1
|
Lee HY, Cooper JE, Kruk ME. Regional determinants of quality of care for sick children: A multilevel analysis in four countries. J Glob Health 2024; 14:04053. [PMID: 38483441 PMCID: PMC10939116 DOI: 10.7189/jogh.14.04053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024] Open
Abstract
Background The limited impact of increased access to care on improvements in health outcomes during the Millennium Development Goal era has been attributed, in part, to inadequate quality of care. We identified regional factors associated with health service quality for sick child care in low-income countries and examined whether provider factors interact with regional factors to affect the quality of care. Methods We conducted cross-sectional random intercept four-level linear regression using the most recent Service Provision Assessment and Demographic Health Survey data from four countries (467 from the Democratic Republic of Congo 2018, 2425 from Afghanistan 2018, 2072 from Nepal 2015, and 813 from Senegal 2017). The outcome variable was the service quality score for sick child care, which was measured as the percentage of clinically recommended tasks completed in the integrated management of childhood illness (ranging from 0 to 100). Regional factors were selected based on the High-Quality Health System Framework. Results The service quality score was found to be positively associated with the proportion of large facilities (β = 8.61; P = 0.004) and the proportion of providers ranked in the top fifth for service quality score (β = 30.15; P < 0.001) in the region. We identified significant cross-level interactions between provider qualifications (β = -16.6; P < 0.001) or job descriptions (β = 12.01; P = 0.002) and the proportion of providers in the top fifth for service quality scores within the region. As the proportion of top-performing providers in a region increased, the increase in the service quality score was more pronounced among providers who were nonmedical doctors or did not have job descriptions than among their counterparts. Conclusions Our findings indicate that the quality of care for sick children in a region improves with a greater proportion of high-performing providers or larger facilities. Providers who are not medical doctors, or those who have specific job descriptions, tend to benefit more from the presence of these top-performing providers.
Collapse
Affiliation(s)
- Hwa-Young Lee
- Graduate School of Public Health and Healthcare Management, The Catholic University of Korea, Seoul, Republic of Korea
- Catholic Institute for Public Health and Healthcare Management, The Catholic University of Korea, Seoul, Republic of Korea
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jan E Cooper
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Adawiyah RA, Boettiger D, Applegate TL, Probandari A, Marthias T, Guy R, Wiseman V. Supply-side readiness to deliver HIV testing and treatment services in Indonesia: Going the last mile to eliminate mother-to-child transmission of HIV. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000845. [PMID: 36962570 PMCID: PMC10021386 DOI: 10.1371/journal.pgph.0000845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 07/06/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Despite national efforts to integrate Prevention of Mother-to-Child Transmission (PMTCT) of HIV services into antenatal care in Indonesia, the rate of mother-to-child transmission of HIV remains the highest in the world. A range of barriers to uptake and long-term engagement in care have been identified, but far less is known about health system preparedness to deliver PMTCT of HIV services. This study explored supply-side barriers to the delivery of PMTCT services in Indonesia and whether these factors are associated with the uptake of antenatal HIV testing. MATERIALS AND METHODS An ecological analysis was undertaken, linking data from the World Bank Quality Service and Delivery Survey (2016) with routine data from Indonesia's HIV and AIDS case surveillance system and district health profile reports (2016). Supply-side readiness scores-generated from a readiness index that measures overall structural capacity and is often used as proxy for quality of care-were adapted from the WHO Service Availability and Readiness Assessment and presented by sector and geographic area. Univariate and multivariate regression analysis was used to explore factors associated with the uptake of antenatal HIV testing in public facilities. RESULTS In general, public facilities scored more highly in most inputs compared to private facilities. Facilities located in urban areas also scored more highly in the majority of inputs compared to ones in rural areas. Readiness scores were lowest for PMTCT services compared to Antenatal Care and HIV Care and Support services, especially for the availability of medicines such as zidovudine and nevirapine. The national composite readiness score for PMTCT was only 0.13 (based on a maximum score of 1) with a composite score of 0.21 for public facilities and 0.06 for private facilities. The multivariate analysis shows that the proportion of pregnant women tested for HIV was more likely to be greater than or equal to 10% in facilities with a higher readiness score and a higher number of trained counsellors available, and less likely in facilities located outside of Java-Bali and in facilities supporting a higher number of village midwives. DISCUSSION Despite targeted efforts by the Indonesian government and multinational agencies, significant gaps exist in the delivery of PMTCT that compromise the standard of care delivered in Indonesia. Future strategies should focus on improving the availability of tests and treatment, especially in the private sector and in rural areas.
Collapse
Affiliation(s)
| | - David Boettiger
- The Kirby Institute, University New South Wales, Sydney, Australia
| | | | - Ari Probandari
- The Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Indonesia
| | - Tiara Marthias
- Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
| | - Rebecca Guy
- The Kirby Institute, University New South Wales, Sydney, Australia
| | - Virginia Wiseman
- The Kirby Institute, University New South Wales, Sydney, Australia
- The London School of Hygiene and Tropical Medicine, London, United Kingdom
| |
Collapse
|
3
|
Otieno P, Angeles G, Quiñones S, van Halsema V, Novignon J, Palermo T. Health services availability and readiness moderate cash transfer impacts on health insurance enrolment: evidence from the LEAP 1000 cash transfer program in Ghana. BMC Health Serv Res 2022; 22:599. [PMID: 35509055 PMCID: PMC9066897 DOI: 10.1186/s12913-022-07964-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 04/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Expanding health insurance coverage is a priority under Sustainable Development Goal 3. To address the intersection between poverty and health and remove cost barriers, the government of Ghana established the National Health Insurance Scheme (NHIS). Government further linked NHIS with the Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer program by waiving premium fees for LEAP 1000 households. This linkage led to increased NHIS enrolment, however, large enrolment gaps remained. One potential reason for failure to enroll may relate to the poor quality of health services. METHODS We examine whether LEAP 1000 impacts on NHIS enrolment were moderated by health facilities' service availability and readiness. RESULTS We find that adults in areas with the highest service availability and readiness are 18 percentage points more likely to enroll in NHIS because of LEAP 1000, compared to program effects of only 9 percentage points in low service availability and readiness areas. Similar differences were seen for enrolment among children (20 v. 0 percentage points) and women of reproductive age (25 v. 10 percentage points). CONCLUSIONS We find compelling evidence that supply-side factors relating to service readiness and availability boost positive impacts of a cash transfer program on NHIS enrolment. Our work suggests that demand-side interventions coupled with supply-side strengthening may facilitate greater population-level benefits down the line. In the quest for expanding financial protection towards accelerating the achievement of universal health coverage, policymakers in Ghana should prioritize the integration of efforts to simultaneously address demand- and supply-side factors. TRIAL REGISTRATION This study is registered in the International Initiative for Impact Evaluation's (3ie) Registry for International Development Impact Evaluations ( RIDIE-STUDY-ID-55942496d53af ).
Collapse
Affiliation(s)
- Peter Otieno
- African Population and Health Research Center, P.O. Box 10787-00100, Nairobi, Kenya
| | - Gustavo Angeles
- Department of Maternal and Child Health, UNC Gillings School of Global Public Health, 400 Meadowmont Circle CB #3446, Chapel Hill, NC, USA
| | - Sarah Quiñones
- Department of Epidemiology and Environmental Health, University at Buffalo, SUNY, 270 Farber Hall, Buffalo, NY, USA
| | | | - Jacob Novignon
- Department of Economics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Tia Palermo
- Department of Epidemiology and Environmental Health, University at Buffalo, SUNY, 270 Farber Hall, Buffalo, NY, USA.
| | | |
Collapse
|
4
|
Tariku A, Berhane Y, Worku A, Biks GA, Persson LÅ, Okwaraji YB. Health postservice readiness and use of preventive and curative services for suspected childhood pneumonia in Ethiopia: a cross-sectional study. BMJ Open 2022; 12:e058055. [PMID: 35477882 PMCID: PMC9047705 DOI: 10.1136/bmjopen-2021-058055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 04/08/2022] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Pneumonia is the single-leading cause of infectious disease deaths in children under-5. Despite this challenge, the utilisation of preventive and curative child health services remains low in Ethiopia. We investigated the association between health post service readiness and caregivers' awareness of pneumonia services, care-seeking and utilisation of pneumonia-relevant immunisation in four Ethiopian regions. DESIGN AND SETTING This cross-sectional study was conducted in 52 districts of four regions of Ethiopia from December 2018 to February 2019. The health posts preparedness for sick child care was assessed using the WHO Health Service Availability and Readiness Assessment tool. Multilevel analyses were employed to examine the associations between health post readiness and household-level awareness and utilisation of services. PARTICIPANTS We included 165 health posts, 274 health extension workers (community health workers) and 4729 caregivers with 5787 children 2-59 months. OUTCOME MEASURES Awareness of pneumonia treatment, care-seeking behaviour and coverage of pentavalent-3 immunisation. RESULTS Only 62.8% of health posts were ready to provide sick child care services. One-quarter of caregivers were aware of pneumonia services, and 56.8% sought an appropriate care provider for suspected pneumonia. Nearly half (49.3%) of children (12-23 months) had received pentavalent-3 immunisation. General health post readiness was not associated with caregivers' awareness of pneumonia treatment (adjusted OR, AOR 0.9, 95% CI 0.7 to 1.1) and utilisation of pentavalent-3 immunisation (AOR=1.2, 95% CI 0.8 to 1.6), but negatively associated with care-seeking for childhood illnesses (AOR=0.6, 95% CI 0.4 to 0.8). CONCLUSION We found no association between facility readiness and awareness or utilisation of child health services. There were significant deficiencies in health post preparedness for services. Caregivers had low awareness and utilisation of pneumonia-related services. The results underline the importance of enhancing facility preparedness, providing high-quality care and intensifying demand generation efforts to prevent and treat pneumonia.
Collapse
Affiliation(s)
- Amare Tariku
- Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Amhara Region, Ethiopia
- Department of Epidemiology and Biostatistics and Department of Reproductive Health and Population, Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
| | - Yemane Berhane
- Department of Epidemiology and Biostatistics and Department of Reproductive Health and Population, Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
| | - Alemayehu Worku
- Department of Epidemiology and Biostatistics and Department of Reproductive Health and Population, Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gashaw Andargie Biks
- Department of Health System and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Lars Åke Persson
- London School of Hygiene and Tropical Medicine, London, UK
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Yemisrach Behailu Okwaraji
- London School of Hygiene and Tropical Medicine, London, UK
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| |
Collapse
|
5
|
Koné S, Bonfoh B, Probst-Hensch N, Utzinger J, N'Goran EK, Fink G. Impact of newly constructed primary healthcare centres on antenatal care attendance, facility delivery and all-cause mortality: quasi-experimental evidence from Taabo health and demographic surveillance system, Côte d'Ivoire. BMJ Open 2022; 12:e054355. [PMID: 35105634 PMCID: PMC8808407 DOI: 10.1136/bmjopen-2021-054355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Access to quality care remains limited, particularly in low-income and middle-income countries. Although better health outcomes for families living in close proximity to healthcare facilities have been documented in cross-sectional studies, evidence on the extent to which additional health facilities can contribute to improved population health remains scanty. We aimed to estimate the causal impact of newly constructed primary healthcare facilities within a health and demographic surveillance (HDSS) site in Côte d'Ivoire. DESIGN We conducted a quasi-experimental study. Logistic and Cox proportional hazards regression models were used to estimate the impact of new healthcare facilities on healthcare-seeking behaviour and all-cause mortality. SETTING Data were collected prospectively through the Taabo HDSS located in south-central Côte d'Ivoire between 2010 and 2018. PARTICIPANTS We analysed 2957 deaths across 440 973 person-year observations as well as 14 132 live births. PRIMARY OUTCOME MEASURES The primary outcomes were antenatal care (ANC) attendance, facility delivery and mortality. Logistic and Cox proportional hazards models were employed to estimate the impact of the new health facilities on ANC attendance, facility delivery and child as well as adult mortality. RESULTS Average distance to the nearest healthcare facility declined from 5.5 km before to 2.8 km after opening of four new healthcare facilities in targeted villages. No improvement was observed for ANC attendance, institutional deliveries and adult mortality. New facilities reduced the risk of post-neonatal infant mortality by 46% (HR 0.54, 95% CI 0.31 to 0.94, p<0.05), suggesting a mortality gradient of 2 deaths per 1000 for each additional km (Coef=0.002, 95% CI 0.000 to 0.004, p<0.05). CONCLUSIONS Our results suggest that new facilities do not necessarily improve healthcare utilisation and health outcomes. Further research is needed to identify the best ways to ensure access to quality care in resource-constrained settings.
Collapse
Affiliation(s)
- Siaka Koné
- Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, Abidjan, Côte d'Ivoire
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Bassirou Bonfoh
- Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | - Nicole Probst-Hensch
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Jürg Utzinger
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Eliézer K N'Goran
- Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, Abidjan, Côte d'Ivoire
- Unité de Formation et de Recherche Biosciences, Université Félix Houphouët-Boigny, Abidjan, Côte d'Ivoire
| | - Günther Fink
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| |
Collapse
|
6
|
Acharya Y, James N, Thapa R, Naz S, Shrestha R, Tamang S. Content of antenatal care and perception about services provided by primary hospitals in Nepal: a convergent mixed methods study. Int J Qual Health Care 2021; 33:6175215. [PMID: 33730154 DOI: 10.1093/intqhc/mzab049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 01/24/2021] [Accepted: 03/16/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Nepal has made significant strides in maternal and neonatal mortality over the last three decades. However, poor quality of care can threaten the gains, as maternal and newborn services are particularly sensitive to quality of care. Our study aimed to understand current gaps in the process and the outcome dimensions of the quality of antenatal care (ANC), particularly at the sub-national level. We assessed these dimensions of the quality of ANC in 17 primary, public hospitals across Nepal. We also assessed the variation in the ANC process across the patients' socio-economic gradient. METHODS We used a convergent mixed methods approach, whereby we triangulated qualitative and quantitative data. In the quantitative component, we observed interactions between providers (17 hospitals from all 7 provinces) and 198 women seeking ANC and recorded the tasks the providers performed, using the Service Provision Assessments protocol available from the Demographic and Health Survey program. The main outcome variable was the number of tasks performed by the provider during an ANC consultation. The tasks ranged from identifying potential signs of danger to providing counseling. We analyzed the resulting data descriptively and assessed the relationship between the number of tasks performed and users' characteristics. In the qualitative component, we synthesized users' and providers' narratives on perceptions of the overall quality of care obtained through focus group discussions and in-depth interviews. RESULTS Out of the 59 tasks recommended by the World Health Organization, providers performed only 22 tasks (37.3%) on average. The number of tasks performed varied significantly across provinces, with users in province 3 receiving significantly higher quality care than those in other provinces. Educated women were treated better than those with no education. Users and providers agreed that the overall quality of care was inadequate, although providers mentioned that the current quality was the best they could provide given the constraints they faced. CONCLUSION The quality of ANC in Nepal's primary hospitals is poor and inequitable across education and geographic gradients. While current efforts, such as the provision of 24/7 birthing centers, can mitigate gaps in service availability, additional equipment, infrastructure and human resources will be needed to improve quality. Providers also need additional training focused on treating patients from different backgrounds equally. Our study also points to the need for additional research, both to document the quality of care more objectively and to establish key determinants of quality to inform policy.
Collapse
Affiliation(s)
- Yubraj Acharya
- Department of Health Policy and Administration, The Pennsylvania State University, 601L Ford Building, University Park, PA 16802, USA
| | - Nigel James
- Department of Health Policy and Administration, The Pennsylvania State University, 601L Ford Building, University Park, PA 16802, USA
| | - Rita Thapa
- Nick Simons Institute, Box 8975, EPC 1813, Lalitpur, Nepal
| | - Saman Naz
- Department of Health Policy and Administration, The Pennsylvania State University, 601L Ford Building, University Park, PA 16802, USA
| | | | - Suresh Tamang
- Nick Simons Institute, Box 8975, EPC 1813, Lalitpur, Nepal
| |
Collapse
|
7
|
Defar A, Alemu K, Tigabu Z, Persson LÅ, Okwaraji YB. Caregivers' and Health Extension Workers' Perceptions and Experiences of Outreach Management of Childhood Illnesses in Ethiopia: A Qualitative Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18073816. [PMID: 33917415 PMCID: PMC8038672 DOI: 10.3390/ijerph18073816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/26/2021] [Accepted: 03/31/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Ethiopian Health Extension Workers provide facility-based and outreach services, including home visits to manage sick children, aiming to increase equity in service coverage. Little is known about the scope of the outreach services and caregivers' and health workers' perceptions of these services. We aimed at exploring mothers' and health extension workers' perceptions and experiences of the outreach services provided for the management of childhood illnesses. METHODS Four focus groups and eight key informant interviews were conducted. A total of 45 community members participated. Interviews were recorded, transcribed verbatim, and translated into English. We applied thematic content analysis, identified challenges in providing outreach services, and suggestions for improvement. We balanced the data collection by selecting half of the participants for interview and focus group discussions from remote areas and the other half from areas closer to the health posts. RESULTS Mothers reported that health extension workers visited their homes for preventive services but not for managing childhood illnesses. They showed lack of trust in the health workers' ability to treat children at home. The health extension workers reported that they provide sick children treatment during outreach services but also stated that in most cases, mothers visit the health posts when their child is sick. On the other hand, mothers considered distance from home to health post not to be a problem if the quality of services improved. Workload, long distances, and lack of incentives were perceived as demotivating factors for outreach services. The health workers called for support, incentives, and capacity development activities. CONCLUSIONS Mothers and health extension workers had partly divergent perceptions of whether outreach curative services for children were available. Mothers wanted improvements in the quality of services while health workers requested capacity development and more support for providing effective community-based child health services.
Collapse
Affiliation(s)
- Atkure Defar
- Ethiopian Public Health Institute, Addis Ababa P.O. Box 1242, Ethiopia; (L.Å.P.); (Y.B.O.)
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar P.O. Box 196, Ethiopia;
- Correspondence:
| | - Kassahun Alemu
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar P.O. Box 196, Ethiopia;
| | - Zemene Tigabu
- Department of Paediatrics and Child Health, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar P.O. Box 196, Ethiopia;
| | - Lars Åke Persson
- Ethiopian Public Health Institute, Addis Ababa P.O. Box 1242, Ethiopia; (L.Å.P.); (Y.B.O.)
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Yemisrach B. Okwaraji
- Ethiopian Public Health Institute, Addis Ababa P.O. Box 1242, Ethiopia; (L.Å.P.); (Y.B.O.)
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| |
Collapse
|
8
|
Leal Neto O, Haenni S, Phuka J, Ozella L, Paolotti D, Cattuto C, Robles D, Lichand G. Combining Wearable Devices and Mobile Surveys to Study Child and Youth Development in Malawi: Implementation Study of a Multimodal Approach. JMIR Public Health Surveill 2021; 7:e23154. [PMID: 33536159 PMCID: PMC7980111 DOI: 10.2196/23154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/05/2020] [Accepted: 02/02/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Multimodal approaches have been shown to be a promising way to collect data on child development at high frequency, combining different data inputs (from phone surveys to signals from noninvasive biomarkers) to understand children's health and development outcomes more integrally from multiple perspectives. OBJECTIVE The aim of this work was to describe an implementation study using a multimodal approach combining noninvasive biomarkers, social contact patterns, mobile surveying, and face-to-face interviews in order to validate technologies that help us better understand child development in poor countries at a high frequency. METHODS We carried out a mixed study based on a transversal descriptive analysis and a longitudinal prospective analysis in Malawi. In each village, children were sampled to participate in weekly sessions in which data signals were collected through wearable devices (electrocardiography [ECG] hand pads and electroencephalography [EEG] headbands). Additionally, wearable proximity sensors to elicit the social network were deployed among children and their caregivers. Mobile surveys using interactive voice response calls were also used as an additional layer of data collection. An end-line face-to-face survey was conducted at the end of the study. RESULTS During the implementation, 82 EEG/ECG data entry points were collected across four villages. The sampled children for EEG/ECG were 0 to 5 years old. EEG/ECG data were collected once a week. In every session, children wore the EEG headband for 5 minutes and the ECG hand pad for 3 minutes. In total, 3531 calls were sent over 5 weeks, with 2291 participants picking up the calls and 984 of those answering the consent question. In total, 585 people completed the surveys over the course of 5 weeks. CONCLUSIONS This study achieved its objective of demonstrating the feasibility of generating data through the unprecedented use of a multimodal approach for tracking child development in Malawi, which is one of the poorest countries in the world. Above and beyond its multiple dimensions, the dynamics of child development are complex. It is the case not only that no data stream in isolation can accurately characterize it, but also that even if combined, infrequent data might miss critical inflection points and interactions between different conditions and behaviors. In turn, combining different modes at a sufficiently high frequency allows researchers to make progress by considering contact patterns, reported symptoms and behaviors, and critical biomarkers all at once. This application showcases that even in developing countries facing multiple constraints, complementary technologies can leverage and accelerate the digitalization of health, bringing benefits to populations that lack new tools for understanding child well-being and development.
Collapse
Affiliation(s)
- Onicio Leal Neto
- Department of Economics, University of Zurich, Zurich, Switzerland
| | - Simon Haenni
- Department of Economics, University of Zurich, Zurich, Switzerland
| | - John Phuka
- College of Medicine, University of Malawi, Lilongwe, Malawi
| | | | | | - Ciro Cattuto
- ISI Foundation, Turin, Italy
- Department of Computer Science, University of Torino, Turin, Italy
| | - Daniel Robles
- Department of Psychology, University of Alberta, Edmonton, AB, Canada
| | | |
Collapse
|
9
|
Bell G, Macarayan EK, Ratcliffe H, Kim JH, Otupiri E, Lipsitz S, Hirschhorn L, Awoonor-Williams JK, Nimako BA, Ofosu A, Leslie H, Bitton A, Schwarz D. Assessment of Bypass of the Nearest Primary Health Care Facility Among Women in Ghana. JAMA Netw Open 2020; 3:e2012552. [PMID: 32785634 PMCID: PMC7424402 DOI: 10.1001/jamanetworkopen.2020.12552] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE Recent reports have highlighted that expanding access to health care is ineffective at meeting the goal of universal health coverage if the care offered does not meet a minimum level of quality. Health care facilities nearest to patient's homes that are perceived to offer inadequate or inappropriate care are frequently bypassed in favor of more distant private or tertiary-level hospital facilities that are perceived to offer higher-quality care. OBJECTIVE To estimate the frequency with which women in Ghana bypass the nearest primary health care facility and describe patient experiences, costs, and other factors associated with this choice. DESIGN, SETTING, AND PARTICIPANTS This nationally representative survey study was conducted in 2017 and included 4203 households to identify women in Ghana aged 15 to 49 years (ie, reproductive age) who sought primary care within the last 6 months. Women who sought care within the past 6 months were included in the study. Data were analyzed from 2018 to 2019. EXPOSURES Bypass was defined as a woman's report that she sought care at a health facility other than the nearest facility. MAIN OUTCOMES AND MEASURES Sociodemographic characteristics, reasons why women sought care, reasons why women bypassed their nearest facility, ratings for responsiveness of care, patient experience, and out-of-pocket costs. All numbers and percentages were survey-weighted to account for survey design. RESULTS A total of 4289 women met initial eligibility criteria, and 4207 women (98.1%) completed the interview. A total of 1993 women reported having sough health care in the past 6 months, and after excluding those who were ineligible and survey weighting, the total sample included 1946 women. Among these, 629 women (32.3%) reported bypassing their nearest facilities for primary care. Women who bypassed their nearest facilities, compared with women who did not, were more likely to visit a private facility (152 women [24.5%] vs 202 women [15.6%]) and borrow money to pay for their care (151 women [24.0%] vs 234 women [17.8%]). After adjusting for covariates, women who bypassed reported paying a mean of 107.2 (95% CI, 79.1-135.4) Ghanaian Cedis (US $18.50 [95% CI, $13.65-$23.36]) for their care, compared with a mean of 58.6 (95% CI, 28.1-89.2) Ghanaian Cedis (US $10.11 [95% CI, $4.85-15.35]) for women who did not bypass (P = .006). Women who bypassed cited clinician competence (136 women [34.3%]) and availability of supplies (93 women [23.4%]) as the most important factors in choosing a health facility. CONCLUSIONS AND RELEVANCE The findings of this survey study suggest that bypassing the nearest health care facility was common among women in Ghana and that available services at lower levels of primary care are not meeting the needs of a large proportion of women. Among the benefits women perceived from bypassing were clinician competence and availability of supplies. These data provide insights to policy makers regarding potential gaps in service delivery and may help to guide primary health care improvement efforts.
Collapse
Affiliation(s)
- Griffith Bell
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Erlyn K. Macarayan
- Lancet Commission on High Quality Health Systems, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Hannah Ratcliffe
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - June-Ho Kim
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine & Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Easmon Otupiri
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Stuart Lipsitz
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lisa Hirschhorn
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | | | - Anthony Ofosu
- Policy Planning Monitoring and Evaluation Division, Ghana Health Service, Accra, Ghana
| | - Hannah Leslie
- Lancet Commission on High Quality Health Systems, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Asaf Bitton
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine & Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Dan Schwarz
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| |
Collapse
|