Identifying delays in healthcare seeking and provision: The Three Delays-in-Healthcare and mortality among infants and children aged 1-59 months.

Delays in illness recognition, healthcare seeking, and in the provision of appropriate clinical care are common in resource-limited settings. Our objective was to determine the frequency of delays in the "Three Delays-in-Healthcare", and factors associated with delays, among deceased infants and children in seven countries with high childhood mortality. We conducted a retrospective, descriptive study using data from verbal autopsies and medical records for infants and children aged 1-59 months who died between December 2016 and February 2022 in six sites in sub-Saharan Africa and one in South Asia (Bangladesh) and were enrolled in Child Health and Mortality Prevention Surveillance (CHAMPS). Delays in 1) illness recognition in the home/decision to seek care, 2) transportation to healthcare facilities, and 3) the receipt of clinical care in healthcare facilities were categorized according to the "Three Delays-in-Healthcare". Comparisons in factors associated with delays were made using Chi-square testing. Information was available for 1,326 deaths among infants and under 5 children. The majority had at least one identified delay (n = 854, 64%). Waiting >72 hours after illness recognition to seek health care (n = 422, 32%) was the most common delay. Challenges in obtaining transportation occurred infrequently when seeking care (n = 51, 4%). In healthcare facilities, prescribed medications were sometimes unavailable (n = 102, 8%). Deceased children aged 12-59 months experienced more delay than infants aged 1-11 months (68% vs. 61%, P = 0.018). Delays in seeking clinical care were common among deceased infants and children. Additional study to assess the frequency of delays in seeking clinical care and its provision among children who survive is warranted.

Post-mortem investigation of deaths due to pneumonia in children aged 1-59 months in sub-Saharan Africa and South Asia from 2016 to 2022: an observational study.

BACKGROUND: The Child Health and Mortality Prevention Surveillance (CHAMPS) Network programme undertakes post-mortem minimally invasive tissue sampling (MITS), together with collection of ante-mortem clinical information, to investigate causes of childhood deaths across multiple countries. We aimed to evaluate the overall contribution of pneumonia in the causal pathway to death and the causative pathogens of fatal pneumonia in children aged 1-59 months enrolled in the CHAMPS Network. METHODS: In this observational study we analysed deaths occurring between Dec 16, 2016, and Dec 31, 2022, in the CHAMPS Network across six countries in sub-Saharan Africa (Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa) and one in South Asia (Bangladesh). A standardised approach of MITS was undertaken on decedents within 24-72 h of death. Diagnostic tests included blood culture, multi-organism targeted nucleic acid amplifications tests (NAATs) of blood and lung tissue, and histopathology examination of various organ tissue samples. An interdisciplinary expert panel at each site reviewed case data to attribute the cause of death and pathogenesis thereof on the basis of WHO-recommended reporting standards. FINDINGS: Pneumonia was attributed in the causal pathway of death in 455 (40·6%) of 1120 decedents, with a median age at death of 9 (IQR 4-19) months. Causative pathogens were identified in 377 (82·9%) of 455 pneumonia deaths, and multiple pathogens were implicated in 218 (57·8%) of 377 deaths. 306 (67·3%) of 455 deaths occurred in the community or within 72 h of hospital admission (presumed to be community-acquired pneumonia), with the leading bacterial pathogens being Streptococcus pneumoniae (108 [35·3%]), Klebsiella pneumoniae (78 [25·5%]), and non-typeable Haemophilus influenzae (37 [12·1%]). 149 (32·7%) deaths occurred 72 h or more after hospital admission (presumed to be hospital-acquired pneumonia), with the most common pathogens being K pneumoniae (64 [43·0%]), Acinetobacter baumannii (19 [12·8%]), S pneumoniae (15 [10·1%]), and Pseudomonas aeruginosa (15 [10·1%]). Overall, viruses were implicated in 145 (31·9%) of 455 pneumonia-related deaths, including 54 (11·9%) of 455 attributed to cytomegalovirus and 29 (6·4%) of 455 attributed to respiratory syncytial virus. INTERPRETATION: Pneumonia contributed to 40·6% of all childhood deaths in this analysis. The use of post-mortem MITS enabled biological ascertainment of the cause of death in the majority (82·9%) of childhood deaths attributed to pneumonia, with more than one pathogen being commonly implicated in the same case. The prominent role of K pneumoniae, non-typable H influenzae, and S pneumoniae highlight the need to review empirical management guidelines for management of very severe pneumonia in low-income and middle-income settings, and the need for research into new or improved vaccines against these pathogens. FUNDING: Bill & Melinda Gates Foundation.

Optimising scale and deployment of community health workers in Sierra Leone: a geospatial analysis.

BACKGROUND: Little is known about strategies for optimising the scale and deployment of community health workers (CHWs) to maximise geographic accessibility of primary healthcare services. METHODS: We used data from a national georeferenced census of CHWs and other spatial datasets in Sierra Leone to undertake a geospatial analysis exploring optimisation of the scale and deployment of CHWs, with the aim of informing implementation of current CHW policy and future plans of the Ministry of Health and Sanitation. RESULTS: The per cent of the population within 30 min walking to the nearest CHW with preservice training increased from 16.1% to 80.4% between 2000 and 2015. Contrary to current national policy, most of this increase occurred in areas within 3 km of a health facility where nearly two-thirds (64.5%) of CHWs were deployed. Ministry of Health and Sanitation-defined 'easy-to-reach' and 'hard-to-reach' areas, geographic areas that should be targeted for CHW deployment, were less well covered, with 19.2% and 34.6% of the population in 2015 beyond a 30 min walk to a CHW, respectively. Optimised CHW networks in these areas were more efficiently deployed than existing networks by 22.4%-71.9%, depending on targeting metric. INTERPRETATIONS: Our analysis supports the Ministry of Health and Sanitation plan to rightsize and retarget the CHW workforce. Other countries in sub-Saharan Africa interested in optimising the scale and deployment of their CHW workforce in the context of broader human resources for health and health sector planning may look to Sierra Leone as an exemplar model from which to learn.

Barriers to the uptake of community-based curative child health services in Ethiopia.

BACKGROUND: Uptake of services to treat newborns and children has been persistently low in Ethiopia, despite being provided free-of-charge by Health Extension Workers (HEWs). In order to increase the uptake of these services, the Optimizing the Health Extension Project was designed to be implemented in four regions in Ethiopia. This study was carried out to identify barriers to the uptake of these services and potential solutions to inform the project. METHODS: Qualitative data were collected in October and November 2015 in 15 purposely selected districts in four regions. We conducted 90 focus group discussions and 60 in-depth interviews reaching a total of 664 participants. Thematic analysis was used to identify key barriers and potential solutions. RESULTS: Five demand-side barriers to utilization of health services were identified. Misconceptions about illness causation, compounded with preference for traditional healers has affected service uptake. Limited awareness of the availability of free curative services for children at health posts; along with the prevailing perception that HEWs were providing preventive services only had constrained uptake. Geographic challenge that made access to the health post difficult was the other barrier. Four supply-side barriers were identified. Health post closure and drug stock-out led to inconsistent availability of services. Limited confidence and skill among HEWs and under-resourced physical facilities affected the service delivery. Study participants suggested demand creation solutions such as increasing community awareness on curative service availability and educating them on childhood illness causation. Maintaining consistent supplies and ensuring service availability; along with regular support to build HEWs' confidence were the suggested supply-side solutions. Creating community feedback mechanisms was suggested as a way of addressing community concerns on the health services. CONCLUSION: This study explored nine demand- and supply-side barriers that decreased the uptake of community-based services. It indicated the importance of increasing awareness of new services and addressing prevailing barriers that deprioritize health services. At the same time, supply-side barriers would have to be tackled by strengthening the health system to uphold newly introduced services and harness sustainable impact.

Effect on Neonatal Mortality of Newborn Infection Management at Health Posts When Referral Is Not Possible: A Cluster-Randomized Trial in Rural Ethiopia.

BACKGROUND: The World Health Organization recently provided guidelines for outpatient treatment of possible severe bacterial infections (PSBI) in young infants, when referral to hospital is not feasible. This study evaluated newborn infection treatment at the most peripheral level of the health system in rural Ethiopia. METHODS: We performed a cluster-randomized trial in 22 geographical clusters (11 allocated to intervention, 11 to control). In both arms, volunteers and government-employed Health Extension Workers (HEWs) conducted home visits to pregnant and newly delivered mothers; assessed newborns; and counseled caregivers on prevention of newborn illness, danger signs, and care seeking. Volunteers referred sick newborns to health posts for further assessment; HEWs referred newborns with PSBI signs to health centers. In the intervention arm only, between July 2011 and June 2013, HEWs treated newborns with PSBI with intramuscular gentamicin and oral amoxicillin for 7 days at health posts when referral to health centers was not possible or acceptable to caregivers. Intervention communities were informed of treatment availability at health posts to encourage care seeking. Masking was not feasible. The primary outcome was all-cause mortality of newborns 2-27 days after birth, measured by household survey data. Baseline data were collected between June 2008 and May 2009; endline data, between February 2013 and June 2013. We sought to detect a 33% mortality reduction. Analysis was by intention to treat. (ClinicalTrials.gov registry: NCT00743691). RESULTS: Of 1,011 sick newborns presenting at intervention health posts, 576 (57%) were identified by HEWs as having at least 1 PSBI sign; 90% refused referral and were treated at the health post, with at least 79% completing the antibiotic regimen. Estimated treatment coverage at health posts was in the region of 50%. Post-day 1 neonatal mortality declined more in the intervention arm (17.9 deaths per 1,000 live births at baseline vs. 9.4 per 1,000 at endline) than the comparison arm (14.4 per 1,000 vs. 11.2 per 1,000, respectively). After adjusting for baseline mortality and region, the estimated post-day 1 mortality risk ratio was 0.83, but the result was not statistically significant (95% confidence interval, 0.55 to 1.24; P=.33). INTERPRETATION: When referral to higher levels of care is not possible, HEWs can deliver outpatient antibiotic treatment of newborns with PSBI, but estimated treatment coverage in a rural Ethiopian setting was only around 50%. While our data suggest a mortality reduction consistent with that which might be expected at this level of coverage, they do not provide conclusive results.

Assessment of the impact of quality improvement interventions on the quality of sick child care provided by Health Extension Workers in Ethiopia.

BACKGROUND: Ethiopia has scaled up integrated community case management of childhood illness (iCCM), including several interventions to improve the performance of Health Extension Workers (HEWs). We assessed associations between interventions to improve iCCM quality of care and the observed quality of care among HEWs. METHODS: We assessed iCCM implementation strength and quality of care provided by HEWs in Ethiopia. Multivariate logistic regression analyses were performed to assess associations between interventions to improve iCCM quality of care and correct management of iCCM illnesses. FINDINGS: Children who were managed by an HEW who had attended a performance review and clinical mentoring meeting (PRCMM) had 8.3 (95% confidence interval (CI) 2.34-29.51) times the odds of being correctly managed, compared to children managed by an HEW who did not attend a PRCMM. Management by an HEW who received follow-up training also significantly increased the odds of correct management (odds ratio (OR) = 2.09, 95% CI 1.05-4.18). Supervision on iCCM (OR = 0.63, 95% CI 0.23-1.72) did not significantly affect the odds of receiving correct care. CONCLUSIONS: These results suggest PRCMM and follow-up training were effective interventions, while implementation of supportive supervision needs to be reviewed to improve impact.

Assessing the Quality of Sick Child Care Provided by Community Health Workers.

BACKGROUND: As community case management of childhood illness expands in low-income countries, there is a need to assess the quality of care provided by community health workers. This study had the following objectives: 1) examine methods of recruitment of sick children for assessment of quality of care, 2) assess the validity of register review (RR) and direct observation only (DO) compared to direct observation with re-examination (DO+RE), and 3) assess the effect of observation on community health worker performance. METHODS: We conducted a survey to assess the quality of care provided by Ethiopian Health Extension Workers (HEWs). The sample of children was obtained through spontaneous consultation, HEW mobilization, or recruitment by the survey team. We assessed patient characteristics by recruitment method. Estimates of indicators of quality of care obtained using RR and DO were compared to gold standard estimates obtained through DO+RE. Sensitivity, specificity, and the area under receiver operator characteristic curve (AUC) were calculated to assess the validity of RR and DO. To assess the Hawthorne effect, we compared estimates from RR for children who were observed by the survey team to estimates from RR for children who were not observed by the survey team. RESULTS: Participants included 137 HEWs and 257 sick children in 103 health posts, plus 544 children from patient registers. Children mobilized by HEWs had the highest proportion of severe illness (27%). Indicators of quality of care from RR and DO had high sensitivity for most indicators, but specificity was low. The AUC for different indicators from RR ranged from 0.47 to 0.76, with only one indicator above 0.75. The AUC of indicators from DO ranged from 0.54 to 1.0, with three indicators above 0.75. The differences between estimates of correct care for observed versus not observed children were small. CONCLUSIONS: Mobilization by HEWs and recruitment by the survey teams were feasible, but potentially biased, methods of obtaining sick children. Register review and DO underestimated performance errors. Our data suggest that being observed had only a small positive effect on the performance of HEWs.

Integrated community case management of childhood illness in Ethiopia: implementation strength and quality of care.

Ethiopia has scaled up integrated community case management of childhood illness (iCCM) in most regions. We assessed the strength of iCCM implementation and the quality of care provided by health extension workers (HEWs). Data collectors observed HEWs' consultations with sick children and carried out gold standard re-examinations. Nearly all HEWs received training and supervision, and essential commodities were available. HEWs provided correct case management for 64% of children. The proportions of children correctly managed for pneumonia, diarrhea, and malnutrition were 72%, 79%, and 59%, respectively. Only 34% of children with severe illness were correctly managed. Health posts saw an average of 16 sick children in the previous 1 month. These results show that iCCM can be implemented at scale and that community-based HEWs can correctly manage multiple illnesses. However, to increase the chances of impact on child mortality, management of severe illness and use of iCCM services must be improved.

Performance of Ethiopia's health system in delivering integrated community-based case management.

BACKGROUND: Analyzing complex health programs by their components and sub-components serves design, documentation, evaluation, research, and gap identification and prioritization. In 2012, we developed a rapid methodology to characterize integrated community case management (iCCM) programs, by assessing benchmarks for eight health system components in three program phases. OBJECTIVE. To assess iCCM benchmarks in Ethiopia three years after scale-up commenced, and to compare the benchmarks across the geographical region. METHODS. Six national iCCM experts scored each of 70 benchmarks (no, partial, or yes) and then were facilitated to reach consensus. RESULTS. Overall, iCCM benchmark achievement in Ethiopia was high (87.3%), highest for pre-introduction (93.0%), followed by introduction (87.9%) and scale-up (78.1%) phases. Achievement by system component was highest for coordination and policy (94.2%) and lowest for costing and finance (70.3%). Six regional, countries benchmark assessments, including two from Ethiopia 14 months apart, were highly correlated with program duration at scale (correlation coefficient: +0.88). CONCLUSION: Ethiopia has a mature, broad-based iCCM program. Despite limitations, the method described here rapidly, systematically, and validly characterized a complex program and highlighted areas for attention through government or partners.

Coverage and equitability of interventions to prevent child mortality in rural Jimma and West Hararghe Zones, Oromia Region, Ethiopia.

BACKGROUND: Interventions to prevent childhood illnesses are important components of the Ethiopian Health Extension Program (HEP). Although the HEP was designed to reduce inequities in access to health care, there is little evidence on equitability of preventive interventions in Ethiopia. PURPOSE: This article describes coverage of preventive interventions and how many interventions individual children received We also examined which factors were associated with the number of preventive interventions received, and assessed the extent to which interventions were equitably distributed. METHODS: We conducted a cross-sectional survey in 3,200 randomly selected households in the rural Jimma and West Hararghe Zones of Ethiopia's Oromia Region. We calculated coverage of 10 preventive interventions and a composite of eight interventions (co-coverage) representing the number of interventions received by children. Mul- tiple linear regressions were used to assess associations between co-coverage and explanatory variables. Finally, we assessed the equitability of preventive interventions by comparing coverage among children in the poorest and the least poor wealth quintiles. RESULTS: Coverage was less than 50% for six of the 10 interventions. Children received on average only three of the eight interventions included in the co-coverage calculation. Zone, gender, caretaker age, religion, and household wealth were all significantly associated with co-coverage, controlling for key covariates. Exclusive breastfeeding, vaccine uptake, and vitamin A supplementation were all relatively equitable. On the other hand, coverage of insecticide-treated nets or indoor residual spraying (ITN/IRS) and access to safe water were significantly higher among the least poor children compared to children in the poorest quintile. CONCLUSION: Coverage of key interventions to prevent childhood illnesses is generally low in Jimma and West Hararghe. Although a number of interventions were equitably distributed, there were marked wealth-based inequities for interventions that are possessed at the household level, even among relatively homogeneous rural communities.

Integrated community case management: quality of care and adherence to medication in Beneshangul-Gumuz Region, Ethiopia.

BACKGROUND: The International Rescue Committee (IRC) supports implementation of integrated Community Case Management (iCCM) in all 20 woredas (districts) of Benishangul Gumuz Region (BSG) in Ethiopia. OBJECTIVES: To identify the gaps in the provision of quality iCCM services provided by Health Extension Workers (HEWs) and to assess caregivers' adherence to prescribed medicines for children under five years of age. METHODS: We conducted a cross-sectional descriptive study with both quantitative and qualitative study methods. We interviewed 233 HEWs and 384 caregivers, reviewed HEW records of 1,082 cases, and organized eight focus groups. RESULTS: Most cases (98%) seen by HEWs were children 2-59 months old, and 85% of the HEWs did not see any sick young infant. The HEWs' knowledge on assessments and classification and need for referral of cases was above 80%. However; some reported challenges, especially in carrying out assessment correctly and not checking for danger signs. Over 90% of caretakers reported compliance with HEWs' prescription. CONCLUSION: Partners have successfully deployed trained HEWs who can deliver iCCM according to protocol; however, additional support is needed to assure a supply of medicines and to mobilize demand for services, especially for young infants.