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

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Study Justification:
– The study aims to identify social and structural barriers to timely healthcare utilization among children under five in rural Mali.
– It analyzes how utilization varies based on symptom manifestation.
– The study highlights the need for improved consideration of barriers to care in order to address delays and low utilization of qualified healthcare providers.
Study Highlights:
– Almost half of recently ill children reported multiple symptoms.
– Over half of the children received some form of treatment, but less than one-quarter received care from a qualified provider within 24 hours of symptom onset.
– Factors such as distance to primary health facility, household wealth, and maternal education were consistently associated with better utilization outcomes.
– Children with potentially severe symptoms were more likely to receive any care, but not necessarily timely care from a qualified provider.
Study Recommendations:
– Improve accessibility to healthcare facilities, as even short distances significantly reduce children’s likelihood of utilizing healthcare.
– Address multiple barriers to care to ensure timely utilization of qualified providers.
– Enhance awareness and education among mothers and caregivers regarding the recognition of potentially severe illnesses.
– Consider socio-demographic factors, such as household wealth and maternal education, in healthcare planning and interventions.
Key Role Players:
– Community Health Workers (CHWs)
– Doctors, nurses, midwives
– Trained community health workers
– Pharmacists
– Drug sellers
– Traditional healers
Cost Items for Planning Recommendations:
– Infrastructure development for healthcare facilities
– Training and capacity building for healthcare providers
– Awareness and education campaigns for mothers and caregivers
– Transportation and logistics for healthcare access in remote areas
– Monitoring and evaluation of healthcare utilization and outcomes

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because it provides a clear description of the study objectives, methods, and results. However, it lacks specific details on the statistical analysis and the significance of the findings. To improve the evidence, the abstract could include more information on the statistical significance of the associations found in the mixed-effect logistic regressions, as well as the implications of the study findings for healthcare policy and practice 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, =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.

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

1. Mobile Health (mHealth) Solutions: Implementing mobile health technologies, such as SMS reminders and telemedicine consultations, can help overcome geographical barriers and improve access to qualified healthcare providers for maternal health.

2. Community Health Worker (CHW) Training and Support: Investing in comprehensive training and support for CHWs can enhance their capacity to provide timely and appropriate care to mothers and children in rural areas. This can include training on identifying maternal health issues, providing basic healthcare services, and referring cases to qualified providers.

3. Transportation Solutions: Developing transportation systems or initiatives specifically designed to address the challenges of accessing maternal health services in rural areas can significantly improve access. This can include providing transportation vouchers, establishing community-based transportation networks, or partnering with local transportation providers.

4. Telemedicine and Teleconsultation: Implementing telemedicine and teleconsultation services can connect mothers and healthcare providers remotely, allowing for timely and convenient access to medical advice, consultations, and follow-up care.

5. Maternal Health Education and Awareness Programs: Conducting targeted education and awareness programs for mothers and communities can help improve knowledge about maternal health, promote early recognition of symptoms, and encourage timely utilization of qualified healthcare providers.

6. Strengthening Health Infrastructure: Investing in the development and improvement of health facilities, particularly in rural areas, can enhance access to maternal health services. This can include building or renovating health centers, ensuring the availability of essential medical equipment and supplies, and recruiting and retaining qualified healthcare professionals.

7. Financial Support and Health Insurance: Providing financial support and implementing health insurance schemes specifically tailored to maternal health can alleviate the financial burden associated with accessing healthcare services. This can include subsidizing healthcare costs, providing cash transfers, or implementing community-based health insurance programs.

It is important to note that the specific context and needs of the target population should be considered when implementing these innovations to ensure their effectiveness and sustainability.
AI Innovations Description
The study mentioned aims to identify social and structural barriers to timely utilization of qualified healthcare providers among children under five years in rural Mali. The study found that multiple barriers to care contributed to delays and low utilization of qualified providers, highlighting the need for improved consideration of these barriers. Some key findings include:

1. Almost half of recently ill children reported multiple symptoms.
2. Over half of the children received some form of treatment, but less than one-quarter received care from a qualified provider within 24 hours of symptom onset.
3. Distance to primary health facilities, household wealth, and maternal education were consistently associated with better utilization outcomes.
4. Children with potentially more severe symptoms were more likely to receive any care, but not necessarily timely care from a qualified provider.
5. Even short distances of 2-5 km significantly reduced children’s likelihood of utilizing healthcare compared to those within 2 km of a facility.

Based on these findings, the study suggests that improving access to maternal health requires addressing multiple barriers, including distance to healthcare facilities, household wealth, and maternal education. It also emphasizes the importance of timely care from qualified providers for children with severe symptoms. Strategies to improve access could include:

1. Increasing the number and accessibility of primary health facilities in rural areas.
2. Implementing transportation solutions to overcome distance barriers, such as mobile clinics or transportation subsidies.
3. Providing financial support or health insurance coverage to reduce the financial burden of seeking care.
4. Enhancing community health worker programs to improve access to qualified providers.
5. Conducting community education and awareness campaigns to promote early recognition of symptoms and the importance of seeking timely care.

These recommendations can be used as a basis for developing innovative solutions to improve access to maternal health in rural Mali.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Strengthening healthcare infrastructure: Investing in the construction and maintenance of primary health facilities in rural areas can help improve access to maternal health services. This includes ensuring that these facilities are well-equipped with necessary medical supplies and staffed with qualified healthcare professionals.

2. Mobile health clinics: Implementing mobile health clinics that travel to remote areas can help bring maternal health services closer to communities that are far from healthcare facilities. These clinics can provide prenatal care, postnatal care, and other essential maternal health services.

3. Community health workers: Training and deploying community health workers (CHWs) can greatly improve access to maternal health services. CHWs can provide basic prenatal and postnatal care, educate women about maternal health, and facilitate referrals to healthcare facilities when necessary.

4. Telemedicine: Utilizing telemedicine technologies can help overcome geographical barriers and improve access to maternal health services. This involves using video conferencing and other communication tools to connect pregnant women in remote areas with healthcare professionals who can provide virtual consultations and guidance.

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

1. Define the baseline: Collect data on the current state of maternal health access in the target area, including information on healthcare facilities, healthcare utilization rates, distance to facilities, and socio-demographic factors.

2. Develop a simulation model: Create a mathematical or computational model that represents the target area’s healthcare system and population. This model should include variables such as population distribution, healthcare facility locations, transportation infrastructure, and healthcare utilization patterns.

3. Introduce the recommendations: Incorporate the recommended innovations into the simulation model. This could involve adding new healthcare facilities, adjusting the distribution of community health workers, or implementing telemedicine services.

4. Simulate scenarios: Run simulations using the model to assess the impact of the recommendations on access to maternal health services. This can involve varying parameters such as the number and location of healthcare facilities, the coverage of community health workers, or the utilization rates of telemedicine services.

5. Analyze results: Evaluate the simulation results to determine the potential impact of the recommendations on improving access to maternal health. This can include measuring changes in healthcare utilization rates, reduction in travel distances, and improvements in timely access to qualified providers.

6. Refine and iterate: Based on the simulation results, refine the recommendations and iterate the simulation to further optimize the impact on improving access to maternal health. This may involve adjusting the implementation strategies, resource allocation, or targeting specific populations.

By using this methodology, policymakers and healthcare stakeholders can gain insights into the potential effectiveness of different innovations and make informed decisions on how to improve access to maternal health in the target area.

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