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

Objectives: To identify social and structural barriers to timely utilisation of qualified providers among children under five years in a high-mortality setting, rural Mali and to analyse how utilisation varies by symptom manifestation. Methods: Using baseline household survey data from a cluster-randomised trial, we assessed symptom patterns and healthcare trajectories of 5117 children whose mothers reported fever, diarrhoea, bloody stools, cough and/or fast breathing in the preceding two weeks. We examine associations between socio-demographic factors, symptoms and utilisation outcomes in mixed-effect logistic regressions. Results: Almost half of recently ill children reported multiple symptoms (46.2%). Over half (55.9%) received any treatment, while less than one-quarter (21.7%) received care from a doctor, nurse, midwife, trained community health worker or pharmacist within 24 h of symptom onset. Distance to primary health facility, household wealth and maternal education were consistently associated with better utilisation outcomes. While children with potentially more severe symptoms such as fever and cough with fast breathing or diarrhoea with bloody stools were more likely to receive any care, they were no more likely than children with fever to receive timely care with a qualified provider. Conclusions: Even distances as short as 2–5 km significantly reduced children’s likelihood of utilising healthcare relative to those within 2 km of a facility. While children with symptoms indicative of pneumonia and malaria were more likely to receive any care, suggesting mothers and caregivers recognised potentially severe illness, multiple barriers to care contributed to delays and low utilisation of qualified providers, illustrating the need for improved consideration of barriers. The data for this study were derived from the baseline survey of the Trial of Proactive Community Case Management to Reduce Child Mortality ({“type”:”clinical-trial”,”attrs”:{“text”:”NCT02694055″,”term_id”:”NCT02694055″}}NCT02694055) [21]. The objective of the trial is to assess the extent to which door‐to‐door proactive case detection for common childhood illnesses (e.g. diarrhoea, malaria, pneumonia and acute malnutrition) by CHWs can reduce under‐five mortality over a three‐year period compared to a conventional approach to the delivery of integrated community case management. The trial is being conducted in Bankass, a rural district of the Mopti region in eastern Mali, about 600 km east of Bamako. The Mopti region has particularly poor reproductive, maternal and child health indicators, with an under‐five mortality rate above the national average [4]. The study area is comprised of seven health catchment areas, each served by one public‐sector primary health centre (PHC), with a centralised public‐sector secondary referral hospital. Pharmacists, drug sellers and traditional healers are common sources of care within communities. At the time of the survey, there were about 55 CHWs operating in the area. In this region, nuclear households are generally grouped together in family compounds based on familial ties. The head of the family compound is generally the eldest family member, male or female. Financial and social resources are often pooled at the compound level, and decisions related to children’s healthcare access and expenditures may be made at this higher level by the head of the family, or at the household level. At baseline, 99 576 individuals in 15 839 households were enrolled across 137 village clusters. Village clusters were defined as a geographical grouping of homes at least one kilometre from the nearest geographical grouping of homes and could comprise a single village or hamlet, or several villages and/or hamlets. The sample included 16 393 children under five years of age whose mother completed a survey module on child health. The analytic sample for the present study included children under age five who reported any illness in the two weeks preceding the survey and had complete information on socio‐demographic characteristics of interest, resulting in an analytic sample of 5117 children (62 children missing information on household wealth and 65 missing ethnicity were excluded). These children resided in 3795 unique households in 2433 unique family compounds. The ProCCM trial baseline survey was conducted from December 2016 to January 2017. The survey instrument was adapted from the Demographic and Health Survey questionnaire and included a household roster and modules on household characteristics, administered to the female head of household or another household member at least 18 years of age. Eligible women of reproductive age (15 to 49 years) completed modules on contraceptive use, maternal health, lifetime birth history and healthcare utilisation for all co‐resident biological children under five years of age. Respondents provided information about children under five who experienced diarrhoea, fever and/or cough in the preceding two weeks, including the presence of blood in stools and fast breathing. Healthcare utilisation and treatment were reported separately for each symptom. Respondents were asked where and when care or advice was sought in relation to the onset of symptoms, as well as treatment(s) administered. All respondents provided written informed consent. Among all children under five, we examined the prevalence of diarrhoea (with or without bloody stools), febrile illness and cough (with or without fast breathing) within the two weeks preceding the survey. Diarrhoea was defined as three or more loose stools within 24 h. We coded symptom manifestations into the following mutually exclusive categories: diarrhoea, diarrhoea with bloody stools, fever, cough, cough with fast breathing, fever and diarrhoea, fever and diarrhoea with bloody stools, fever and cough, fever and cough with fast breathing, and diarrhoea and cough with or without fever (including bloody stools and/or fast breathing). We examined four outcomes among children reporting an illness, representing utilisation behaviours that are increasingly likely to lead to optimal child health outcomes. Each outcome was coded as a binary variable according to the following definitions: We included a number of covariates that represent social and structural barriers to care in regression analyses. These included indicators for mother’s ethnicity (Dogon, Peulh, other minority), educational attainment (any formal schooling, none) and decision‐making power. Women were coded as having any decision‐making power if they self‐reported that they either solely or jointly made decisions in any of three domains: regarding household purchases, visiting relatives or their own healthcare, using measures from the Demographic and Health Surveys [4]. Shared decision‐making could be joint with any other person. Household size was based on the household roster, which included household members who resided at the location more than half of the time. Using an index of ownership of durable goods, livestock and physical housing characteristics, we estimated relative wealth quintiles within the full trial sample using principle components analysis to generate asset scores for each household, replicating the procedure used by the Demographic and Health Surveys [4, 22]. Household distance to the nearest PHC was determined using orthodromic (great circle) distance estimates between family compound and PHC GPS coordinates, categorised as follows: <2 km, 2 to <5 km, 5 to <7 km, <7 to 10 km and >=10 km. We rounded categories to the nearest integer to facilitate interpretation. Households were considered to have clean water and improved sanitation in accordance with WHO standards [23]; we included these factors because they are markers of a household’s ability and willingness to invest in health. Finally, we controlled for child’s age and sex. We first described the characteristics of children in the analytic sample, their symptoms and healthcare utilisation trajectories. We then conducted multilevel mixed‐effects regression analyses to assess the four utilisation outcomes for sick children. Regressions included random effects for family compound and village cluster; all other covariates were entered as fixed effects. Results were robust to alternate specifications of covariates. Analyses were performed using Stata version 16.1 (Stata Corporation, TX, USA). The larger trial study (NCT026940550) received ethical approval from the Ethics Committee of the Faculty of Medicine, Pharmacy and Dentistry, University of Bamako.