Care-seeking patterns among families that experienced under-five child mortality in rural Rwanda

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Study Justification:
– Over half of under-five deaths occur in sub-Saharan Africa, making it crucial to understand the care-seeking patterns of families in this region.
– Appropriate, timely, and quality care is essential for saving children’s lives.
– This study aims to describe the context surrounding children’s deaths, including the care-seeking patterns leading up to the child’s death, in rural Rwanda.
– By identifying factors associated with care-seeking, this study can provide insights into barriers and facilitators of accessing healthcare for children in this region.
Study Highlights:
– Among the 516 eligible deaths among children under-five, 22.7% did not seek care from the health system.
– Community health workers were the most common first point of contact for those who sought care.
– Factors significantly associated with formal care-seeking included higher maternal education, presence of diarrhea or fever, full household insurance coverage, and longer duration of illness.
– Interventions such as community health workers and insurance promote access to care, but a gap remains as many children had no contact with the health system prior to death.
– Further efforts are needed to respond to urgent cases in communities and understand remaining barriers to accessing appropriate, quality care.
Recommendations for Lay Reader and Policy Maker:
– Strengthen community health worker programs to ensure they are accessible and well-equipped to provide timely care for children.
– Increase awareness and utilization of health insurance coverage among families to promote access to formal care.
– Improve education and awareness about common childhood illnesses, such as diarrhea and fever, to encourage early care-seeking.
– Invest in research and interventions to address remaining barriers to accessing appropriate, quality care for children in rural areas.
Key Role Players:
– Ministry of Health in Rwanda
– Partners In Health/Inshuti Mu Buzima (PIH/IMB)
– Community health workers
– Health centers and hospitals
– Research institutions and universities
Cost Items for Planning Recommendations:
– Training and capacity building for community health workers
– Health insurance coverage for families
– Education and awareness campaigns on childhood illnesses
– Research and evaluation of interventions
– Infrastructure and equipment for health facilities
– Monitoring and evaluation systems for tracking care-seeking patterns and outcomes

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a secondary analysis of a verbal and social autopsy study. The study collected data from primary caregivers who experienced the death of a child under-five in rural Rwanda. The study used bivariate and multivariate analyses to identify factors associated with care-seeking for these children. The sample size is relatively large (516 eligible deaths) and the statistical methods used are appropriate. However, to improve the evidence, the abstract could provide more information on the representativeness of the sample and the generalizability of the findings. Additionally, it would be helpful to include information on the limitations of the study and potential biases that may have influenced the results.

Background Over half of under-five deaths occur in sub-Saharan Africa and appropriate, timely, quality care is critical for saving children’s lives. This study describes the context surrounding children’s deaths from the time the illness was first noticed, through the care-seeking patterns leading up to the child’s death, and identifies factors associated with care-seeking for these children in rural Rwanda. Methods Secondary analysis of a verbal and social autopsy study of caregivers who reported the death of a child between March 2013 to February 2014 that occurred after discharge from the child’s birth facility in southern Kayonza and Kirehe districts in Rwanda. Bivariate analyses using Fisher’s exact tests were conducted to identify child, caregiver, and household factors associated with care-seeking from the formal health system (i.e., community health worker or health facility). Factors significant at α = 0.10 significance level were considered for backwards stepwise multivariate logistic regression, stopping when remaining factors were significantly associated with care-seeking at α = 0.05 significance level. Results Among the 516 eligible deaths among children under-five, 22.7% (n = 117) did not seek care from the health system. For those who did, the most common first point of contact was community health workers (45.8%). In multivariate logistic regression, higher maternal education (OR = 3.36, 95% CI: 1.89, 5.98), having diarrhea (OR = 4.21, 95%CI: 1.95, 9.07) or fever (OR = 2.03, 95%CI: 1.11, 3.72), full household insurance coverage (3.48, 95%CI: 1.79, 6.76), and longer duration of illness (OR = 22.19, 95%CI: 8.88, 55.48) were significantly associated with formal care-seeking. Conclusion Interventions such as community health workers and insurance promote access to care, however a gap remains as many children had no contact with the health system prior to death and those who sought formal care still died. Further efforts are needed to respond to urgent cases in communities and further understand remaining barriers to accessing appropriate, quality care.

This study is a secondary analysis of data that the authors collected for a verbal and social autopsy study, which interviewed primary caregivers that experienced the death of a child under-five years of age between March 2013 to February 2014 in the Kirehe District Hospital and Rwinkwavu District Hospital catchment areas, in Kirehe and southern Kayonza Districts, respectively. In these two catchment areas, there are three levels of healthcare delivered by the Ministry of Health (MOH) with support from Partners In Health/Inshuti Mu Buzima (PIH/IMB). At the community level, there are three community health workers for each village and two of them (called “binomes”) provide services for children under-five, including the diagnosis and treatment of pneumonia, malaria, and diarrhea through community IMCI. Health centers (15 in Kirehe District and 8 in southern Kayonza District) provide mainly outpatient primary healthcare. District hospitals provide secondary care, mostly to patients referred from health centers. The most complicated cases are referred to tertiary hospitals [25], which are primarily based in the capital city of Kigali. The terrain in rural Rwanda is hilly and the average walking distance from households to the nearest health facility in Kirehe is 92.4 minutes and 64.2 minutes in Kayonza [26]. The most common forms of transportation in these districts are walking and fee-per-use methods such as bicycles, minibuses, and motorcycle taxis. The STROBE checklist (S1 File) is available in the supplementary materials. The original data collection aimed to have a census of all under-five deaths during the study period. For the main verbal and social autopsy study, all under-five deaths during the study period were identified from community and health facility records by triangulating existing MOH reporting systems and the Monitoring of Vital Events using Information Technology (MoVe-IT) program. MoVe-IT was introduced in the two districts in 2012 to complement existing reporting systems, and consisted of text message reporting by community health workers of all vital events among mothers and under-five children [27]. Families that experienced an under-five death were located in the community with the help of community health workers. For this secondary analysis, all children under-five that died and were captured in the original data collection were included unless they met the exclusion criteria for our secondary analysis: neonatal deaths that occurred before discharge from the facility where they were born and children whose caregivers did not report on care-seeking were excluded. Those born outside of a facility were included if the caregivers reported on care-seeking. Data was collected through household interviews with caregivers of the deceased child. Caregivers were asked to report on demographic characteristics, and the symptoms and care-seeking patterns prior to the child’s death using a structured interview questionnaire adapted from the World Health Organization’s (WHO) verbal autopsy tool [28]. The WHO’s verbal autopsy tool contains a series of questions about specific symptoms the child experienced during the illness that resulted in the child’s death, such as presence of a fever or diarrhea, the duration of the illness prior to death, as well as contextual factors such as whether the child was involved in an accident, distance of the household to a health facility, and caregiver perception of illness severity. The questionnaire also included a subset of questions from the MOH’s Death Audit Tool (i.e, place of birth, places where care was sought, reasons for not seeking care, time spent in health facilities, perceived quality of care, status of mother and father, household religion, household occupation, and health insurance coverage) and the 2010 Rwanda Demographic and Health Survey (i.e., household assets and housing materials). Variables were grouped into predisposing factors, enabling factors, and perceived and evaluated need based on the Andersen framework for care-seeking (Fig 1).[6] No personal identifiers were stored on the data collection form; instead, caregivers’ identifiers were stored in a separate file in a secure location with matching study IDs for data cleaning and validation. Initial data were collected on paper with double entry for data quality control but the majority of data were collected using Android tablets. The primary outcome of interest in this study was formal care-seeking prior to the child’s death, which was defined as seeking care from the formal health system through community health workers or health facilities (health posts, health centers, hospitals, or private clinics). Taking a child to traditional healers or seeking self-treatment from a pharmacy or from neighbors were all categorized as not seeking formal care. We describe child, caregiver and household variables and test for their associations with care-seeking using a Fisher’s exact test. All variables associated with care-seeking at α = 0.10 significance level in the bivariate analyses were entered into a full logistic regression model. We used backwards stepwise regression to identify predictors and risk factors associated with seeking care upon noticing the child’s illness among children under-five, stopping when all remaining variables were significant at the α = 0.05 significance level. All analyses were completed in Stata version 13 (StataCorp 2011. College Station, TX). This study was approved by Rwanda National Ethics Committee (RNEC) and the Partners Institutional Review Board in Boston, Massachusetts under the Population Health Implementation and Training (PHIT) program, a partnership between PIH/IMB, the University of Rwanda and the Rwanda MOH. All caregivers who participated provided written informed consent. Given the sensitive nature of the questionnaire, all data collectors were trained to be considerate of and sensitive to the caregiver’s needs such as giving time to respond, ensuring caregivers understood that all answers were voluntary, providing comfort in any instance where a caregiver may have become upset, and postponing or ending the interview if preferred by the caregivers.

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

1. Mobile Health (mHealth) Solutions: Implementing mobile health technologies, such as text message reminders for prenatal care appointments, educational messages about maternal health, and access to telemedicine consultations, can help improve access to maternal health services in rural areas.

2. Community Health Worker Training and Support: Strengthening the training and support for community health workers can enhance their capacity to provide maternal health services, including prenatal care, postnatal care, and health education, in remote areas where formal health facilities are not easily accessible.

3. Transportation Support: Providing transportation support, such as subsidized transportation vouchers or community-based transportation services, can help overcome the geographical barriers faced by pregnant women in accessing maternal health services.

4. Telemedicine and Teleconsultation: Implementing telemedicine and teleconsultation services can enable pregnant women in remote areas to receive medical advice and consultations from healthcare professionals without the need for physical travel to health facilities.

5. Maternal Health Insurance: Expanding and promoting maternal health insurance coverage can help reduce financial barriers to accessing maternal health services, ensuring that pregnant women can afford the necessary care.

6. Community-Based Maternal Health Clinics: Establishing community-based maternal health clinics staffed by skilled healthcare providers can bring essential maternal health services closer to rural communities, reducing the need for long-distance travel.

7. Maternal Health Education and Awareness Programs: Implementing targeted maternal health education and awareness programs can help increase knowledge and understanding of the importance of prenatal care, safe delivery practices, and postnatal care, encouraging more women to seek appropriate care.

8. Partnerships and Collaborations: Strengthening partnerships and collaborations between government agencies, non-governmental organizations, and community-based organizations can help leverage resources and expertise to improve access to maternal health services in rural areas.

It is important to note that the specific recommendations for improving access to maternal health should be tailored to the local context and take into account the unique challenges and needs of the target population.
AI Innovations Description
Based on the description provided, the recommendation to improve access to maternal health in rural Rwanda is to focus on the following interventions:

1. Strengthening community health worker programs: Community health workers (CHWs) were found to be the most common first point of contact for seeking care. Therefore, investing in the training, support, and supervision of CHWs can help improve access to maternal health services. This can include providing them with the necessary skills and resources to diagnose and treat common maternal health issues, such as prenatal care, postnatal care, and family planning.

2. Increasing maternal education: The study found that higher maternal education was significantly associated with formal care-seeking. Therefore, efforts should be made to improve access to education for women in rural areas. This can include providing scholarships, promoting girls’ education, and implementing adult education programs.

3. Enhancing health insurance coverage: Full household insurance coverage was found to be significantly associated with formal care-seeking. Expanding health insurance coverage and ensuring its affordability for rural communities can help remove financial barriers to accessing maternal health services.

4. Addressing remaining barriers: Despite the availability of community health workers and insurance, a significant number of children had no contact with the health system prior to death. Further efforts are needed to identify and address the remaining barriers to accessing appropriate and quality care. This can include improving transportation infrastructure, increasing awareness about the importance of seeking care, and addressing cultural beliefs and practices that may hinder care-seeking.

By implementing these recommendations, it is expected that access to maternal health services in rural Rwanda can be improved, leading to better health outcomes for mothers and their children.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations for improving access to maternal health:

1. Strengthen community health worker programs: Community health workers play a crucial role in providing healthcare services at the community level. By expanding and strengthening these programs, more women can receive timely and appropriate care during pregnancy, childbirth, and postpartum.

2. Improve transportation infrastructure: The hilly terrain and long walking distances to health facilities pose a significant barrier to accessing maternal health services. Investing in transportation infrastructure, such as roads and transportation subsidies, can help reduce travel time and improve access to healthcare facilities.

3. Increase health insurance coverage: Full household insurance coverage was found to be significantly associated with formal care-seeking. Expanding health insurance coverage, particularly for vulnerable populations, can help reduce financial barriers to accessing maternal health services.

4. Enhance health education and awareness: Higher maternal education was found to be significantly associated with formal care-seeking. Implementing health education programs that target women and their families can increase awareness about the importance of seeking timely and appropriate care during pregnancy and childbirth.

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 measure access to maternal health, such as the percentage of pregnant women receiving antenatal care, the percentage of births attended by skilled health personnel, or the percentage of women receiving postnatal care.

2. Collect baseline data: Gather data on the current status of these indicators in the target population or region. This can be done through surveys, interviews, or existing health records.

3. Introduce the recommendations: Implement the recommended interventions, such as strengthening community health worker programs, improving transportation infrastructure, increasing health insurance coverage, and enhancing health education and awareness.

4. Monitor and evaluate: Continuously monitor the implementation of the interventions and collect data on the selected indicators. This can be done through regular surveys, health facility records, or other data collection methods.

5. Analyze the data: Compare the baseline data with the data collected after the implementation of the interventions. Analyze the changes in the selected indicators to assess the impact of the recommendations on improving access to maternal health.

6. Draw conclusions and make recommendations: Based on the analysis of the data, draw conclusions about the effectiveness of the interventions in improving access to maternal health. Identify any gaps or areas for further improvement and make recommendations for future interventions or policy changes.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different interventions on improving access to maternal health and make informed decisions to address the existing barriers.

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