Four delays of child mortality in Rwanda: A mixed methods analysis of verbal social autopsies

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Study Justification:
– The study aimed to understand healthcare-seeking patterns and delays in obtaining effective treatment for rural Rwandan children aged 1-5 years.
– The study focused on factors in the home, related to transport, and to quality of care in the formal health sector that contribute to delays in seeking care for children.
– By analyzing verbal and social autopsies, the study aimed to identify the delays and factors that contribute to child mortality in Rwanda.
Study Highlights:
– The study analyzed 77 verbal and social autopsies of children aged 1-5 years who died in rural Rwanda between March 2013 and February 2014.
– Most children (74%) had contact with the formal health sector before dying, but the majority (59%) died at home.
– Caregivers considered using traditional medicine (44%) and a significant number (33%) actually did.
– Delays in deciding to seek care and receiving quality care in the formal health sector were the main themes identified in the narratives.
– An additional delay phase was identified after leaving formal healthcare facilities, which was associated with caregiver dissatisfaction or inability to adhere to care plans.
Study Recommendations:
– Improve the quality of care in the formal health sector, especially in terms of provider capacity to communicate danger signs and treatment plans.
– Promote adherence to treatment plans after leaving healthcare facilities, taking into account alternative explanatory models informed by traditional medicine.
– Enhance healthcare-seeking behavior by addressing delays in deciding to seek care and improving access to healthcare facilities.
Key Role Players:
– Nurses and healthcare providers in health centers and district hospitals.
– Community health workers (CHWs) who provide integrated community case management of pediatric illnesses.
– Rwandan Ministry of Health (RMOH) for policy guidance and implementation.
– Partners in Health/Inshuti Mu Buzima (PIH/IMB) for supporting healthcare delivery and systems strengthening.
Cost Items for Planning Recommendations:
– Training programs for healthcare providers to improve communication skills and knowledge of danger signs and treatment plans.
– Development and implementation of strategies to promote adherence to treatment plans after leaving healthcare facilities.
– Support for community health workers in terms of training, supervision, and resources.
– Health system strengthening initiatives to improve the quality of care in the formal health sector.
– Public awareness campaigns to promote healthcare-seeking behavior and educate caregivers about the importance of seeking timely and appropriate care for children.
Please note that the provided information is based on the description and objectives of the study. For specific details and accurate cost estimates, it is recommended to refer to the original publication in BMJ Open, Volume 9, No. 5, Year 2019.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a mixed methods analysis of verbal and social autopsies, which provides a comprehensive understanding of healthcare-seeking patterns and delays in obtaining effective treatment for rural Rwandan children aged 1-5 years. The study collected both quantitative and qualitative data using a validated tool and conducted thematic content analysis. The findings highlight delays in deciding to seek care, receiving quality care in formal healthcare facilities, and adherence to treatment plans after leaving facilities. To improve the strength of the evidence, the study could have included a larger sample size and conducted a more detailed analysis of the factors contributing to delays. Additionally, the study could have considered the perspectives of healthcare providers and community health workers to gain a more comprehensive understanding of the barriers to timely and effective healthcare for children in rural Rwanda.

Objectives We sought to understand healthcare-seeking patterns and delays in obtaining effective treatment for rural Rwandan children aged 1-5 years by analysing verbal and social autopsies (VSA). Factors in the home, related to transport and to quality of care in the formal health sector (FHS) were thought to contribute to delays. Design We collected quantitative and qualitative cross-sectional data using the validated 2012 WHO VSA tool. Descriptive statistics were performed. We inductively and deductively coded narratives using the three delays model, conducted thematic content analysis and used convergent mixed methods to synthesise findings. Setting The study took place in the catchment areas of two rural district hospitals in Rwanda-Kirehe and Southern Kayonza. Participants were caregivers of children aged 1-5 years who died in our study area between March 2013 and February 2014. Results We analysed 77 VSAs. Although 74% of children (n=57) had contact with the FHS before dying, most (59%, n=45) died at home. Many caregivers (44%, n=34) considered using traditional medicine and 23 (33%) actually did. Qualitative themes reflected difficulty recognising the need for care, the importance of traditional medicine, especially for â € poisoning’ and poor perceived quality of care. We identified an additional delay-phase IV-which occurred after leaving formal healthcare facilities. These delays were associated with caregiver dissatisfaction or inability to adhere to care plans. Conclusion Delays in deciding to seek care (phase I) and receiving quality care in FHS (phase III) dominated these narratives; delays in reaching a facility (phase II) were rarely discussed. An unwillingness or inability toadhere to treatment plans after leaving facilities (phase IV) were an important additional delay. Improving quality of care, especially provider capacity to communicate danger signs/treatment plans and promote adherence in the presence of alternative explanatory models informed by traditional medicine, could help prevent childhood deaths.

During the study period, there were 23 health centres (HC) in Kirehe and Southern Kayonza serving a population of 538 405. HCs were staffed by nurses who provided inpatient and outpatient services.11 12 Community health workers (CHWs) provided integrated community case management of paediatric illnesses (c-IMCI).13 They diagnosed and treated pneumonia, diarrhoea and malaria, monitored malnutrition and made referrals. An estimated average of one CHW served 50 people under age 5; there were two c-IMCI-trained CHWs per village.13 14 Kirehe was served by one district hospital and Kayonza by two. The study was conducted in the catchment area of one hospital in Kirehe and another in Kayonza. Area households in the two districts were located a median 3.5 km from their closest HC.11 Community-based health insurance (CBHI, also referred to as ‘Mutuelle de Santé’ or ‘mutuelle’) was available in the study districts and achieved over 90% coverage in Rwanda overall (Makaka et al, 2012).15 The catchment area for this study was rural and the majority of families relied on subsistence agriculture. Paved roads connected the main towns, and unpaved roads extended to most communities. Homes were predominantly made of natural materials such as earth and thatch and few communities had access to electricity. According to the 2014 Rwandan Demographic and Health Survey, nearly 40% of the population lived below the poverty line, although nearly all women in Kirehe and Kayonza worked in agriculture. Educational attainment was low in both areas, with most women not having completed primary school.16 Data were collected through VSAs with caregivers of 259 U5s who died between March 2013 and February 2014. VSA is a process used to assign causes of death in cases where no standard autopsy was done and social autopsy augments the structured interview of a verbal autopsy with open-ended questions about the beliefs, decisions and perspectives of those who cared for the decedent.10 17–24 Quantitative and qualitative data were collected during one visit with a family. Deaths were identified through health records, Rwandan Ministry of Health (RMOH) reporting systems and the Monitoring of Vital Events Using Information Technology programme in which CHWs reported vital events by telephone. CHWs then helped locate families, and families who consented were interviewed between 3 weeks and 1 year after the death. The minimum waiting period of 3 weeks was selected considering the Rwandan custom of a formal 1-week mourning period and literature from other countries suggesting that several weeks is an appropriate delay.25 26 Importantly, families could decline participation and could choose a time for the interview if they consented. This paper is a subanalysis of VSA data of children between the ages of 1 year and 5 years. This age range was chosen because it includes children with shared developmental characteristics (eg, the ability to crawl/walk), clinical characteristics (eg, causes of pneumonia) and social experiences (eg, not being in primary school). Quantitative data were collected using the validated WHO 2012 verbal autopsy semi-structured interview tool (InterVA4)27 and supplemented by questions from the RMOH’s Death Audit Tool and the 2010 Rwanda Demographic and Health Survey. Trained interviewers used handheld electronic devices and conducted semi-structured interviews in the local language, Kinyarwanda. Informants were asked to describe events surrounding the death of the child. Segments during which interviewees expanded on symptoms, decision-making, care-seeking and perceptions of care received were transcribed and then back-transcribed from Kinyarwanda to English for quality and accuracy review. The research question was informed by the work of Partners in Health/Inshuti Mu Buzima (PIH/IMB), which has supported the RMOH to strengthen healthcare delivery and systems in Kirehe and Southern Kayonza districts since 2005. This VSA project was part of a larger initiative to better understand and reduce U5 mortality. Patients were not involved in the recruitment to and conduct of the study, nor were they involved in the design of the study. However, as a service delivery organisation, PIH/IMB has a deep experience with patients and their families/caregivers that helped shape the study. Aggregated early results were shared with the MOH and IMB in a timely manner to facilitate improved healthcare delivery. We used the three delays model28 as a framework to begin our thematic content analysis. This model was originally developed to understand maternal mortality.28 Phase I delays relate to deciding to seek care, phase II delays occur while trying to reach a facility and phase III delays occur after arrival at a facility in the form of poor quality of care. We use the Lancet Global Health Commission on High Quality Health Systems framework to understand high-quality care. Specifically, high-quality care includes competent care and systems, positive user experience as well as better health, confidence in the system and economic benefit.29 A mix of inductive and deductive coding was used to develop a codebook,30 which was discussed and revised by an interdisciplinary team of researchers, physicians and public health professionals. A subset of interviews (11) were double coded to ensure inter-rater reliability and then the codebook was applied to the dataset until saturation of codes was reached at 77 interviews. Iterative thematic analysis using coding, recoding, categorisation and reorganisation was used to further develop the themes and generate hypotheses. Dedoose was used for qualitative and mixed methods analysis (V.7.5.9, SocioCultural Research Consultants, Los Angeles, California, USA). The most likely cause of death (COD) was determined using InterVA4.27 COD and sociodemographic variables from verbal autopsies were analysed using descriptive statistics. Quantitative analytics were performed using STATA V.14 (StataCorp, College Station, Texas, USA). Associations between descriptive variables and qualitative themes were explored using a convergent mixed methods approach.31 This approach is recommended by experts to better understand complex phenomenon, such as care-seeking behaviour, because it helps uncover patterns that may not have been accessible through only quantitative data analysis or only qualitative data analysis.32 Excerpts were first organised by phase of delay and then divided by quantitative variables. These variables were chosen based on hypotheses which were generated during the qualitative analysis of the interviews. Hypotheses included 1) maternal education impacts care-seeking by giving caregivers more access to accurate health information, 2) children who died at home experienced more phase I delays, 3) less common causes of death are associated with more phase III delays. Thematic analysis of these subgroups of excerpts was conducted to identify divergent themes. Interviews were coded and analysed until saturation of codes was achieved, ie, saturation was achieved when no new codes or ideas were identified.33 Verbal consent was deemed permissible by two ethics review boards. A consent form was read to potential participants by Kinyarwanda-speaking data collectors who also answered questions. Participants were asked to verbally confirm that the consent was understood. Data collectors were trained in sensitivity, patience and consideration with families who had lost a child. Each interview was assigned a number that matched with caregiver identifying information and was stored in a separate file in a secure location. No individual identifiers were recorded on the data collection forms.

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

1. Strengthening Community Health Worker (CHW) Programs: Enhancing the training and capacity of CHWs to provide integrated community case management of maternal health issues, including prenatal care, postnatal care, and family planning. This would involve equipping CHWs with the necessary knowledge and resources to identify and address maternal health needs in their communities.

2. Mobile Health (mHealth) Solutions: Implementing mobile health technologies, such as text messaging and mobile applications, to provide pregnant women and new mothers with important health information, reminders for appointments, and access to teleconsultations with healthcare providers. This would help overcome geographical barriers and improve communication between healthcare providers and patients.

3. Improving Quality of Care in Health Facilities: Enhancing the quality of care provided in health facilities by training healthcare providers on effective communication, danger signs during pregnancy and childbirth, and respectful maternity care. This would help address the delays in receiving quality care in formal health sector facilities (phase III delays) identified in the study.

4. Addressing Socioeconomic Barriers: Implementing interventions to address socioeconomic barriers that prevent women from seeking and accessing maternal health services, such as providing financial support for transportation to health facilities, reducing out-of-pocket expenses for maternal health services, and promoting women’s empowerment through education and income-generating activities.

5. Integrating Traditional Medicine and Biomedical Approaches: Promoting collaboration and integration between traditional medicine practitioners and biomedical healthcare providers to ensure a holistic approach to maternal health. This would involve training healthcare providers on traditional medicine practices and beliefs, as well as educating traditional medicine practitioners on evidence-based maternal health practices.

These innovations aim to address the delays in deciding to seek care (phase I) and receiving quality care in formal health sector facilities (phase III) identified in the study, as well as other barriers to accessing maternal health services.
AI Innovations Description
Based on the information provided, here is a recommendation that can be used to develop an innovation to improve access to maternal health:

1. Improve quality of care in formal health sector (FHS): The study identified delays in receiving quality care in FHS as a major factor contributing to child mortality. To address this, it is recommended to focus on improving the quality of care provided in health facilities. This can be done by enhancing provider capacity to communicate danger signs and treatment plans, promoting adherence to care plans, and addressing caregiver dissatisfaction.

2. Enhance communication and education: Maternal education was found to impact care-seeking behavior. Therefore, it is important to invest in health education programs that provide accurate and accessible information to mothers and caregivers. This can help them recognize the need for care and make informed decisions regarding maternal health.

3. Strengthen community-based healthcare: Community health workers (CHWs) play a crucial role in providing healthcare services, especially in rural areas. It is recommended to strengthen the capacity of CHWs and expand their scope of practice to include maternal health services. This can be achieved through training programs, supportive supervision, and adequate resources.

4. Improve transportation infrastructure: Delays in reaching healthcare facilities were rarely discussed in the study. However, it is important to address transportation barriers that may hinder access to maternal health services. This can be done by improving road infrastructure, providing transportation subsidies or incentives, and exploring innovative solutions such as telemedicine or mobile health clinics.

By implementing these recommendations, it is possible to develop innovative solutions that improve access to maternal health and reduce child mortality rates in rural areas.
AI Innovations Methodology
Based on the information provided, here are some potential recommendations to improve access to maternal health:

1. Strengthening community-based healthcare: Enhance the role of community health workers (CHWs) in providing maternal health services, such as prenatal care, postnatal care, and family planning. This can be done by providing additional training and resources to CHWs, ensuring they have the necessary skills and knowledge to provide quality care.

2. Improving transportation infrastructure: Enhance the accessibility of healthcare facilities by improving transportation infrastructure, such as roads and transportation services. This can help pregnant women and new mothers reach healthcare facilities more easily, reducing delays in seeking care.

3. Promoting awareness and education: Increase awareness and education about maternal health, including the importance of prenatal care, safe delivery practices, and postnatal care. This can be done through community outreach programs, educational campaigns, and the use of local media.

4. Enhancing quality of care: Improve the quality of maternal healthcare services by ensuring healthcare providers have the necessary skills, knowledge, and resources to provide effective care. This can be achieved through training programs, regular supervision and monitoring, and the implementation of evidence-based practices.

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

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

2. Collect baseline data: Gather data on the current status of maternal health access and outcomes in the target population. This can include information on healthcare utilization, maternal health practices, and maternal health outcomes.

3. Implement the recommendations: Introduce the recommended interventions and initiatives to improve access to maternal health. This can involve training CHWs, improving transportation infrastructure, conducting awareness campaigns, and enhancing the quality of care.

4. Monitor and evaluate: Continuously monitor and evaluate the implementation of the recommendations. Collect data on the indicators identified in step 1 to assess the impact of the interventions on improving access to maternal health.

5. Analyze the data: Analyze the collected data to determine the effectiveness of the recommendations. Compare the baseline data with the post-intervention data to identify any changes or improvements in maternal health access and outcomes.

6. Adjust and refine: Based on the findings of the analysis, make any necessary adjustments or refinements to the interventions. This can involve scaling up successful initiatives, addressing any challenges or barriers identified, and continuously improving the interventions to maximize their impact.

By following these steps, it is possible to simulate the impact of the recommendations on improving access to maternal health and make evidence-based decisions for further interventions and improvements.

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