Sociocultural and health system factors associated with mortality among febrile inpatients in Tanzania: a prospective social biopsy cohort study

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.

Exploring the spatial variation and associated factors of childhood febrile illness among under-five children in Ethiopia: Geographically weighted regression analysis

BACKGROUND

The global burden of febrile illness and the contribution of many fever inducing pathogens have been difficult to quantify and characterize. However, in sub-Saharan Africa it is clear that febrile illness is a common cause of hospital admission, illness and death including in Ethiopia. Therefore the major aim of this study is to explore the spatial variation and associated factors of childhood febrile illness among under-five children in Ethiopia.

METHODS

This study were based on the 2016 Ethiopian Demographic health survey data. A total weighted sample of 10,127 under- five children was included. Data management was done using Stata version-14, Arc-GIS version-10.8 and SatsScan version- 9.6 statistical software. Multi-level log binomial model was fitted to identify factors associated with childhood febrile illness. Variables with a p-value < 0.2 in the bi-variable analysis were considered for the multivariable analysis. In the multivariable multilevel log binomial regression analysis p-value< 0.05, the APR with the 95% CI was reported. Global spatial autocorrelation was done to assess the spatial pattern of childhood febrile illness. Spatial regression was done to identify factors associated with the spatial variations of childhood febrile illness and model comparison was based on adjusted R2 and AICc.

RESULT

The prevalence of febrile illness among under-five children was 13.6% (95% CI: 12.6%, 14 .7%) with significant spatial variation across regions of Ethiopia with Moran's I value of 0.148. The significant hotspot areas of childhood febrile illness were identified in the Tigray, Southeast of Amhara, and North SNPPR. In the GWR analysis, the proportion of PNC, children who had diarrhea, ARI, being 1st birth order, were significant explanatory variables. In the multilevel log binomial regression age of children 7-24 months(APR = 1.33, 95% CI: (1.03, 1.72)), maternal age 30-39 years (APR = 1.36 95% CI: 1.02, 1.80)), number of children (APR = 1.78, 95% CI: 0.96, 3.3), diarrhea(APR = 5.3% 95% CI: (4.09, 6.06)), ARI (APR = 11.5, 95% CI: (9.2, 14.2)) and stunting(APR = 1.21; 95% CI: (0.98, 1.49) were significantly associated with childhood febrile illness.

CONCLUSION

Childhood febrile illness remains public health problem in Ethiopia. On spatial regression analysis proportion of women who had PNC, proportion of children who had diarrhea, proportion of children who had ARI, and proportion of children who had being 1st birth order were associated factors. The detailed map of childhood febrile illness and its predictors could assist health program planners and policy makers to design targeted public health interventions for febrile illness.

Mathematical Models for Typhoid Disease Transmission: A Systematic Literature Review

Explaining all published articles on the typhoid disease transmission model was carried out. It has been conducted to understand how Salmonella is transmitted among humans and vectors with variation interventions to control the spread of the typhoid disease. Specific objectives were to (1) identify the model developed, (2) describe the studies, and (3) identify the interventions of the model. It systemically searched and reviewed Dimension, Scopus, and ScienceDirect databases from 2013 through to 2022 for articles that studied the spread of typhoid fever through a compartmental mathematical model. This study obtained 111 unique articles from three databases, resulting in 23 articles corresponding to the created terms. All the articles were elaborated on to identify their identities for more explanation. Various interventions were considered in the model of each article, are identified, and then summarized to find out the opportunities for model development in future works. The whole article’s content was identified and outlined regarding how mathematics plays a role in model analysis and study of typhoid disease spread with various interventions. The study of mathematical modeling for typhoid disease transmission can be developed on analysis and creating the model with direct and indirect interventions to the human population for further work.

Healthcare-seeking behaviour, barriers to care and predictors of symptom improvement among patients with cardiovascular disease in northern Tanzania

BACKGROUND

Little is known about healthcare-seeking behaviour and barriers to care for cardiovascular disease (CVD) in sub-Saharan Africa.

METHODS

Emergency department patients in Tanzania with acute CVD were prospectively enrolled. Questionnaires were administered at enrollment and 30 d later.

RESULTS

Of 241 patients, 186 (77.2%) had visited another facility for the same illness episode (median symptom duration prior to presentation was 7 d) and 82 (34.0%) reported that they were initially unaware of the potential seriousness of their symptoms. Of the 208 (86.3%) patients completing follow-up, 16 (7.7%) had died, 38 (18.3%) had visited another facility for persistent symptoms, 99 (47.6%) felt they understood their diagnosis, 87 (41.8%) felt they understood their treatment and 11 (7.8%) could identify any of their medications. Predictors of 30 d survival with symptom improvement included medication compliance (p<0.001), understanding the diagnosis (p=0.007), understanding the treatment (p<0.001) and greater CVD knowledge (p=0.008).

CONCLUSIONS

Patients with CVD in Tanzania usually visit multiple facilities for the same illness episode, typically after prolonged delays. Only a minority understand their diagnosis and treatment, and such understanding is correlated with survival with symptom improvement. Patient-centred interventions are needed to improve the quality of cardiovascular care in Tanzania.

Timely health care seeking and first source of care for acute febrile illness in children in Hawassa, southern Ethiopia

Background

Timely health care seeking with access to quality health care are crucial to improve child survival. We conducted a study which aimed to identify factors influencing timely health care seeking and choice of first source of health care in Ethiopia.

Methods

A total of 535 caregivers who sought health care for febrile children aged under 5 years at a tertiary hospital, and one urban and two rural health centres in Hawassa, southern Ethiopia were recruited to participate in the study from August to November 2019. Caregivers were interviewed using pretested structured questionnaires on socio-demographic and clinical factors to identify associations with health care seeking practice and first source of care, and reasons for particular practices. Delayed care seeking was defined as seeking care from a health facility after 24 hours of onset of fever.

Results

Of 535 caregivers who participated, 271 (50.7%) had sought timely health care; 400 (74.8%) utilized a primary health care (PHC) facility as first source; and 282 (52.7%) bypassed the nearest PHC facility. Rural residents (adjusted odds ratio (AOR) 1.85; 95% CI 1.11–3.09), and those who reported cough (AOR 1.87; 95% CI 1.20–2.93) as a reason for consultation were more likely to delay seeking health care. While caregivers were less likely delayed for children aged 24–35 months (AOR 0.50; 95% CI 0.28–0.87) compared to infants. Utilizing higher-level hospitals as the first source of care was less frequent among rural residents (AOR 0.15; 95% CI 0.06–0.39) and in those with no formal education (AOR 0.03; 95% CI 0.01–0.27). Those having a longer travel time to the provider (AOR 2.11; 95% CI 1.09–4.08) more likely utilized higher hospitals.

Conclusion

We identified a need to improve timely health seeking among rural residents, infants, and those presenting with respiratory symptoms. Improvements may be achieved by educating communities on the need of early care seeking, and ensuring the communities members’ expectations of services at each level consistent with the services capacity.

Definitions of Severity in Treatment Seeking Studies of Febrile Illness in Children in Low and Middle Income Countries: A Scoping Review

Objectives: Understanding treatment seeking for severe febrile illness (SFI) is methodologically challenging. In this scoping review, we investigate definitions of severe febrile illness in treatment seeking studies on children under 5 years of age in low and middle income countries. We analyze the association of SFI definitions with different concepts of treatment seeking and identify related research gaps.

Methods: We searched Pubmed, Scopus and WHOLIS, and screened references of included publications for eligibility.

Results: Definitions of SFI had either a biomedical perspective (predominantly in quantitative studies) or a caregiver perspective (predominantly in qualitative studies). In quantitative analyses of treatment seeking, severity was more often conceptualized as a determinant rather than an outcome of a treatment seeking process. The majority of quantitative analyses only included surviving children or did not explicitly mention dead children.

Conclusion: Different research questions lead to diverse definitions and concepts of severity and treatment seeking outcomes, which limits the comparability of the available evidence. Systematic exclusion of dead children is likely to bias inferences on the association of treatment seeking and health outcomes of children with SFI in low and middle income countries.

Relationship between symptoms, barriers to care and healthcare utilisation among children under five in rural Mali

Objectives

To identify social and structural barriers to timely utilisation of qualified providers among children under five years in a high‐mortality setting, rural Mali and to analyse how utilisation varies by symptom manifestation.

Methods

Using baseline household survey data from a cluster‐randomised trial, we assessed symptom patterns and healthcare trajectories of 5117 children whose mothers reported fever, diarrhoea, bloody stools, cough and/or fast breathing in the preceding two weeks. We examine associations between socio‐demographic factors, symptoms and utilisation outcomes in mixed‐effect logistic regressions.

Results

Almost half of recently ill children reported multiple symptoms (46.2%). Over half (55.9%) received any treatment, while less than one‐quarter (21.7%) received care from a doctor, nurse, midwife, trained community health worker or pharmacist within 24 h of symptom onset. Distance to primary health facility, household wealth and maternal education were consistently associated with better utilisation outcomes. While children with potentially more severe symptoms such as fever and cough with fast breathing or diarrhoea with bloody stools were more likely to receive any care, they were no more likely than children with fever to receive timely care with a qualified provider.

Conclusions

Even distances as short as 2–5 km significantly reduced children’s likelihood of utilising healthcare relative to those within 2 km of a facility. While children with symptoms indicative of pneumonia and malaria were more likely to receive any care, suggesting mothers and caregivers recognised potentially severe illness, multiple barriers to care contributed to delays and low utilisation of qualified providers, illustrating the need for improved consideration of barriers.

Effect of Delays in Maternal Access to Healthcare on Neonatal Mortality in Sierra Leone: A Social Autopsy Case-Control Study at a Child Health and Mortality Prevention Surveillance (CHAMPS) Site

INTRODUCTION

In low-resource settings, a social autopsy tool has been proposed to measure the effect of delays in access to healthcare on deaths, complementing verbal autopsy questionnaires routinely used to determine cause of death. This study estimates the contribution of various delays in maternal healthcare to subsequent neonatal mortality using a social autopsy case-control design.

METHODS

This study was conducted at the Child Health and Mortality Prevention Surveillance (CHAMPS) Sierra Leone site (Makeni City and surrounding rural areas). Cases were neonatal deaths in the catchment area, and controls were sex- and area-matched living neonates. Odds ratios for maternal barriers to care and neonatal death were estimated, and stratified models examined this association by neonatal age and medical complications.

RESULTS

Of 53 neonatal deaths, 26.4% of mothers experienced at least one delay during pregnancy or delivery compared to 46.9% of mothers of stillbirths and 18.6% of control mothers. The most commonly reported delay among neonatal deaths was receiving care at the facility (18.9%). Experiencing any barrier was weakly associated (OR 1.68, CI 0.77, 3.67) and a delay in receiving care at the facility was strongly associated (OR 19.15, CI 3.90, 94.19) with neonatal death.

DISCUSSION

Delays in healthcare are associated with neonatal death, particularly delays experienced at the healthcare facility. Heterogeneity exists in the prevalence of specific delays, which has implications for local public health policy. The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Complications and mortality of typhoid fever: A global systematic review and meta-analysis

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Complications and death are considerable among hospitalized patients with typhoid fever.

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Case fatality ratio of typhoid fever was higher in Africa compared to Asia.

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Among studies in Africa, 20% of patients with typhoid intestinal perforation died.

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Delays in care were correlated with increased typhoid case fatality ratio in Asia.

Objectives

Updated estimates of the prevalence of complications and case fatality ratio (CFR) among typhoid fever patients are needed to understand disease burden.

Methods

Articles published in PubMed and Web of Science from 1 January 1980 through 29 January 2020 were systematically reviewed for hospital or community-based non-surgical studies that used cultures of normally sterile sites, and hospital surgical studies of typhoid intestinal perforation (TIP) with intra- or post-operative findings suggestive of typhoid. Prevalence of 21 pre-selected recognized complications of typhoid fever, crude and median (interquartile range) CFR, and pooled CFR estimates using a random effects meta-analysis were calculated.

Results

Of 113 study sites, 106 (93.8%) were located in Asia and Africa, and 84 (74.3%) were non-surgical. Among non-surgical studies, 70 (83.3%) were hospital-based. Of 10,355 confirmed typhoid patients, 2,719 (26.3%) had complications. The pooled CFR estimate among non-surgical patients was 0.9% for the Asia region and 5.4% for the Africa region. Delay in care was significantly correlated with increased CFR in Asia (r = 0.84; p<0.01). Among surgical studies, the median CFR of TIP was 15.5% (6.7–24.1%) per study.

Conclusions

Our findings identify considerable typhoid-associated illness and death that could be averted with prevention measures, including typhoid conjugate vaccine introduction.

Provider-perceived barriers to diagnosis and treatment of acute coronary syndrome in Tanzania: a qualitative study

Background

The incidence of acute coronary syndrome (ACS) is growing across sub-Saharan Africa and many healthcare systems are ill-equipped for this growing burden. Evidence suggests that healthcare providers may be underdiagnosing and undertreating ACS, leading to poor health outcomes. The goal of this study was to examine provider perspectives on barriers to ACS care in Tanzania in order to identify opportunities for interventions to improve care.

Methods

Semistructured in-depth interviews were conducted with physicians and clinical officers from emergency departments and outpatient departments in northern Tanzania. Thematic analysis was conducted using an iterative cycle of coding and consensus building.

Results

The 11 participants included six physicians and five clinical officers from health centers, community hospitals and one referral hospital. Providers identified barriers related to providers, systems and patients. Provider-related barriers included inadequate training regarding ACS and poor application of textbook-based knowledge. System-related barriers included lack of diagnostic equipment, unavailability of treatments, referral system delays, lack of data regarding disease burden, absence of locally relevant guidelines and cost of care. Patient-related barriers included inadequate ACS knowledge, inappropriate healthcare-seeking behavior and non-adherence.

Conclusions

This study identified actionable barriers to ACS care in northern Tanzania. Multifaceted interventions are urgently needed to improve care.

"If You Have No Money, You Might Die": A Qualitative Study of Sociocultural and Health System Barriers to Care for Decedent Febrile Inpatients in Northern Tanzania

Infectious diseases are a leading cause of mortality in low- and middle-income countries (LMICs) despite effective treatments. To study the sociocultural and health system barriers to care, we conducted a qualitative social autopsy study of patients who died from febrile illness in northern Tanzania. From December 2016 through July 2017, we conducted in-depth interviews in Arusha and Kilimanjaro regions with a purposive sample of 20 family members of patients who had died at two regional referral hospitals. Of the deceased patients included in this study, 14 (70%) were adults and 10 (50%) were female. Patients identified their religion as Catholic (12, 60%), Lutheran (six, 30%), and Muslim (two, 10%), and their ethnicity as Chagga (14, 70%) and Sambaa (two, 10%), among others. Family members reported both barriers to and facilitators of receiving health care. Barriers included a perceived lack of capacity of local health facilities, transportation barriers, and a lack of formal referrals to higher levels of care. Family members also reported the cost of health care as a barrier. However, one facilitator of care was access to financial resources via families' social networks-a phenomenon we refer to as social capital. Another facilitator of care was families' proactive engagement with the health system. Our results suggest that further investment in lower level health facilities may improve care-seeking and referral patterns and that future research into the role of social capital is needed to fully understand the effect of socioeconomic factors on healthcare utilization in LMICs.

Relative Measures of Association for Binary Outcomes: Challenges and Recommendations for the Global Health Researcher

Background:

Binary outcomes—which have two distinct levels (e.g., disease yes/no)—are commonly collected in global health research. The relative association of an exposure (e.g., a treatment) and such an outcome can be quantified using a ratio measure such as a risk ratio or an odds ratio. Although the odds ratio is more frequently reported than the risk ratio, many researchers, policymakers, and the general public frequently interpret it as a risk ratio. This is particularly problematic when the outcome is common because the magnitude of association is larger on the odds ratio scale than the risk ratio scale. Some recently published global health studies included misinterpretation of the odds ratio, which we hypothesize is because statistical methods for risk ratio estimation are not well known in the global health research community.

Objectives:

To compare and contrast available statistical methods to estimate relative measures of association for binary outcomes and to provide recommendations regarding their use.

Methods:

Logistic regression for odds ratios and four approaches for risk ratios: two direct regression approaches (modified log-Poisson and log-binomial) and two indirect methods (standardization and substitution) based on logistic regression.

Findings:

Illustrative examples demonstrate that misinterpretation of the odds ratio remains a common issue in global health research. Among the four methods presented for estimation of risk ratios, the modified log-Poisson approach is generally preferred because it has the best numerical performance and it is as easy to implement as is logistic regression for odds ratio estimation.

Conclusions:

We conclude that, when study design allows, studies with binary outcomes should preferably report risk ratios to measure relative association.

Knowledge of myocardial infarction symptoms and perceptions of self-risk in Tanzania

Background

Little is known about community knowledge of myocardial infarction symptoms and perceptions of self-risk in sub-Saharan Africa.

Methods

A community survey was conducted in northern Tanzania, where the prevalence of cardiovascular risk factors is high. Households were selected randomly in a population-weighted fashion and surveys were administered to self-identified household healthcare decision-makers. Respondents were asked to list all symptoms of a heart attack and asked whether they thought they had a chance of suffering a heart attack. Associations between participant sociodemographic features and responses to these questions were assessed with Pearson's chi-squared and the Student t test.

Results

There were 718 survey participants, with median (IQR) age 48 (32, 62) years. Of these, 115 (16.0%) were able to identify any conventional symptom of a heart attack, including 24 (3.3%) respondents who cited chest pain as a possible symptom. There was no association between ability to identify a conventional symptom and gender, level of education, socioeconomic status, urban residence, or age. Of respondents, 198 (27.6%) thought they had a chance of suffering a heart attack. Older respondents were more likely to perceive themselves to be at risk (P < .001), but there was no association between perception of self-risk and gender, level of education, socioeconomic status, or urban residence.

Conclusions

In northern Tanzania, knowledge of myocardial infarction symptoms is poor among all segments of the population and only a minority of residents perceive themselves to be at risk of this disease. Educational interventions regarding ischemic heart disease are urgently needed.