ObjectiveTo identify determinants of intended versus actual care-seeking behaviours in a pluralistic healthcare system that is reliant on both conventional and non-conventional providers and discover opportunities to catalyse improved healthcare access.DesignCross-sectional study.Setting and participantsIn Haiti 568 households (incorporating 2900 members) with children less than 5 years of age were randomly sampled geographically with stratifications for population density. These households identified the healthcare providers they frequented. Among 140 providers, 65 were located and enrolled.Outcome measuresHousehold questionnaires with standardised cases (intentions) were compared with self-recall of health events (behaviours). The connectedness of households and their providers was determined by network analysis.ResultsHouseholds reported 636 health events in the prior month. Households sought care for 35% (n=220) and treated with home remedies for 44% (n=277). The odds of seeking care increased 217% for severe events (adjusted OR (aOR)=3.17; 95% CI 1.99 to 5.05; p<0.001). The odds of seeking care from a conventional provider increased by 37% with increasing distance (aOR=1.37; 95% CI 1.06 to 1.79; p=0.016). Despite stating an intention to seek care from conventional providers, there was a lack of congruence in practice that favoured non-conventional providers (McNemar’s χ2 test p<0.001). Care was sought from primary providers for 68% (n=150) of cases within a three-tiered network; 25% (n=38/150) were non-conventional.ConclusionAddressing geographic barriers, possibly with technology solutions, should be prioritised to meet healthcare seeking intentions while developing approaches to connect non-conventional providers into healthcare networks when geographic barriers cannot be overcome.
SUMMARYIntroductionGains to ensure global healthcare access are at risk of stalling because some old resilient challenges require new solutions. Our objective was to study a pluralistic healthcare system that is reliant on both conventional and non-conventional providers to discover opportunities to catalyze renewed progress.MethodsA cross-sectional study was conducted among households with children less than 5 years of age in Haiti. Households were randomly sampled geographically with stratifications for population density. Household questionnaires with standardized cases (intentions) were compared to self-recall of health events (behaviors). The connectedness of households and their providers was determined by network analysis.ResultsA total of 568 households (incorporating 2900 members) and 65 providers were enrolled. Households reported 636 health events in the prior month. Households sought care for 35% (n=220) and treated with home remedies for 44% (n=277). The odds of seeking care increased 217% for severe events (aOR=3.17; 95%CI 1.99-5.05; p< 0.001). The odds of seeking care from a conventional provider increased by 37% with increasing distance (aOR=1.37; 95%CI 1.06-1.79; p=0.016). Despite stating an intention to seek care from conventional providers, there was a lack of congruence in practice that favored non-conventional providers (McNemar’s Chi-squared Test p<0.001). Care was sought from primary providers for 68% (n=150) of cases within a three-tiered network; 25% (n=38/150) were non-conventional.ConclusionAddressing geographic barriers, possibly with technology solutions, should be prioritized to meet healthcare seeking intentions while developing approaches to connect non-conventional providers into healthcare networks when geographic barriers cannot be overcome.
Objective: Despite the emergence of telemedicine as an important model for healthcare delivery, there is a lack of evidence-based telemedicine guidelines, especially for resource-limited settings. We sought to develop and evaluate a guideline for a pediatric telemedicine and medication delivery service (TMDS). Methods: A prospective cohort study was conducted at a TMDS in Haiti; children ≤10 years were enrolled. Among non-severe cases, paired virtual and in-person exams were conducted at the call center and household; severe cases were referred to the hospital. The primary outcome was the performance of the virtual exam compared to the in-person exam (reference standard). Findings: A total of 391 cases were enrolled. Among 320 cases with paired exams, no general World Health Organization (WHO) danger signs were identified at the household; problem-specific danger signs were identified in 6 cases (2%). Cohen's kappa for the designation of mild cases was 0.78 (95%CI 0.69-0.87). Among components of the virtual exam, the sensitivity and specificity of a reported fever were 91% (87%-96%) and 69% (62%-74%), respectively; the sensitivity and specificity of 'fast breathing' were 47% (21%-72%) and 89% (85%-94%), respectively. Kappa for dehydration assessments indicated moderate congruence (0.69; 95%CI 0.41-0.98). At 10 days, 95% (273) of the 287 cases reached were better/recovered. Conclusion: This study, and resulting guideline, represents a formative step towards an evidence-based pediatric telemedicine guideline built on WHO clinical principles. In-person exams for select cases were important to address limitations with virtual exams and identify cases for escalation.
ObjectiveDetermine the clinical safety and feasibility of implementing a telemedicine and medication delivery service (TMDS) to address gaps in nighttime healthcare access for children in low-resource settings.MethodsWe implemented a TMDS in Haiti called ‘MotoMeds’: (i) A parent/guardian of a child ≤10 years contacted the call center (6pm-5am). (ii) A provider used paper clinical decision support tools to triage the case as mild, moderate, or severe. Severe cases were referred to emergency care. For non-severe cases, call center providers gathered clinical findings to generate an assessment and plan. (iii) For households within the delivery zone, a provider and driver were dispatched with medications/fluids; the provider performed a paired in-person exam. For households outside the delivery zone, the family received phone consult alone. All families received a follow-up call at 10-days. Data were analyzed for clinical safety and feasibility.ResultsA total of 391 cases were enrolled from September 9th, 2019 to January 19th, 2021; 89% (347) received a household visit. Most cases were triaged as mild or moderate (92%; 361). Among the severe cases, 83% (20) sought subsequent referred care. The most common complaint was a respiratory problem (63%; 246). At 10-days, 95% (329) of parents reported their child’s condition as “improved” or “recovered”. Ninety-nine percent (344) rated the TMDS as “good” or “great”. The median phone consultation was 20 minutes, time to arrival at the household was 73 minutes and total workflow per case was 114 minutes.ConclusionThe TMDS was a feasible healthcare delivery model with high rates of improved clinical status at 10-days.Study registration (clinicaltrials.gov)NCT03943654
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