Effect of seasonal malaria chemoprevention in children between 5 and 9 years old in Kita and Bafoulabe districts, Mali.

Background: Seasonal malaria chemoprevention (SMC) has been widely expanded in Mali since its recommendation by the the World Health Organization in 2012. SMC guidelines currently target children between three months and five years of age. The SMC initiative has been largely successful. Children at least five years of age are not currently covered by current SMC guidelines but bear a considerable portion of the malaria burden. For this reason, this study sought to determine the feasibility and effectiveness for extending SMC to children aged 5-9 years. Methods: A non-randomized, pre-post study was performed with an intervention district (Kita) and a comparison district (Bafoulabe). Children aged 3-59 months received SMC in both comparison districts, and children aged 60-120 months received SMC in the intervention district. SMC was delivered as sulfadoxine-pyriméthamine plus amodiaquine (SP-AQ) at monthly intervals from July to October in 2017 and 2018 during the historical transmission seasons. Baseline and endline cross-sectional surveys were conducted in both comparison districts. A total of 200 household surveys were conducted at each of the four monthly SMC cycles to determine adherence and tolerance to SMC in the intervention district. Results: In July 2017, 633 children aged 60-120 months old were enrolled at the Kita and Bafoulabe study sites (n = 310 and n = 323, respectively). Parasitemia prevalence was similar in the intervention and comparison districts prior the SMC campaign (27.7% versus 21.7%, p = 0.07). Mild anemia was observed in 14.2% children in Kita and in 10.5% of children in Bafoulabé. At the Kita site, household surveys showed an SMC coverage rate of 89.1% with a response rate of 93.3% among child caregivers. The most common adverse event reported by parents was drowsiness (11.8%). One year following SMC implementation in the older age group in Kita, the coverage of three doses per round was 81.2%. Between the baseline and endline surveys, there was a reduction in parasitemia prevalence of 40% (OR = 0.60, CI: 0.41-0.89). Malaria molecular resistance was low in the intervention district following the intervention. A significant reduction in the prevalence of parasitemia in children 60 to 120 months was observed in the intervention district, but the prevalance of clinical malaria remained relatively constant. Conclusion: This study shows that the prospect of extending SMC coverage to children between five and nine years old is encouraging. The reduction in the parasitemia could also warrant consideration for adapting SMC policy to account for extended malaria transmission seasons.

Development and Initial Validation of a Frontline Health Worker mHealth Assessment Platform (MEDSINC®) for Children 2-60 Months of Age.

Approximately 3 million children younger than 5 years living in low- and middle-income countries (LMICs) die each year from treatable clinical conditions such as pneumonia, dehydration secondary to diarrhea, and malaria. A majority of these deaths could be prevented with early clinical assessments and appropriate therapeutic intervention. In this study, we describe the development and initial validation testing of a mobile health (mHealth) platform, MEDSINC®, designed for frontline health workers (FLWs) to perform clinical risk assessments of children aged 2-60 months. MEDSINC is a web browser-based clinical severity assessment, triage, treatment, and follow-up recommendation platform developed with physician-based Bayesian pattern recognition logic. Initial validation, usability, and acceptability testing were performed on 861 children aged between 2 and 60 months by 49 FLWs in Burkina Faso, Ecuador, and Bangladesh. MEDSINC-based clinical assessments by FLWs were independently and blindly correlated with clinical assessments by 22 local health-care professionals (LHPs). Results demonstrate that clinical assessments by FLWs using MEDSINC had a specificity correlation between 84% and 99% to LHPs, except for two outlier assessments (63% and 75%) at one study site, in which local survey prevalence data indicated that MEDSINC outperformed LHPs. In addition, MEDSINC triage recommendation distributions were highly correlated with those of LHPs, whereas usability and feasibility responses from LHP/FLW were collectively positive for ease of use, learning, and job performance. These results indicate that the MEDSINC platform could significantly increase pediatric health-care capacity in LMICs by improving FLWs' ability to accurately assess health status and triage of children, facilitating early life-saving therapeutic interventions.

Differential community response to introduction of zinc for childhood diarrhea and combination therapy for malaria in southern Mali.

Developing effective, affordable, and sustainable delivery strategies for the isolated low-income populations that stand to gain the most from micronutrient interventions has proven difficult. We discuss our experience with implementation of zinc as treatment for diarrhea in children less than 5 y of age over the course of 3 operational research studies in rural Sikasso Region, Mali, West Africa. The initial formative research study highlighted how malaria affects perceptions of diarrhea and its causes and that malaria and diarrhea are not necessarily viewed as distinct conditions. The second-phase pilot introduction demonstrated that, in introducing zinc treatment in malaria-endemic regions, it is especially important that both community- and facility-level providers be trained to manage sick children presenting with multiple symptoms. The third-phase study on large-scale implementation detected that the experience with implementation of new treatments for malaria is distinct from that of diarrhea. To some extent zinc treatment is the solution to a problem that communities may not recognize at all. Interventions to improve case management of sick children must be integrated across diseases and nutritional problems at both the facility and community levels. Operational research can identify points where integration should occur and how it should be carried out. Programs targeting single diseases or single nutritional problems can have a variety of deleterious effects on health systems, no matter how well they are planned.

Operational issues and trends associated with the pilot introduction of zinc for childhood diarrhoea in Bougouni district, Mali.

Zinc for the treatment of childhood diarrhoea was introduced in a pilot area in southern Mali to prepare for a cluster-randomized effectiveness study and to inform policies on how to best introduce and promote zinc at the community level. Dispersible zinc tablets in 14-tablet blister packs were provided through community health centres and drug kits managed by community health workers (CHWs) in two health zones in Bougouni district, Mali. Village meetings and individual counselling provided by CHWs and head nurses at health centres were the principal channels of communication. A combination of methods were employed to (a) detect problems in communication about the benefits of zinc and its mode of administration; (b) identify and resolve obstacles to implementation of zinc through existing health services; and (c) describe household-level constraints to the adoption of appropriate home-management practices for diarrhoea, including administration of both zinc and oral rehydration solution (ORS). Population-based household surveys with caretakers of children sick in the previous two weeks were carried out before and four months after the introduction of zinc supplementation. Household follow-up visits with children receiving zinc from the health centres and CHWs were conducted on day 3 and 14 after treatment for a subsample of children. A qualitative process evaluation also was conducted to investigate operational issues. Preliminary evidence from this study suggests that the introduction of zinc does not reduce the use of ORS and may reduce inappropriate antibiotic use for childhood diarrhoea. Financial access to treatments, management of concurrent diarrhoea and fever, and high use of unauthorized drug vendors were identified as factors affecting the effectiveness of the intervention in this setting. The introduction of zinc, if not appropriately integrated with other disease-control strategies, has the potential to decrease the appropriate presumptive treatment of childhood malaria in children with diarrhoea and fever in malaria-endemic areas.

Home management of childhood diarrhoea in southern Mali--implications for the introduction of zinc treatment.

Diarrhoea remains one of the leading killers of young children. A recent meta-analysis demonstrated that a two-week course of zinc tablets once daily significantly reduces the severity and duration of diarrhoea and mortality in young children (Bhutta et al., 2000. Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: Pooled analysis of randomized controlled trials. American Journal of Clinical Nutrition, 72(6), 1516-1522). Formative research is being conducted in a number of countries to prepare for the large-scale promotion of this new treatment. In-depth and semi-structured interviews with parents, community health workers, and traditional healers were conducted to examine the household management of diarrhoea in the Sikasso region of southern Mali in preparation for the introduction of a short-course of daily zinc for childhood diarrhoea at the community level. Supporting data from a subsequent household survey are also presented. Although nearly all parents knew oral rehydration solution (ORS) could replace lost fluids, its inability to stop diarrhoea caused parents to seek antibiotics from local markets, traditional medicines or anti-malarials to cure the illness. The notion of combining multiple treatments to ensure the greatest therapeutic benefit was prevalent, and modern medicines were often administered simultaneously with traditional therapies. As parents often deem ORS insufficient and judge that an additional treatment should be combined with ORS to cure diarrhoea, the concept of joint therapy of zinc and ORS should be well accepted in the community. Mothers-in-law and fathers, who play a significant role in decisions to seek treatment for sick children, as well as traditional healers, should also be considered when designing new programs to promote zinc. Similarities with formative research conducted for a previous generation of diarrhoea control programmes are discussed.

Prescription and administration of a 14-day regimen of zinc treatment for childhood diarrhea in Mali.

We evaluated prescription and correct dosing of a 14-day course of dispersible zinc tablets prescribed to young children with diarrhea by community and facility workers in rural, southern Mali, West Africa. One hundred twenty-three children were followed at home on days 3 and 14 after being prescribed zinc. The age-appropriate dose of zinc was dispensed in 94% of cases. Ninety-five percent of mothers dissolved the tablet in a small amount of water and gave it with a spoon. Only eight caretakers reported problems with zinc administration: either vomiting or refusal to take the tablets. Sixty-four percent of children received the full 14-day course of treatment, and more than 89% of children were given at least a 10-day course of zinc treatment. The levels of correct administration were very good but might be lower under non-research conditions.

The positive deviance approach: challenges and opportunities for the future.

The positive deviance (PD) approach offers an alternative to needs-based approaches for development. The "traditional" application of the PD approach for childhood malnutrition involves studying children who grow well despite adversity, identifying uncommon, model practices among PD families, and designing an intervention to transfer these behaviors to the mothers of malnourished children. A common intervention for child malnutrition, the so-called "hearth," brings mothers together to practice new feeding and caring behaviors under the encouragement of a village volunteer. Hearths probably work because they modify unmeasured behavioral determinants and unmonitored behaviors, which, in turn, result in better child growth. Some health outcomes require a better understanding of behavioral determinants and are not best served by hearth-like facilitated group skills-building. We propose testing "booster PD inquiries" during implementation to confirm behavioral determinants and efficiently focus interventions. We share early experience with the PD approach for HIV/AIDS and food security. The attributable benefit of the PD approach within a program has not been quantified, but we suspect that it is a catalyst that accelerates change through the processes of community attention getting, awareness raising, problem-solving, motivating for behavior change, advocacy, and actual adopting new behaviors. Program-learners should consider identifying and explicitly attempting to modify the determinants of critical behavior(s), even if the desired outcome is a change in health status that depends on multiple behaviors; measure and maintain program quality, especially at scale; and creatively expand and test additional roles for PD within a given program.

Beyond distance: an approach to measure effective access to case management for sick children in Africa.

Health planners commonly use geographic proximity to define access to health services. However, effective access to case management requires reliable access to a trained, supplied provider. We defined effective access as the proportion of the study population with geographic access, corrected for other barriers, staffing patterns, and medicine availability. We measured effective access through a cross-sectional survey of 32 health facilities in Malawi, Mali, and Zambia and modeled the potential contribution of community case management (CCM). The population living within Ministry of Health (MOH)-defined geographic access was 43% overall (range = 18-52%), but effective access was only 14% overall (range = 9-17%). Implementing CCM as per MOH plans increased geographic access to 63-90% and effective access to 30-57%. Access to case management is much worse than typically estimated by distance. The CCM increases access dramatically, again if providers are available and supplied, and should be considered even for those within MOH-defined access areas.

Pro-sustainability choices and child deaths averted: from project experience to investment strategy.

The pursuit of the Millennium Development Goals and advancing the 'global health agenda' demand the achievement of health impact at scale through efficient investments. We have previously offered that sustainability-a necessary condition for successful expansion of programmes-can be addressed in practical terms. Based on benchmarks from actual child survival projects, we assess the expected impact of translating pro-sustainability choices into investment strategies. We review the experience of Save the Children US in Guinea in terms of investment, approach to sustainability and impact. It offers three benchmarks for impact: Entry project (21 lives saved of children under age five per US$100 000), Expansion project (37 LS/US$100k), and Continuation project (100 LS/US$100k). Extrapolating this experience, we model the impact of a traditional investment scenario against a pro-sustainability scenario and compare the deaths averted per dollar spent over five project cycles. The impact per dollar spent on a pro-sustainability strategy is 3.4 times that of a traditional one over the long run (range from 2.2 to 5.7 times in a sensitivity analysis). This large efficiency differential between two investment approaches offers a testable hypothesis for large-scale/long-term studies. The 'bang for the buck' of health programmes could be greatly increased by following a pro-sustainability investment strategy.

Qualitative research to make practical sense of sustainability in primary health care projects implemented by non-governmental organizations.

Sustainability continues to be a serious concern for Primary Health Care (PHC) interventions targeting the death of millions of children in developing countries each year. Our work with over 30 Non-Governmental Organizations (NGOs) implementing USAID's Child Survival and Health Grants Program (CSHGP)-funded projects revealed the need for a study to develop a framework for sustainability assessment in these projects. We surveyed NGO informants and project managers through semi-structured interviews and questionnaires. This paper summarizes our study findings. The NGOs share key values about sustainability, but are skeptical about approaches perceived as disconnected from field reality. In their experience, sustainable achievements occur through the interaction of capable local stakeholders and communities. This depends strongly on enabling conditions, which NGO projects should advance. Sustainability assessment is multidimensional, value-based and embeds health within a larger sustainable development perspective. It reduces, but does not eliminate, the unpredictability of long-term outcomes. It should start with the consideration of the 'local systems' which need to develop a common purpose. Our ability to address the complexity inherent to sustainability thinking rests with the validity of the models used to design interventions. A participant, qualitative research approach helped us make sense of sustainability in NGO field practice.

A methodological approach and framework for sustainability assessment in NGO-implemented primary health care programs.

An estimated 10.8 million children under 5 continue to die each year in developing countries from causes easily treatable or preventable. Non governmental organizations (NGOs) are frontline implementers of low-cost and effective child health interventions, but their progress toward sustainable child health gains is a challenge to evaluate. This paper presents the Child Survival Sustainability Assessment (CSSA) methodology--a framework and process--to map progress towards sustainable child health from the community level and upward. The CSSA was developed with NGOs through a participatory process of research and dialogue. Commitment to sustainability requires a systematic and systemic consideration of human, social and organizational processes beyond a purely biomedical perspective. The CSSA is organized around three interrelated dimensions of evaluation: (1) health and health services; (2) capacity and viability of local organizations; (3) capacity of the community in its social ecological context. The CSSA uses a participatory, action-planning process, engaging a 'local system' of stakeholders in the contextual definition of objectives and indicators. Improved conditions measured in the three dimensions correspond to progress toward a sustainable health situation for the population. This framework opens new opportunities for evaluation and research design and places sustainability at the center of primary health care programming.