Access to a health facility and care-seeking for danger signs in children: before and after a community-based intervention in Lusaka, Zambia.

OBJECTIVE: To assess the association of accessibility to a health facility with caregivers' care-seeking practices for children with danger signs before and after community-based intervention in Lusaka, Zambia. METHOD: Health education on childhood danger signs was started in September 2003 at the monthly Growth Monitoring Program Plus (GMP+) service through various channels of health talk and one-on-one communication in a peri-urban area of Lusaka. Two repeated surveys were conducted: in 2003 to collect baseline data before the intervention and in 2006 for 3-year follow-up data. Caregivers who had perceived one or more danger signs in their children within 2 months of the surveys were eligible for the analysis. The association between appropriate and timely care-seeking practices and socio-demographic and socio-economic factors, attendance at community-based intervention and the distance to a health facility was examined with logistic regression analysis. RESULTS: The percentage of caregivers immediately seeking care from health professionals increased from 56.1% (106/189) at baseline to 65.8% (148/225) at follow-up 3 years later (OR = 1.51, P < 0.05). Long distance to the health facility and low-household income negatively influenced caregivers' appropriate and timely care-seeking practices at baseline, but 3 years later, after the implementation of a community-based intervention, distance and household income were not significantly related to caregivers' care-seeking practices. CONCLUSION: Poor accessibility to health facilities was a significant barrier to care-seeking in a peri-urban area. However, when caregivers are properly educated about danger signs and appropriate responses through community-based intervention, this barrier can be overcome through behavioural change in caregivers.

Autonomous Continuation of Community Health Workers' Activities in Thegon Township, Bago Region, Myanmar.

Background: Few studies have reported on the autonomous continuation of Community Health Worker (CHW) activities after external supervision and support have ended. Objective: The study reports CHW activity continuation in Thegon Township, Bago Region, Myanmar, observed after the supervision by the external organization is completed. Method: Following the completion of a child nutrition program in Thegon Township, CHWs were left unsupervised and uninformed of a follow-up at 10, 23, and 40 months from the end of the program survey due to unforeseen circumstances. In a follow-up survey in 2014, data on the activity implementation status from CHWs and activity attendance from caregivers of the target children were collected. Focus group discussions were held with caregivers concerning their information sources on child nutrition and health. Results: On average, CHWs were found to have continued with 2.6 of the four core activities, often with modifications, irrespective of the time since completion of the non-profit-organization-led program. Meanwhile, caregiver attendance decreased over time. Caregivers recognized CHWs as information sources. Discussion: Although unsupervised, CHWs ambitiously continued with their activities, but sorted through and modified them, which may have been unrelated to the local acceptance of the program, as caregiver attendance decreased even as CHWs continued the activities. The observation may highlight the importance of proactive engagement and thus, the autonomy of CHWs in their activity continuation.

Impact of drainage networks on cholera outbreaks in Lusaka, Zambia.

OBJECTIVES: We investigated the association between precipitation patterns and cholera outbreaks and the preventative roles of drainage networks against outbreaks in Lusaka, Zambia. METHODS: We collected data on 6542 registered cholera patients in the 2003-2004 outbreak season and on 6045 cholera patients in the 2005-2006 season. Correlations between monthly cholera incidences and amount of precipitation were examined. The distribution pattern of the disease was analyzed by a kriging spatial analysis method. We analyzed cholera case distribution and spatiotemporal cluster by using 2590 cholera cases traced with a global positioning system in the 2005-2006 season. The association between drainage networks and cholera cases was analyzed with regression analysis. RESULTS: Increased precipitation was associated with the occurrence of cholera outbreaks, and insufficient drainage networks were statistically associated with cholera incidences. CONCLUSIONS: Insufficient coverage of drainage networks elevated the risk of cholera outbreaks. Integrated development is required to upgrade high-risk areas with sufficient infrastructure for a long-term cholera prevention strategy.

Improvement in mothers' immediate care-seeking behaviors for children's danger signs through a community-based intervention in Lusaka, Zambia.

The large number of child deaths in developing countries is associated with delays in care-seeking by families, but the community-based efforts of the Integrated Management of Childhood Illnesses developed by WHO/UNICEF has remained ineffectual. To improve caregivers' ability to recognise potentially life-threatening symptoms of major childhood illnesses, we provided education about the importance of danger signs and immediate care-seeking practices through a community-based intervention of 'the Growth Monitoring Programme Plus (GMP+)' in low-income areas of Lusaka, Zambia. Using repeated cross-sectional data from interviews, we compared attendance and non-attendance groups to assess the impacts of intervention on mothers' care-seeking. Of 1717 and 1546 attendance mothers in the baseline and the final survey, 1097 and 1035, respectively, sought care from a health centre after perceiving the danger signs. The proportion of mothers with immediate response increased from 35.7% (392/1097) to 51.5% (533/1035) (p < 0.01). In the final survey, the attendance mothers became more likely to respond immediately to the danger signs than the non-attendance mothers (adjusted odds ratio: 2.140, 95% confidence interval: [1.408-3.252]), and the higher educational level the attendance mothers had, the more likely they were to respond immediately to the danger signs (primary level: 2.067 [1.050-4.068], secondary level and above: 2.174 [1.098-4.306]). In conclusion, GMP+ with danger sign education can improve mothers' care-seeking for severely sick children. Therefore, GMP+ has the potential to reduce child death in developing countries, i.e., contribute to the Millennium Development Goal 4 aiming at reducing child mortality by two-thirds by 2015.

The impact of community-based outreach immunisation services on immunisation coverage with GIS network accessibility analysis in peri-urban areas, Zambia.

BACKGROUND: Accessibility to health services is a critical determinant for health outcome. OBJECTIVES: To examine the association between immunisation coverage and distance to an immunisation service as well as socio-demographic and economic factors before and after the introduction of outreach immunisation services, and to identify optimal locations for outreach immunisation service points in a peri-urban area in Zambia. METHODS: Repeated cross-sectional surveys were conducted for two groups of children born between 1999 and 2001, and between 2003 and 2005.The association between immunisation coverage for DPT3 and measles, and access distance, child sex, female headed households, and monthly household income were assessed using logistic regression analysis. Optimal locations for outreach service points were identified using GIS network analysis and genetic algorithms. RESULTS: Before the introduction of outreach services, longer distances to the service points were associated with lower DPT3 and measles immunisation coverage (OR=0.24, 95% CI 0.10 to 0.56, p<0.01 for DPT3; and OR=0.38, 95% CI 0.17 to 0.83, p<0.05 for measles). However, access distances were not an impediment to immunisation coverage once the outreach services were introduced. The average distance to immunisation services could be decreased from 232.3 to 168.4 metres if the current 12 outreach service points were repositioned at optimal locations. CONCLUSION: Access distance to immunisation services was a critical determinant of immunisation coverage in a peri-urban area. Intervention via outreach services played an important role in averting the risk of missing out on immunisation. Optimal location analysis has the potential to contribute to efficient decision making regarding the delivery of immunisation services.

The impact of an immunization programme administered through the Growth Monitoring Programme Plus as an alternative way of implementing Integrated Management of Childhood Illnesses in urban-slum areas of Lusaka, Zambia.

A time-lag study design was used to examine the effects of an immunization programme implemented through an integrated community-based child health approach called the Growth Monitoring Programme Plus (GMP+) in peri-urban areas of Lusaka, Zambia. The immunization coverage and sociodemographic data of eligible children and households were obtained from three repeated surveys in two intervention areas. Logistic regression analysis was performed to explore the factors affecting immunization coverage. For assessing the timeliness of immunization, a Computerised Immunization Coverage Calculation System (CICCS) was used. Full immunization coverage significantly increased in both the primary intervention (P<0.001) and lagged intervention (P = 0.011) areas after the initiation of the GMP+. Frequent attendance to GMP+ sessions played a significant role in the improvement of immunization coverage (P<0.001 for the final survey in the primary intervention area), whereas other sociodemographic characteristics of the child and caretaker were not associated with immunization coverage. Analysis of the timeliness of three doses of diphtheria, pertussis and tetanus DPT3 immunization by CICCS showed that coverage in the primary intervention area had significantly improved compared to the lagged intervention area. Our study indicated that immunization coverage was improved effectively with the intervention of the GMP+ as a model of an integrated immunization programme for child health in line with the Integrated Management of Childhood Illnesses (IMCI) and the Global Immunization Vision and Strategy (GIVS).