Prevalence and associated factors of Tunga penetrans infestation among 5-14-year-olds in rural Ethiopia

PLoS ONE, Volume 16, No. 10 October, Year 2021

Interpretation

Background Tunga penetrans, also known as sand flea, causes Tungiasis in humans and animals. Despite its notoriety as an entomological problem, however, the ectoparasite receives little consideration from public health professionals. It is against this background that this article aims to assess the prevalence of and factors associated with Tunga penetrans infestation among 5-14-year-olds in rural Western Ethiopia. Methods From November to December 2020, 487 children aged 5 to 14 were selected from four primary schools in a cross-sectional study using systematic random sampling. Clinical exams, Interviews with parents/guardians and observations of the housing and classroom environments were used to collect data. Descriptive statistics and multivariable regression were used to characterize the data and identify factors associated with Tunga penetrans infestation. Result Tunga penetrans infestation (Tungiasis) was diagnosed in 138 of the 487 children examined, placing the prevalence at 28.3% (95% CI: 24.2%, 32.2%). Mud plastered walls [AOR: 5.83, % CI (3.44–9.88)], having cats in the house [AOR: 5.91, 95% CI (3.51–10.11)], not having separated sleeping quarters for animals [AOR: 4.60, 95% CI (2.69–7.86)], using self-supplied water [AOR: 6.30, 95% CI (3.33–11.93)], walking>30 minutes to school [AOR: 2.37, 95% CI (1.48–3.80)] were associated with Tungiasis. Conclusion In one way or another, several of the identified factors were linked to poverty. Improved house wall materials, fumigation of mud-plastered houses, dusting or spraying insecticides on domestic animals (such as cats), improved access to water, community education about keeping animals separated from living spaces, and hygiene promotion are all needed, with a focus on locally available, low-cost technologies that the poorest families can afford. A cross-sectional study was carried out in the Oromia Region, one of Ethiopia’s ten federal states, from November to December 2020. Limu Saka district is situated 450 kilometres west of Addis Ababa, Ethiopia’s capital, and is divided into 12 rural and 4 urban Kebeles (the lowest administrative unit in Ethiopia). This district has a total population of 189,463, with 95,869 men and 93,594 women; urban dwellers account for 5,185 people or 2.74% of the total population [10]. Farmers and livestock breeders make up the majority of the district’s residents. Among the animals raised are cows, pigs, hens, and domestic pets. The sample size required to estimate the prevalence and correlates of Tunga penetrans infestation in the Limu Saka district was calculated using the Epi Info 7 software. The sample sizes for objectives one and two were determined separately based on different assumptions, using a formula for a single population for the first objective and a formula for a double population for the second. Finally, for both objectives, the sample size (n = 492) with assumptions of an estimated prevalence of 25% [11], a 95% level of confidence, a 5% margin of error, a design effect of 1.5, and an expected non-response rate of 10% was found to be the largest. To achieve the study’s objective, a multi-stage sampling technique was employed. In the first phase, 4 (30%) of the total Kebeles were chosen at random from the district’s 12 rural Kebele administrations. In the selected Kebeles, there were a total of seven schools. The goal of this study was to undertake a Tungiasis prevalence investigation in very rural and dispersed settlements as Tungiasis investigations had previously been conducted in urban, semi-urban, and compact rural settlements. Accordingly, relevant school districts in very remote and dispersed sections of the district were chosen after consultations with district officials. The four most rural schools were chosen to offer crucial information that could not be collected through other approaches (Urban slums, suburban, and compact rural settlements). The goal of this study was to undertake a Tungiasis prevalence investigation in very rural and dispersed settlements as Tungiasis investigations had previously been conducted in urban, semi-urban, and compact rural settlements. Accordingly, 30% of the schools in very remote and dispersed sections of the district were randomly chosen. In the third step, the total sample size, i.e.,492was allocated to the selected primary schools proportional to the schools’ pupil numbers ((Sample size/Population size) x Stratum size) (Table 1). Finally, systematic random sampling with a skip interval approach was used to draw study participants from each selected school. The lists of students present in each class room on the day of visit were taken from the record offices of their respective schools. They were then allocated ordinal numbers based on their alphabetical order. The skip interval (K) was calculated by dividing the total number of students in each chosen school by the sample sizes proportionally allocated. Using a random starting point, every eighth student on the sampling frame was chosen for data collection until the completion. The selection of study participants emphasized unrelated subsets of individuals where only one member of a family is included. If more than one sibling was chosen, one sibling per sibship was chosen at random. If the guardians of the chosen child declined to participate in the study, the next child on the sample frame was chosen. The district initiated the Rural Health Extension Program 16 years ago, with a focus on improving environmental and community health [12]. Since then, two health extension personnel have been assigned to provide door-to-door education in each Kebele. After receiving training on data collection tools and procedures, these health extension workers collected data in the present study. Physical assessment of the children, interviews with their parents/guardians, and observation of the children’s home and school environment were used to collect data. Tunga Penetrans infestation (Tungiasis) was evaluated in all students for whom informed consent was provided. The students’ feet were thoroughly washed with soap in a bucket before the clinical assessment. Each person was then screened for Tungiasis using a standardized procedure [13]. This assessment took place at their residences. Data were obtained via face-to-face interviews with participants using a pretested and closed-ended questionnaire developed by the investigator (S1 File). Primary care providers were asked about their educational backgrounds, household conditions, water sources and water access, hygiene practices, livestock, and domestic animals. In addition, observations were made about the physical layout of the classrooms where the children learnt, students’ hygiene, and the type of shoes they wore if any. The infestation with Tunga penetrans was used as the dependent variable in this study. Socio-demographic characteristics (sex of the child, age of the child, time spent commuting to school, maternal education, income, family size), household conditions (household water supply, household latrine system, household waste disposal system, nature of household roof material, nature of household floor material), environmental conditions of school (floor type, wall type), and behavioural characteristics (frequency of washing feet, frequency of washing feet with soap, the habit of wearing shoes) were all independent variables. Based on the Fortaleza classification, the results were deemed pathognomonic for T.penetrans infestation at the time of the examination if nodules with black centers, suppurative ulcers or punctiform cavities, itching spots, trouble walking, oedema, and skin redness around lesions, loss of toenails or deformed nails were detected [11]. Lesions that have been manipulated with a sharp instrument (by the patient or their caregiver) to remove the parasite that has become embedded [11]. The severity of the lesions can be categorized as light (1–5 lesions), moderate (6–30 lesions), or severe (>30 lesions) [14]. Absolute poverty is characterized as a family’s inability to meet the food budget, as well as a separate allowance for non-food products, per the poor’s spending patterns. For 2020, the absolute poverty line is set at 163.09 birr per week per adult equivalent (1 United States Dollar equals 40.25 Ethiopian birr) [15]. Pit latrine with a slab, ventilated improved pit latrine, composting toilet, flush, pour/flush facility connected to a piped sewer system/septic tank/pit [16]. Flush or pour/flush facility not connected to a piped sewer system/septic tank/pit, pit latrine without a slab/ open pit, hanging latrine/bucket latrine [16]. A person/household that withdraws water from a groundwater or surface-water source rather than using a piped supply. Water from domestic wells, rainwater, rivers, and so on… is deemed to be self-supplied water [17]. The investigator employed four data collectors and one field supervisor. A professional translator produced forward and reverse translations of the questionnaire. The supervisor and data collectors received two days of rigorous training on data collection instruments and techniques. The training included both a theoretical and a practical session, during which the data collectors visited another school in a neighbouring district and practiced conducting some of the physical inspection tasks. The questionnaire was then pre-tested in another school in the neighbouring district on 5% of the overall sample size. The tool was finalized after the pre-test and necessary changes. The results of the pre-test were excluded from the main analysis. Before being entered into the computer, all the data collected via questionnaires were reviewed for errors and coded. The data was inserted into Epi info version 7 software using a data entry template; the data was then cleaned and analyzed using the statistical package for social sciences (SPSS V.20). Descriptive results were presented as frequency tables, percentages, and proportions with a 95% confidence level (CI). Factors associated with Tungiasis were identified using binary logistic regression. The logistic regression analysis commenced with a crude analysis in which each potential determinant was independently investigated for a correlation to the outcome variable. In the initial multivariable model, variables with p-values up to 0.25 in the crude analysis and those considered significant in previous studies were included. This cut-off point was chosen to minimize a superfluous number of variables and an unstable estimate in the multivariable regression. In the multivariable analysis, variables with a p-value of less than 0.05 were considered statistically significant and presented by an Adjusted Odds Ratio (AOR) with a 95%% confidence interval. In the course of the analysis, multicollinearity among the explanatory variables was tested using the variance inflation factor (VIF<10), suggesting that one independent variable was not explained by another in the model. The Hosmer-Lemeshow goodness of fit test (p-value = 0.43) was used to determine model fitness. At a p-value of 0.05, the Hosmer-Lemeshow test should be insignificant; signalling that the variable entered fits the model. This study was authorized and carried out per the Helsinki Declaration’s principles. The Institutional Review Board of Wachemo University College of Medicine and Health Sciences granted ethical approval. An approval letter from the Oromia Regional Health Bureau and the Limu Saka District Health Bureau was obtained before data collection. The parents/guardians of the children gave their written informed consent. Participants’ privacy and confidentiality were ensured before, during, and after data collection. Soap, sterile needle, surgical blade, and Vaseline ointment were given to all children who took part in the study.

AI Digest

Study Justification:

The study aimed to assess the prevalence and factors associated with Tunga penetrans infestation (Tungiasis) among 5-14-year-olds in rural Western Ethiopia. This research is important because Tungiasis is a neglected public health issue, and little attention has been given to it by public health professionals. Understanding the prevalence and associated factors can help inform interventions and policies to prevent and manage Tungiasis in the affected population.

Highlights:

– The prevalence of Tungiasis among the studied population was found to be 28.3%.
– Factors associated with Tungiasis included mud plastered walls, having cats in the house, not having separated sleeping quarters for animals, using self-supplied water, and walking more than 30 minutes to school.
– Several of the identified factors were linked to poverty, highlighting the need for interventions that are affordable and accessible to the poorest families.
– Recommendations include improving house wall materials, fumigating mud-plastered houses, dusting or spraying insecticides on domestic animals, improving access to water, promoting hygiene practices, and educating the community about keeping animals separated from living spaces.

Recommendations for Lay Reader and Policy Maker:

1. Improve house wall materials: Encourage the use of materials that are less conducive to Tunga penetrans infestation, such as cement or other insect-repellent materials.
2. Fumigate mud-plastered houses: Implement regular fumigation of houses with Tungiasis infestation to reduce the presence of sand fleas.
3. Dust or spray insecticides on domestic animals: Promote the use of insecticides on animals, particularly cats, to prevent Tungiasis transmission.
4. Improve access to water: Ensure communities have access to clean water sources to promote hygiene and reduce the risk of Tungiasis.
5. Promote hygiene practices: Educate the community about the importance of regular foot washing, especially with soap, to prevent Tungiasis.
6. Educate about animal separation: Raise awareness about the need to keep animals separated from living spaces to reduce the risk of Tungiasis transmission.
7. Focus on low-cost technologies: Develop and promote locally available, low-cost interventions that can be afforded by the poorest families to address Tungiasis.

Key Role Players:

1. Public health professionals: Provide expertise and guidance in developing and implementing interventions to prevent and manage Tungiasis.
2. Community health workers: Educate the community about Tungiasis prevention and promote hygiene practices.
3. Local government authorities: Support and allocate resources for Tungiasis prevention programs and interventions.
4. Non-governmental organizations (NGOs): Collaborate with local communities and government agencies to implement Tungiasis prevention and control measures.
5. Health researchers: Conduct further studies to gather more evidence on effective interventions and strategies for Tungiasis prevention and management.

Cost Items for Planning Recommendations:

1. Materials for house wall improvement: Estimate the cost of materials such as cement or insect-repellent materials for improving house walls.
2. Fumigation services: Budget for regular fumigation of mud-plastered houses to control Tungiasis infestation.
3. Insecticides: Include the cost of insecticides for dusting or spraying on domestic animals.
4. Water infrastructure: Calculate the cost of improving access to clean water sources in the community.
5. Hygiene promotion materials: Budget for educational materials and campaigns to promote hygiene practices.
6. Community education programs: Allocate funds for training community health workers and conducting awareness campaigns on animal separation and Tungiasis prevention.
7. Research funding: Provide resources for further studies and research on Tungiasis prevention and management.
Note: The provided cost items are for planning purposes and do not reflect the actual costs.

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it presents the findings of a cross-sectional study with a large sample size and provides specific prevalence rates and associated factors. However, to improve the evidence, the abstract could include more details about the study design, such as the sampling method and data collection procedures. Additionally, it would be helpful to mention any limitations of the study and potential implications of the findings.

Abstract

A cross-sectional study was carried out in the Oromia Region, one of Ethiopia’s ten federal states, from November to December 2020. Limu Saka district is situated 450 kilometres west of Addis Ababa, Ethiopia’s capital, and is divided into 12 rural and 4 urban Kebeles (the lowest administrative unit in Ethiopia). This district has a total population of 189,463, with 95,869 men and 93,594 women; urban dwellers account for 5,185 people or 2.74% of the total population [10]. Farmers and livestock breeders make up the majority of the district’s residents. Among the animals raised are cows, pigs, hens, and domestic pets. The sample size required to estimate the prevalence and correlates of Tunga penetrans infestation in the Limu Saka district was calculated using the Epi Info 7 software. The sample sizes for objectives one and two were determined separately based on different assumptions, using a formula for a single population for the first objective and a formula for a double population for the second. Finally, for both objectives, the sample size (n = 492) with assumptions of an estimated prevalence of 25% [11], a 95% level of confidence, a 5% margin of error, a design effect of 1.5, and an expected non-response rate of 10% was found to be the largest. To achieve the study’s objective, a multi-stage sampling technique was employed. In the first phase, 4 (30%) of the total Kebeles were chosen at random from the district’s 12 rural Kebele administrations. In the selected Kebeles, there were a total of seven schools. The goal of this study was to undertake a Tungiasis prevalence investigation in very rural and dispersed settlements as Tungiasis investigations had previously been conducted in urban, semi-urban, and compact rural settlements. Accordingly, relevant school districts in very remote and dispersed sections of the district were chosen after consultations with district officials. The four most rural schools were chosen to offer crucial information that could not be collected through other approaches (Urban slums, suburban, and compact rural settlements). The goal of this study was to undertake a Tungiasis prevalence investigation in very rural and dispersed settlements as Tungiasis investigations had previously been conducted in urban, semi-urban, and compact rural settlements. Accordingly, 30% of the schools in very remote and dispersed sections of the district were randomly chosen. In the third step, the total sample size, i.e.,492was allocated to the selected primary schools proportional to the schools’ pupil numbers ((Sample size/Population size) x Stratum size) (Table 1). Finally, systematic random sampling with a skip interval approach was used to draw study participants from each selected school. The lists of students present in each class room on the day of visit were taken from the record offices of their respective schools. They were then allocated ordinal numbers based on their alphabetical order. The skip interval (K) was calculated by dividing the total number of students in each chosen school by the sample sizes proportionally allocated. Using a random starting point, every eighth student on the sampling frame was chosen for data collection until the completion. The selection of study participants emphasized unrelated subsets of individuals where only one member of a family is included. If more than one sibling was chosen, one sibling per sibship was chosen at random. If the guardians of the chosen child declined to participate in the study, the next child on the sample frame was chosen. The district initiated the Rural Health Extension Program 16 years ago, with a focus on improving environmental and community health [12]. Since then, two health extension personnel have been assigned to provide door-to-door education in each Kebele. After receiving training on data collection tools and procedures, these health extension workers collected data in the present study. Physical assessment of the children, interviews with their parents/guardians, and observation of the children’s home and school environment were used to collect data. Tunga Penetrans infestation (Tungiasis) was evaluated in all students for whom informed consent was provided. The students’ feet were thoroughly washed with soap in a bucket before the clinical assessment. Each person was then screened for Tungiasis using a standardized procedure [13]. This assessment took place at their residences. Data were obtained via face-to-face interviews with participants using a pretested and closed-ended questionnaire developed by the investigator (S1 File). Primary care providers were asked about their educational backgrounds, household conditions, water sources and water access, hygiene practices, livestock, and domestic animals. In addition, observations were made about the physical layout of the classrooms where the children learnt, students’ hygiene, and the type of shoes they wore if any. The infestation with Tunga penetrans was used as the dependent variable in this study. Socio-demographic characteristics (sex of the child, age of the child, time spent commuting to school, maternal education, income, family size), household conditions (household water supply, household latrine system, household waste disposal system, nature of household roof material, nature of household floor material), environmental conditions of school (floor type, wall type), and behavioural characteristics (frequency of washing feet, frequency of washing feet with soap, the habit of wearing shoes) were all independent variables. Based on the Fortaleza classification, the results were deemed pathognomonic for T.penetrans infestation at the time of the examination if nodules with black centers, suppurative ulcers or punctiform cavities, itching spots, trouble walking, oedema, and skin redness around lesions, loss of toenails or deformed nails were detected [11]. Lesions that have been manipulated with a sharp instrument (by the patient or their caregiver) to remove the parasite that has become embedded [11]. The severity of the lesions can be categorized as light (1–5 lesions), moderate (6–30 lesions), or severe (>30 lesions) [14]. Absolute poverty is characterized as a family’s inability to meet the food budget, as well as a separate allowance for non-food products, per the poor’s spending patterns. For 2020, the absolute poverty line is set at 163.09 birr per week per adult equivalent (1 United States Dollar equals 40.25 Ethiopian birr) [15]. Pit latrine with a slab, ventilated improved pit latrine, composting toilet, flush, pour/flush facility connected to a piped sewer system/septic tank/pit [16]. Flush or pour/flush facility not connected to a piped sewer system/septic tank/pit, pit latrine without a slab/ open pit, hanging latrine/bucket latrine [16]. A person/household that withdraws water from a groundwater or surface-water source rather than using a piped supply. Water from domestic wells, rainwater, rivers, and so on… is deemed to be self-supplied water [17]. The investigator employed four data collectors and one field supervisor. A professional translator produced forward and reverse translations of the questionnaire. The supervisor and data collectors received two days of rigorous training on data collection instruments and techniques. The training included both a theoretical and a practical session, during which the data collectors visited another school in a neighbouring district and practiced conducting some of the physical inspection tasks. The questionnaire was then pre-tested in another school in the neighbouring district on 5% of the overall sample size. The tool was finalized after the pre-test and necessary changes. The results of the pre-test were excluded from the main analysis. Before being entered into the computer, all the data collected via questionnaires were reviewed for errors and coded. The data was inserted into Epi info version 7 software using a data entry template; the data was then cleaned and analyzed using the statistical package for social sciences (SPSS V.20). Descriptive results were presented as frequency tables, percentages, and proportions with a 95% confidence level (CI). Factors associated with Tungiasis were identified using binary logistic regression. The logistic regression analysis commenced with a crude analysis in which each potential determinant was independently investigated for a correlation to the outcome variable. In the initial multivariable model, variables with p-values up to 0.25 in the crude analysis and those considered significant in previous studies were included. This cut-off point was chosen to minimize a superfluous number of variables and an unstable estimate in the multivariable regression. In the multivariable analysis, variables with a p-value of less than 0.05 were considered statistically significant and presented by an Adjusted Odds Ratio (AOR) with a 95%% confidence interval. In the course of the analysis, multicollinearity among the explanatory variables was tested using the variance inflation factor (VIF<10), suggesting that one independent variable was not explained by another in the model. The Hosmer-Lemeshow goodness of fit test (p-value = 0.43) was used to determine model fitness. At a p-value of 0.05, the Hosmer-Lemeshow test should be insignificant; signalling that the variable entered fits the model. This study was authorized and carried out per the Helsinki Declaration’s principles. The Institutional Review Board of Wachemo University College of Medicine and Health Sciences granted ethical approval. An approval letter from the Oromia Regional Health Bureau and the Limu Saka District Health Bureau was obtained before data collection. The parents/guardians of the children gave their written informed consent. Participants’ privacy and confidentiality were ensured before, during, and after data collection. Soap, sterile needle, surgical blade, and Vaseline ointment were given to all children who took part in the study.

Materials

https://efashare.b-cdn.net/materials/38dd9cc652117b349136b50ef4c9aba0b773965455cb11a553f1ab5b88a0085e/pone.0259411.s001.docx

Innovations

Based on the information provided, here are some potential innovations that can be used to improve access to maternal health:

1. Mobile Clinics: Implementing mobile clinics that can travel to rural areas, providing maternal health services and education to pregnant women and new mothers who may not have easy access to healthcare facilities.

2. Telemedicine: Utilizing telemedicine technology to connect pregnant women in remote areas with healthcare professionals, allowing them to receive prenatal care and consultations without having to travel long distances.

3. Community Health Workers: Training and deploying community health workers in rural areas to provide basic maternal health services, conduct health education sessions, and identify high-risk pregnancies that require referral to healthcare facilities.

4. Maternal Health Vouchers: Introducing voucher programs that provide pregnant women with access to essential maternal health services, such as prenatal care, delivery, and postnatal care, at reduced or no cost.

5. Transportation Support: Establishing transportation support systems, such as ambulances or transportation vouchers, to ensure that pregnant women can safely and easily reach healthcare facilities for prenatal care, delivery, and emergency obstetric care.

6. Health Education Programs: Implementing comprehensive health education programs that focus on maternal health, including topics such as nutrition during pregnancy, birth preparedness, breastfeeding, and postpartum care.

7. Maternal Waiting Homes: Setting up maternal waiting homes near healthcare facilities, where pregnant women from remote areas can stay during the final weeks of pregnancy, ensuring they are close to medical care when they go into labor.

8. Task-Shifting: Training and empowering non-medical healthcare providers, such as midwives and nurses, to perform certain tasks traditionally done by doctors, thereby increasing the availability of skilled maternal healthcare providers in underserved areas.

9. Mobile Apps: Developing mobile applications that provide pregnant women with information, reminders, and guidance on prenatal care, nutrition, and self-care during pregnancy, helping them to better manage their health.

10. Public-Private Partnerships: Collaborating with private healthcare providers and organizations to expand access to maternal health services in underserved areas, leveraging their resources and expertise to reach more women in need.

These innovations aim to address the challenges faced by pregnant women in accessing maternal health services in rural areas, ultimately improving their health outcomes and reducing maternal mortality rates.

AI Innovations Description

Based on the information provided, here is a recommendation that can be developed into an innovation to improve access to maternal health:

In order to address the prevalence of Tunga penetrans infestation (Tungiasis) among 5-14-year-olds in rural Ethiopia and its associated factors, it is recommended to implement a comprehensive maternal and child health program that focuses on improving housing conditions, hygiene practices, and access to clean water in the community.

1. Improved house wall materials: Introduce and promote the use of alternative materials for house walls that are less prone to infestation by Tunga penetrans. This could include materials such as cement or other insect-repellent materials.

2. Fumigation of mud-plastered houses: Conduct regular fumigation campaigns in the community to eliminate Tunga penetrans infestation in mud-plastered houses. This can be done using safe and effective insecticides.

3. Dusting or spraying insecticides on domestic animals: Educate the community about the importance of dusting or spraying insecticides on domestic animals, such as cats, to prevent Tunga penetrans infestation. Provide training and resources to community members to ensure proper application of insecticides.

4. Improved access to water: Improve access to clean water sources in the community, as the use of self-supplied water was found to be associated with Tungiasis. This can be achieved through the construction of water supply systems or the provision of water purification methods.

5. Community education: Conduct community education programs to raise awareness about the importance of keeping animals separated from living spaces. Promote hygiene practices, such as regular washing of feet with soap, and the use of appropriate footwear to prevent Tunga penetrans infestation.

6. Hygiene promotion: Implement hygiene promotion activities in schools and households to encourage proper hygiene practices, including regular washing of feet and maintaining clean living environments.

7. Low-cost technologies: Focus on developing and promoting locally available, low-cost technologies that the poorest families can afford. This will ensure that all members of the community have access to the necessary resources to prevent Tunga penetrans infestation.

By implementing these recommendations, it is expected that the prevalence of Tunga penetrans infestation among children in rural Ethiopia will decrease, leading to improved maternal and child health outcomes.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations for improving access to maternal health:

1. Increase awareness and education: Implement community education programs to raise awareness about the importance of maternal health and the available services. This can include educating women and their families about the benefits of antenatal care, skilled birth attendance, and postnatal care.

2. Improve infrastructure: Enhance the physical infrastructure of healthcare facilities to ensure they are equipped to provide quality maternal health services. This can involve renovating or constructing new facilities, ensuring they have adequate space, equipment, and supplies.

3. Strengthen healthcare workforce: Invest in training and capacity building for healthcare providers, particularly midwives and other skilled birth attendants. This can help improve the quality of care provided during pregnancy, childbirth, and postpartum.

4. Enhance transportation services: Develop or improve transportation systems to ensure pregnant women have access to healthcare facilities. This can include providing ambulances or other means of transportation for emergency cases and improving road infrastructure in rural areas.

5. Increase availability of essential medicines and supplies: Ensure that healthcare facilities have a reliable supply of essential medicines and supplies needed for maternal health services. This can involve strengthening supply chains and improving procurement processes.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define indicators: Identify specific indicators that can measure the impact of the recommendations, such as the number of women receiving antenatal care, the percentage of births attended by skilled birth attendants, or the maternal mortality rate.

2. Collect baseline data: Gather data on the current status of maternal health in the target population, including the baseline values of the selected indicators.

3. Develop a simulation model: Create a simulation model that incorporates the recommendations and their potential impact on the selected indicators. This model should consider factors such as population size, healthcare infrastructure, transportation systems, and availability of resources.

4. Input data and parameters: Input the baseline data and parameters into the simulation model. This can include information on the population, healthcare facilities, healthcare workforce, transportation systems, and availability of medicines and supplies.

5. Run simulations: Run multiple simulations using different scenarios, such as implementing one or more of the recommendations at varying levels of coverage or intensity. This will help assess the potential impact of each recommendation on the selected indicators.

6. Analyze results: Analyze the simulation results to determine the potential impact of the recommendations on improving access to maternal health. This can involve comparing the outcomes of different scenarios and identifying the most effective interventions.

7. Refine and validate the model: Refine the simulation model based on the analysis of the results and validate it using additional data or expert input. This will help ensure the accuracy and reliability of the model.

8. Communicate findings: Present the findings of the simulation study to relevant stakeholders, such as policymakers, healthcare providers, and community members. This can help inform decision-making and prioritize interventions for improving access to maternal health.

It is important to note that the methodology described above is a general framework and can be adapted based on the specific context and available data.

Author

Dima Health

Identifiers:

DOI: 10.1371/journal.pone.0259411

Research Areas:

Community Interventions, Environmental, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Social Determinants

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Male & Female