%) and critical illnessin 14 (2.3%). Of the 432 pneumonia cases who received oral amoxicillin treatment without referral, 419 (97.0%) were successfully treated without any deaths. Of 169 sick young infants with either CSI or critical illness, only 110 were referred to a hospital; 83 did not accept referral advice and received outpatient injectable gentamicin plus oral amoxicillin treatment either at a health post or health centre. Additionally, 59 infants who should have been referred, but were not received injectable gentamicin plus oral amoxicillin outpatient treatment. Of infants with CSI, 129 (82.2%) were successfully treated as outpatients, while two died (1.3%). Of 14 infants with critical illness, the caregivers of five accepted referral to a hospital, and nine were treated with simplified antibiotics on an outpatient basis. Two of 14 (14.3%) infants with critical illness died within 14 days of initial presentation. Conclusion In settings where referral to a hospital is not feasible, young infants with PSBI can be treated on an outpatient basis at either a health post or health centre, which can contribute to saving many lives. Scaling-up will require health system strengthening including community mobilization. Registration Trial is registered on Australian New Zealand Clinical Trials registry (ANZCTR) ACTRN12617001373369.
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Affiliation(s)
- Melkamu Berhane
- Department of Pediatrics and Child Health, Jimma University, Jimma, Ethiopia
- * E-mail:
| | - Tsinuel Girma
- Department of Pediatrics and Child Health, Jimma University, Jimma, Ethiopia
| | - Workneh Tesfaye
- Department of Pediatrics and Child Health, Jimma University, Jimma, Ethiopia
| | - Nega Jibat
- College of Social Sciences and Humanities, Jimma University, Jimma, Ethiopia
| | - Mulumebet Abera
- Department of Population and Family Health, Jimma University, Jimma, Ethiopia
| | | | - Samira Aboubaker
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization (Retired) Currently WHO consultants, Geneva, Switzerland
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Shamim Ahmad Qazi
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization (Retired) Currently WHO consultants, Geneva, Switzerland
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Alemseged Abdissa
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
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Berhanu D, Allen E, Beaumont E, Tomlin K, Taddesse N, Dinsa G, Mekonnen Y, Hailu H, Balliet M, Lensink N, Schellenberg J, Avan BI. Coverage of antenatal, intrapartum, and newborn care in 104 districts of Ethiopia: A before and after study four years after the launch of the national Community-Based Newborn Care programme. PLoS One 2021; 16:e0251706. [PMID: 34351944 PMCID: PMC8341496 DOI: 10.1371/journal.pone.0251706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 04/30/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Access to health services across the continuum of care improves maternal and newborn health outcomes. Ethiopia launched the Community-Based Newborn Care programme in 2013 to increase the coverage of antenatal care, institutional delivery, postnatal care and newborn care. The programme also introduced gentamicin and amoxicillin treatment by health extension workers for young infants with possible serious bacterial infection when referral was not possible. This study aimed to assess the extent to which the coverage of health services for mothers and their young infants increased after the initiation of the programme. METHODS A baseline survey was conducted in October-December 2013 and a follow-up survey four years later in November-December 2017. At baseline, 10,224 households and 1,016 women who had a live birth in the 3-15 months prior to the survey were included. In the follow-up survey, 10,270 households and 1,057 women with a recent live birth were included. Women were asked about their experience of care during pregnancy, delivery and postpartum periods, as well as the treatment provided for their child's illness in the first 59 days of life. RESULTS Between baseline and follow-up surveys the proportion of women reporting at least one antenatal care visit increased by 15 percentage points (95% CI: 10,19), four or more antenatal care visits increased by 17 percentage points (95%CI: 13,22), and institutional delivery increased by 40 percentage points (95% CI: 35,44). In contrast, the proportion of newborns with a postnatal care visit within 48 hours of birth decreased by 6 percentage points (95% CI: -10, -3) for home deliveries and by 14 percentage points (95% CI: -21, -7) for facility deliveries. The proportion of mothers reporting that their young infant with possible serious bacterial infection received amoxicillin for seven days increased by 50 percentage points (95% CI: 37,62) and gentamicin for seven days increased by 15 percentage points (95% CI: 5,25). Concurrent use of both antibiotics increased by 12 percentage points (95% CI: 4,19). CONCLUSION The Community-Based Newborn Care programme was an ambitious initiative to enhance the access to services for pregnant women and newborns. Major improvements were seen for the number of antenatal care visits and institutional delivery, while postnatal care remained alarmingly low. Antibiotic treatment for young infants with possible serious bacterial infection increased, although most treatment did not follow national guidelines. Improving postnatal care coverage and using a simplified antibiotic regimen following recent World Health Organization guidelines could address gaps in the care provided for sick young infants.
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Affiliation(s)
- Della Berhanu
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Elizabeth Allen
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Emma Beaumont
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Keith Tomlin
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | | | - Girmaye Dinsa
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, United States of America
- Department of Public Health and Health Policy, College of Health and Medical Sciences Haramaya University, Ethiopia
| | | | | | - Manuela Balliet
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Joanna Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Bilal Iqbal Avan
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Koffi AK, Kalter HD, Kamwe MA, Black RE. Verbal/social autopsy analysis of causes and determinants of under-5 mortality in Tanzania from 2010 to 2016. J Glob Health 2021; 10:020901. [PMID: 33274067 PMCID: PMC7699006 DOI: 10.7189/jogh.10.020901] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background Tanzania has decreased its child mortality rate by more than 70 percent in the last three decades and is striving to develop a nationally-representative sample registration system with verbal autopsy to help focus health policies and programs toward further reduction. As an interim measure, a verbal and social autopsy study was conducted to provide vital information on the causes and social determinants of neonatal and child deaths. Methods Causes of neonatal and 1-59 month-old deaths identified by the 2015-16 Tanzania Demographic and Health Survey were assessed using the expert algorithm verbal autopsy method. The social autopsy examined prevalence of key household, community and health system indicators of preventive and curative care provided along the continuum of care and Pathway to Survival models. Careseeking for neonates and 1-59 month-olds was compared, and tests of associations of age and cause of death to careseeking indicators and place of death were conducted. Results The most common causes of death of 228 neonates and 351 1-59 month-olds, respectively, were severe infection, intrapartum related events and preterm delivery, and pneumonia, diarrhea and malaria. Coverage of early initiation of breastfeeding (24%), hygienic cord care (29%), and full immunization of 12-59 month-olds (33%) was problematic. Most (88.8%) neonates died in the first week, including 44.3% in their birth facility before leaving. Formal care was sought for just 41.9% of newborns whose illness started at home and was delayed by 5.3 days for 1-59 month-olds who sought informal care. Care was less likely to be sought for the youngest neonates and infants and severely ill children. Although 70.3% of 233 under-5 year-olds were moderately or severely ill on discharge from their first provider, only 29.0%-31.2% were referred. Conclusions The study highlights needed actions to complete Tanzania’s child survival agenda. Low levels of some preventive interventions need to be addressed. The high rate of facility births and neonatal deaths requires strengthening of institutionally-based interventions targeting maternal labor and delivery complications and neonatal causes of death. Scale-up of Integrated Community Case Management should be considered to strengthen careseeking for the youngest newborns, infants and severely ill children and referral practices at first level facilities.
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Affiliation(s)
- Alain K Koffi
- Institute for International Programs, Department of International Health, Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Henry D Kalter
- Institute for International Programs, Department of International Health, Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Robert E Black
- Institute for International Programs, Department of International Health, Bloomberg School of Public Health, Baltimore, Maryland, USA
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Story WT, Amare Y, Vaz LME, Gardner H, Tura H, Snetro G, Kinney MV, Wall S, Bekele A. Changes in attitudes and behaviors supportive of maternal and newborn health in Ethiopia: an evaluative case study. BMC Pregnancy Childbirth 2021; 21:407. [PMID: 34049509 PMCID: PMC8161997 DOI: 10.1186/s12884-021-03865-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/07/2021] [Indexed: 11/29/2022] Open
Abstract
Background Ethiopia’s high neonatal mortality rate led to the government’s 2013 introduction of Community-Based Newborn Care (CBNC) to bring critical prevention and treatment interventions closer to communities in need. However, complex behaviors that are deeply embedded in social and cultural norms continue to prevent women and newborns from getting the care they need. A demand creation strategy was designed to create an enabling environment to support appropriate maternal, newborn, and child health (MNCH) behaviors and CBNC. We explored the extent to which attitudes and behaviors during the prenatal and perinatal periods varied by the implementation strength of the Demand Creation Strategy for MNCH-CBNC. Methods Using an embedded, multiple case study design, we purposively selected four kebeles (villages) from two districts with different levels of implementation strength of demand creation activities. We collected information from a total of 150 key stakeholders across kebeles using multiple qualitative methods including in-depth interviews, focus group discussions, and illness narratives; sessions were transcribed into English and coded using NVivo 10.0. We developed case reports for each kebele and a final cross-case report to compare results from high and low implementation strength kebeles. Results We found that five MNCH attitudes and behaviors varied by implementation strength. In high implementation strength kebeles women felt more comfortable disclosing their pregnancy early, women sought antenatal care (ANC) in the first trimester, families did not have fatalistic ideas about newborn survival, mothers sought care for sick newborns in a timely manner, and newborns received care at the health facility in less than an hour. We also found changes across all kebeles that did not vary by implementation strength, including male engagement during pregnancy and a preference for giving birth at a health facility. Conclusions Findings suggest that a demand creation approach—combining participatory approaches with community empowering strategies—can promote shifts in behaviors and attitudes to support the health of mothers and newborns, including use of MNCH services. Future studies need to consider the most efficient level of intervention intensity to make the greatest impact on MNCH attitudes and behaviors. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03865-8.
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Affiliation(s)
- William T Story
- Department of Community and Behavioral Health, University of Iowa, Iowa City, IA, 52242, USA.
| | - Yared Amare
- Independent Consultant, Addis Ababa, Ethiopia
| | - Lara M E Vaz
- Save the Children US, Washington, DC, 20001, USA
| | | | - Halkeno Tura
- Department of Community and Behavioral Health, University of Iowa, Iowa City, IA, 52242, USA
| | - Gail Snetro
- Save the Children US, Washington, DC, 20001, USA
| | | | - Steve Wall
- Save the Children US, Washington, DC, 20001, USA
| | - Abeba Bekele
- Ethiopia Country Office, Save the Children International, Addis Ababa, Ethiopia
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Mothabbir G, Rana S, Baqui AH, Ahmed S, Ahmed AN, Taneja S, Mundra S, Bhandari N, Dalpath S, Tigabu Z, Andargie G, Teklu A, Tazebew A, Alemu K, Awoke T, Gebeyehu A, Jenda G, Nsona H, Mathanga D, Nisar YB, Bahl R, Sadruddin S, Muhe L, Moschovis P, Aboubaker S, Qazi S. Management of fast breathing pneumonia in young infants aged 7 to 59 days by community level health workers: protocol for a multi-centre cluster randomized controlled trial. ACTA ACUST UNITED AC 2020; 7:83-93. [PMID: 33163583 PMCID: PMC7644113 DOI: 10.18203/2349-3259.ijct20201715] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background: WHO does not recommend community-level health workers (CLHWs) using integrated community case management (iCCM) to treat 7–59 days old infants with fast breathing with oral amoxicillin, whereas World Health Organization (WHO) integrated management of childhood illness (IMCI) recommends it. We want to collect evidence to help harmonization of both protocols. Methods: A cluster, randomized, open-label trial will be conducted in Africa and Asia (Ethiopia, Malawi, Bangladesh and India) using a common protocol with the same study design, inclusion criteria, intervention, comparison, and outcomes to contribute to the overall sample size. This trial will also identify hypoxaemia in young infants with fast breathing. CLHWs will assess infants for fast breathing, which will be confirmed by a study supervisor. Enrolled infants in the intervention clusters will be treated with oral amoxicillin, whereas in the control clusters they will be managed as per existing iCCM protocol. An independent outcome assessor will assess all enrolled infants on days 6 and 14 of enrolment for the study outcomes in both intervention and control clusters. Primary outcome will be clinical treatment failure by day 6. This trial will obtain approval from the WHO and site institutional ethics committees. Conclusions: If the research shows that CLHWs can effectively and safely treat fast breathing pneumonia in 7–59 days old young infants, it will increase access to pneumonia treatment substantially for infants living in communities with poor access to health facilities. Additionally, this evidence will contribute towards the review of the current iCCM protocol and its harmonization with IMCI protocol. Trial Registration: The trial is registered at AZNCTR International Trial Registry as ACTRN12617000857303.
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Affiliation(s)
| | | | | | | | | | | | - Sunita Taneja
- Center for Health Research and Development, Society for Applied Studies
| | - Sudarshan Mundra
- Center for Health Research and Development, Society for Applied Studies
| | - Nita Bhandari
- Center for Health Research and Development, Society for Applied Studies
| | | | | | | | | | | | | | | | | | | | | | | | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing
| | | | | | - Peter Moschovis
- Pediatric Pulmonary Medicine, Pediatric Global Health, Massachusetts General Hospital, Harvard Medical School, USA
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Neonatal care and community-level treatment seeking for possible severe bacterial infection (PSBI) in Amhara, Ethiopia. BMC Health Serv Res 2020; 20:264. [PMID: 32228682 PMCID: PMC7106804 DOI: 10.1186/s12913-020-05081-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 03/09/2020] [Indexed: 12/12/2022] Open
Abstract
Background In Ethiopia, neonatal mortality accounts for approximately 54% of under-five deaths with the majority of these deaths driven by infections. Possible Severe Bacterial Infection (PSBI) in neonates is a syndromic diagnosis that non-clinical health care providers use to identify and treat newborns with signs of sepsis. In low- and middle–income countries, referral to a hospital may not be feasible due to transportation, distance or finances. Growing evidence suggests health extension workers (HEWs) can identify and manage PSBI at the community level when referral to a hospital is not possible. However, community-based PSBI care strategies have not been widely scaled-up. This study aims to understand general determinants of household-level care as well as household care seeking and decision-making strategies for neonatal PSBI symptoms. Methods We conducted eleven focus group discussions (FGDs) to explore illness recognition and care seeking intentions from four rural kebeles in Amhara, Ethiopia. FGDs were conducted among mothers, fathers and households with recruitment stratified among households that have had a newborn with at least one symptom of PSBI (Symptomatic Group), and households that have had a newborn regardless of the child’s health status (Community Group). Data were thematically analyzed using MAXQDA software. Results Mothers were described as primary caretakers of the newborn and were often appreciated for making decisions for treatment, even when the father was not present. Type of care accessed was often dependent on conceptualization of the illness as simple or complex. When symptoms were not relieved with clinical care, or treatments at facilities were perceived as ineffective, alternative methods were sought. Most participants identified the health center as a reliable facility. While designed to be the first point of access for primary care, health posts were not mentioned as locations where families seek clinical treatment. Conclusions This study describes socio-contextual drivers for PSBI treatment at the community level. Future programming should consider the role community members have in planning interventions to increase demand for neonatal care at primary facilities. Encouragement of health post utilization could further allow for heightened accessibility-acceptability of a simplified PSBI regimen.
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Lungu EA, Darker C, Biesma R. Determinants of healthcare seeking for childhood illnesses among caregivers of under-five children in urban slums in Malawi: a population-based cross-sectional study. BMC Pediatr 2020; 20:20. [PMID: 31952484 PMCID: PMC6966883 DOI: 10.1186/s12887-020-1913-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 01/07/2020] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND There is considerable evidence that health systems, in so far as they ensure access to healthcare, promote population health even independent of other determinants. Access to child health services remains integral to improving child health outcomes. Cognisant that improvements in child health have been unevenly distributed, it is imperative that health services and research focus on the disadvantaged groups. Children residing in urban slums are known to face a health disadvantage that is masked by the common view of an urban health advantage. Granted increasing urbanisation rates and proliferation of urban slums resulting from urban poverty, the health of under-five children in slums remains a public health imperative in Malawi. We explored determinants of healthcare-seeking from a biomedical health provider for childhood symptoms of fever, cough with fast breathing and diarrhoea in three urban slums of Lilongwe, Malawi. METHODS This was a population-based cross-sectional study involving 543 caregivers of under-five children. Data on childhood morbidity and healthcare seeking in three months period were collected using face-to-face interviews guided by a validated questionnaire. Data were entered in CS-Pro 5.0 and analysed in SPSS version 20 using descriptive statistics and logistic regression analyses. RESULTS 61% of caregivers sought healthcare albeit 53% of them sought healthcare late. Public health facilities constituted the most frequently used health providers. Healthcare was more likely to be sought: for younger than older under-five children (AOR = 0.54; 95% CI: 0.30-0.99); when illness was perceived to be severe (AOR = 2.40; 95% CI: 1.34-4.30); when the presenting symptom was fever (AOR = 1.77; 95% CI: 1.10-2.86). Home management of childhood illness was negatively associated with care-seeking (AOR = 0.54; 95% CI: 0.36-0.81) and timely care-seeking (AOR = 0.44; 95% CI: 0.2-0.74). Caregivers with good knowledge of child danger signs were less likely to seek care timely (AOR = 0.57; 95% CI: 0.33-0.99). CONCLUSIONS Even in the context of geographical proximity to healthcare services, caregivers in urban slums may not seek healthcare or when they do so the majority may not undertake timely healthcare care seeking. Factors related to the child, the type of illness, and the caregiver are central to the healthcare decision making dynamics. Improving access to under-five child health services therefore requires considering multiple factors.
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Affiliation(s)
| | - Catherine Darker
- Department of Public Health & Primary Care, Trinity College Dublin, Tallaght Hospital, Dublin 24, 24 Ireland
| | - Regien Biesma
- Global Health Unit, Department of Health Sciences, University of Groningen, P.O Box 196, 9700 AD Groningen, Netherlands
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