Impact of COVID-19 pandemic on food availability and affordability: an interrupted time series analysis in Ghana.

BACKGROUND: In Africa, approx. 675 million people were at risk of food insecurity. COVID-19 pandemic is likely to have exacerbated this situation, by damaging populations' access to and affordability of foods. This study is aimed at estimating the impacts of the COVID-19 pandemic on availability and prices of essential food commodities at 20 large markets in Ghana. METHODS: Data on food availability and food retail prices collected through weekly market-level data during the period from July 2017 to September 2020 were used in this study. We performed interrupted time-series analyses and estimated the percentage increases between the observed and predicted food prices by food group and by region to assess the impact of COVID-19 pandemic on food prices. RESULTS: As a result, the impact of COVID-19 on food availability was limited. However, the results of interrupted time-series analyses indicate a significant increase in overall mean food prices in Greater Accra, Eastern and Upper East regions. It was also found that mean price of starchy roots, tubers and plantains significantly increased across regions. DISCUSSION: The impact of COVID-19 pandemic on food availability and prices was significant but varied by food type and regions in Ghana. Continuous monitoring and responses are critical to maintain food availability and affordability.

The prevalence of hypertension and its distribution by sociodemographic factors in Central Mozambique: a cross sectional study.

BACKGROUND: Hypertension (HTN) is a major risk factor for cardiovascular diseases, and its prevalence has been rising in low- and middle-income countries. The current study describes HTN prevalence in central Mozambique, association between wealth and blood pressure (BP), and HTN monitoring and diagnosis practice among individuals with elevated BP. METHODS: The study used data from a cross-sectional, representative household survey conducted in Manica and Sofala provinces, Mozambique. There were 4101 respondents, aged ≥20 years. We measured average systolic and diastolic BP (SBP and DBP) from three measurements taken in the household setting. Elevated BP was defined as having either SBP ≥140 or DBP ≥90 mmHg. RESULTS: The mean age of the participants was 36.7 years old, 59.9% were women, and 72.5% were from rural areas. Adjusting for complex survey weights, 15.7% (95%CI: 14.0 to 17.4) of women and 16.1% (13.9 to 18.5) of men had elevated BP, and 7.5% (95% CI: 6.4 to 8.7) of the overall population had both SBP ≥140 and DBP ≥90 mmHg. Among participants with elevated BP, proportions of participants who had previous BP measurement and HTN diagnosis were both low (34.9% (95% CI: 30.0 to 40.1) and 12.2% (9.9 to 15.0) respectively). Prior BP measurement and HTN diagnosis were more commonly reported among hypertensive participants with secondary or higher education, from urban areas, and with highest relative wealth. In adjusted models, wealth was positively associated with higher SBP and DBP. CONCLUSIONS: The current study found evidence of positive association between wealth and BP. The prevalence of elevated BP was lower in Manica and Sofala provinces than the previously estimated national prevalence. Previous BP screening and HTN diagnosis were uncommon in our study population, especially among rural residents, individuals with lower education levels, and those with relatively less wealth. As the epidemiological transition advances in Mozambique, there is a need to develop and implement strategies to increase BP screening and deliver appropriate clinical services, as well as to encourage lifestyle changes among people at risk of developing hypertension in near future.

Community unit performance: factors associated with childhood diarrhea and appropriate treatment in Nyanza Province, Kenya.

BACKGROUND: The government of Kenya launched its community health strategy in 2006 to improve certain aspects of its community health program. Under the strategy, community units (CUs) were established as level one of the Kenyan health system. A core member at this level is the community health worker (CHW). The objective of this study was to assess the relationship among the performance of the CUs, the prevalence of childhood diarrhea and appropriate treatment for it by controlling individual and community-level factors. METHODS: The main dataset used in this study was the 2011 Nyanza Province county-based Multiple Indicator Cluster Survey (MICS). In addition, based on the list of community units in Nyanza Province, Kenya, we identified the area's CUs and their performance. MICS data and data on CUs were merged using sub-location names. There were 17 individual and two community-level independent variables in this study. Bivariate analysis and a multilevel logistic regression were performed. RESULTS: Factors significantly associated with a lower prevalence of diarrhea among children under five were the child's increasing age, middle-aged household heads, children who received more attention, water treatment and rural versus urban area residence, while male children and highly performing CUs were significantly associated with a higher prevalence of diarrhea. In addition, middle wealth index, severity of diarrhea and middle- and high-CU performance were significantly associated with appropriate treatment for childhood diarrhea. CONCLUSIONS: Although this study found that children living in areas of high CU performance were more likely to have diarrhea, these areas would have been identified as being more at risk for diarrhea prevalence and other health concerns, prioritized for the establishment of a CU and allocated more resources to improve the performance of CUs. A higher CU performance was significantly associated with the appropriate treatment. It was suggested that CHWs could have a positive effect on the community, as demonstrated and promoted by appropriate health-seeking behavior and treatment for childhood diarrhea.

Effectiveness of and factors related to possession of a mother and child health handbook: an analysis using propensity score matching.

BACKGROUND: Mother and Child Health handbooks (MCH handbooks) serve as useful health education tools for mothers and sources of information that allow health care professionals to understand patient status. Therefore, it is necessary to clarify the effectiveness of and identify the factors related to possession of an MCH handbook among parents in rural Western Kenya using propensity score matching (PSM). METHODS: A community-based cross-sectional survey using a structured questionnaire was conducted in rural western Kenya from August to September, 2011. We targeted 2560 mothers with children aged 12-24 months. Both PSM and multivariate logistic analyses were used in this study. RESULTS: Impacts of 5.9, 9.4, and 12.6 percentage points for higher health knowledge and for proper health-seeking behavior for fever and diarrhea, respectively, were statistically significant. The significant factors affecting possession of the MCH Handbook were the child's sex, the caregiver's relationship to the child, maternal age, health knowledge, birth interval, household wealth index and CHW performance accordingly. CONCLUSIONS: An MCH handbook was an effective tool for improving both health knowledge and health-seeking behavior in Kenya. The further distribution and utilization of an MCH handbook is expected to be an effective way to improve both maternal and child health.

Individual and contextual factors associated with community health workers' performance in Nyanza Province, Kenya: a multilevel analysis.

BACKGROUND: Several African and South Asian countries are currently investing in new cadres of community health workers (CHWs) as a major part of strategies aimed at reaching the Millennium Development Goals. However, one review concluded that community health workers did not consistently provide services likely to have substantial effects on health and that quality was usually poor. The objective of this research was to assess the CHWs' performance in Western Kenya and describe determinants of that performance using a multilevel analysis of the two levels, individual and supervisor/community. METHODS: This study conducted three surveys between August and September 2011 in Nyanza Province, Kenya. The participants of the three surveys were all 1,788 active CHWs, all their supervisors, and 2,560 randomly selected mothers who had children aged 12 to 23 months. CHW performance was generated by three indicators: reporting rate, health knowledge and household coverage. Multilevel analysis was performed to describe the determinants of that performance. RESULTS: The significant factors associated with the CHWs' performance were their marital status, educational level, the size of their household, their work experience, personal sanitation practice, number of supervisions received and the interaction between their supervisors' better health knowledge and the number of supervisions. CONCLUSION: A high quality of routine supervisions is one of the key interventions in sustaining a CHW's performance. In addition, decreasing the dropout rate of CHWs is important both for sustaining their performance and for avoiding the additional cost of replacing them. As for the selection criteria of new CHWs, good educational status, availability of supporters for household chores and good sanitation practices are all important in selecting CHWs who can maintain their high performance level.

Determinants of health facility utilization for childbirth in rural western Kenya: cross-sectional study.

BACKGROUND: Skilled attendance at delivery is recognized as one of the most important factors in preventing maternal death. However, more than 50% of births in Kenya still occur in non-institutional locations supported by family members and/or traditional birth attendants (TBAs). To improve this situation, a study of the determinants of facility delivery, including individual, family and community factors, was necessary to consider effective intervention in Kenya. METHODS: This study was conducted to identify the factors which influence the place of delivery in rural western Kenya, and to recommend ways to improve women's access to skilled attendants at delivery. A community-based cross-sectional survey was carried out from August to September 2011 in all 64 sub-locations which were covered by community health workers (CHWs). An interviewer-administered questionnaire on seventeen comprehensive variables was administered to 2,560 women who had children aged 12-24 months. RESULTS: The response rate was 79% (n = 2,026). Of the respondents, 48% of births occurred in a health facility and 52% in a non-institutional location. The significant determinants of facility delivery examined using multivariate analysis were: maternal education level, maternal health knowledge, ANC visits, birth interval, economic status of household, number of household members, household sanitation practices and traveling time to nearest health facility. CONCLUSIONS: The results suggest that the involvement of TBAs to promote facility delivery is still one of the most important strategies. Strengthening CHWs' performance by focusing on a limited number of topics and clear management guidance might also be an effective intervention. Stressing the importance of regular attendance at ANC (at least four times) would be effective in enhancing motivation for a facility delivery. Based on our findings, those actions to improve the facility delivery rate should focus more on pregnant women who have a low education level, poor health knowledge and short pregnancy spacing. In addition, women with low economic status, a large number of family members and a long distance to travel to a health facility should also be targeted by further interventions.

High-resolution mapping of essential maternal and child health service coverage in Nigeria: a machine learning approach.

BACKGROUND: National-level coverage estimates of maternal and child health (MCH) services mask district-level and community-level geographical inequities. The purpose of this study is to estimate grid-level coverage of essential MCH services in Nigeria using machine learning techniques. METHODS: Essential MCH services in this study included antenatal care, facility-based delivery, childhood vaccinations and treatments of childhood illnesses. We estimated generalised additive models (GAMs) and gradient boosting regressions (GB) for each essential MCH service using data from five national representative cross-sectional surveys in Nigeria from 2003 to 2018 and geospatial socioeconomic, environmental and physical characteristics. Using the best-performed model for each service, we map predicted coverage at 1 km2 and 5 km2 spatial resolutions in urban and rural areas, respectively. RESULTS: GAMs consistently outperformed GB models across a range of essential MCH services, demonstrating low systematic prediction errors. High-resolution maps revealed stark geographic disparities in MCH service coverage, especially between rural and urban areas and among different states and service types. Temporal trends indicated an overall increase in MCH service coverage from 2003 to 2018, although with variations by service type and location. Priority areas with lower coverage of both maternal and vaccination services were identified, mostly located in the northern parts of Nigeria. CONCLUSION: High-resolution spatial estimates can guide geographic prioritisation and help develop better strategies for implementation plans, allowing limited resources to be targeted to areas with lower coverage of essential MCH services.

Effects of the COVID-19 pandemic on essential health and nutrition service utilisations in Ghana: interrupted time-series analyses from 2016 to 2020.

OBJECTIVES: This study aimed to assess the national-level and subnational-level effects of the COVID-19 pandemic on essential health and nutrition service utilisation in Ghana. DESIGN: Interrupted time-series. SETTING AND PARTICIPANTS: This study used facility-level data of 7950 governmental and non-governmental health facilities in Ghana between January 2016 and November 2020. OUTCOME MEASURES: As the essential health and nutrition services, we selected antenatal care (ANC); institutional births, postnatal care (PNC); first and third pentavalent vaccination; measles vaccination; vitamin A supplementations (VAS); and general outpatient care. We performed segmented mixed effects linear models for each service with consideration for data clustering, seasonality and autocorrelation. Losses of patient visits for essential health and nutrition services due to the COVID-19 pandemic were estimated as outcome measures. RESULTS: In April 2020, as an immediate effect of the COVID-19 pandemic, the number of patients for all the services decreased except first pentavalent vaccine. While some services (ie, institutional birth, PNC, third pentavalent and measles vaccination) recovered by November 2020, ANC, VAS and outpatient services had not recovered to prepandemic levels. The total number of lost outpatient visits in Ghana was estimated to be 3 480 292 (95% CI: -3 510 820 to -3 449 676), followed by VAS (-180 419, 95% CI: -182 658 to -177 956) and ANC (-87 481, 95% CI: -93 644 to -81 063). The Greater Accra region was the most affected region by COVID-19, where four out of eight essential services were significantly disrupted. CONCLUSION: COVID-19 pandemic disrupted the majority of essential healthcare services in Ghana, three of which had not recovered to prepandemic levels by November 2020. Millions of outpatient visits and essential ANC visits were lost. Furthermore, the immediate and long-term impacts of the COVID-19 pandemic on service utilisation varied by service type and region.

Strengthening polio vaccine demand in Ghana: Understanding the factors influencing uptake of the vaccine and the effectiveness of different message frames.

BACKGROUND: Ghana has experienced recent polio outbreaks. Behavioral insights can be used to understand behavior and create demand for the polio vaccine. METHODS: This cross-sectional study is based on an interactive mobile phone survey that explored factors influencing the uptake of the polio vaccine among Ghanaian mothers with children younger than five years old. The survey also explores the mothers' intention to vaccinate their children in the future as well as an experiment with short polio vaccine voice message nudges to identify the most effective message frames in encouraging vaccination. The study sample was drawn from volunteers from a mobile service platform. Linear probability model regressions with Ordinary Least Squares (OLS) estimates were used to analyze the data. RESULTS: In total, data from 708 caregivers was assessed. Out of the sample, 35% (n = 250) had not vaccinated their children against polio, around 8% (n = 53) of respondents stated they did not plan to do so, while 28% expressed intent to do so during the next polio vaccination campaign. Higher vaccination of children against polio, i.e. better uptake of the polio vaccine, appeared to be associated with children's caregivers knowing that polio causes paralysis (with a coefficient of 0.13 (95% CI: 0.02, 0.24), i.e. 13% more likely than not to have their child vaccinated). Higher vaccine uptake also appeared to be associated with the perception that the polio vaccine is safe (with a coefficient of 0.11 (95% CI: 0.01, 0.22), i.e. 11% more likely than not to have their child vaccinated). Another factor in increasing vaccine uptake is whether caregivers receive support from healthcare workers with a coefficient of 0.11 (95% CI: 0.02, 0.20), i.e. 11% more likely than not to have their child vaccinated. Crucially, difficulty accessing the polio vaccine appeared to be associate with a negative change in vaccine uptake (with a coefficient of -0.16 (95% CI: -0.23, -0.08), i.e. 16% less likely to have their child vaccinated). Satisfaction with the information provided by vaccinators was also associated with better vaccine uptake (with a coefficient of 0.12 (95% CI: 0.05, 0.20) i.e. 12% more likely than not to have their child vaccinated); and having seen or heard something negative about the polio vaccine with a coefficient of 0.10 (95% CI: 0.03, 0.17), i.e. 10% more likely than not to have their child vaccinated. The social norms message frame was statistically significant with a coefficient of 0.06 (95% CI: -0.004, 012). CONCLUSION: The findings from this study suggest that most women with children under the age of 5 appear to have vaccinated their children against polio. Many more caregivers express an intention to vaccinate their children, never having done so before. The behavior and the intention to vaccinate are both driven by a number of factors that must be addressed to create demand for the polio vaccine. Targeted message frames appeared to be statistically significant drivers of vaccine uptake. However, more research is required to understand how they impact vaccine behavior and future intention for vaccination.

Prevalence and risk factors of neurological impairment among children aged 6-9 years: from population based cross sectional study in western Kenya.

BACKGROUND: The burden of disability is more severe among children in low income countries. Moreover, the number of children with disabilities (CWDs) in sub-Saharan Africa is predicted to increase with reduction in child mortality. Although the issue on CWDs is important in sub-Saharan Africa, there are few researches on risk factors of disabilities. The purpose of this study was to evaluate the risk factors of neurological impairment (NI) among children in western Kenya. METHODS: The present study was conducted in Mbita district (which has high HIV infectious prevalence), Kenya from April 2009 to December 2010. The study consisted of two phases. In phase 1, the Ten Question Questionnaire (TQQ) was administered to all 6362 caregivers of children aged 6-9 years. In phase two, all 413 children with TQQ positive and a similar number of controls (n=420) which were randomly selected from children with TQQ negative were examined for physical and cognitive status. In addition, a structured questionnaire was also conducted to their caregivers. RESULTS: The prevalence was estimated to be 29/1000. Among the types of impairments, cognitive impairment was the most common (24/1000), followed by physical impairment (5/1000). In multivariate analysis, having more than five children [adjusted odds ratio (AOR): 2.85; 95%IC: 1.25-6.49; p=0.013], maternal age older than 35 years old [AOR: 2.31; 95%IC: 1.05-5.07; p=0.036] were significant factors associated with NI. In addition, monthly income under 3000 ksh [AOR: 2.79; 95%IC: 1.28-6.08; p=0.010] and no maternal tetanus shot during antenatal care [AOR: 5.17; 95%IC: 1.56-17.14; p=0.007] were also significantly related with having moderate/severe neurological impairment. CONCLUSION: It was indicated that increasing coverage of antenatal care including maternal tetanus shot and education of how to take care of neonatal children to prevent neurological impairment are important.

Effectiveness of four interventions in improving community health workers' performance in western Kenya: a quasi-experimental difference-in-differences study using a longitudinal data.

BACKGROUND: Community health workers (CHWs) are up-front health workers delivering the most effective life-saving health services to communities. They are the key driver to achieve Universal Health Coverage. However, maintaining CHWs' performance is one of the challenges in sustaining their effectiveness. This article assessed the effectiveness of the four interventions and their combinations on the CHWs' performance in terms of health knowledge, job satisfaction, and household coverage. METHODS: We used the longitudinal survey data collected in western Kenya. Our study participants were the representative of all CHWs working in the four districts, Kenya. The four types of interventions were composed of a basic core intervention (i.e., refresher training with/without defaulter tracing) and three supplementary interventions (i.e., provision of a bicycle, frequent supportive supervision, and financial incentives). We performed the three fixed-effect models to assess the effectiveness of the four interventions and their combinations on the three performance indicators. RESULTS: Three single and combination interventions significantly increased CHWs' health knowledge: refresher training only [Coef.: 48.43, 95% CI: 42.09-54.76, P < 0.001]; refresher training plus defaulter-tracing [Coef.: 38.80, 95% CI: 32.71-44.90, P < 0.001]; combination of refresher training plus defaulter-tracing and frequent supervision [Coef.: 17.02, 95% CI: 7.90-26.15, P < 0.001]. Financial support was the only intervention that significantly increased job satisfaction among CHWs [Coef.: 4.97, 95% CI: 0.20-9.75, P = 0.041]. There was no single intervention that significantly increased household coverage. Yet, the combinations of the interventions significantly increased household coverage. CONCLUSIONS: There was no single intervention to improve all the aspects of CHWs' performance. The refresher training significantly improved their health knowledge, while financial incentive enhanced the level of their job satisfaction. The combinations of regular refresher training and other intervention(s) are the recommended as the effective interventions in improving and further sustaining CHWs' performance.

Do mothers pick up a phone? A cross-sectional study on delivery of MCH voice messages in Lagos, Nigeria.

BACKGROUND: Voice messages have been employed as an effective and efficient approach for increasing health service utilization and health promotion in low- and middle-income countries. However, unlike SMS, voice message services require their users to pick up a phone call at its delivery time. Furthermore, voice messages are difficult for the users to review their contents afterward. While recognizing that voice messages are more friendly to specific groups (eg, illiterate or less literate populations), there should be several challenges in successfully operationalizing its intervention program. OBJECTIVE: This study is aimed to estimate the extent to which voice message service users pick up the phone calls of voice messages and complete listening up to or beyond the core part of voice messages. METHODS: A voice message service program composed of 14 episodes on maternal, newborn, and child health was piloted in Lagos, Nigeria, from 2018 to 2019. A voice message call of each of 14 episodes was delivered to the mobile phones of the program participants per day for 14 consecutive days. A total of 513 participants in the voice message service chose one of five locally spoken languages as the language to be used for voice messages. Two multilevel logistic regression models were created to understand participants' adherence to the voice message: (a) Model 1 for testing whether a voice message call is picked up; and (b) Model 2 for testing whether a voice message call having been picked up is listened to up to the core messaging part. RESULTS: The greater the voice message episode number became, the smaller proportion of the participants picked up the phone calls of voice message (aOR: 0.98; 95% CI: 0.97-0.99; P = .01). Only 854 of 3765 voice message calls having been picked up by the participants (22.7%) were listened to up to their core message parts. It was found that picking up a phone call did not necessarily ensure listening up to the core message part. This indicates a discontinuity between these two actions. CONCLUSIONS: The participants were likely to stop picking up the phone as the episode number of voice messages progressed. In view of the discontinuity between picking up a phone call and listening up to the core message part, we should not assume that those picking up the phone would automatically complete listening to the entire or core voice message.

Factors consistently associated with utilisation of essential maternal and child health services in Nigeria: analysis of the five Nigerian national household surveys (2003-2018).

OBJECTIVE: This study aims to identify the individual and contextual factors consistently associated with utilisation of essential maternal and child health services in Nigeria across time and household geolocation. DESIGN, SETTING AND PARTICIPANTS: Secondary data from five nationally representative household surveys conducted in Nigeria from 2003 to 2018 were used in this study. The study participants are women and children depending on essential maternal and child health (MCH) services. OUTCOME MEASURES: The outcome measures were indicators of whether participants used each of the following essential MCH services: antenatal care, facility-based delivery, modern contraceptive use, childhood immunisations (BCG, diphtheria, tetanus, pertussis/Pentavalent and measles) and treatments of childhood illnesses (fever, cough and diarrhoea). METHODS: We estimated generalised additive models with logit links and smoothing terms for households' geolocation and survey years. RESULTS: Higher maternal education and households' wealth were significantly associated with utilisation of all types of essential MCH services (p<0.05). On the other hand, households with more children under 5 years of age and in poor communities were significantly less likely to use essential MCH services (p<0.05). Except for childhood immunisations, greater access to transport was positively associated with utilisation (p<0.05). Households with longer travel times to the most accessible health facility were less likely to use all types of essential MCH services (p<0.05), except modern contraceptive use and treatment of childhood fever and/or cough. CONCLUSION: This study adds to the evidence that maternal education and household wealth status are consistently associated with utilisation of essential MCH services across time and space. To increase utilisation of essential MCH services across different geolocations, interventions targeting poor communities and households with more children under 5 years of age should be appropriately designed. Moreover, additional interventions should prioritise to reduce inequities of essential MCH service utilisation between the wealth quantiles and between education status.

The neglected epidemic-Risk factors associated with road traffic injuries in Mozambique: Results of the 2016 INCOMAS study.

In 2019, 93% of road traffic injury related mortality occurred in low- and middle-income countries, an estimated burden of 1.3 million deaths. This problem is growing; by 2030 road traffic injury will the seventh leading cause of death globally. This study both explores factors associated with RTIs in the central region of Mozambique, as well as pinpoints geographical "hotspots" of RTI incidence. A cross-sectional, population-level survey was carried out in two provinces (Sofala and Manica) of central Mozambique where, in addition to other variables, the number of road traffic injuries sustained by the household within the previous six months, was collected. Urbanicity, household ownership of a car or motorcycle, and socio-economic strata index were included in the analysis. We calculated the prevalence rate ratios using a generalized linear regression with a Poisson distribution, as well as the spatial prevalence rate ratio using an Integrated Nested Laplace Approximation. The survey included 3,038 households, with a mean of 6.29 (SD 0.06) individuals per household. The road traffic injury rate was 6.1% [95%CI 7.1%, 5.3%]. Urban residence was associated with a 47% decrease in rate of injury. Household motorbike ownership was associated with a 92% increase in the reported rate of road traffic injury. Higher socio-economic status households were associated with a 26% increase in the rate of road traffic injury. The rural and peri-urban areas near the "Beira corridor" (national road N6) have higher rates of road traffic injuries. In Mozambique, living in the rural areas near the "Beira corridor", higher household socio-economic strata, and motorbike ownership are risk factors for road traffic injury.

Household Economic Consequences of Rheumatic Heart Disease in Uganda.

Background: Rheumatic heart disease (RHD) has declined dramatically in wealthier countries in the past three decades, but it remains endemic in many lower-resourced regions and can have significant costs to households. The objective of this study was to quantify the economic burden of RHD among Ugandans affected by RHD. Methods: This was a cross-sectional cost-of-illness study that randomly sampled 87 participants and their households from the Uganda National RHD registry between December 2018 and February 2020. Using a standardized survey instrument, we asked participants and household members about outpatient and inpatient RHD costs and financial coping mechanisms incurred over the past 12 months. We used descriptive statistics to analyze levels and distributions of costs and the frequency of coping strategies. Multivariate Poisson regression models were used to assess relationships between socioeconomic characteristics and utilization of financial coping mechanisms. Results: Most participants were young or women, demonstrating a wide variation in socioeconomic status. Outpatient and inpatient costs were primarily driven by transportation, medications, and laboratory tests, with overall RHD direct and indirect costs of $78 per person-year. Between 20 and 35 percent of households experienced catastrophic healthcare expenditure, with participants in the Northern and Western Regions 5-10 times more likely to experience such hardship and utilize financial coping mechanisms than counterparts in the Central Region, a wealthier area. Increases in total RHD costs were positively correlated with increasing use of coping behaviors. Conclusion: Ugandan households affected by RHD, particularly in lower-income areas, incur out-of-pocket costs that are very high relative to income, exacerbating the poverty trap. Universal health coverage policy reforms in Uganda should include mechanisms to reduce or eliminate out-of-pocket expenditures for RHD and other chronic diseases.

Examining the Ugandan health system's readiness to deliver rheumatic heart disease-related services.

BACKGROUND: In 2018, the World Health Assembly mandated Member States to take action on rheumatic heart disease (RHD), which persists in countries with weak health systems. We conducted an assessment of the current state of RHD-related healthcare in Uganda. METHODOLOGY/PRINCIPAL FINDINGS: This was a mixed-methods, deductive simultaneous design study conducted in four districts of Uganda. Using census sampling, we surveyed health facilities in each district using an RHD survey instrument that was modeled after the WHO SARA tool. We interviewed health workers with experience managing RHD, purposively sampling to ensure a range of qualification and geographic variation. Our final sample included 402 facilities and 36 health workers. We found major gaps in knowledge of clinical guidelines and availability of diagnostic tests. Antibiotics used in RHD prevention were widely available, but cardiovascular medications were scarce. Higher levels of service readiness were found among facilities in the western region (Mbarara district) and private facilities. Level III health centers were the most prepared for delivering secondary prevention. Health worker interviews revealed that limited awareness of RHD at the district level, lack of diagnostic tests and case management registries, and absence of clearly articulated RHD policies and budget prioritization were the main barriers to providing RHD-related healthcare. CONCLUSIONS/SIGNIFICANCE: Uganda's readiness to implement the World Health Assembly RHD Resolution is low. The forthcoming national RHD strategy must focus on decentralizing RHD diagnosis and prevention to the district level, emphasizing specialized training of the primary healthcare workforce and strengthening supply chains of diagnostics and essential medicines.

Cost-effectiveness of SMS appointment reminders in increasing vaccination uptake in Lagos, Nigeria: A multi-centered randomized controlled trial.

OBJECTIVE: It is expected that mHealth largely contribute to increasing the coverages of key maternal and child health services. This study aims to estimate the cost-effectiveness of the SMS text reminders in clients' return visits to the health facilities for child vaccinations (incl. vitamin A supplementations), antenatal care (ANC) and family planning (FP), in urban communities of Lagos, Nigeria. METHODS: A multi-centered randomized control trial was conducted at 33 primary health centers (PHCs) in Lagos, Nigeria. All the clients having visited any of the 33 PHCs for child vaccinations, ANC and FP were randomly assigned either to intervention group or to control group. The participants in the intervention group were sent an SMS text reminder two days before their appointments. Those not having showed up on the appointment dates received an additional SMS text reminder seven days after original appointment dates as defaulter tracing. The primary outcome was whether a client made return visit to PHCs for the upcoming appointments. RESULTS: Of 12,779 appointments for 9,368 clients during the period of 1stApril to 30thJune 2019, 12,175 were included in the analysis. The return rate for child vaccinations in the intervention group was significantly higher (p < 0.001) by 4.8% - 6.0% than that in the control group, consistently across all the five different timings (on time as scheduled, and by 7 days, 14 days, 30 days, and 3 months after appointment dates). No significant difference between the two groups was detected in the increase in return rates for ANC and FP services. The incremental recurrent cost was estimated at 7.90 US Dollars per return case. CONCLUSION: SMS text reminders led to a significant increase in the number of return visits for child vaccinations, Lagos, Nigeria, while no significant increase in return visits was confirmed for ANC and FP appointments.

Socioeconomic barriers to facility-based delivery in urban poor communities of Lagos: Wealth, linguistic capacity, and residential area.

Background: The objective of this study is to describe delivery care utilizations and to identify socioeconomic barriers to practicing facility-based deliveries, in urban poor communities of Lagos, Nigeria. Methods: The study was a prospective cohort study conducted in Lagos Mainland, a local government area of Lagos State, Nigeria. A total of 723 randomly selected pregnant women participated in this study. The socio-economic barriers were sought from three different perspectives, i.e., household wealth as a financial barrier, linguistic capacity as a social barrier, and residential area as a physical barrier. The data were analyzed with descriptive and multivariate statistical methods using the imputed datasets. Results: While 41.9% of the participants delivered at governmental health facilities, 28.3% and 29.8% of them gave births at private health facilities and other places, respectively. As the results of the analyses, household wealth was positively associated with childbirth at a governmental health facility. Egun-speaking women were more likely to give births at private facilities than Yoruba-speaking women, while Igbo-speaking and Hausa-speaking women were more likely to choose other places for their childbirths. Conclusion: This study identified the financial and linguistic barriers to facility-based deliveries among women in urban poor communities.

Underlying causes of underutilization of maternal, neonatal and child health (MNCH) services in Africa: A survey from Lagos State, Nigeria.

Lagos State, Nigeria, Africa's largest city with an estimaed 21 million population, continues to face challenges in its attempts to reduce maternal mortality (555 deaths per 100,000 live births) and deaths of children under five (59 per 1,000 live births). These deaths are more common among women and children living in poverty, many of whom rarely utilize health services. This paper describes the trend in the use of maternal, neonatal and child health (MNCH) services in the State in the past decade and shows barriers to the use of the services. Significant improvement in the coverage of the services were not observed. We identified the following five types of barriers to the use of MNCH services: i) financial barriers, ii) physical barriers, iii) cognitive barriers, iv) organizational barriers, and v) psychological and socio-cultural barriers. To address these interrelated barriers, the Lagos State Ministry of Health should prioritize regular outreach health services including health promotion, and realize the current initiative for massive recruitment of health personnel and appropriate deployment of them.