RESUMEN
BACKGROUND: With increasing interest in strengthening community health programs nationally comes a need for operationalizing them in a realistic and achievable way. Limited information is available to help program managers establish appropriate parameters for their context. We examined aspects of program implementation related to deployment patterns of community health workers, called agents communautaires or ACs, in 2 districts of Madagascar. METHODS: By analyzing program data and publicly available datasets in a geographic information system (GIS), we estimated the population and surface area coverage expected of ACs in 445 fokontany (communities). Additional modeling on travel time demands examined 1-way pedestrian travel time for ACs to receive routine support from their assigned health facilities and from socially marketed supply points under dry season conditions, as well as the impact on travel time based on ACs being reassigned to other facilities or supply points. RESULTS: With the current distribution, ACs in 90% of fokontany have a catchment population of 1,000 or fewer people (2020 estimates) and ACs in 84% of fokontany have a catchment area of 25 km2 or less. We estimated that ACs in 58% of fokontany were located more than 2 hours from their supporting health facility, and the proportion of fokontany with ACs more than 2 hours away from their assigned supply point was 61%. Reassigning ACs to the closest facility or supply point led to modest improvements in those figures (7 and 4 percentage points, respectively). CONCLUSION: Findings allow visualizing the practical implications of coverage ratios for ACs to assess whether current demands are realistic. The physical access between ACs and the health system warrants significant attention due to challenges in transport and logistics. Analyses are timely to inform the Ministry of Public Health's strategic thinking in the context of the development of the National Strategic Plan on Strengthening Community Health.
Asunto(s)
Agentes Comunitarios de Salud/organización & administración , Sistemas de Información Geográfica , Accesibilidad a los Servicios de Salud/organización & administración , Transportes/estadística & datos numéricos , Humanos , Madagascar , Estaciones del Año , Medicina Estatal/organización & administración , Factores de TiempoRESUMEN
BACKGROUND: The World Health Organization recently provided guidelines for outpatient treatment of possible severe bacterial infections (PSBI) in young infants, when referral to hospital is not feasible. This study evaluated newborn infection treatment at the most peripheral level of the health system in rural Ethiopia. METHODS: We performed a cluster-randomized trial in 22 geographical clusters (11 allocated to intervention, 11 to control). In both arms, volunteers and government-employed Health Extension Workers (HEWs) conducted home visits to pregnant and newly delivered mothers; assessed newborns; and counseled caregivers on prevention of newborn illness, danger signs, and care seeking. Volunteers referred sick newborns to health posts for further assessment; HEWs referred newborns with PSBI signs to health centers. In the intervention arm only, between July 2011 and June 2013, HEWs treated newborns with PSBI with intramuscular gentamicin and oral amoxicillin for 7 days at health posts when referral to health centers was not possible or acceptable to caregivers. Intervention communities were informed of treatment availability at health posts to encourage care seeking. Masking was not feasible. The primary outcome was all-cause mortality of newborns 2-27 days after birth, measured by household survey data. Baseline data were collected between June 2008 and May 2009; endline data, between February 2013 and June 2013. We sought to detect a 33% mortality reduction. Analysis was by intention to treat. (ClinicalTrials.gov registry: NCT00743691). RESULTS: Of 1,011 sick newborns presenting at intervention health posts, 576 (57%) were identified by HEWs as having at least 1 PSBI sign; 90% refused referral and were treated at the health post, with at least 79% completing the antibiotic regimen. Estimated treatment coverage at health posts was in the region of 50%. Post-day 1 neonatal mortality declined more in the intervention arm (17.9 deaths per 1,000 live births at baseline vs. 9.4 per 1,000 at endline) than the comparison arm (14.4 per 1,000 vs. 11.2 per 1,000, respectively). After adjusting for baseline mortality and region, the estimated post-day 1 mortality risk ratio was 0.83, but the result was not statistically significant (95% confidence interval, 0.55 to 1.24; P=.33). INTERPRETATION: When referral to higher levels of care is not possible, HEWs can deliver outpatient antibiotic treatment of newborns with PSBI, but estimated treatment coverage in a rural Ethiopian setting was only around 50%. While our data suggest a mortality reduction consistent with that which might be expected at this level of coverage, they do not provide conclusive results.
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Antibacterianos/uso terapéutico , Infecciones Bacterianas/tratamiento farmacológico , Mortalidad Infantil/tendencias , Derivación y Consulta/estadística & datos numéricos , Servicios de Salud Rural , Atención Ambulatoria , Infecciones Bacterianas/mortalidad , Análisis por Conglomerados , Agentes Comunitarios de Salud , Etiopía/epidemiología , Humanos , Lactante , Recién Nacido , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
Kangaroo mother care (KMC) is an evidence-based approach to reducing mortality and morbidity in preterm infants. Although KMC is a key intervention package in newborn health initiatives, there is limited systematic information available on the barriers to KMC practice that mothers and other stakeholders face while practicing KMC. This systematic review sought to identify the most frequently reported barriers to KMC practice for mothers, fathers, and health practitioners, as well as the most frequently reported enablers to practice for mothers. We searched nine electronic databases and relevant reference lists for publications reporting barriers or enablers to KMC practice. We identified 1,264 unique publications, of which 103 were included based on pre-specified criteria. Publications were scanned for all barriers / enablers. Each publication was also categorized based on its approach to identification of barriers / enablers, and more weight was assigned to publications which had systematically sought to understand factors influencing KMC practice. Four of the top five ranked barriers to KMC practice for mothers were resource-related: "Issues with the facility environment / resources," "negative impressions of staff attitudes or interactions with staff," "lack of help with KMC practice or other obligations," and "low awareness of KMC / infant health." Considering only publications from low- and middle-income countries, "pain / fatigue" was ranked higher than when considering all publications. Top enablers to practice were included "mother-infant attachment" and "support from family, friends, and other mentors." Our findings suggest that mother can understand and enjoy KMC, and it has benefits for mothers, infants, and families. However, continuous KMC may be physically and emotionally difficult, and often requires support from family members, health practitioners, or other mothers. These findings can serve as a starting point for researchers and program implementers looking to improve KMC programs.
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Método Madre-Canguro , Padre , Femenino , Humanos , Lactante , Mortalidad Infantil , Recién Nacido de Bajo Peso , Recien Nacido Prematuro , Madres , Estimulación Física/métodos , Aumento de Peso/fisiologíaRESUMEN
BACKGROUND: Despite a substantial decrease in child mortality in Ethiopia over the past decade, neonatal mortality remains unchanged (37/1000 live-births). This paper describes a qualitative study on beliefs and practices on immediate newborn and postnatal care in four rural communities of Ethiopia conducted to inform development of a package of community-based interventions targeting newborns. METHODS: The study team conducted eight key informant interviews (KII) with grandmothers, 27 in-depth interviews (IDI) with mothers; seven IDI with traditional birth attendants (TBA) and 15IDI with fathers, from four purposively selected communities located in Sidama Zone of Southern Nationalities, Nations, and Peoples (SNNP) Region and in East Shewa and West Arsi Zones of Oromia Region. RESULTS: In the study communities deliveries occurred at home. After cutting the umbilical cord, the baby is put to the side of the mother, not uncommonly with no cloth covering. This is largely due to attendants focusing on delivery of the placenta which is reinforced by the belief that the placenta is the 'house' or 'blanket' of the baby and that any "harm" caused to the placenta will transfer to the newborn. Applying butter or ointment to the cord "to speed drying" is common practice. Initiation of breastfeeding is often delayed and women commonly report discarding colostrum before initiating breastfeeding. Sub-optimal breastfeeding practices continue, due to perceived inadequate maternal nutrition and breast milk often leading to the provision of herbal drinks. Poor thermal care is also demonstrated through lack of continued skin-to-skin contact, exposure of newborns to smoke, frequent bathing-often with cold water baths for low-birth weight or small babies; and, poor hygienic practices are reported, particularly hand washing prior to contact with the newborn. CONCLUSION: Cultural beliefs and newborn care practices do not conform to recommended standards. Local perspectives related to newborn care practices should inform behaviour change messages. Such messages should target mothers, grandmothers, TBAs, other female family members and fathers.
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Cultura , Parto Obstétrico , Conocimientos, Actitudes y Práctica en Salud , Parto Domiciliario , Atención Perinatal , Muerte Perinatal/prevención & control , Población Rural , Adolescente , Adulto , Comprensión , Etiopía/epidemiología , Padre , Femenino , Humanos , Lactante , Cuidado del Lactante , Mortalidad Infantil , Recién Nacido , Masculino , Desnutrición/complicaciones , Partería , Madres , Muerte Perinatal/etiología , Embarazo , Investigación Cualitativa , Adulto JovenRESUMEN
This paper describes the integrated approach taken by the Government of Ethiopia with support from the Essential Services for Health in Ethiopia (ESHE) Project and assesses its effect on the coverage of six child health practices associated with reducing child mortality. The ESHE Project was designed to contribute to reducing high child mortality rates at scale among 14.5 million people through the 'three pillars' approach. This approach aimed to (i) strengthen health systems, (ii) improve health workers' performance, and (iii) engage the community. The intervention was designed with national and subnational stakeholders' input. To measure the Project's effect on the coverage of child health practices, we used a quasi-experimental design, with representative household survey data from the three most populous regions of Ethiopia, collected at the 2003-2004 baseline and 2008 endline surveys of the Project. Adifference-in-differences analysis model detected an absolute effect of the ESHE intervention of 8.4% points for DTP3 coverage (p=0.007), 12.9% points for measles vaccination coverage (p<0.001), 12.6% points for latrines (p=0.002), and 9.8% points for vitamin A supplementation (p<0.001) across the ESHE-intervention districts (woredas) compared to all non-ESHE districts of the same three regions. Improvements in the use of modern family planning methods and exclusive breastfeeding were not significant. Important regional variations are discussed. ESHE was one of several partners of the Ministry of Health whose combined efforts led to accelerated progress in the coverage of child health practices.