Facilitators and barriers to the implementation of a Mobile Health Wallet for pregnancy-related health care: A qualitative study of stakeholders’ perceptions in Madagascar

Financial barriers are a major obstacle to accessing maternal health care services in low-resource settings. In Madagascar, less than half of live births are attended by skilled health staff. Although mobile money-based savings and payment systems are often used to pay for a variety of services, including health care, data on the implications of a dedicated mobile money wallet restricted to health-related spending during pregnancy–a mobile health wallet (MHW)–are not well understood. In cooperation with the Madagascan Ministry of Health, this study aims to elicit the perceptions, experiences, and recommendations of key stakeholders in relation to a MHW amid a pilot study in 31 state-funded health care facilities. We conducted a two-stage qualitative study using semi-structured in-depth interviews with stakeholders (N = 21) representing the following groups: community representatives, health care providers, health officials and representatives from phone provider companies. Interviews were conducted in Atsimondrano and Renivohitra districts, between November and December of 2017. Data was coded thematically using inductive and deductive approaches, and found to align with a social ecological model. Key facilitators for successful implementation of the MHW, include (i) close collaboration with existing communal structures and (ii) creation of an incentive scheme to reward pregnant women to save. Key barriers to the application of the MHW in the study zone include (i) disruption of informal benefits for health care providers related to the current cash-based payment system, (ii) low mobile phone ownership, (iii) illiteracy among the target population, and (iv) failure of the MHW to overcome essential access barriers towards institutional health care services such as fear of unpredictable expenses. The MHW was perceived as a potential solution to reduce disparities in access to maternal health care. To ensure success of the MHW, direct demand-side and provider-side financial incentives merit consideration

A Mobile Health Wallet for Pregnancy-Related Health Care in Madagascar: Mixed-Methods Study on Opportunities and Challenges

Background: Mobile savings and payment systems have been widely adopted to store money and pay for a variety of services, including health care. However, the possible implications of these technologies on financing and payment for maternal health care services-which commonly require large 1-time out-of-pocket payments-have not yet been systematically assessed in low-resource settings. Objective: The aim of this study was to determine the structural, contextual, and experiential characteristics of a mobile phone-based savings and payment platform, the Mobile Health Wallet (MHW), for skilled health care during pregnancy among women in Madagascar. Methods: We used a 2-stage cluster random sampling scheme to select a representative sample of women utilizing either routine antenatal (ANC) or routine postnatal care (PNC) in public sector health facilities in 2 of 8 urban and peri-urban districts of Antananarivo, Madagascar (Atsimondrano and Renivohitra districts). In a quantitative structured survey among 412 randomly selected women attending ANC or PNC, we identified saving habits, mobile phone use, media consumptions, and perception of an MHW with both savings and payment functions. To confirm and explain the quantitative results, we used qualitative data from 6 semistructured focus group discussions (24 participants in total) in the same population. Results: 59.3% (243/410, 95% CI 54.5-64.1) saved toward the expected costs of delivery and, out of those, 64.4% (159/247, 95% CI 58.6-70.2) used household cash savings for this purpose. A total of 80.3% (331/412, 95% CI 76.5-84.1) had access to a personal or family phone and 35.7% (147/412, 95% CI 31.1-40.3) previously used Mobile Money services. Access to skilled health care during pregnancy was primarily limited because of financial obstacles such as saving difficulties or unpredictability of costs. Another key barrier was the lack of information about health benefits or availability of services. The general concept of an MHW for saving toward and payment of pregnancy-related care, including the restriction of payments, was perceived as beneficial and practicable by the majority of participants. In the discussions, several themes pointed to opportunities for ensuring the success of an MHW through design features: (1) intuitive technical ease of use, (2) clear communication and information about benefits and restrictions, and (3) availability of personal customer support. Conclusions: Financial obstacles are a major cause of limited access to skilled maternal health care in Madagascar. An MHW for skilled health care during pregnancy was perceived as a useful and desirable tool to reduce financial barriers among women in urban Madagascar. The design of this tool and the communication strategy will likely be the key to success. Particularly important dimensions of design include technical user friendliness and accessible and personal customer service

A Semiquantitative Non-invasive Measurement of PcomA Patency in C57BL/6 Mice Explains Variance in Ischemic Brain Damage in Filament MCAo

Numerous studies on experimental ischemic stroke use the filament middle cerebral artery occlusion (fMCAo) model in C57BL/6 mice, but lesion sizes in this strain are highly variable. A known contributor is variation in the posterior communicating artery (PcomA) patency. We therefore aimed to provide a semiquantitative non-invasivein vivomethod to routinely assess PcomA patency. We included 43 male C57BL/6 mice from four independent studies using a transient 45 min fMCAo model. Edema-corrected lesion sizes were measured by magnetic resonance (MR) imaging 24 h after reperfusion. Time-of-flight MR angiography was performed 7 days before and 24 h after fMCAo. Scores of PcomA size measured 24 h after, but not scores measured 7 days before fMCAo were negatively correlated with lesion size. Variability in PcomA patency explained 30% of the variance in our cohort (p< 0.0001, coefficient of determinationr(2)= 0.3). In a simulation using parameters typical for experimental stroke research, the power to detect a true effect ofd= 1 between two groups increased by 15% when an according covariate was included in the statistical model. We have demonstrated thatin vivomeasurement of PcomA size is feasible and can lead to increased accuracy in assessing the effect of treatments

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

Neuroprotective role of the PPARδ agonist SAR145 in a murine ischemic stroke model

Ein besseres Verständnis der Pathophysiologie des Schlaganfalls hat die Modulation der postischämischen Inflammation als Ansatzpunkt für eine neuroprotektive Therapie nach zerebralen ischämischen Ereignissen in den Fokus gerückt. Berichte über die antiinflammatorischen Eigenschaften der peroxisome proliferator‑activated receptor (PPAR)‑Familie mit den Subtypen α, γ und δ gaben Anlass zur Hoffnung, dass Agonisten dieser Rezeptoren neuroprotektive Eigenschaften besitzen. Agonisten des im Gehirn prädominanten Rezeptorsubtyps PPARδ waren jedoch lange Zeit nicht verfügbar. Erst in den letzten Jahren wurde die neuroprotektive Wirksamkeit einer intrathekalen Vorbehandlung mit PPARδ‑Agonisten untersucht. In in-vivo- und in-vitro-Modellen des ischämischen Schlaganfalls wurde in der vorliegenden Arbeit nun erstmals der neuartige PPARδ‑Agonist SAR145 untersucht, der auch bei oraler Gabe eine hohe zerebrale Bioverfügbarkeit zeigt. Im transienten proximalen middle cerebral artery occlusion (MCAo)‑Modell des ischämischen Schlaganfalls wurden dazu an C57Bl/6 Mäusen in Übereinstimmung mit den Empfehlungen des Stroke Therapy Academic Industry Roundtable (STAIR) im ersten Schritt die wirksamste Dosis und das effektive Zeitfenster für die Behandlung mit SAR145 bestimmt. Um eine nicht PPARδ‑spezifische neuroprotektive Wirkung von SAR145 auszuschließen, wurde die effektivste Dosis/Behandlungszeitpunktkombination zudem an PPARδ‑Knock‑out (KO)‑Tieren getestet. Im letzten Schritt wurde mit einer Verhaltenstestbatterie der Einfluss von SAR145 auf das funktionelle Defizit nach MCAo über einen Zeitraum von 28 Tagen analysiert. Zusätzlich wurde der Effekt von SAR145 auf die Aktivierung von Mikroglia und Endothelzellen durch inflammatorische Stimuli in vitro untersucht. In drei unabhängigen Gruppen führte die Behandlung mit 10 mg SAR145 pro Kilogramm (kg) Körpergewicht (KG) zum Zeitpunkt der Reperfusion im Mittel zu einer Reduktion der Infarktgröße um im Vergleich zu den Vehikelgruppen. Dieser Effekt war jedoch in keiner der Subgruppen statistisch signifikant. PPARδ‑Knock‑out‑Tiere zeigten im Vergleich zu Wildtyp‑Tieren eine signifikant höhere Mortalität nach MCAo. Tiere der Knock‑out‑Verumgruppe zeigten im Vergleich zu Tieren der Knock‑out‑Vehikelgruppe im Mittel keine kleineren Infarkte. In der Analyse des funktionellen Endergebnisses zeigte sich keine signifikante Neuroprotektion durch eine Behandlung mit SAR145. In vitro kam es bei Behandlung mit SAR145 zu einer signifikanten Reduktion der Aktivierung von Mikroglia und Endothelzellen durch einen inflammatorischen Stimulus. Insgesamt zeichnete sich das Bild einer allenfalls moderaten neuroprotektiven Wirkung von SAR145, die jedoch mit den verwendeten Methoden in vivo nicht zu belegen war. Die vorliegende Arbeit steht damit im Widerspruch zu bisherigen Publikationen, die eine deutliche Neuroprotektion durch eine Behandlung mit PPARδ‑Agonisten berichteten. Neben Unterschieden im experimentellen Design und den verwendeten Substanzen könnten auch Unterschiede in der Studienqualität, das sogenannte Proteus‑Phänomen und publication bias zu einer scheinbaren Vergrößerung der bisher berichteten Effektgrößen beigetragen haben. Aufgrund der geringen Anzahl bisher veröffentlichter Studien zu PPARδ-Agonisten in Modellen des ischämischen Schlaganfalls lässt sich dies jedoch mit den bislang zur Verfügung stehenden statistischen Methoden nicht eindeutig belegen.Better understanding of the pathophysiology of ischemic stroke led to the insight that neuronal injury after stroke progresses for days to weeks after onset of symptoms. One of the key players in this process is an ischemia induced inflammatory reaction in the affected area. Reports about the important role of the nuclear Peroxisome Proliferator Activated Receptor (PPAR)-family in regulating inflammatory signaling fostered hope to use PPAR agonists as a neuroprotective therapy even in a wider time window. The PPAR- family consists of the subtypes α, γ and δ, with subtype δ being the most abundant one in the brain. PPARδ agonists however have only become available rather recently. As yet there is little knowledge about the neuroprotective potency of pharmacological PPARδ activation after an ischemic event. We tested the novel orally administered PPARδ agonist SAR145 in the in vivo transient proximal middle cerebral artery occlusion (MCAo) filament model of ischemic stroke and the effect of SAR145 treatment on microglial and endothelial activation in vitro. In accordance with the stroke academic industry roundtable (STAIR) recommendations we first established the most effective dose and time point after reperfusion in C57Bl/6 mice using histological papanicolaou staining to determine infarct sizes. To rule out non-specific neuroprotective effects we then used PPARδ knockout mice to test the neuroprotective potency of SAR145 in the absence of PPARδ. The effect of SAR145 on the functional longer-term outcome was further evaluated using a battery of behavioural tests up to four weeks after MCAo. Three independent groups treated with 10 mg/kg bodyweight SAR145 directly after reperfusion showed a consistent mean reduction in infarct size of 18 ±10 % compared to vehicle treated groups. However, in rigorous statistical testing these effects were not significant. PPARδ knockout mice showed a significantly higher mortality after MCAo and there was no reduction in infarct size observed in the verum treated knockout group. The assessment of functional longer-term outcome yielded no significant neuroprotection by SAR145 treatment. In vitro activation of microglia and endothelial cells by an inflammatory stimulus was significantly reduced by treatment with SAR145. In this study we could not confirm prior reports of strong neuroprotection yielded by treatment with PPARδ agonists. This could be due to differences in the experimental design or the used substances but may also be explained by differences in study quality, the “proteus phenomenon” or publication bias. However, as to date only very few studies on PPARδ agonists in models of cerebral ischemia are available, the influence of these factors could not yet be statistically proven

A cross-sectional analysis of the effectiveness of a nutritional support programme for people with tuberculosis in Southern Madagascar using secondary data from a non-governmental organisation

Abstract Background There is a strong, bi-directional link between tuberculosis (TB) and undernutrition: TB often causes undernutrition, and undernourished people are more likely to contract TB and experience worse outcomes. Globally, several TB nutritional support programmes exist; however, evidence on their effectiveness is limited and contested. This study evaluates the effect of a nutritional support programme implemented for people with TB in the Atsimo-Andrefana region, Madagascar in 2022. Within this programme, undernourished people with TB [with a body mass index (BMI) of < 18.5 kg/m2] receive 0.6 L of vegetable oil and 6.0 kg of a soy-wheat blend per month throughout their TB treatment. Methods We analysed secondary non-governmental organisation data collected between January and November 2022 in the Atsimo-Andrefana region, Southern Madagascar, including information on an individual’s medical conditions (e.g., type of TB, treatment outcomes) and nutritional status measured prior to, during, and after completion of treatment (e.g., height, weight, mid-upper arm circumference). We conducted descriptive analyses of patient baseline characteristics and outcomes to assess the impact of the provided nutritional support on the BMI of people with TB. Results A total of 1310 people with TB were included in the study [9.9% (130) children under the age of 5, 32.1% (420) children between 5 and 18 years, 58.0% (760) adults]. 55.4% of children under 5, 28.1% of children between ages 5 and 18, and 81.3% of adults were undernourished at treatment initiation. 42.3% (55/130) of children under 5 experienced severe acute malnutrition at treatment uptake. While the average BMI of adults with TB receiving food support increased over time, from 17.1 kg/m2 (interquartile range: 15.8–18.3, range: 10.3–22.5) to 17.9 kg/m2 (interquartile range: 16.6–19.1, range: 11.9–24.1), most adults remained undernourished even after completing TB treatment. Conclusions The current TB nutritional support programme falls short of sufficiently increasing the BMI of people with TB to overcome malnutrition. There is an urgent need to revise the nutritional support available for people with TB, particularly for children under 5. Graphical Abstrac

Final-year medical students’ perspective: a survey on the use of computed tomography in sepsis

Abstract Objectives To determine the perspective of final-year medical students on the use of computed tomography (CT) in patients with sepsis. Methods A total of 207 questionnaires were distributed to final-year medical students at a large university medical center, and 113 returned questionnaires met the criteria for inclusion in the analysis. Questions referred to sepsis guidelines, CT indications, and the use of contrast agents. Control variables included a level of practical experience as a final-year student (trimester of student’s practical year) and previous radiological experience. Statistical hypothesis tests such as the Mann-Whitney U test and chi-square test were performed. Results The majority of participating students, 85% (n = 91/107), considered a Systemic Organ Failure Assessment (SOFA) score ≥ 2 as a diagnostic criterion for sepsis. The presence of ≥ 2 positive systemic inflammatory response syndrome (SIRS) criteria was considered relevant for diagnosing sepsis by 34% (n = 34/100). Ninety-nine percent (n = 64/65) of the participants who fully agreed with a SOFA score ≥ 2 being relevant for diagnosing sepsis would also use it as an indication for a CT scan. Seventy-six percent (n = 78/103) of the students rated a known severe allergic reaction to contrast agents as an absolute contraindication for its administration. Ninety-five percent (n = 78/82) considered radiation exposure as problematic in CT examinations, especially in repeat CTs. Conclusion Most final-year medical students were familiar with the sepsis criteria. Still, some referred to outdated diagnostic criteria. Participants saw the ability to plan further patient management based on CT as a major benefit. Most participants were aware of radiation as a risk of CT. Critical relevance statement More detailed knowledge of CT in septic patients should be implemented in the medical curriculum. Retraining of medical students could help increase student confidence potentially improving patient care. Key points 1. Whereas the majority of final-year medical students were familiar with sepsis criteria, some referred to outdated diagnostic criteria. 2. Participants saw the ability to plan further patient management based on CT as a major benefit. 3. Most participants were aware of radiation as a risk of CT. Graphical Abstrac