Access to care For children under‐five across high pneumonia mortality countries in sub‐Saharan Africa Camielle Noordam Promotor Prof. dr. G.J. Dinant Copromotor Dr. J.W.L. Cals Beoordelingscommissie Prof. dr. C.J.P.A. Hoebe (voorzitter) Dr. P. van den Hombergh Dr. J.S.M. Krumeich Prof. dr. J.F.M. Metsemakers Prof. dr. S.S. Peterson Contents Part I Introduction 5 Chapter 1 General introduction 7 Part II The three phases of delay in care 17 Chapter 2 Associations between caregivers’ kowledge and care seeking 19 behaviour for children with suspected pneumonia in six sub‐Saharan African countries Submitted Chapter 3 Care seeking behaviour for children with suspected pneumonia 33 in countries in sub‐Saharan Africa with high pneumonia mortality PLoS One 2015;10:e0117919 Chapter 4 The use of counting beads to improve the classification of fast 53 breathing in low resource settings: A multi‐country review Health Policy and Planning 2015;30:696–704 Part III A potential solution to decrease delays 71 Chapter 5 Improvement of maternal health services through the use of 73 mobile phones Tropical Medicine & International Health 2011;16:622–626 Chapter 6 Improving care‐seeking for facility‐based health services in a rural, 83 resource‐limited setting: Effects and potential of an mHealth project African Population Studies 2015;28:1643‐1662 Chapter 7 Assessing scale‐up of mHealth innovations based on intervention 103 complexity: Two case studies on child health programmes in Malawi and Zambia Journal of Health Communication 2015; 0: 1–11 Part IV Discussion 123 Chapter 8 General discussion 125 Summary 135 List of publications 139 PART I Introduction 5 6 CHAPTER 1 General introduction 7 Chapter 1 8 General introduction CHILD MORTALITY Over the past decades, child mortality has reduced significantly. Estimates from the United Nations illustrate that there has been a global decline in the under‐five mortality of 53 percent; from 91 deaths per 1,000 live births in 1990 to 43 in 2015.1‐2 Despite these changes, 5.9 million children died before their fifth birthday in 2015 (i.e., more than 16,000 deaths a day), mostly from preventable diseases.2 Infectious diseases, also known as transmissible or communicable diseases, accounted globally for more than half of the under‐five deaths, followed by deaths during or shortly after birth. Of the infectious diseases, pneumonia is the leading cause of the under‐five mortality attributing to 16% of all child deaths, followed by diarrhoea (9%) and malaria (5%). Nutritional status influences these outcomes; about 45 percent of the under‐five mortality is attributable to under‐nutrition.1‐5 Of the children under the age of five, the incidence of infectious diseases is the highest for those under the age of 2; more specifically 81% of the deaths due to pneumonia occur within the first two years of a child’s life.6 Figure 1.1 shows the differences in causes of under‐five mortality between high‐ and low‐income countries, illustrating that as income levels within countries decrease, the proportion of deaths due to infectious diseases increases. Malaria Diarrhoea 10% Other 10% 22% Infectious AIDS diseases 2% 51% Other Pneumonia neonatal 17% Pertussis, 27% tetanus, Sepsis measles, 5% meningitis b 7% Figure 1.1 Causes of under‐five mortality for high‐ and low income countries; a) high‐income countries, 1.4% of global under‐five mortality, and b) low‐income countries, 33% of global under‐five mortality. Data from Committing to Child Survival: A Promise Renewed. Progress Report 2013. © United Nations Children’s Fund (UNICEF) September 2013 9 Chapter 1 Of all children, a child living in sub‐Saharan Africa is most likely to die before the age of five, where on average 1 out of every 8 children dies before their fifth birthday.2 Huge differences are seen in the chance of survival within and between these countries, where Angola has the highest mortality rate (157 per 1,000 live births) and Seychelles the lowest (14 per 1,000).1‐2 Figure 1.2 shows the differences in mortality by country. Figure 1.2 The differences in under‐five mortality by country, with the highest rates found in sub‐Saharan Africa. Printed with permission from Committing to Child Survival: A Promise Renewed. Progress Report 2015. © United Nations Children’s Fund (UNICEF) September 2015 One of the reasons for child mortality to decline over the past decades is due to an increase in coverage of effective health interventions. These interventions focus not only on increasing access to care upon the onset of an illness (i.e., more effective and affordable treatments), but also on measures which prevent children from becoming ill in the first place (e.g., clean water, sanitation, education, improved nutrition and vaccinations).2‐4 While improved access to these interventions has saved a lot of lives, especially children living in isolated and marginalized settings still fail to reach them.7 Not only do these children fail to access preventive measures, but upon illness they also often fail to reach acceptable, affordable and appropriate health care, in time. 10 General introduction ACCESS TO CARE To know how to increase coverage of these interventions for children in sub‐Saharan Africa, especially amongst those who currently fail to reach them in time, is important. To do so, donors and policy makers need to understand the underlying determinants which prevent children from accessing these interventions in the first place. The model of ‘three delays’ has been used to help untangle challenges associated with care seeking. The model focuses on delays in accessing care, as the understanding is that the chance to survive is linked to the timelines in which care is received.8 In this thesis, the model will be applied to assess the challenges associated with delays in accessing care for children, more specifically those with symptoms of pneumonia (also referred to as ‘suspected pneumonia cases’). While the model was initially designed to categorize factors affecting the onset of obstetric complications and its outcomes, it is not the first time it is used to assess child health outcomes.9‐10 Analyses based on such modelling help create a more comprehensive understanding of why care is – or is not sought in time. This as it looks at challenges at household, as well as facility level. This is needed, as the children accessing care represent only a subset of all the children actually requiring health services. Hence delays which occur at home need to be examined too – even more so in sub‐Saharan African settings, where sick children often fail to reach the formal health system.10 How challenges in accessing care can be captured by three stages of delays Thaddeus and Maine designed the model of three phases of delay, which was first presented in 1994.8 The three phases are as followed; 1. The delay in deciding to seek care on the part of the individual, the family or both, which can be influenced – amongst others – by the status of women; distance from the health facility; costs; poor recognition and/or understanding of the illness (to assess the complications and/ or risks); previous experiences; and perceived quality of care. 2. The delay in reaching an adequate health care facility, which is mostly determined by geographical aspects, such as the distribution of facilities and the conditions of the road. 3. And, the delay in receiving adequate health care at the health facility, which can be influenced by poor quality and lack of resources as a result of inadequately trained and/ or motivated staff; out‐of‐stocks; inadequate referral systems; etc. As the chance to survive is linked to the timelines in which care is received, it is evident that in areas where mortality is high, coverage of effective interventions is insufficient. 11 Chapter 1 Therefore, the analyses of care seeking behaviour, based on the model of three delays, can help improve programming to ensure more effective coverage of life‐saving health interventions.11 To date, little is known on how these delays affect care seeking behaviour across high mortality countries in sub‐Saharan African countries, to which extent care seeking patterns are similar, and what lessons learned and potential best practices are which should be shared across resource limited settings. Leveraging mobile technology to reduce delays in accessing care To improve coverage of effective programs, it is not only important to understand what the existing challenges are, but also to identify ways in which these can be overcome. With mobile phone users increasing almost a three‐fold between 2005 and 2010 and reaching 367 million subscribers in mid‐2015 in sub‐Saharan Africa,12 there are high expectations that this technology can help connect isolated communities and healthcare services, thereby reducing delays in accessing care. The use of mobile phones to improve access to health is referred to as mHealth. Over the past decade, mHealth initiatives have focussed on addressing various aspects of the three phases of delay; for example by focussing on increasing knowledge, providing financial support, strengthening provider‐to‐provider communication systems, data collection methods, and ‐ amongst others – strengthening the supply chain management.13 Nevertheless, there is limited evidence on how mobile phones can most affectively address these delays, with only few evaluating the effectiveness of these initiatives in resource limited settings.14‐19 Finally, while the expectations are high, little is known on why these initiatives fail to go to scale in rural settings in sub‐Saharan Africa.20 Problem statement In summary, in sub‐Saharan African countries most children die of preventable and treatable illnesses because they fail to reach acceptable, affordable and appropriate health care in time.