The 4MOTHERS trial of the impact of a mobile money-based intervention on maternal and neonatal health outcomes in Madagascar: study protocol of a cluster-randomized hybrid effectiveness-implementation trial

Background
Mobile money—a service enabling users to receive, store, and send electronic money using mobile phones—has been widely adopted across low- and middle-income economies to pay for a variety of services, including healthcare. However, evidence on its effects on healthcare access and health outcomes are scarce and the possible implications of using mobile money for financing and payment of maternal healthcare services—which generally require large one-time out-of-pocket payments—have not yet been systematically assessed in low-resource settings. The aim of this study is to determine the impact on health outcomes, cost-effectiveness, feasibility, acceptability, and usefulness of mobile phone-based savings and payment service, the Mobile Maternal Health Wallet (MMHW), for skilled healthcare during pregnancy and delivery among women in Madagascar.

Methods
This is a hybrid effectiveness-implementation type-1 trial, determining the effectiveness of the intervention while evaluating the context of its implementation in Madagascar’s Analamanga region, containing the capital, Antananarivo. Using a stratified cluster randomized design, 61 public-sector primary-care health facilities were randomized within 6 strata to either receive the intervention or not (29 intervention vs. 32 control facilities). The strata were defined by a health facility’s antenatal care visit volume and its capacity to offer facility-based deliveries. The registered pre-specified primary outcomes are (i) delivery at a health facility, (ii) antenatal care visits, and (iii) total healthcare expenditure during pregnancy, delivery, and neonatal period. The registered pre-specified secondary outcomes include additional health outcomes, economic outcomes, and measurements of user experience and satisfaction. Our estimated enrolment number is 4600 women, who completed their pregnancy between July 1, 2020, and December 31, 2021. A series of nested mixed-methods studies will elucidate client and provider perceptions on feasibility, acceptability, and usefulness of the intervention to inform future implementation efforts.

Discussion
A cluster-randomized, hybrid effectiveness-implementation design allows for a robust approach to determine whether the MMHW is a feasible and beneficial intervention in a resource-restricted public healthcare environment. We expect the results of our study to guide future initiatives and health policy decisions related to maternal and neonatal health and universal healthcare coverage through technology in Madagascar and other countries in sub-Saharan Africa.

Trial registration
This trial was registered on March 12, 2021: Deutsches Register Klinischer Studien (German Clinical Trials Register), identifier: DRKS00014928. For World Health Organization Trial Registration Data Set see Additional file 1.

Patterns, travel to care and factors influencing obstetric referral: Evidence from Nigeria’s most urbanised state

The criticality of referral makes it imperative to study its patterns and factors influencing it at a health systems level. This study of referral in Lagos, Nigeria is based on health records of 4181 pregnant women who presented with obstetric emergencies at one of the 24 comprehensive emergency obstetric care (EmOC) facilities in the state between November 2018 and October 2019 complemented with distance and time data extracted from Google Maps. Univariate, bivariate, and multivariate analyses were conducted. About a quarter of pregnant women who presented with obstetric emergencies were referred. Most referrals were from primary health centres (41.9 %), private (23.5 %) and public (16.2 %) hospitals. Apart from the expected low-level to high-level referral pattern, there were other patterns observed including non-formal, multiple, and post-delivery referrals. Travel time and distance to facilities that could provide needed care increased two-fold on account of referrals compared to scenarios of going directly to the final facility, mostly travelling to these facilities by private cars/taxis (72.8 %). Prolonged/obstructed labour was the commonest obstetric indication for referral, with majority of referred pregnant women delivered via caesarean section (52.9 %). After adjustment, being married, not being registered for antenatal care at facility of care, presenting at night or with a foetus in distress increased the odds of referral. However, parity, presentation in the months following the commissioning of a new comprehensive EmOC facility or with abortion reduced the likelihood of being referred. Our findings underscore the need for health systems strengthening interventions that support women during referral and the importance of antenatal care and early booking to aid identification of potential pregnancy complications whilst establishing robust birth preparedness plans that can minimise the need for referral in the event of emergencies. Indeed, there are context-specific influences that need to be addressed if effective referral systems are to be designed.

Integration of mHealth Information and Communication Technologies Into the Clinical Settings of Hospitals in Sub-Saharan Africa: Qualitative Study

Background:
There is a rapid uptake of mobile-enabled technologies in lower- and upper-middle–income countries because of its portability, ability to reduce mobility, and facilitation of communication. However, there is limited empirical evidence on the usefulness of mobile health (mHealth) information and communication technologies (ICTs) to address constraints associated with the work activities of health care professionals at points of care in hospital settings.

Objective:
This study aims to explore opportunities for integrating mHealth ICTs into the work activities of health care professionals at points of care in clinical settings of hospitals in Sub-Saharan Africa. Thus, the research question is, “How can mHealth ICTs be integrated into the work activities of health care professionals at points of care in hospital settings?”

Methods:
A qualitative approach was adopted to understand the work activities and points at which mHealth ICTs could be integrated to support health care professionals. The techniques of inquiry were semistructured interviews and co-design activities. These techniques were used to ensure the participation of frontline end users and determine how mHealth ICTs could be integrated into the point of care in hospital settings. Purposive and snowball sampling techniques were used to select tertiary hospitals and participants for this study from South Africa and Nigeria. A total of 19 participants, including physicians, nurses, and hospital managers, were engaged in the study. Ethical clearance was granted by the University research committee and the respective hospitals. The data collected were sorted and interpreted using thematic analysis and Activity Analysis and Development model.

Results:
The findings show that mHealth ICTs are suitable at points where health care professionals consult with patients in the hospital clinics, remote communication is needed, and management of referrals and report writing are required. It was inferred that mHealth ICTs could be negatively disruptive, and some participants perceived the use of mobile devices while engaging with patients as unprofessional. These findings were informed by the outcomes of the interplay between human attributes and technology capabilities during the transformation of the motives of work activity into the intended goal, which is enhanced service delivery.

Conclusions:
The opportunities to integrate mHealth ICTs into clinical settings depend on the inefficiencies of interaction moments experienced by health care professionals at points of care during patient consultation, remote communication, referrals, and report writing. Thus, the timeliness of mHealth ICTs to address constraints experienced by health care professionals during work activities should take into consideration the type of work activity and the contextual factors that may result in contradictions in relation to technology features. This study contributes toward the design of mHealth ICTs by industry vendors and its usability evaluation for the work activity outcomes of health care professionals.

Understanding patient health-seeking behaviour to optimise the uptake of cataract surgery in rural Kenya, Zambia and Uganda: findings from a multisite qualitative study

Background
Cataract is a major cause of visual impairment globally, affecting 15.2 million people who are blind, and another 78.8 million who have moderate or severe visual impairment. This study was designed to explore factors that influence the uptake of surgery offered to patients with operable cataract in a free-of-charge, community-based eye health programme.

Methods
Focus group discussions and in-depth interviews were conducted with patients and healthcare providers in rural Zambia, Kenya and Uganda during 2018–2019. We identified participants using purposive sampling. Thematic analysis was conducted using a combination of an inductive and deductive team-based approach.

Results
Participants consisted of 131 healthcare providers and 294 patients. Two-thirds of patients had been operated on for cataract. Two major themes emerged: (1) surgery enablers, including a desire to regain control of their lives, the positive testimonies of others, family support, as well as free surgery, medication and food; and (2) barriers to surgery, including cultural and social factors, as well as the inadequacies of the healthcare delivery system.

Conclusions
Cultural, social and health system realities impact decisions made by patients about cataract surgery uptake. This study highlights the importance of demand segmentation and improving the quality of services, based on patients’ expectations and needs, as strategies for increasing cataract surgery uptake.

Unmet Surgical Need in Malawi

Introduction
Globally, and especially in sub-Saharan Africa, including Malawi, surgical conditions receive a low level of priority in national health systems. The burden of surgical diseases is not well documented and the reasons for which people still live with treatable conditions and disabilities or sometimes present late for care have also not been studied. There is also little information on surgical deaths from untreated conditions in both adults and children, including trauma, as well as potential barriers to obtaining surgical care.
Objectives
The aim of this thesis was therefore to describe the untreated surgical conditions, in both adults and children, the barriers to surgical health care, as well as to document information about deaths from surgical conditions in Malawi.
Methods
This thesis is based on four papers. All four involved data collected using the SOSAS tool, which is a questionnaire-based data collection tool for documenting household information in the communities. The tool had three sections, the first section capturing demographic data for the households; including number of occupants, ages, gender, location and type of household, and tribe. The next two sections were similar but involved interviewing two different people and asking about information relating to surgical conditions present for both adults and paediatric age groups, including injuries, associated disability from acquired or congenital disorders, transportation to health facility and location of death from different surgical conditions. The two household members interviewed, included the head of household and another random member within the household. Data collection was centrally organized by a project group, and performed by third year medical students from the University of Malawi, College of Medicine.
Data was collected as a national survey from the 28 districts in Malawi. The National Statistics Board helped us to identify the villages used in the study.
Results
We found that a third of the Malawian population were living with a surgical condition and were in need of a surgical consultation or treatment. These conditions were either congenital or the result of a traumatic or other non-traumatic condition. We also found that almost one fifth of the children with a surgical condition that could have been treated by surgery, instead remained with a disability that affected their daily lives.
In addition, we found that transportation poses a barrier to timely access to surgical health care. Transportation barriers included the lack of efficient public transportation, cost implications, and long travel distances to get to a health facility capable of offering care by either consultation or surgical procedures.
Other findings were that acute abdominal distention, body masses and trauma, contribute to surgical conditions that are highly associated with mortality in Malawian communities. We also noted that there are various reasons that lead to delays in obtaining formal health care, including initial consultations with traditional herbalists before going to the hospital.
Conclusion
Almost 6 million Malawian people, including an estimated 2 million children, are living with a condition that could be treated by either a surgical procedure or consultation. There are an estimated 1 million disabled children currently living with such surgically treatable conditions. The treatment of these conditions is hampered by transportation barriers. The transportation barriers have led to delays in obtaining timely surgical health care service, something that often leads to mortality. The common causes of these deaths are from injuries, but also other surgical emergencies. Most of these deaths occur outside a health facility environment.

Treating Children With Advanced Rheumatic Heart Disease in Sub-Saharan Africa: The NGO EMERGENCY’s Project at the Salam Centre for Cardiac Surgery in Sudan

Rheumatic heart disease is endemic in Sub-Saharan Africa and while efforts are under way to boost prophylaxis and early diagnosis, access to cardiac surgery is rarely affordable. In this article, we report on a humanitarian project by the NGO EMERGENCY, to build and run the Salam Centre for Cardiac Surgery in Sudan. This hospital is a center of excellence offering free-of-charge, high-quality treatment to patients needing open-heart surgery for advanced rheumatic and congenital heart disease. Since it opened in 2007, more than 8,000 patients have undergone surgery there; most of them Sudanese, but ~20% were admitted from other countries, an example of inter-African cooperation. The program is not limited to surgical procedures. It guarantees long-term follow-up and anticoagulant treatment, where necessary. By way of example, we report clinical features and outcome data for the pediatric cohort: 1,318 children under the age of 15, operated on for advanced rheumatic heart disease between 2007 and 2019. The overall 5-year survival rate was 85.0% (95% CI 82.7–87.3). The outcomes for patients with mitral valves repaired and with mitral valves replaced are not statistically different. Nevertheless, observing the trend of patients undergoing valve repair, a better outcome for this category might be assumed. RHD in children is an indicator of poor socio-economic conditions and an inadequate health system, which clearly will not be cured by cardiac surgery alone. Nevertheless, the results achieved by EMERGENCY, with the crucial involvement and participation of the Sudanese government over the years, show that building a hospital, introducing free cardiac surgery, and offering long-term post-operative care may help spread belief in positive change in the future.

Incidence patterns, care continuum and impact of treatment on survival among women with breast cancer in Ghana and the United States

Breast cancer is the most commonly diagnosed cancer among women worldwide. Of the five breast cancer subtypes, triple negative breast cancer (TNBC) is the most aggressive subtype. Black women in the US and Ghana are more likely to be diagnosed with TNBC, at young ages and advanced stages. Combining information from Ghana and the US, this project identified the breast cancer care continuum in Ghana, examined the breast cancer incidence patterns in Ghana and the US and assessed the optimal surgical treatment for TNBC. In the first manuscript, we examined how women in Ghana navigate the healthcare system and factors that influence their decisions and ability to seek and access breast cancer care. We interviewed thirty-one women diagnosed with breast cancer in Kumasi, Ghana. Based on the findings from the interviews, we presented a framework showing specific steps in the pathways and how women transition from one step to another. In the second manuscript, we assessed factors explaining the younger age at breast cancer diagnosis among Ghanaian women compared to women in the US. To achieve these aims we analyzed breast cancer data from the Kumasi Cancer Registry, the only population-based cancer registry in Ghana, and compared it to the US Surveillance, Epidemiology and End Results (SEER) data. Population age structure, screening and cohort effects explain the younger age at breast cancer diagnosis among women in Ghana In the third manuscript, we examined whether the poor prognosis of TNBC warrants a more aggressive surgical approach and whether there is value in expanded use of radiation therapy among women with TNBC who receive mastectomy. We found that breast conserving surgery followed by radiotherapy is an effective treatment for women with early-stage TNBC. Findings from this dissertation are timely due to the rapidly rising burden of breast cancer in sub-Saharan Africa and persistent disparities in the US.

Health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa: a systematic review

Background
Breast cancer patients in sub-Saharan Africa experience long time intervals between their first presentation to a health care facility and the start of cancer treatment. The role of the health system in the increasing treatment time intervals has not been widely investigated. This review aimed to identify existing information on health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa to contribute to the reorientation of health policies in the region.

Methods
PubMed, ScienceDirect, African Journals Online, Mendeley, ResearchGate and Google Scholar were searched to identify relevant studies published between 2010 and July 2020. We performed a qualitative synthesis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Related health system factors were extracted and classified according to the World Health Organization’s six health system building blocks. The quality of qualitative and quantitative studies was assessed by using the Critical Appraisal Skills Program Quality-Assessment Tool and the National Institute of Health Quality Assessment Tool, respectively. In addition, we used the Confidence in the Evidence from Reviews of Qualitative Research tool to assess the evidence for each qualitative finding.

Results
From 14,184 identified studies, this systematic review included 28 articles. We identified a total of 36 barriers and 8 facilitators that may influence diagnostic and treatment intervals in women with breast cancer. The principal health system factors identified were mainly related to human resources and service delivery, particularly difficulty accessing health care, diagnostic errors, poor management, and treatment cost.

Conclusion
The present review shows that diagnostic and treatment intervals among women with breast cancer in sub-Saharan Africa are influenced by many related health system factors. Policy makers in sub-Saharan Africa need to tackle the financial accessibility to breast cancer treatment by adequate universal health coverage policies and reinforce the clinical competencies for health workers to ensure timely diagnosis and appropriate care for women with breast cancer in this region.

The role of health service delivery networks in achieving universal health coverage in Africa

Most countries in Africa are faced with health system problems that vary from one to the next. Countries with a low Human Development Index (HDI) seem to be more prone to challenges in health service delivery. To mark its 70th anniversary on World Health Day, the World Health Organization (WHO) selected the theme “Universal Health Coverage (UHC): Everyone, Everywhere” and the slogan “Health for All. ”UHC refers to ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation, and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship. UHC is a WHO’s priority objective. Most governments have made it their major goal.

This paper provides a perspective on the challenges of achieving UHC in Sub-Saharan Africa (SSA). It also endeavors to spotlight the successful models of Health Service Delivery Networks (HSDNs) that make significant strides in making progress towards achieving UHC. HSDNs propose models that facilitate the attainment of affordability and accessibility while maintaining quality in delivering health services. Additionally, it brings up to speed the challenges associated with setting up HSDNs in health systems in SSA. It then makes propositions of what measures and strategic approaches should be implemented to strengthen HSDNs in SSA. This paper further argues that UHC is not only technically feasible but it is also attainable if countries embrace HSDNs in SSA.

Oxygen delivery systems for adults in Sub-Saharan Africa: A scoping review

Background
Respiratory diseases are the leading cause of death and disability worldwide. Oxygen is an essential medicine used to treat hypoxemia from respiratory diseases. However, the availability and utilization of oxygen delivery systems for adults in sub-Saharan Africa is not well-described. We aim to identify and describe existing data around oxygen availability and provision for adults in sub-Saharan Africa, determine knowledge or research gaps, and make recommendations for future research and capacity building.

Methods
We systematically searched four databases for articles on April 22, 2020, for variations of keywords related to oxygen with a focus on countries in sub-Saharan Africa. Inclusion criteria were studies that included adults and addressed hypoxemia assessment or outcome, oxygen delivery mechanisms, oxygen availability, oxygen provision infrastructure, and oxygen therapy and outcomes.

Results
35 studies representing 22 countries met inclusion criteria. Availability of oxygen delivery systems ranged from 42%-94% between facilities, with wide variability in the consistency of availability. There was also wide reported prevalence of hypoxemia, with most studies focusing on specific populations. In facilities where oxygen is available, health care workers are ill-equipped to identify adult patients with hypoxemia, provide oxygen to those who need it, and titrate or discontinue oxygen appropriately. Oxygen concentrators were shown to be the most cost-effective delivery system in areas where power is readily available.

Conclusions
There is a substantial need for building capacity for oxygen delivery throughout sub-Saharan Africa. Addressing this critical issue will require innovation and a multi-faceted approach of developing infrastructure, better equipping facilities, and health care worker training