Access to oncology care in Mali: a qualitative study on breast cancer.

BACKGROUND: Breast cancer is the most common cancer in terms of incidence and mortality among women worldwide, including in Africa, and a rapid increase in the number of new cases of breast cancer has recently been observed in sub-Saharan Africa. Oncology is a relatively new discipline in many West African countries, particularly Mali; thus, little is known about the current state of cancer care infrastructure and oncology practices in these countries. METHODS: To describe the challenges related to access to oncology care in Mali, we used a qualitative approach, following the Consolidated Criteria for Reporting Qualitative Research (COREQ). Thirty-eight semistructured interviews were conducted with health professionals treating cancer in Mali (n = 10), women with breast cancer (n = 25), and representatives of associations (n = 3), and 40 participant observations were conducted in an oncology unit in Bamako. We used the theoretical framework on access to health care developed by Levesque et al. a posteriori to organise and analyse the data collected. RESULTS: Access to oncology care is partly limited by the current state of Mali's health infrastructure (technical platform failures, repeated strikes in university hospitals, incomplete free health care and the unavailability of medicines) and exacerbated by the security crisis that has been occurring the country since 2012. The lack of specialist doctors, combined with limited screening campaigns and a centralised and fragmented technical platform in Bamako, is particularly detrimental to breast cancer treatment. Women's lack of awareness, lack of information throughout the treatment process, stereotypes and opposition to amputations all play a significant role in their ability to seek and access quality care, leading some women to therapeutically wander and others to want to leave Mali. It also leaves them in debt and jeopardises the future of their children. However, the high level of trust in doctors, the involvement of international actors, the level of social support and the growing influence of civil society on the issue of cancer also represent great current opportunities to fight cancer in Mali. CONCLUSION: Despite the efforts of successive Malian governments and the commitment of international actors, the provision of health care is still limited in the country, entrenching global inequalities in women's bodies.

Formative research to adapt the 'Diabetes Prevention Program- Power to Prevent' for implementation in Bamako, Mali.

BACKGROUND: There are few community-level behaviors change interventions for reducing diabetes and hypertension risk in Africa, despite increasing cases of type 2 diabetes and cardiovascular diseases. Thus, this study was designed to adapt the United States Centers for Disease Control and Prevention's "Diabetes Prevention Program Power to Prevent" (DPP-P2P) for use in low-income urban communities of Bamako, Mali. METHODS: Feedback was elicited on an initial French PowerPoint adaptation of the DPP-P2P session guidelines from stakeholders at the ministry of health, organizational partners, and medical care providers. Two community health centers in districts with high levels of diabetes or hypertension were selected to assist in developing the Malian adaptation. Focus groups were conducted with 19 community health workers (CHWs) of these centers. Based on feedback from these discussions, more graphics, demonstrations, and role plays were added to the PowerPoint presentations. The 19 CHWs piloted the proposed 12 sessions with 45 persons with diabetes or at-risk patients over a one-month period. Feedback discussions were conducted after each session, and changes in dietary and exercise habits were assessed pre and post participation in the program. This feedback contributed to finalization of a 14-session sequence. RESULTS: The DPP-P2P session guidelines were adapted for use by low-literacy CHWs, converting the written English guidelines into French PowerPoint presentations with extensive use of pictures, role plays and group discussions to introduce diabetes, diet, and exercise concepts appropriately for the Bamako context. CHWs recommendations for a strong family-oriented program led to expanded sessions on eliciting support from all adults in the household. The 45 participants in the pilot adaptation were enthusiastic about the program. At the end of the program, there were significant increases in the frequency of daily exercise, efforts to limit fat intake, and goals for more healthy diets and exercise levels. CONCLUSION: This study documents how an iterative process of developing the DPP-P2P adaptation led to the development of a culturally appropriate set of materials welcomed by participants and having promise for reaching the low-income, low-literacy population with or at risk for diabetes in Bamako, Mali.

Highly precarious general and sexual health conditions of young domestic servants: results from a qualitative exploratory study and perspectives for community-based research in Bamako, Mali.

Most domestic servants (DS) in Mali are very young female migrants living in precarious conditions. We aimed to understand their living and working conditions in relation to their general and sexual health. Seven focus groups (53 participants) were conducted by the DS community-based organization ADDAD. Narratives were thematically analyzed using an inductive method. The dominant emerging theme was DS' strong dependence on their employers. Employers' attitudes regarding DS workload, the provision of food, water and hygiene products, housing conditions, and healthcare cover, appeared decisive for DS' physical and mental health, and the type of healthcare they used (self-medication, traditional care, healthcare facilities). Psychological, physical and sexual violence in employers' households was frequent. HIV/STI prevention knowledge was poor. These results highlight the serious risks for DS in terms of HIV/STI and unwanted pregnancies. DS were interested in receiving healthcare from ADDAD; this was motivated by the organization's trusting and understanding community-based environment, and DS' fear of discrimination in healthcare facilities. This study highlights the relevance of tackling the defense of rights and sexual health promotion for DS at the community level. Its findings can help identify research questions to evaluate the extent to which DS constitute a key HIV population.

Benefits and challenges of a community-based programme for women living with HIV in Mali.

Gundo-So is a community-based programme developed by and for women living with HIV (WLHIV) in Mali through the ARCAD-Santé-PLUS association. It provides support, co-constructed with WLHIV, to develop strategies on whether or not to disclose their status. The aim of the ANRS-12373 research is to evaluate the impact of this programme in the short and medium term. As part of this research, semi-structured interviews were conducted with participants (14). These interviews were analysed thematically. Three themes are presented here: positive feedback from the programme, which enabled them to be listened to and supported them both psychologically and financially. The impact of the programme on the participants' social network is also described, in terms of the links made with peers met during the programme. Finally, a new perspective on issues such as disease management, which improved through the contribution of knowledge, and also through the development of psychosocial resources. The programme enabled participants to acquire psychosocial skills, the ability to effectively self-manage their condition, and strategies on whether or not to disclose their HIV status. Participants' empowerment and social support in relation to the disease were developed through the programme, particularly through the links created with other women living with HIV.

Master's degree in sexual and reproductive health: enhancing career development opportunities for midwives in Mali.

BACKGROUND: Midwives' contribution to improving outcomes for women and newborns depends on factors such as quality of pre-service training, access to continuing professional development, and the presence of an enabling work environment. The absence of opportunities for career development increases the likelihood that health professionals, including midwives, will consider leaving the profession due to a lack of incentives to sustain and increase motivation to remain in the field. It also limits the opportunities to better contribute to policy, training, and research. This study aimed to assess the influence of a Master in Sexual and Reproductive Health (SRH) at the INFSS on midwives' career progression in Mali. METHODS: This mixed methods study was conducted using an online questionnaire, semi-structured interviews, and a document review. The study participants included graduates from two cohorts (N = 22) as well as employers, managers, and teachers of the graduates (N = 20). Data were analysed according to research questions, comparing, and contrasting answers between different groups of respondents. RESULTS: The study revealed that graduates enrolled in the programme primarily to improve their knowledge and skills in management and public health. The graduates' expected roles are those of programme and health project manager and participation in planning and monitoring activities at national or sub-national level. The managers expected the programme to reflect the needs of the health system and equip midwives with skills in management and planning. The Master enhanced opportunities for graduates to advance their career in fields they are not usually working in such as management, research, and supervision. However, the recognition of the master's degree and of the graduates' profile is not yet fully effective. CONCLUSION: The master's degree in SRH is a capacity building programme. Graduates developed skills and acquired advanced knowledge in research and management, as well as a postgraduate degree. However, the master programme needs to be better aligned with health system needs to increase the recognition of graduates' skills and have a more positive impact on graduates' careers.

Internally displaced persons in Mali facing the COVID 19 pandemic: A qualitative study / Les personnes déplacées internes au Mali face à la COVID-19 : une étude qualitative

Introduction: The COVID-19 pandemic has exacerbated an already existing security crisis leading to massive population displacements that have been taking place since 2012. Purpose of research: This study aims to explore the representations of internally displaced persons (IDPs) about the existence of COVID-19 and their knowledge about its signs, symptoms, modes of transmission and prevention measures. Methods: The study was qualitative and exploratory. Individual and group interviews were used to collect data from 52 IDPs in six sites in Bamako and Segou. All interviews were recorded and transcribed. Thematic content analysis and N-Vivo software were used. Results: The majority of IDPs believed in the existence of COVID-19 and had good knowledge of the signs, symptoms, modes of transmission and prevention measures against the disease. However, this was not sufficient for the adoption of public health measures. Among those who believed in its existence, some thought that it was a disease of the white and rich. Finally, a group of participants believed in conspiracy theories and claimed that the government and humanitarian organizations were only trying to make money through these campaigns. Conclusion: To our knowledge, this is the first study in Mali to explore IDPs' beliefs and knowledge about COVID-19. These results could inform policies, strategies, and interventions to combat COVID-19 in IDP sites and in the general population.

Introduction: Le Mali fait face depuis 2012 à une crise sécuritaire qui a entraîné des déplacements massifs des populations à laquelle s'est greffée la pandémie de la COVID-19. But de l'étude: Cette étude vise à explorer les représentations des personnes « déplacées internes ¼ (PDIs), c'est-à-dire des personnes forcées de fuir leur lieu d'origine, sur l'existence de la COVID-19 ainsi que leurs connaissances sur ses signes, ses symptômes, les modes de transmission et les mesures de prévention. Méthodes: L'étude est qualitative et exploratoire. Des entretiens individuels et en groupes ont permis de collecter les données auprès de 52 PDIs de six sites de Bamako et Ségou. Tous les entretiens ont été enregistrés et transcrits. L'analyse de contenu thématique et le logiciel NVivo ont été utilisés. Résultats: Dans leur majorité, les PDIs croyaient en l'existence de la COVID-19 et avaient de bonnes connaissances sur les signes, les symptômes, les modes de transmission et les mesures de prévention contre la maladie. Toutefois, cela n'a pas été suffisant pour l'adoption des mesures de santé publique. Parmi ceux qui croient en son existence, certains pensent que c'est toutefois une maladie des blancs et des riches. Enfin, un groupe de participants croyait plutôt en des théories du complot selon lesquelles le gouvernement et les organisations humanitaires ne chercheraient qu'à gagner de l'argent à travers ces campagnes. Conclusions: Il s'agit à notre connaissance de la première étude au Mali explorant les représentations et les connaissances des PDIs sur la COVID-19. Ces résultats pourraient éclairer les politiques, stratégies et interventions de lutte contre la COVID-19 dans les sites PDI et dans la population générale.

Social representations of malaria in a southern malian community: an ethnographic qualitative study.

BACKGROUND: Malaria is one of the prime reasons for medical consultation and the major cause of morbidity and mortality in Mali. To assess and understand the dynamics of social representations of malaria, the anthropological research was conducted in the Wayerema II neighbourhood of the health district of Sikasso, southern Mali. METHODS: This was an ethnographic study conducted qualitatively in 2011 and 2016 through informal conversations, 70 semi-structured interviews, and participant observations with key actors. The observations, conversations, and interviews investigated local people's perceptions and knowledge about malaria, and how and to what extent the cultural and popular representations of the disease can have an impact on therapeutic routes. RESULTS: Mosquitoes are the principal agent of the transmission of malaria. However, the ubiquitous yet casually-claimed aetiological agents, causative, nosographic entities differ from-although sometimes integrated into-the biomedical dimension. For example, some communities perceive Kono, a complicated and pernicious form of malaria that often occurs among children, to originate from a supernatural force. "Bird disease" is another term used for Kono in Mali and other West African countries. Thus, overall, Kono is defined through the entanglements with cultural factors, namely the idiosyncratic habits, customs, and beliefs of the population of Wayerema II neighbourhood in the health district of Sikasso, Southern Mali. Wayerema II residents particularly tend to link therapeutic recourse amongst the afflicted not only to biomedical models but to sociocultural and popular perceptions and representations of malaria. CONCLUSION: In the findings, self-medication through both traditional and modern medical techniques was the most frequent therapeutic modality. Hence, the integration of local popular knowledge with the biomedical register can contribute to a comprehensive understanding of social representations and perceptions of malaria, and qualitative improvements in the malaria control programme.

Cost-effectiveness of district-wide seasonal malaria chemoprevention when implemented through routine malaria control programme in Kita, Mali using fixed point distribution.

BACKGROUND: Seasonal malaria chemoprevention (SMC) is a strategy for malaria control recommended by the World Health Organization (WHO) since 2012 for Sahelian countries. The Mali National Malaria Control Programme adopted a plan for pilot implementation and nationwide scale-up by 2016. Given that SMC is a relatively new approach, there is an urgent need to assess the costs and cost effectiveness of SMC when implemented through the routine health system to inform decisions on resource allocation. METHODS: Cost data were collected from pilot implementation of SMC in Kita district, which targeted 77,497 children aged 3-59 months. Starting in August 2014, SMC was delivered by fixed point distribution in villages with the first dose observed each month. Treatment consisted of sulfadoxine-pyrimethamine and amodiaquine once a month for four consecutive months, or rounds. Economic and financial costs were collected from the provider perspective using an ingredients approach. Effectiveness estimates were based upon a published mathematical transmission model calibrated to local epidemiology, rainfall patterns and scale-up of interventions. Incremental cost effectiveness ratios were calculated for the cost per malaria episode averted, cost per disability adjusted life years (DALYs) averted, and cost per death averted. RESULTS: The total economic cost of the intervention in the district of Kita was US $357,494. Drug costs and personnel costs accounted for 34% and 31%, respectively. Incentives (payment other than salary for efforts beyond routine activities) accounted for 25% of total implementation costs. Average financial and economic unit costs per child per round were US $0.73 and US $0.86, respectively; total annual financial and economic costs per child receiving SMC were US $2.92 and US $3.43, respectively. Accounting for coverage, the economic cost per child fully adherent (receiving all four rounds) was US $6.38 and US $4.69, if weighted highly adherent, (receiving 3 or 4 rounds of SMC). When costs were combined with modelled effects, the economic cost per malaria episode averted in children was US $4.26 (uncertainty bound 2.83-7.17), US $144 (135-153) per DALY averted and US $ 14,503 (13,604-15,402) per death averted. CONCLUSIONS: When implemented at fixed point distribution through the routine health system in Mali, SMC was highly cost-effective. As in previous SMC implementation studies, financial incentives were a large cost component.

Predictors of contraceptive method discontinuation among adolescent and young women in three West African countries (Burkina Faso, Mali, and Niger).

BACKGROUND: The effective use of contraception among adolescents and young women can reduce the risk of unintended pregnancies. However, the prevalence of contraceptive use remains low in this age group. The objective of this study was to estimate the rate of contraceptive method discontinuation among adolescents and young women and to identify its associated factors in Burkina Faso, Mali, and Niger. METHOD: This was a secondary analysis of data from Demographic and Health Surveys of Burkina Faso (2010), Mali (2012-2013), and Niger (2012). The dependent variable was the time to discontinuation of contraceptive methods. Independent variables were represented by sociodemographic, socioeconomic, and cultural characteristics. Mixed-effects survival analysis with proportional hazards was used to identify the predictors. RESULTS: A total of 2,264 adolescents and young women aged 15 to 24 years were included in this analysis, comprising 1,100 in Burkina Faso, 491 in Mali, and 673 in Niger. Over the last five years, the overall contraceptive discontinuation rate was 68.7% (50.1% in Burkina Faso, 59.6% in Mali, and 96.8% in Niger). At the individual level, in Burkina Faso, occupation (aHR = 0.33), number of living children (aHR = 2.17), marital status (aHR = 2.93), and region (aHR = 0.54) were associated with contraceptive discontinuation. Except for education and marital status, we found the same factors in Mali. In Niger, a women's education level (aHR = 1.47) and her partner (aHR = 0.52) were associated with discontinuation. At the community level, the region of origin was associated with discontinuation of contraceptive methods. CONCLUSION: Most adolescents and young women experienced at least one episode of discontinuation. Discontinuation of contraceptive methods is associated with the level of education, occupation, number of children, marital status, and desire for children with the spouse. Promotion of contraceptive interventions should target adolescents, young women, and their partners, as well as those with a low education level or in a union.

Describing, analysing and understanding the effects of the introduction of HIV self-testing in West Africa through the ATLAS programme in Côte d'Ivoire, Mali and Senegal.

BACKGROUND: The ATLAS programme aims to promote and implement HIV self-testing (HIVST) in three West African countries: Côte d'Ivoire, Mali, and Senegal. During 2019-2021, in close collaboration with the national AIDS implementing partners and communities, ATLAS plans to distribute 500,000 HIVST kits through eight delivery channels, combining facility-based, community-based strategies, primary and secondary distribution of HIVST. Considering the characteristics of West African HIV epidemics, the targets of the ATLAS programme are hard-to-reach populations: key populations (female sex workers, men who have sex with men, and drug users), their clients or sexual partners, partners of people living with HIV and patients diagnosed with sexually transmitted infections and their partners. The ATLAS programme includes research support implementation to generate evidence for HIVST scale-up in West Africa. The main objective is to describe, analyse and understand the social, health, epidemiological effects and cost-effectiveness of HIVST introduction in Côte d'Ivoire, Mali and Senegal to improve the overall HIV testing strategy (accessibility, efficacy, ethics). METHODS: ATLAS research is organised into five multidisciplinary workpackages (WPs): Key Populations WP: qualitative surveys (individual in-depth interviews, focus group discussions) conducted with key actors, key populations, and HIVST users. Index testing WP: ethnographic observation of three HIV care services introducing HIVST for partner testing. Coupons survey WP: an anonymous telephone survey of HIVST users. Cost study WP: incremental economic cost analysis of each delivery model using a top-down costing with programmatic data, complemented by a bottom-up costing of a representative sample of HIVST distribution sites, and a time-motion study for health professionals providing HIVST. Modelling WP: Adaptation, parameterisation and calibration of a dynamic compartmental model that considers the varied populations targeted by the ATLAS programme and the different testing modalities and strategies. DISCUSSION: ATLAS is the first comprehensive study on HIV self-testing in West Africa. The ATLAS programme focuses particularly on the secondary distribution of HIVST. This protocol was approved by three national ethic committees and the WHO's Ethical Research Committee.

Skilled birth attendance in Sierra Leone, Niger, and Mali: analysis of demographic and health surveys.

BACKGROUND: Skilled birth attendance (SBA) is a key strategy for averting maternal mortality ratio (MMR). The lifetime risk of maternal death is high in countries with low SBA. With the presence of a skilled birth attendant, the possibility of death owing to intrapartum-related complications or stillbirth can be reduced by 20%. METHODS: Using data from the most recent Demographic and Health Surveys, we investigated the prevalence of skilled birth attendance, variations, and associated factors. The sample was drawn from women aged 15-49 who were surveyed in these countries as part of the Demographic and Health Survey (DHS) program. With multivariate logistic regression, we explored the socio-demographic factors that predict women's likelihood of seeking skilled birth attendance or otherwise. RESULTS: Less than half of the women in Niger, Sierra Leone, and Mali obtained skilled birth attendance, with the worst case occurring in Niger (32.6%). Women in rural areas have less likelihood of obtaining skilled birth attendance (OR 0.21; 95% CI 0.16-0.28), as compared to women in urban locations. Highly educated women (OR 2.50; 95% CI 0.72-8.69), those who had subscribed to health insurance (OR 1.39; 95% CI 0.88-2.20), those who obtain four or more antenatal care visits (OR 1.63; 95% CI 1.43-1.86), and women who watch television at least once a week (OR 2.33; 95% CI 1.88-2.88) are more probable to seek SBA. CONCLUSION: Interventions to increase SBA rates in these countries need to be reassessed to focus on the rural-urban disparity in healthcare, female education, and ANC attendance.

Management of uncomplicated malaria among children under five years at public and private sector facilities in Mali.

BACKGROUND: Prompt and effective malaria diagnosis and treatment is a cornerstone of malaria control. Case management guidelines recommend confirmatory testing of suspected malaria cases, then prescription of specific drugs for uncomplicated malaria and for severe malaria. This study aims to describe case management practices for children aged 1-59 months seeking treatment with current or recent fever from public and private, rural and urban health providers in Mali. METHODS: Data were collected at sites in Sikasso Region and Bamako. Health workers recorded key information from the consultation including malaria diagnostic testing and result, their final diagnosis, and all drugs prescribed. Children with signs of severe diseases were ineligible. Consultations were not independently observed. Appropriate case management was defined as both 1) tested for malaria using rapid diagnostic test or microscopy, and 2) receiving artemisinin combination therapy (ACT) and no other antimalarials if test-positive, or receiving no antimalarials if test-negative. RESULTS: Of 1602 participating children, 23.7% were appropriately managed, ranging from 5.3% at public rural facilities to 48.4% at community health worker sites. The most common reason for 'inappropriate' management was lack of malaria diagnostic testing (50.4% of children). Among children with confirmed malaria, 50.8% received a non-ACT antimalarial (commonly artesunate injection or artemether), either alone or in combination with ACT. Of 215 test-negative children, 44.2% received an antimalarial drug, most commonly ACT. Prescription of multiple drugs was common: 21.7% of all children received more than one type of antimalarial, while 51.9% received an antibiotic and antimalarial. Inappropriate case management increased in children with increasing axillary temperatures and those seeking care over weekends. CONCLUSIONS: Multiple limitations in management of febrile children under five were identified, including inconsistent use of confirmatory testing and apparent use of severe malaria drugs for uncomplicated malaria. While we cannot confirm the reasons for these shortcomings, there is a need to address the high use of non-ACT antimalarials in this context; to minimize potential for drug resistance, reduce unnecessary expense, and preserve life-saving treatment for severe malaria cases. These findings highlight the challenge of managing febrile illness in young children in a high transmission setting.

Coordinating the research response to COVID-19: Mali's approach.

Mali, like the rest of the world, has seen a rapid spread of COVID-19 since the first report of imported cases. Despite being a low-income country, Mali has leveraged scientific research resources via coordinated approaches to enable public health emergency planning and response to the COVID-19 pandemic. Mali's approach includes the harmonization of research activities; leveraging of research laboratory capacity of the University Clinical Research Center, Mali International Center for Excellence and three other in-country laboratories for community COVID-19 testing; strengthening relationships amongst local and international stakeholders; and collaboration with the Ministry of Health to integrate scientific evidence into public policy and emergency management of COVID-19 through a platform of consultation and open communication. The country has implemented national coordination of its COVID-19 response by establishing a COVID-19 Scientific Advisory Committee and a COVID-19 Technical Coordination Committee, both within the Ministry of Health and working collaboratively with other stakeholders. Members of Mali's COVID-19 Scientific Advisory Committee also serve as leaders of its principal academic and government clinical and public health research entities. This centralised approach has enabled the prioritisation of COVID-19 control activities, informed allocation of resources, evidence-based public health practices and timely decision-making in the pandemic setting. Though challenges remain, lessons learned from Mali's harnessing of clinical research capacity to guide and support its COVID-19 response can be applied to future global health research challenges and illustrate the power of building public health-responsive research capacity in resource-limited settings through international collaboration.

Percent Fat Mass Increases with Recovery, But Does Not Vary According to Dietary Therapy in Young Malian Children Treated for Moderate Acute Malnutrition.

BACKGROUND: Moderate acute malnutrition (MAM) affects 34.1 million children globally. Treatment effectiveness is generally determined by the amount and rate of weight gain. Body composition (BC) assessment provides more detailed information on nutritional stores and the type of tissue accrual than traditional weight measurements alone. OBJECTIVE: The aim of this study was to compare the change in percentage fat mass (%FM) and other BC parameters among young Malian children with MAM according to receipt of 1 of 4 dietary supplements, and recovery status at the end of the 12-wk intervention period. METHODS: BC was assessed using the deuterium oxide dilution method in a subgroup of 286 children aged 6-35 mo who participated in a 12-wk community-based, cluster-randomized effectiveness trial of 4 dietary supplements for the treatment of MAM: 1) lipid-based, ready-to-use supplementary food (RUSF); 2) special corn-soy blend "plus plus" (CSB++); 3) locally processed, fortified flour (MI); or 4) locally milled flours plus oil, sugar, and micronutrient powder (LMF). Multivariate linear regression modeling was used to evaluate change in BC parameters by treatment group and recovery status. RESULTS: Mean ± SD %FM at baseline was 28.6% ± 5.32%. Change in %FM did not vary between groups. Children who received RUSF vs. MI gained more (mean; 95% CI) weight (1.43; 1.13, 1.74 kg compared with 0.84; 0.66, 1.03 kg; P = 0.02), FM (0.70; 0.45, 0.96 kg compared with 0.20; 0.05, 0.36 kg; P = 0.01), and weight-for-length z score (1.23; 0.79, 1.54 compared with 0.49; 0.34, 0.71; P = 0.03). Children who recovered from MAM exhibited greater increases in all BC parameters, including %FM, than children who did not recover. CONCLUSIONS: In this study population, children had higher than expected %FM at baseline. There were no differences in %FM change between groups. International BC reference data are needed to assess the utility of BC assessment in community-based management of acute malnutrition programs. This trial was registered at clinicaltrials.gov as NCT01015950.

Chronic patient as intermittent partner for policy-makers: the case of patient participation in the fight against diabetes and HIV/AIDS in Mali.

BACKGROUND: National and international strategies have increasingly promoted chronic patient participation at different levels of the health care system, building the image of an 'active' chronic patient engaged for example in his/her daily self-care and within associations dealing with service delivery and/or policy advocacy. Drawing upon examples of the fight against diabetes and HIV/AIDS in Mali, this article explores the factors that influence the engagement of patient associations at policy level. We focus on the openness of the institutionalised political system, and explore the role that public authorities, caregivers and donors give to diabetes and HIV/AIDS patients. METHODS: Data was collected between 2008 and 2014 in Bamako in the framework of a qualitative research. Thirty-eight actors fighting against diabetes were interviewed, as well as 17 representatives of donors. For HIV/AIDS, 27 actors were interviewed. In both cases, non-participant observation was carried out and documentary sources were collected. Based on theory of public and collective action, a historical and cognitive approach was adopted. Data analysis followed an inductive and iterative method. RESULTS: Partnerships between public authorities and diabetes patient associations have been intermittent over time and remained rather informal. In the case of people living with HIV/AIDS, the partnership between their associations and public authorities has steadily grown and was progressively institutionalised. Three political factors explain this difference: focus and extent of the commitment of public authorities, existing policy-making processes, and how the law frames patients' roles. Moreover, opportunities for patient participation depend on the nature and extent of the support provided by international donors. Finally, the cognitive dimension is also at stake, notably in relation to the way the two diseases and patients have been perceived by public authorities, caregivers, and donors. CONCLUSIONS: Chronic patients are intermittent partners for policy-makers. Despite the image of chronic active patients conveyed by national and international public health strategies, patient participation is not straightforward. Rather, political, economic, and cognitive factors underpin the presence of political opportunities that enable patient participation. Chronicity of the disease appears to play an ambiguous role in the shaping of these factors.

Do free caesarean section policies increase inequalities in Benin and Mali?

BACKGROUND: Benin and Mali introduced user fee exemption policies focused on caesarean sections (C-sections) in 2005 and 2009, respectively. These policies had a positive impact on access to C-sections and facility based deliveries among all women, but the impact on socioeconomic inequality is still highly uncertain. The objective of this study was to observe whether there was an increase or a decrease in urban/rural and socioeconomic inequalities in access to C-sections and facility based deliveries after the free C-section policy was introduced. METHODS: We used data from three consecutive Demographic and Health Surveys (DHS): 2001, 2006 and 2011-2012 in Benin and 2001, 2006 and 2012-13 in Mali. We evaluated trends in inequality in terms of two outcomes: C-sections and facility based deliveries. Adjusted odds ratios were used to estimate whether the distributions of C-sections and facility based deliveries favoured the least advantaged categories (rural, non-educated and poorest women) or the most advantaged categories (urban, educated and richest women). Concentration curves were used to observe the degree of wealth-related inequality in access to C-sections and facility based deliveries. RESULTS: We analysed 47,302 childbirths (23,266 in Benin and 24,036 in Mali). In Benin, we found no significant difference in access to C-sections between urban and rural women or between educated and non-educated women. However, the richest women had greater access to C-sections than the poorest women. There was no significant change in these inequalities in terms of access to C-sections and facility based deliveries after introduction of the free C-section policy. In Mali, we found a reduction in education-related inequalities in access to C-sections after implementation of the policy (p-value = 0.043). Inequalities between urban and rural areas had already decreased prior to implementation of the policy, but wealth-related inequalities were still present. CONCLUSIONS: Urban/rural and socioeconomic inequalities in C-section access did not change substantially after the countries implemented free C-section policies. User fee exemption is not enough. We recommend switching to mechanisms that combine both a universal approach and targeted action for vulnerable populations to address this issue and ensure equal health care access for all individuals.

Cost-effectiveness of the treatment of uncomplicated severe acute malnutrition by community health workers compared to treatment provided at an outpatient facility in rural Mali.

BACKGROUND: The Malian Nutrition Division of the Ministry of Health and Action Against Hunger tested the feasibility of integrating treatment of severe acute malnutrition (SAM) into the existing Integrated Community Case Management package delivered by community health workers (CHWs). This study assessed costs and cost-effectiveness of CHW-delivered care compared to outpatient facility-based care. METHODS: Activity-based costing methods were used, and a societal perspective employed to include all relevant costs incurred by institutions, beneficiaries and communities. The intervention and control arm enrolled different numbers of children so a modelled scenario sensitivity analysis was conducted to assess the cost-effectiveness of the two arms, assuming equal numbers of children enrolled. RESULTS: In the base case, with unequal numbers of children in each arm, for CHW-delivered care, the cost per child treated was 244 USD and cost per child recovered was 259 USD. Outpatient facility-based care was less cost-effective at 442 USD per child and 501 USD per child recovered. The conclusions of the analysis changed in the modelled scenario sensitivity analysis, with outpatient facility-based care being marginally more cost-effective (cost per child treated is 188 USD, cost per child recovered is 214 USD), compared to CHW-delivered care. This suggests that achieving good coverage is a key factor influencing cost-effectiveness of CHWs delivering treatment for SAM in this setting. Per week of treatment, households receiving CHW-delivered care spent half of the time receiving treatment and three times less money compared with those receiving treatment from the outpatient facility. CONCLUSIONS: This study supports existing evidence that the delivery of treatment by CHWs is a cost-effective intervention, provided that good coverage is achieved. A major benefit of this strategy was the lower cost incurred by the beneficiary household when treatment is available in the community. Further research is needed on the implementation costs that would be incurred by the government to increase the operability of these results.

Addressing social and gender norms to improve uptake of maternal health services in Mali: a descriptive study of CARE's Project Hope for Mothers and Newborns (PEMN).

This study examines the design and implementation of a maternal mortality prevention intervention in central Mali. It uses Project Hope for Mothers and Newborns (PEMN) as a case study to examine the context around implementation, with special emphasis on the role of social, gender and power norms in meeting programme objectives. Interventions to strengthen the health system and workforce were coupled with a social norms change approach to catalyse the personal transformation of staff, community-level health workers and communities via critical reflection and dialogue on gender and social power norms related to maternal health. Processes of reflection among staff, health workers and the community, coupled with activities that challenged restrictive norms, provided a platform for critical thinking, communication and motivation for change. Rigorous and comprehensive monitoring and evaluation is needed to identify and understand unique pathways to transformative change.

Disaster risk reduction amidst armed conflict: informal institutions, rebel groups, and wartime political orders.

Extant research has explored the effect of natural hazards on the risk of armed conflict, but very few studies have examined how conflict dynamics affect disaster risk reduction (DRR), including climate change adaptation. This is surprising given the empirical evidence that indicates how often disasters and armed conflicts collide. To understand better the impact of armed conflict on DRR, this paper develops a conceptual typology that is based on rebel groups' territorial control and on the strength of informal institutions. It documents three main political orders amid conflict: rebel stability; informal stability; and fragmented landscape. These wartime political orders will have different effects on DRR and other development programmes, revealing the importance of desegregating armed conflict to facilitate tailor-made and more efficient interventions. The paper provides empirical evidence from Mali and the Philippines that illustrates the influence of these wartime political orders on DRR programmes.

Dusukasi-The Heart That Cries: An Idiom of Mental Distress Among Perinatal Women in Rural Mali.

Perinatal mental health problems such as depression and anxiety are prevalent in low and middle-income countries. In Mali, the lack of mental health care is compounded by few studies on mental health needs, including in the perinatal period. This paper examines the ways in which perinatal women experience and express mental distress in rural Mali. We describe a process, relying on several different qualitative research methods, to identify understandings of mental distress specific to the Malian context. Participants included perinatal women, maternal health providers, and community health workers in rural southwest Mali. Participants articulated several idioms of distress, including gèlèya (difficulties), tôôrô (pain, suffering), hamin (worries, concerns), and dusukasi (crying heart), that occur within a context of poverty, interpersonal conflict, and gender inequality. These idioms of distress were described as sharing many key features and operating on a continuum of severity that could progress over time, both within and across idioms. Our findings highlight the context dependent nature of experiences and expressions of distress among perinatal women in Mali.