Starting at the community: Treatment seeking pathways of children with suspected severe malaria in Uganda

IntroductionCommunity health workers (CHW) usually refer children with suspected severe malaria to the nearest public health facility or a designated public referral health facility (RHF). Caregivers do not always follow this recommendation. This study aimed at identifying post-referral treatment-seeking pathways that lead to appropriate antimalarial treatment for children less than five years with suspected severe malaria.MethodsAn observational study in Uganda enrolled children below five years presenting to CHWs with signs of severe malaria. Children were followed up 28 days after enrolment to assess their condition and treatment-seeking history, including referral advice and provision of antimalarial treatment from visited providers.ResultsOf 2211 children included in the analysis, 96% visited a second provider after attending a CHW. The majority of CHWs recommended caregivers to take their child to a designated RHF (65%); however, only 59% followed this recommendation. Many children were brought to a private clinic (33%), even though CHWs rarely recommended this type of provider (3%). Children who were brought to a private clinic were more likely to receive an injection than children brought to a RHF (78% vs 51%, p<0.001) and more likely to receive the second or third-line injectable antimalarial (artemether: 22% vs. 2%, p<0.001, quinine: 12% vs. 3%, p<0.001). Children who only went to non-RHF providers were less likely to receive an artemisinin-based combination therapy (ACT) than children who attended a RHF (odds ratio [OR] = 0.64, 95% CI 0.51–0.79, p<0.001). Children who did not go to any provider after seeing a CHW were the least likely to receive an ACT (OR = 0.21, 95% CI 0.14–0.34, p<0.001).ConclusionsHealth policies should recognise local treatment-seeking practices and ensure adequate quality of care at the various public and private sector providers where caregivers of children with suspected severe malaria actually seek care.

Does disrespect and abuse during childbirth differ between public and private hospitals in Southeast Nigeria

Background Disrespect and Abuse (D&A) during childbirth represents an important barrier to skilled birth utilization, indicating a problem with quality of care and a violation of women‘s human rights. This study compared prevalence of D&A during childbirth in a public and a private hospital in Southeast Nigeria. Methods This study was a cross-sectional study among women who gave birth in two specialized health facilities: a public teaching and a private-for-profit faith-based hospital in Southeast Nigeria. In each facility, systematic random sampling was used to select 310 mothers who had given birth in the facility and were between 0-14 weeks after birth. Study participants were recruited through the immunization clinics. Semi-structured, interviewer-administered questionnaires using the Bowser and Hills classification of D&A during childbirth were used for data collection. Data were analyzed using SPSS version 20 at 95% significance level. Results Mean age of the participants in the public hospital was 30.41 ± 4.4 and 29.31 ± 4.4 in the private hospital. Over three-fifths (191; 61.6%) in the public and 156 women (50.3%) in the private hospital had experienced at least one form of D&A during childbirth [cOR1.58; 95% CI 1.15, 2.18]. Abandonment and neglect [Public153 (49.4%) vs. Private: 91 (29.4%); cOR2.35; 95% CI. 1.69, 3.26] and non-consented care [Public 45 (14.5%) vs. Private 67(21.6%): cOR0.62; 95% CI. 0.41, 0.93] were the major types of D&A during childbirth. Denial of companionship was the most reported subtype of D&A during childbirth in both facilities [Public 135 (43.5%) vs. Private66 (21.3%); cOR2.85; 95% CI. 2.00, 4.06]. Rural residents were less likely to report at least one form of D&A during childbirth (aOR 0.53; CI 0.35-0.79). Conclusion Although prevalence was high in both facilities, overall prevalence of D&A during childbirth and most subtypes were higher in the public health facility. There is a need to identify contextual factors enabling D&A during childbirth in public and private health care settings.

GIS Application for Health Facility Coverage Mapping in Temanggung Regency, Central Java Province

Adequate health facilities have become one of the interesting issues to be discussed since this pandemic situation. Availability and accessibility of health facilities are the vital aspects that should be accomplished by both local and central government. Nevertheless, some population especially those living in rural areas have some difficulties in reaching these facilities due to the inequality condition within regions. This study aims to analyze the coverage of health facilities in Temanggung Regency, Central Java province and cluster its subdistricts according to their condition in accessing these facilities. The analysis is limited to public health facility (PUSKESMAS) and hospital levels. Both statistical and spatial data were processed using the GIS network analysis approach in producing the coverage number of each health facility and they were compared to the applied standard range of service and threshold. Then, a hierarchy is created using the weighted centrality index approach to represent disparities among subdistricts in Temanggung Regency regarding the availability and its coverage to health facilities. The results show that there is an inequality condition on health facilities coverage between central and peripheral areas within this regency, both at the public health facility level and hospital level. Several population in several districts, mostly residing in outer areas, are not covered by both public health facility and hospital. On the other hand, people in the capital and its surrounding subdistricts have better access to these facilities. Several factors are identified in producing this inequality, such as spatial distribution of housing areas, spatial allocation of health facilities, road network, and topographic condition. The topographic condition in some uncovered areas, which is relatively hilly and has steep slope, causes limited access to the road network and less coverage of health facilities.

Equity of geographical access to public health facilities in Nepal

IntroductionGeographical accessibility is important against health equity, particularly for less developed countries as Nepal. It is important to identify the disparities in geographical accessibility to the three levels of public health facilities across Nepal, which has not been available.MethodsBased on the up-to-date dataset of Nepal formal public health facilities in 2021, we measured the geographical accessibility by calculating the travel time to the nearest public health facility of three levels (ie, primary, secondary and tertiary) across Nepal at 1×1 km2 resolution under two travel modes: walking and motorised. Gini and Theil L index were used to assess the inequality. Potential locations of new facilities were identified for best improvement of geographical efficiency or equality.ResultsBoth geographical accessibility and its equality were better under the motorised mode compared with the walking mode. If motorised transportation is available to everyone, the population coverage within 5 min to any public health facilities would be improved by 62.13%. The population-weighted average travel time was 17.91 min, 39.88 min and 69.23 min and the Gini coefficients 0.03, 0.18 and 0.42 to the nearest primary, secondary and tertiary facilities, respectively, under motorised mode. For primary facilities, low accessibility was found in the northern mountain belt; for secondary facilities, the accessibility decreased with increased distance from the district centres; and for tertiary facilities, low accessibility was found in most areas except the developed areas like zonal centres. The potential locations of new facilities differed for the three levels of facilities. Besides, the majority of inequalities of geographical accessibility were from within-province.ConclusionThe high-resolution geographical accessibility maps and the assessment of inequality provide valuable information for health resource allocation and health-related planning in Nepal.

Undernutrition, Food Insecurity and Associated Factors among Adult HIV Positive people on HAART in Public Health Facility in Oromia Special Zone Surrounding Finfinne, Oromia, Ethiopia.

Background: Malnutrition is resulted from inequalities in nutrients intake and body demands. People living with Human Immunodeficiency virus (PLHIV) are more vulnerable to malnutrition, due to opportunistic infection, metabolic disorder, and increased need of energy during infection. Worldwide, over 800 million people are chronically undernourished. The dual burden in areas of severe food insecurity and Human Immunodeficiency virus (HIV) epidemic are highly contributing to morbidity and mortality of people living with HIV, especially in developing countries particularly Sab- Saharan Africa is considered as home of malnutrition and food insecurity. The major problem of PLHIV in Ethiopia is under nutrition and its complication. Objective: This study aimed to assess magnitude of under nutrition, food insecurity and associated factors among adult clients on ART attending ART clinic, at public health facilities, Oromia regional states central Ethiopia Method: An institution based cross-sectional study was conducted among adult PLHIV and on highly active antiretroviral therapy(HAART) attending public health facility in Oromia Special Zone Surrounding Finfinne (OSZSF) was conducted from August 2020 to May 2021. A systematic sampling was applied for sample selection. A pre tested semi structured questionnaire was used to collect data. Bivariate and multivariable analysis also employed to identify the presence, strength, direction of association and other confounding. After calculating for both first objective (prevalence of under nutrition) and second objective or factors associated with under nutrition the maximum sample size 305 was selected for this study.Result: The prevalence of under nutrition was 22.4% and house hold food insecurity was also high in current study 54.3%. Factors associated with under nutrition among participants were absence of ration (AOR=0.42, 95%CI: 0.0-0.9), World health organization clinical stage II, III and VI (AOR= 6.8, 95%CI: 2.5-18.6) and household food in secure (AOR=0.51, 95%CI: 0.27-0.95) while literacy status primary and less (AOR=2.24, 95%CI: 1.1-4.6), household average monthly income <2250 Ethiopian birr (AOR=0.41, 95%CI:0.21-0.8) and meal frequency less or equal to two (AOR=4.14, 95%CI:1.3-13.46).Conclusion and recommendation: This study finding reveals high prevalence of under nutrition and HH food insecurity results in disturbing the success of the program, thus Comprehensive care and support bio-medical and inter-sectorial collaboration is suggested for alleviating the problem.

Mobility for maternal health among women in hard-to-reach fishing communities on Lake Victoria, Uganda; a community-based cross-sectional survey

Background Maternal mortality is still a challenge in Uganda, at 336 deaths per 100,000 live births, especially in rural hard to reach communities. Distance to a health facility influences maternal deaths. We explored women’s mobility for maternal health, distances travelled for antenatal care (ANC) and childbirth among hard-to-reach Lake Victoria islands fishing communities (FCs) of Kalangala district, Uganda. Methods A cross sectional survey among 450 consenting women aged 15–49 years, with a prior childbirth was conducted in 6 islands FCs, during January-May 2018. Data was collected on socio-demographics, ANC, birth attendance, and distances travelled from residence to ANC or childbirth during the most recent childbirth. Regression modeling was used to determine factors associated with over 5 km travel distance and mobility for childbirth. Results The majority of women were residing in communities with a government (public) health facility [84.2 %, (379/450)]. Most ANC was at facilities within 5 km distance [72 %, (157/218)], while most women had travelled outside their communities for childbirth [58.9 %, (265/450)]. The longest distance travelled was 257.5 km for ANC and 426 km for childbirth attendance. Travel of over 5 km for childbirth was associated with adolescent girls and young women (AGYW) [AOR = 1.9, 95 % CI (1.1–3.6)], up to five years residency duration [AOR = 1.8, 95 % CI (1.0-3.3)], and absence of a public health facility in the community [AOR = 6.1, 95 % CI (1.4–27.1)]. Women who had stayed in the communities for up to 5 years [AOR = 3.0, 95 % CI (1.3–6.7)], those whose partners had completed at least eight years of formal education [AOR = 2.2, 95 % CI (1.0-4.7)], and those with up to one lifetime birth [AOR = 6.0, 95 % CI (2.0-18.1)] were likely to have moved to away from their communities for childbirth. Conclusions Despite most women who attended ANC doing so within their communities, we observed that majority chose to give birth outside their communities. Longer travel distances were more likely among AGYW, among shorter term community residents and where public health facilities were absent. Trial registration PACTR201903906459874 (Retrospectively registered). https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5977.

Patient Pathways and Diagnostic Value in Sierra Leone

What is the value of a diagnostic test? Most obviously for primary healthcare settings, laboratory tests can inform clinical decision making about treatment and patient management. Their predominant value in this context is therefore medical. But what about when that healthcare setting is chronically under-resourced, healthcare workers (including laboratory workers) are underpaid, and government supply chains fail to deliver basic laboratory supplies? In this contribution to the Field Notes section, we describe a Community Health Centre (CHC) in Sierra Leone where such conditions have given rise to a quasi-private laboratory service within the public health facility. Through detailed ethnographic description of patients’ diagnostic pathways through the facility, we examine and assess the impact on patient care when the medical and economic value of diagnostic tests diverge.

Determinants of household catastrophic costs for drug sensitive tuberculosis patients in Kenya

Background Despite free diagnosis and treatment for tuberculosis (TB), the costs during treatment impose a significant financial burden on patients and their households. The study sought to identify the determinants for catastrophic costs among patients with drug-sensitive TB (DSTB) and their households in Kenya. Methods The data was collected during the 2017 Kenya national patient cost survey from a nationally representative sample (n = 1071). Treatment related costs and productivity losses were estimated. Total costs exceeding 20% of household income were defined as catastrophic and used as the outcome. Multivariable Poisson regression analysis was performed to measure the association between selected individual, household and disease characteristics and occurrence of catastrophic costs. A deterministic sensitivity analysis was carried using different thresholds and the significant predictors were explored. Results The proportion of catastrophic costs among DSTB patients was 27% (n = 294). Patients with catastrophic costs had higher median productivity losses, 39 h [interquartile range (IQR): 20–104], and total median costs of USD 567 (IQR: 299–1144). The incidence of catastrophic costs had a dose response with household expenditure. The poorest quintile was 6.2 times [95% confidence intervals (CI): 4.0–9.7] more likely to incur catastrophic costs compared to the richest. The prevalence of catastrophic costs decreased with increasing household expenditure quintiles (proportion of catastrophic costs: 59.7%, 32.9%, 23.6%, 15.9%, and 9.5%) from the lowest quintile (Q1) to the highest quintile (Q5). Other determinants included hospitalization: prevalence ratio (PR) = 2.8 (95% CI: 1.8–4.5) and delayed treatment: PR = 1.5 (95% CI: 1.3–1.7). Protective factors included receiving care at a public health facility: PR = 0.8 (95% CI: 0.6–1.0), and a higher body mass index (BMI): PR = 0.97 (95% CI: 0.96–0.98). Pre TB expenditure, hospitalization and BMI were significant predictors in all sensitivity analysis scenarios. Conclusions There are significant inequities in the occurrence of catastrophic costs. Social protection interventions in addition to existing medical and public health interventions are important to implement for patients most at risk of incurring catastrophic costs. Graphic abstract

Creating a healthy Wirobrajan community from an early age through psychoeducation and early detection of people with mental disorders

Public concern for mental health problems is still very minimal, including in the Wirobrajan neighborhood, Yogyakarta, Indonesia. Wirobrajan Public Health Center as a public health facility has carried out various kinds of health education activities. However, the results were not optimal considering this requires the participation of the community in paying attention to health in the family environment. The mental health early detection movement is one of the factors for preventing mental health problems in the family. The purpose of this activity is to conduct psychoeducation and early detection of people with mental disorders (ODGJ) in the Wirobrajan environment. The method used was a cross-sector mini workshop in the form of ODGJ socialization, inauguration of the alert village decree and counseling on the role of families in preventing ODGJ recurrence. The results of the activity showed that mental health cadres had a better understanding of the concept, causes, and treatment of mental disorders, as well as the role of family and the environment in ODGJ. Thus, the cadres will understand more about people with mental disorders and have new abilities related to early detection of mental health.