Treatment seeking, access to care and child health: Evidence from the Taabo health and demographic surveillance site (HDSS) in Côte d’Ivoire

Background: Despite substantial progress over the last two decades, under-five mortality remains high in many African settings. Current estimates suggest that Sustainable Development Goal 3.2 of reducing under-5 mortality (U5MR) to levels below 25 deaths per 1000 live births by 2030 will not be achieved in sub-Saharan Africa. In countries with high under-five mortality, further improvements in child mortality will only be possible if essential health services become available and accessible for those most in need. Access is a complex concept. Even if there is easy access to health facilities and an adequate supply of services, the extent to which specific populations access these services depends on the livelihood of the household, the community,
and the wider society. Half of all under-five deaths are neonatal deaths many of which could be prevented through improved antenatal care (ANC). Access to adequate health care in remote areas, including prenatal and post-natal health services, as well as delayed attendance of health
facilities have been identified as key determinants of the continued high burden of under-five mortality in these settings. Child mortality and its underlying factors vary substantially across and within countries. Thus, a local understanding of under-five mortality and its relation with
treatment seeking and access to care is important in the development of local sustainable intervention strategies aiming to reduce the continued high burden of under-five mortality.
Goal and specific objectives: The overall objective of this PhD project was to identify effective ways to improve health service access and child health in low and middle-income country settings in general, and in the Taabo health and demographic surveillance system (HDSS) in Côte d’Ivoire in particular. To address this general objective, we pursued three specific aims. First, we aimed to identify the most critical household and community characteristics
influencing treatment seeking for under-five children. Second, we assessed whether the construction of additional health facilities can improve treatment seeking and child health outcomes. Third, we assessed whether access to essential antenatal services as well as maternal and child health can be improved through community programmes.
Methods: The thesis pursued three complementary approaches to address key challenges in health care access and delivery. For the first aim, we used prospectively collected data from 736 non-fatal and 82 fatal cases reports of under-five children during the year 2017 from the Taabo HDSS. Caregivers of children with a recent non-fatal illness episode residing in the Taabo health district, south-central Côte d’Ivoire were interviewed using a social autopsy
questionnaire. For the second aim, we used detailed demographic surveillance data obtained from the Taabo HDSS. Since 2009, the Taabo HDSS has been continuously monitoring a population of over 40,000 inhabitants by reporting vital events such as pregnancies, births, deaths, and migration through surveillance rounds. We used panel data from the HDSS covering all children under age five born in the HDSS between 2010 and 2018. Between 2010 and 2018, four new health facilities were constructed within the Taabo HDSS area with the ambition to reduce distance and travel times to health facilities, and ultimately to improve health outcomes.
We conducted a quasi-experimental study assessing the impact of newly constructed facilities.
For the third aim, we conducted a three-arm cluster Randomized Control Trial (cRCT) to assess the effectiveness of two complementary strategies in increasing iron and folic acid supplementation and malaria chemoprophylaxis coverage among pregnant women. We randomly assigned 39 clusters to the control group, 39 clusters to the information group, and
40 clusters to the information plus home delivery of iron and folic acid (IFA) supplements group. Trial participants were pregnant women who were at least 15 years old and in their first or second trimester. The interventions consisted of an information package, designed to increase uptake of essential antenatal services through targeted information, and an information plus home delivery intervention, designed to provide both information and immediate access to
supplements and chemoprophylaxis. Through an end line survey within the first two weeks after delivery, we assessed the relative effectiveness of each intervention.
Results: In this primarily rural part of Côte d’Ivoire, treatment seeking was largely directed towards modern medicine. In non-fatal cases, modern treatment seeking was associated with child-specific factors (age, relationship with caregiver), caregiver education, and household
proximity to the nearest health facility as well as clinical signs such as fever, severe vomiting, inability to drink, convulsion, and inability to play. In fatal cases, modern healthcare was sought only for signs of lower respiratory disease. The lack of awareness regarding disease-related
clinical danger signs were identified as the potential barriers to accessing health care.
The results of our quasi-experimental study showed that local provision of new health facilities declined the average distance to the nearest health facility. However, this decline did not improve neonatal survival outcome or maternal health services utilization. Positive impacts
were found for post-neonatal infant mortality, which was reduced by 46%.
Our intervention trial suggest that community-based programs can improve compliance with IFA supplementation and malaria chemoprophylaxis during pregnancy. High compliance with Sulfadoxine-pyrimethamine (SP) treatment was sufficient to largely remove the risk of malaria infection. Increased compliance with standard IFA supplementation was insufficient to address the high prevalence of postpartum anemia in the study setting.
Conclusion: The findings presented here from a primarily rural part of Côte d’Ivoire suggest that a large
proportion of caregivers seek modern care for their under 5-year-old children, but that some mild and severe illness cases continue to remain untreated. Interventions promoting prompt healthcare seeking and the recognition of danger signs may help improve treatment seeking in rural settings of Côte d’Ivoire, and can potentially help further reduce under-five mortality. Our study suggests that local construction of new health centers in a mainly rural part of south-central Côte d’Ivoire may have only relatively limited impact on healthcare utilization and overall population health. More research will be needed to better understand the somewhat limited impacts seen in this study as well as to identify the health infrastructure needed more
generally for improving health outcomes in this setting. The results from our trial suggest that combining information with direct home delivery of supplements and hemoprophylaxis can increase compliance with IFA supplementation and malaria prevention and reduce the risk of malaria infection. However, more powerful interventions are likely needed to address the high burden of anemia in this population.