According to recent United Nations High Commissioner for Refugees (UNHCR) estimates, ~90 million people are forcibly displaced due to conflict, persecution, violence, human rights violations, public disorder, natural disasters, or famine. Of those forcibly displaced, 27.1 million are refugees.1 By the 1951 Refugee Convention, a refugee is defined as a person, who, "owing to a well-founded fear of persecution for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country."2 More than half of all refugees are children.3 Refugees worldwide have steadily increased, almost tripling over the past decade. Most refugees today, roughly 80%, are hosted by low- and middle-income countries, while the United States receives the largest applications of refugees worldwide.1 Regardless of a host country's health system capacity, refugees universally face barriers to access and delivery of quality health services.4 Children are considered among the most vulnerable throughout the migration process, with regard to health risks, physical and mental well-being, and adverse outcomes.5 Surgical conditions comprise a large and rising portion of the global burden of disease, but the majority of people around the world, including refugee children, cannot receive safe surgical and anesthesia care when needed.6,7 For forcibly displaced persons, there is an estimated surgical need of 3 million procedures annually.8 At least 60% of refugees live in urban settings, with resettlement in host communities.9 The area of focus for this work is based on an urban tertiary care center and partnering primary care clinic in the United States. First, we present the conceptual frameworks with regard to refugee policies and perioperative care. Next, we examine the health considerations of refugee children and a case scenario to illustrate this. Finally, we propose an integrated, patient-centered care model to equitably address the perioperative health care of refugee children. Frameworks Refugee policies Over the last century, the United Nations has been instrumental in advancing the rights of refugees and children. Some of the earliest international agreements include the United Nations Universal Declaration of Human Rights of 1948 and the United Nations Convention Relating to the Status of Refugees in 1951 and its 1967 Protocol, which defined refugee and nonrefoulement rights, that is protection against being returned back to a state of harm or danger.10 In 1989, the United Nations Convention on the Rights of the Child (CRC) recognized children as individuals, with full rights to develop and grow with dignity, such as the right to health, welfare, and education. CRC also emphasized the rights of displaced and refugee children are to be held to the same standards of resident populations.5,11 More recently, since 2015, the United Nations offers a vision forward with The Compact for Migration and its Comprehensive Refugee Response Framework (CRRF) and the Sustainable Development Goals (SDGs). CRRF focuses on equitable responsibility sharing and solutions among international stakeholders to support the burden of host communities and to improve refugee self-reliance.12 SDGs recognize some of the root causes and issues associated with forced migration, such as poverty, hunger, education, clean water, climate change, employment, and peace.9 SDG 3 is dedicated to health, setting targets such as ending preventable deaths of newborns and children, and achieving universal health coverage for all.13,14 SDG 10 aims to reduce inequality within and among countries, with an indicator focusing on migration of people.13,15 Translating core principles of the United Nations into real-world health care settings, the Society of Social Pediatrics and Child Health (ISSOP) Budapest Declaration—On the Rights, Health and Well-Being of Children and Youth on the Move provides a practical guide for physicians caring for refugee patients. ISSOP recognizes the realities of health systems, such that even the well-established ones are "fragmented with many barriers to optimal care." The Budapest Declaration promotes "comprehensive" care of the child, not only physical and mental health, but also ranging from preventative to curative care, and with appropriate referrals. With regard to direct clinical care, a provider must be "sensitive to linguistic, cultural, and ethnic origins, take place with informed consent, include participation in physical and mental health care decision making, and incorporate trauma-informed approach to care."16 In doing so, ISSOP promotes holistic care, recognizes a patient's individuality, and strives for equal standard of care to all in a community. Pediatric perioperative surgical home (PPSH) model The perioperative surgical home (PSH) describes a patient-centered, team-based approach to perioperative care. The PSH emphasizes integrated care between surgical and medical specialties that meet the individual perioperative needs of a patient. The PSH spans the entire patient experience of surgery from preoperative evaluations and shared decision-making through postoperative recovery and transition back to the primary care provider/medical home.17 This streamlined delivery model focuses on standardizing evidence-based protocols, optimizing quality and safety measures, and assessing cost-reduction strategies to improve patient engagement, multidisciplinary care coordination, perioperative outcomes, and health care system reform.18,19 Historically, the PSH was proposed in 2011 by the American Society of Anesthesiologists in response to the volume-based care model for surgical procedures that frequently resulted in fragmented care, increased health care costs, and patient dissatisfaction in the United States. Shifting the lens toward value-based population health, cost efficiency, and high-quality patient experience is the Triple Aim Goal of the PSH.17,20 The PSH model aligns with the American College of Surgeon Pediatric Surgical Verification System created in 2012, which recommends optimizing pre-anesthesia assessment and subsequent perioperative care.21 Globally, PSH-like models or perioperative patient management systems have been introduced in Canada, Europe, and Australia.22 While adopted early in adult hospitals, the PSH has more recently gained momentum in pediatric centers. Compared with adults, children have additional factors to be considered in the perioperative period, such as age-related differences in physical, psychosocial and emotional development, undiagnosed congenital disorders, and health care access if dependent on their family. Approximately 15% of children younger than 18 years old have special health care needs.23 Special needs entail any chronic condition that pose functional limitations or require additional health services. Pediatric readmission after surgery is related to these comorbidities;24 with readmission rates higher among children with medically complex needs.23 Limited examples of the PPSH models exist. These PPSH initiatives are centered around a specific surgical indication, such as posterior spinal fusion for adolescent idiopathic scoliosis,25,26 outpatient adenoidectomy for obstructive sleep apnea,27 and endoscopic repair of laryngeal cleft disorders.28 Measurable outcomes showed a decrease in length of stay, intensive care unit use, blood transfusion requirements, and opioid consumption. Over the last 5 years there has been increased recognition of a need to move beyond surgery-specific PPSH care, and address more comprehensively children undergoing surgery.29 As such, the pediatric PSH model must emphasize holistic care and coordination between the family unit, various specialists, and other hospital-based teams at each stage of the surgical journey.19,24 An essential component of the pediatric PSH is being "family centered." The American Academy of Pediatrics introduced the concept of the "patient/family centered medical home" 30 years ago, with the vision of the primary care physician providing "coordinated, compassionate care," alongside family and community providers.23,24 This provides the opportunity for a collaborative team model and building patient-provider trust, by recognizing individual perspectives, family strengths, and cultural sensitivity.30 The pediatric PSH should serve as an extension of the patient/family-centered medical home to improve patient satisfaction and quality of care during the entire perioperative period.22,24 The health of children in refugee families Prearrival overview Before resettlement and establishing care in a primary care medical home, children in refugee families have varied experiences. This variation includes whether or not their family was able to migrate together; if they or their family experienced or witnessed trauma; their opportunity to interact with health care systems; their privilege to access the school system; their families' literacy and health literacy; and their level of trust for institutions. Celebrating the strengths of families and understanding different migration paths31 are key places that health care providers can support children in refugee families, even though we may not know the details of the varied experiences of a child and their family before arrival. Varied opportunity to interact with health care systems for children in refugee families may mean that children have not had routine preventive care, such as developmental screening and regular well-child visits with primary care providers. However, they may have accessed health care for emergencies, immunizations, supplementary feeding programs or for the management of a chronic condition.32 Overseas medical examinations before resettlement into a host country depend on each country's guidance.33,34 For children traveling to the United States, they undergo a health assessment overseas following Centers for Disease Control (CDC) and Prevention Guidance and conducted by a physician appointed by the United States State Department.35 This overseas examination identifies conditions that may pose public health risks as well as conditions that may impact fitness to fly and the health of children after arrival.33 Information about the child's overseas examination is communicated through the Electronic Disease Notification system of CDC36 and through the resettlement agency partnering in care with the family. In addition to this overseas guidance, the CDC has domestic guidance that recommends a more comprehensive examination after arrival and screening 37 that occurs within 30 to 90 days after arrival. Establishing care in a medical home In the United States, children in refugee families establish primary care with the support of their refugee resettlement agency within 90 days of arrival.38 The American Academy of Pediatrics Policy Statement on Caring for Children in Immigrant Families describes: "The medical home, infused with cultural humility and safety, supports continuous, comprehensive, and compassionate care and increases collaboration with community supports."39 One example of a medical home is the Refugee Health Promotion Project based at the University of Washington, Harborview Medical Center in Seattle, where the overseas health records of children are reviewed before establishing primary care in partnership with refugee resettlement agencies and the WA Department of Health Refugee Health Program.40 Many children establishing primary care after refugee resettlement are healthy and typically developing. However, some children may arrive with chronic conditions that were diagnosed overseas or with the beginning of a workup and they may need additional diagnostics for confirmation and subspecialty referral.31 In addition, some children will have malnutrition,41 an infection, or an elevated blood lead level42 that will benefit from treatment. Surgical considerations There is a paucity of literature that comprehensively delineates the surgical needs of children after resettlement in host countries. However, surgical conditions faced by these patients can be as varied as the experiences that shaped their resettlement journeys. Reasons for migration, prior availability of health care services, acuity of departure, regions of the world inhabited, and overall health and nutritional status can influence surgical disease and disease severity. For example, children coming from regions of conflict or disaster may have injuries or traumatic sequelae that could benefit from surgical intervention or rehabilitation specialists.43 Thermal or chemical burn manifestations may be present, affecting a child's daily functional capacity and physical appearance.44 Health care providers may see surgical effects of infectious diseases not frequently encountered in the host country, such as those from tuberculosis, amoebiasis, or hydatid disease in the United States.45 Children who have not had access to surgical services for much of their lives could have untreated congenital anomalies, such as cleft lip46 and palate or congenital heart disease.47 The presence of malnutrition and anemia, as discussed above, can influence disease severity and ability to heal from an operation. Taking time to understand migration paths is key. All care should be approached from a trauma-informed perspective, recognizing that it may take time for providers to earn the trust of families and that if families choose to share challenging stories this will happen on their timeline. Enhancing communication with the primary medical home, and approaching all conversations with humility, and cultural awareness is also important. A crucial component of all medical homes providing care to children in refugee families is the provision of care in the language that their family would like to communicate in for health care, which may be a language other than English. Following these principles can help guide surgical disease diagnosis and inform individual treatment plans. Case scenario We present a fictional case, based on a compilation of refugee pediatric patients, their migration experiences, and navigation through the United States health care system. The description of the fictional case is based on patients establishing their medical home at the Pediatric Clinic at Harborview Medical Center and the Refugee Health Promotion Project for recently resettled refugee children to Washington state.40 Children in this clinic are referred for surgical intervention and anesthetic care at Seattle Children's Hospital in Seattle, Washington, USA if it is needed. E.A. is an 8-year-old who resettled to the United States and establishes care in a primary care medical home where his migration history31 is elicited. His family lived in a refugee camp in Turkey after fleeing armed conflict and initial separation in Syria. His parents and four siblings traveled together to Seattle, where they reconnected with his aunt, who previously resettled here. His family now lives in an apartment through support of refugee cash assistance. Their resettlement agency helped them sign up for SNAP (supplemental nutrition assessment program) benefits. They receive assistance with transportation from Hopelink, a van service for health services through Medicaid. His father was a farmer before they left Syria and completed primary school. His mother shared with EA's primary care provider that she did not have the opportunity to learn to read or write. Both parents communicate for health care in Arabic. After reviewing overseas medical records and completing a history and physical examination, notable for a heart murmur, EA is identified with a ventricular septal defect (VSD), a seizure disorder, and difficulty with feeding. He also has severe acute malnutrition with a body mass index z-score of −4. He has seizures often, taking levetiracetam daily that he was prescribed in Turkey before resettlement. Several referrals are made, including cardiology, neurology, rehabilitation medicine, occupational, physical and speech therapy, and a swallow evaluation. He is seen in the primary care clinic by a dietitian and started on Compleat, with improvement in his nutrition. A baseline echocardiogram is also arranged. The cardiologist discusses with the pediatrician findings of a small to moderate sized perimembranous VSD with left heart dilation on echocardiography and conveys her impression that his defect may be amenable to device closure in the catheterization laboratory. The primary care team begins a conversation with E.A.'s family about a cardiac intervention. His parents explain that his cousin died during a hospital stay back home, and they are worried what surgery could mean for his safety and well-being. His parents agree to connect with the interventional cardiologist to discuss further. After thoughtful deliberation, the family makes the decision to proceed with the interventional procedure. Over the past few months, E.A. and his parents have made several trips to the hospital for specialist evaluations and diagnostic workup. As the day of the procedure approaches, the family is unable to visit the preanesthesia clinic because this would require an additional trip with Hopelink van service involving a 1-hour commute to the hospital, and E.A.'s father needs to save time off from work for the recovery period. Given their initial separation during migration, E.A. and his parents are concerned about leaving him to go into the operating room. They will have to wait to ask this question on what to expect until the day of surgery. On surgery day, the family has difficulty navigating around the hospital. They are unsure where to go in this unfamiliar environment to check-in for surgery. In the preoperative zone, the family is informed that an in-person interpreter is offered only for more commonly spoken languages, such as Spanish. A video interpreter was used by the nursing, surgical, and anesthesiology teams. The family felt rushed and not included in discussing their parental presence preference for induction due to time-pressure demands and language barriers. A discussion on the family history death was not elicited either. The patient appeared quiet, and the options of a premedication or child life consultation were not offered. Upon entry into the operating room alone, E.A. was tearful. Anesthesia induction finally proceeded with suboptimal reassurance. Device closure of his VSD was uneventful and E.A. was brought to the postanesthesia care unit (PACU). There was a delay in bringing E.A.'s mother to PACU, and E.A. was anxious to see his family. With the one parent hospital policy in recovery, E.A.'s mother was selected to visit as she has been E.A.'s primary caregiver. When E.A.'s mother arrived, she wanted to ask the nurse how her son was doing, but she did not know she could ask for an interpreter. Video interpreter service was not offered either in PACU because E.A. was being transported shortly to his hospital room. During the hospital stay, the family requested dietary abstention from pork products as a cultural preference. It was at this time that the parents were informed that heparin, a pork-derived medication, was used during the catheterization procedure for anticoagulation. E.A.'s father stated that he never wanted his child to receive this medication and he was upset. Many discussions were required by the care team to earn back the trust of the family. In preparation for discharge, care instructions were provided in English to E.A.'s mother. E.A. will require annual cardiologist follow-up. They look forward to returning to their primary care physician in a few weeks. Providing a PSH model for refugee children This case example highlights the current system of patient, provider, and health care system factors48 that directly impact the clinical encounters experienced by refugee children and their families throughout their perioperative journey (Fig. 1). Key themes illustrated in this case scenario include: (1) trauma and resilience—we learn about the family's experiences of trauma before and during their resettlement journey and bear witness to their strength as they navigate a new system and advocate for their child's needs. (2) Basic needs and community support—uncertainty surrounding fundamental necessities, such as transportation, health insurance, housing, food, and employment, interferes with the family's ability to attend to new demands related to the surgical procedure, such as making it to multiple medical appointments, being available for phone calls, or picking up prescriptions. Their support network—inclusive of extended family and community members—is not recognized by the health care system and is, in fact, undermined by rigid institutional policies. (3) Fragmented care—the case illustrates how multiple steps of coordinating before a surgical procedure, communicating with several care teams across the community-hospital health system from the time of surgical indication to hospital discharge and beyond, and navigating an unfamiliar hospital system on arrival and throughout the surgical stay are often disjointed for families. (4) Communication and trust—we see how the confluence of the language barrier, limited interpreter services in Arabic, and inadequacy of educational materials in other languages results in communication failures. Providers lacking knowledge about refugee health are unprepared to incorporate family preferences and beliefs into an informed shared decision-making process, which may subsequently diminish trust. Overall, providers caring for refugee children must attend not only to medical considerations, but also the social determinants of health. Access barriers that are inherent in the planning and delivery of surgical care must be recognized and addressed at the individual and health system levels.Figure 1: Refugee Perioperative Surgical Home (RPSH) care model. Adapted from Kilbourne et al.48 Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.We propose a Refugee Perioperative Surgical Home (RPSH) care model to address the gap in perioperative care and coordination for refugee children more effectively. RPSH care incorporates holistic principles of the International Society for Social Pediatrics and Child Health (ISSOP) Budapest Declaration and the CRC tenet of equitable care for refugees, alongside core elements of the Pediatric Perioperative Surgical Home. In this RPSH care model, the key ISSOP refugee care principles are summarized as: (1) Trauma-informed Care, (2) Cultural Humility and Communication, and (3) Multidisciplinary Coordinated Care. These refugee care principles align conceptually with the PPSH call for patient/family-centered compassionate care and team-based integrated care through a streamlined approach. In Figure 1, we demonstrate these refugee care principles and PPSH core elements at every stage of a patient's surgical experience, with the aim of improving equity in care for children in refugee families, patient satisfaction, quality of care, and cost efficiency. The first RPSH pillar, trauma-informed care, needs to be adopted by all who work with the patient and their family. In the primary health care setting, pediatricians, social workers, interpreters, and navigators are likely already quite adept at this approach. There is a knowledge gap among perioperative providers. Training in trauma-informed care would emphasize safety, trustworthiness and transparency, collaboration and mutuality, and empowerment and choice.49,50 When care is transitioned for surgical procedures, a refugee patient moves from a migrant-friendly and trusted primary care setting into the unfamiliar perioperative environment on the day of surgery. Trauma-informed and patient-centered care calls for engaging the patient and parents in shared decision-making, particularly around induction plans, reuniting in the recovery room, coping strategies, postoperative pain management, and family support during the hospital stay. Child life team involvement should also be considered. The second RPSH pillar, cultural humility, and communication, is similarly provided at a primary health care clinic. As noted earlier, community settings are typically migrant-friendly, 51 with resources such as language interpretation and cultural navigation services. Pediatricians often have a strong knowledge base in refugee health needs and considerations.39 This should be extended into the hospital setting. Preanesthesia clinics and preoperative encounters should allow time for building trust. Cultural navigators can provide additional context for specialists regarding the family's cultural or religious views.52 Anesthesiologist and hospital-based teams should establish cultural humility training in residency programs53 and maintain this knowledge base. For example, clinical encounters should offer timely and appropriate interpreter services for informed consent, incorporate cultural beliefs into treatment plans, and provide relevant health literacy materials,54 such as pre-anesthesia information and discharge care instructions. The third RPSH pillar, multidisciplinary coordinated care, seeks to improve the patient experience by moving away from fragmented care. The primary care provider team can serve as a liaison, contextualizing the specialists' roles and building trust to the family, while providing information to the specialists regarding the patient's medical and social background. Ideally, as an extension of the primary care medical home, pre-anesthesia clinics can serve as an integral role in coordinating care and optimizing a patient before surgery.24 As discussed earlier, anesthesiologists should be encouraged to collaborate throughout the surgical stay with other hospital teams, such as navigators and family/patient advisors, child life specialists, interpreters, social workers, nurses, surgeons, medical specialists, and intensivists. Integrating referrals and testing is also important. In preparation for surgery, hospital appointments should be bundled as best as possible, such as arranging for same day visits to minimize transportation, employment, and other access to care concerns. Hospital scheduling notifications such as NPO instructions and preoperative COVID testing should be streamlined as well. To promote the health and well-being of children in refugee families, coordination and collaboration across health systems and disciplines should be optimized and frequently reevaluated. We acknowledge limitations to this RPSH care model. First, we apply the RPSH model to a high-resourced tertiary center, in a leading area for refugee resettlement. We also operate within a community-hospital referral network and have an established pre-anesthesia clinic. Other institutions may be working within a limited health care capacity, or an acute influx of migration which may impact optimal RPSH care, particularly in terms of coordinated care and access to services. However, even in resource-strained settings, the pillars of trauma-informed care and cultural humility from the RPSH model can be applied to any clinical encounter and phase of care. Second, in proposing a model for a defined population of our patients, we must appreciate that refugees are heterogeneous in their experiences. For example, experiences of trauma, migration history, social determinants, and clinical conditions will vary. We must recognize patient individuality to ensure quality care for all. Conclusion In summary, we serve an ever-increasing number of children from refugee families in the perioperative period. Ensuring access and quality of care for refugee children demands our attention and necessitates change. In our current system, we delineate patient, provider, and health care system factors that directly impact the clinical encounters of refugee children and their families throughout their surgical experience. We propose the integrated, patient-centered RPSH care model, with specific actions around trauma-informed care, cultural humility and provider education, communication and related supportive services, trust and shared decision-making, and coordinated care across the health system and medical specialties to meet the perioperative needs of refugee children and provide equitable care. Conflict of interest disclosure The authors declare that they have nothing to disclose.
The Salud Mesoamérica Initiative is a public-private partnership aimed at reducing maternal and child morbidity and mortality for the poorest populations in Central America and the southernmost state of Mexico. Currently at the midpoint of implementation and with external funding expected to phase out by 2020, SMI’s sustainability warrants evaluation. In this study, we examine if the major SMI components fit into the Dynamic Sustainability Framework to predict whether SMI benefits could be sustainable beyond the external funding and to identify threats to sustainability. Through the 2016 Salud Mesoamérica Initiative Process Evaluation, we applied qualitative methods including document review, key informant interviews, focus group discussions, and a social network analysis to address our objective. SMI’s design continuously evolves and aligns with national needs and objectives. Partnerships, the regional approach, and the results-based aid model create a culture that prioritizes health care. SMI’s sector-wide approach and knowledge-sharing framework strengthen health systems. Evidence-based practice promotes policy dialogue and scale-up of interventions. Most SMI elements fit within the Dynamic Sustainability Framework, suggesting a likelihood of sustainability after external funding ceases, and subsequent application of lessons learned by the global community. This includes a flexible design, partnerships and a culture of prioritizing healthcare, health systems strengthening mechanisms, policy changes, and scale-ups of interventions. However, threats to sustainability, including possible transient culture of prioritizing health care, dissipation of reputational risk and financial partnerships, and personnel turnover, need to be addressed.
Despite her apparent economic success, India is plagued by a high burden of under-nutrition among children under five. This study was aimed at understanding some of the risk factors for under-nutrition in a region with favourable maternal and child health indicators.A case control study was carried out among children aged one to five years attending the paediatric outpatient department in six rural health care centres in Udupi taluk of Karnataka in Southern India. A total of 162 children were included in the study, of which 56 were cases. A semi-structured questionnaire was used to interview the caregivers of the children and the nutritional status was graded according to the Indian Academy of Paediatrics (IAP) grading of protein-energy malnutrition.Under-nutrition was associated with illness in the last one month [OR- 4.78 (CI: 1.83 -12.45)], feeding diluted milk [OR-14.26 (CI: 4.65 - 43.68)] and having more than two children with a birth interval ≤2 years [OR- 4.93 (CI: 1.78 - 13.61)]. Lack of exclusive breast feeding, level of education of the caregiver and environmental factors like source of water did not have an association.Childhood illness, short birth interval and consumption of diluted milk were some of the significant contributory factors noted among this population. Information, Education, Communication (IEC) campaigns alleviating food fads and promoting birth spacing is needed.
To know the range of services provided by the various health providers, to study their criteria for determining fees for the services provided, to understand their barriers in providing the services and to study the factors responsible for their job satisfaction and dissatisfaction in rural areas of Udupi taluk, Karnataka state, India.
Materials and Methods
A cross sectional study was conducted in rural areas of Udupi taluk between September 2007 and October 2008 among 150 rural practitioners. Data were collected by interviewing the practitioners using pre-tested, semi-structured questionnaire. The quantitative data were analysed using SPSS 14.0. The qualitative data were collected using In-depth interview technique.
Results and Conclusion
Provision of preventive health services and participation in national programmes by the private practitioners was found to be inadequate. Practitioners determine their fees based on the economic status of the patient and the cost of medicines dispensed. Inadequate and irregular income is the major barrier for both government and private sector doctors and most of them were moderately satisfied with their job.
Teratomas are germ cell tumours arising as the result of abnormal development of totipotential cells. They are commonly encountered in the gonads and occasionally found in mediastinum. We report a case of asymptomatic 28 years old lady with concomitant mature cystic teratoma in her mediastinum and left ovary which was diagnosed incidentally during health check up. This case is reported because of its rare and unusual coexistence.
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Abstract Background Reducing neonatal and child mortality is a top priority for global health agendas and relies in part on the degree to which the population can access quality health services in a timely manner. This study explores the delays faced during the search for care by caregivers of children under the age of 5 who died in the State of Yucatan, Mexico, during 2015–2016 using the three delays framework as a way to identify bottlenecks and areas susceptible to intervention to reduce these deaths.Methods Cross-sectional study of all children under 5 years of age who died in the State of Yucatan, Mexico, during 2015 – 2016. Information on delays was obtained through household interviews with the caregiver of the child.Results Among 298 cases of children who experienced a health problem and searched for care, 252 had complete information for the study. Over 61% of those children visited more than one facility to seek care and had long times to start seeking care. The beginning of the search for care process was shorter when mothers or caregivers sought care initially at a public facility, and when some symptoms like coughing, lethargy, or rash were detected in the child. The second delay, travel time to facilities, was longer in children enrolled in Seguro Popular as compared to children covered by other forms of social security. Finally, the third delay, waiting time to be seen in the facility, was more common in public facilities that are not hospitals, and more common among children who also experienced a long travel time.Conclusions The results suggest that health promotion actions to reduce the time to search for care when facing a health problem and providing resources to mothers and caregivers to access health services in a timely manner may reduce these delays. This information can help in the planning of health services and improve their impact on population health.
BackgroundSustainable Development Goal 3.2 has targeted elimination of preventable child mortality, reduction of neonatal death to less than 12 per 1000 livebirths, and reduction of death of children younger than 5 years to less than 25 per 1000 livebirths, for each country by 2030. To understand current rates, recent trends, and potential trajectories of child mortality for the next decade, we present the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 findings for all-cause mortality and cause-specific mortality in children younger than 5 years of age, with multiple scenarios for child mortality in 2030 that include the consideration of potential effects of COVID-19, and a novel framework for quantifying optimal child survival.MethodsWe completed all-cause mortality and cause-specific mortality analyses from 204 countries and territories for detailed age groups separately, with aggregated mortality probabilities per 1000 livebirths computed for neonatal mortality rate (NMR) and under-5 mortality rate (U5MR). Scenarios for 2030 represent different potential trajectories, notably including potential effects of the COVID-19 pandemic and the potential impact of improvements preferentially targeting neonatal survival. Optimal child survival metrics were developed by age, sex, and cause of death across all GBD location-years. The first metric is a global optimum and is based on the lowest observed mortality, and the second is a survival potential frontier that is based on stochastic frontier analysis of observed mortality and Healthcare Access and Quality Index.FindingsGlobal U5MR decreased from 71·2 deaths per 1000 livebirths (95% uncertainty interval [UI] 68·3–74·0) in 2000 to 37·1 (33·2–41·7) in 2019 while global NMR correspondingly declined more slowly from 28·0 deaths per 1000 live births (26·8–29·5) in 2000 to 17·9 (16·3–19·8) in 2019. In 2019, 136 (67%) of 204 countries had a U5MR at or below the SDG 3.2 threshold and 133 (65%) had an NMR at or below the SDG 3.2 threshold, and the reference scenario suggests that by 2030, 154 (75%) of all countries could meet the U5MR targets, and 139 (68%) could meet the NMR targets. Deaths of children younger than 5 years totalled 9·65 million (95% UI 9·05–10·30) in 2000 and 5·05 million (4·27–6·02) in 2019, with the neonatal fraction of these deaths increasing from 39% (3·76 million [95% UI 3·53–4·02]) in 2000 to 48% (2·42 million; 2·06–2·86) in 2019. NMR and U5MR were generally higher in males than in females, although there was no statistically significant difference at the global level. Neonatal disorders remained the leading cause of death in children younger than 5 years in 2019, followed by lower respiratory infections, diarrhoeal diseases, congenital birth defects, and malaria. The global optimum analysis suggests NMR could be reduced to as low as 0·80 (95% UI 0·71–0·86) deaths per 1000 livebirths and U5MR to 1·44 (95% UI 1·27–1·58) deaths per 1000 livebirths, and in 2019, there were as many as 1·87 million (95% UI 1·35–2·58; 37% [95% UI 32–43]) of 5·05 million more deaths of children younger than 5 years than the survival potential frontier.InterpretationGlobal child mortality declined by almost half between 2000 and 2019, but progress remains slower in neonates and 65 (32%) of 204 countries, mostly in sub-Saharan Africa and south Asia, are not on track to meet either SDG 3.2 target by 2030. Focused improvements in perinatal and newborn care, continued and expanded delivery of essential interventions such as vaccination and infection prevention, an enhanced focus on equity, continued focus on poverty reduction and education, and investment in strengthening health systems across the development spectrum have the potential to substantially improve U5MR. Given the widespread effects of COVID-19, considerable effort will be required to maintain and accelerate progress.FundingBill & Melinda Gates Foundation.
Populations in rural communities have more limited access to health care and attention than urban populations. The present study aimed to evaluate barriers to access to health care in mothers and caregivers of children under five years of age, twelve months after an educational intervention. The study was carried out from February to September 2022, and 472 mothers from eight communities in the state of Yucatán, in the southeast of the United Mexican States, participated. A comparative analysis was carried out on help-seeking times, obstacles to reaching it, and illnesses in children. The results revealed that the main barriers to access to care were long times to decide to seek help, lack of financial resources to pay for the transfer to another health unit, lack of someone to accompany the mother or caregiver when the child needed be transferred, and lack of transportation for the transfer. Disease knowledge remained at different levels in the eight communities; the significant differences occurred in four communities, one specifically for heart defects. It was concluded that, in the rural populations studied, there are barriers to access to health care which have to do with neglected social determinants, such as those related to conditions of gender, income, social support network, and the health system. Access to health care must be universal, so public health interventions should be aimed at reducing the barriers that prevent the population from demanding and using services in a timely manner.
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