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

Pauvreté, genre et stratégies de survie des ménages en Côte d'Ivoire

Does the increasing of women-headed households mean the feminization of poverty ? The present research aims at verifying this hypothesis in the specific context of Côte d'Ivoire. In this respect, it joins a utilitarian approach of poverty and has appeal to the equivalence scales - to seize the differences of size and composition of the households. The analyses put in evidence the fragility of the correlation between gender and poverty in Côte d'Ivoire. Poverty affects indifferently the households steered by men as well as those depending economically on a woman, in spite of the social discrimination that undergo, generally, these last ones in terms of incomes and jobs. In fact, the study reveals that beyond the sex of the household's head, lack of active persons on the labour market turns out to be a determining factor of the households' poverty in Côte d'Ivoire. In this context, the work of the secondary women constitutes one of the major articulations of the strategies of survival, in particular in the men-headed households. The analyses are based on the exploitation of the data taken from the Côte d'Ivoire living standard surveys, conducted in 1995 and covering the whole territory. (Full text in French)

Le boom de l'anacarde en Côte d'Ivoire : transition écologique et sociale des systèmes à base de coton et de cacao

Le dynamisme agricole de la Côte d'Ivoire continue de surprendre les marchés de matières premières, en particulier ceux du cacao et du caoutchouc. Le pays s'empare aussi de la place de premier producteur mondial d'anacarde. Comment interpréter ce boom ? Il est en partie lié aux marchés (stagnation des prix du coton et du cacao, hausse du prix de l'anacarde sur deux périodes), mais les déterminants sont beaucoup plus complexes. L'hypothèse de l'étude est que l'adoption de l'anacardier relève en partie d'une transition écologique d'adaptation à l'épuisement de la rente forêt et au changement climatique, au coût croissant des intrants chimiques pour le coton et le cacao, mais répond aussi à l'insécurité foncière. Cette hypothèse a été testée en 2016–2017 sur 6 sites d'étude, choisis selon un gradient nord-sud : Mankono, Konanhiri, Bonon, Yamoussoukro, Bayota-Gagnoa et Soubré, à raison de 40 à 100 exploitations par site, avec des actualisations partielles en 2018. Ces enquêtes confirment l'hypothèse. L'anacardier, arbre robuste, résistant aux sécheresses, évite pour l'instant aux planteurs tout recours aux intrants chimiques et au crédit, reconstitue un ombrage forestier et est aussi un marqueur de terre (il apporte une sécurité foncière informelle dans le village d'origine des planteurs migrants, mais aussi dans leur village cacaoyer). Il devient l'outil d'une transition écologique et sociale. Cette transition inclut des flux significatifs d'information, de travail et d'investissement entre les deux espaces économiques. Elle relève essentiellement d'une innovation paysanne. En zone cacaoyère, l'anacardier, dans sa dimension agroforestière sous forme d'association avec le cacaoyer, réduit la mortalité des jeunes plants de cacao, et son adoption prend tout son sens de transition agroécologique. L'agriculture familiale est-elle en train de réaliser seule ce que l'industrie du chocolat promet sur le papier : une cacaoculture " zéro-déforestation " et durable

Heckman-type selection models to obtain unbiased estimates with missing measures outcome: theoretical considerations and an application to missing birth weight data

In low-income settings, key outcomes such as biomarkers or clinical assessments are often missing for a substantial proportion of the study population. The aim of this study was to assess the extent to which Heckman-type selection models can create unbiased estimates in such settings.; We introduce the basic Heckman model in a first stage, and then use simulation models to compare the performance of the model to alternative approaches used in the literature for missing outcome data, including complete case analysis (CCA), multiple imputations by chained equations (MICE) and pattern imputation with delta adjustment (PIDA). Last, we use a large population-representative data set on antenatal supplementation (AS) and birth outcomes from Côte d'Ivoire to illustrate the empirical relevance of this method.; All models performed well when data were missing at random. When missingness in the outcome data was related to unobserved determinants of the outcome, large and systematic biases were found for CCA and MICE, while Heckman-style selection models yielded unbiased estimates. Using Heckman-type selection models to correct for missingness in our empirical application, we found supplementation effect sizes that were very close to those reported in the most recent systematic review of clinical AS trials.; Missingness in health outcome can lead to substantial bias. Heckman-selection models can correct for this selection bias and yield unbiased estimates, even when the proportion of missing data is substantial

L’appendagite aiguë : une étiologie rare à ne pas méconnaître dans les douleurs abdominales: Acute appendagitis: a rare etiology not to be overlooked in abdominal pain

Acute appendagitis is a rare cause of abdominal pain. Its diagnosis is based on medical imaging and its treatment is medical. We report a case of acute appendagitis diagnosed on the abdominal CT scan in the context of epigastralgia. L’appendagite aiguë est une cause rare de douleurs abdominales. Son diagnostic repose sur l’imagerie médicale et son traitement est médical. Nous rapportons un cas d’appendagite aiguë diagnostiquée au scanner abdominal au décours d’une mise au point d’épigastralgies

Comparative study of chemical variability of essential oils from the leaves of Lippia multiflora Mold (Verbenaceae) collected in five regions of Côte d'Ivoire

Chemical variability of a plant from various continents or collected in different localities justifies its different biological activities. Thus, the present study was undertaken to evaluate the statistical study of chemical variability of essential oils from leaves of Lippia multiflora Mold from five localities in the center of Côte d'Ivoire. Essential oils have been extracted by hydrodistillation with yields varying from 0.34 to 1.20% depending on localities. Analysis of their chemical compositions showed the predominance of eucalyptol / germacrene D (13.91 / 11.02%), α-citral / β-citral / α-phellandrene (21.87 / 16.74 / 12.79%), linalool / (±)-trans-nerolidol / α-citral (19.99 / 18.68 / 12.10%), α-citral / β-citral (17.20 / 11.59%) and α-citral / β-citral (16.38 / 11.57%) in the oils from Yamoussoukro, Tiébissou, Bouaflé, Toumodi and Dimbokro, respectively. Principal Component Analysis and Hierarchical Ascending Classification revealed that these essential oils can be classified in three groups or chemotypes dominated by Eucalyptol, Citral / Linalool and trans-Geraniol

Epidemiology of malaria in the Taabo health and demographic surveillance system, south-central Côte d'Ivoire

A deep understanding of the local epidemiology of malaria is essential for the design and implementation of setting-specific control and elimination efforts. In Côte d'Ivoire, new initiatives are underway to reduce the burden of malaria, which requires high-quality longitudinal data. The epidemiology of malaria was studied in the Taabo health and demographic surveillance system (HDSS) in south-central Côte d'Ivoire and implications for control are discussed.; Two cross-sectional surveys were carried out in the rainy season of June/July in 2010 and 2011. Inhabitants of approximately 7 % of randomly selected households in the Taabo HDSS were invited to participate. People were clinically examined, ear temperature was measured and spleen size determined. Finger-prick blood samples were collected and subjected to a rapid diagnostic test (RDT). Additionally, thick and thin blood films were prepared on microscope slides and diagnosed under a microscope for Plasmodium infection and parasitaemia. Haemoglobin (Hb) level was determined using a HemoCue device.; A total of 1187 and 1264 people in 2010 and 2011, respectively, had complete data records. The prevalence of Plasmodium infection was 46.0 % in 2010 and 56.6 % in 2011, owing to a statistically significant difference (p < 0.05). Males showed a higher Plasmodium infection prevalence than females (49.6 and 62.8 % versus 42.6 and 51.2 %; respectively, in 2010 and 2011; both p < 0.05). The highest malaria prevalence was observed among infants and young children (aged ≤9 years). The risk of Plasmodium infection was significantly higher in villages compared to small hamlets and urban settings (p < 0.05). Fever, Hb level and splenomegaly were associated with parasitaemia.; Malaria is highly endemic in the Taabo HDSS in south-central Côte d'Ivoire with considerable spatial heterogeneity of Plasmodium infection. There is a pressing need to scale-up control interventions against malaria

Etat Phytosanitaire Dans Les Plantations Industrielles De Bananiers Dans La Lutte Contre La Cercosporiose Noire En Côte d’Ivoire

La cercosporiose noire causée par le champignon Mycosphaerella fijiensis détruit le feuillage du bananier. Cette maladie apparaît sous forme de petits tirets noirs allongés sur les feuilles qui évoluent très rapidement en nécroses généralisées qui peuvent aboutir à la destruction totale des feuilles du bananier avant la récolte du régime. Elle entraîne ainsi une diminution des rendements et une maturation précoce des fruits. Les stratégies de lutte raisonnée pour le contrôle de la maladie qui s’appuient sur les méthodes d’avertissement, reposent sur le suivi de la maladie en bananeraie et sur l’observation de descripteurs climatiques (pluies, humidité, etc.). Cette étude portant sur l’environnement de production et sur l’organisation des équipes phytosanitaires, a été menée de 2008 à 2012 dans douze plantations industrielles de bananiers de Côte d’Ivoire. L’évaluation de l’état phytosanitaire a porté sur les caractéristiques environnementales (contrôle de l’enherbement, gestion de l’humidité et bordures des parcelles) et sur l’organisation des équipes phytosanitaires. Les résultats ont montré que les plantations Eglin à Agboville, à Azaguié et à Motobé ; WANITA Dabou ont présenté un état sanitaire acceptable, avec une nette progression des paramètres environnementaux observés. Quant aux plantations TIABAM, Rouchard Tagbadié, CDBCI Azaguié et SAKJ Aboisso, elles présentent des inquiétudes dans le redressement de l’état sanitaire de leurs parcelles. Dès 2010, toutesles plantations avaient la présence des équipes phytosanitaires qui numérisaient les observations de la maladie et faisaient le suivi régulier de l’évolution de la maladie. L’ensemble des plantations a montré une évolution positive dans la prise en compte des paramètres essentiels pour une gestion efficiente de la cercosporiose noire. Black Sigatoka caused by the fungus Mycosphaerella fijiensis, destroys the foliage of banana. This disease appears as small elongated black dashes on the leaves which develop very rapidly into widespread necrosis which can lead to total destruction of banana leaves before the harvest of the bunch. It thus leads to reduced yields and early fruit ripening. Rational disease control strategies based on warning methods are based on monitoring the disease in banana plantations and on the observation of climatic descriptors (rainfall, humidity, etc.). This study on the production environment and the organization of phytosanitary teams was carried out from 2008 to 2012 in twelve industrial banana plantations in Ivory Coast. The evaluation of the phytosanitary status focused on the environmental characteristics (grassing control, moisture management and plot borders) and on the organization of the phytosanitary teams. The results showed that the Eglin plantations in Agboville, Azaguié and Motobé; WANITA Dabou presented an acceptable sanitary state, with a clear progression of the observed environmental parameters. As for the TIABAM, Rouchard Tagbadié, CDBCI Azaguié and SAKJ Aboisso plantations, they showed concern in the recovery of the sanitary state of their plots. As of 2010, all plantations had the presence of phytosanitary teams who digitized the observations of the disease and regularly monitored the evolution of the disease. All the plantations showed a positive evolution in taking into account the essential parameters for an efficient management of black Sigatoka

Determinants of Modern Paediatric Healthcare Seeking in Rural Côte d'Ivoire

Objectives:; To determine factors that influence healthcare seeking among children with fatal and non-fatal health problems.; Methods:; Last disease episodes of surviving children and fatal outcomes of children under 5 years of age were investigated by means of an adapted social autopsy questionnaire administered to main caregivers. Descriptive analysis and logistic models were employed to identify key determinants of modern healthcare use.; Results:; Overall, 736 non-fatal and 82 fatal cases were assessed. Modern healthcare was sought for 63.9% of non-fatal and 76.8% of fatal cases, respectively. In non-fatal cases, young age, caregiver being a parent, secondary or higher education, living <5 km from a health facility, and certain clinical signs (i.e., fever, severe vomiting, inability to drink, convulsion, and inability to play) were positively associated with modern healthcare seeking. In fatal cases, only signs of lower respiratory disease were positively associated with modern healthcare seeking. A lack of awareness regarding clinical danger signs was identified in both groups.; Conclusion:; 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