Sarah Louart

Background: Integrated Management of Childhood Illness (IMCI) guidelines, used alone, fail to reliably identify severe hypoxaemia (SpO ₂ 2 measurement, except those 2–59 months classified as simple non-respiratory cases using IMCI. Monthly aggregated data were collected from 202 AIRE PHC’s through a cross-sectional study to estimate the added value of PO within IMCI in diagnosing severe cases (SCs) which should be referred. The added value was defined as the number of additional IMCI SCs with severe hypoxaemia, diagnosed using IMCI+PO, divided by the number of SCs diagnosed using IMCI alone. In a subset of 16 PHCs, we conducted a 14-day cohort follow-up for SCs. We analysed their management and mortality according to hypoxaemia status. Results: Of the 514 901 IMCI consultations between June 2021 and December 2022, 74.2% were eligible for PO use. Of those, 5.4% were SCs diagnosed using IMCI+PO. The added value of PO was +4.9% (+962 SCs; 95% CI 4.6% to 5.2%). This was similar for all countries except Guinea (+0.9%). Healthcare workers’ referral decisions were significantly higher for SCs with severe hypoxaemia (74.5%) than for those without (22.2%), p value <0.0001. In the research PHCs, the 142 SCs with severe hypoxaemia were significantly more likely to be referred and admitted to hospital, although their survival rates were similar. However, oxygen therapy remained suboptimal. Conclusion: At PHC level, PO improves the diagnosis of SCs with severe hypoxaemia and is associated with improved management. However, subsequent care in these settings remains challenging. Trial registration number: PanAfrican Clinical Trial Registry (PACTR202206525204526).

Les infections respiratoires représentent l'une des principales causes de mortalité infantile dans les pays à faible et moyen revenu, notamment en raison de la difficulté à détecter l'hypoxémie et d'un accès limité à l'oxygène. L'hypoxémie, définie par une saturation anormalement basse de l'oxygène dans le sang, constitue un indicateur clé de gravité et un important prédicteur de mortalité. Cependant, son diagnostic reste difficile sans appareils appropriés comme les oxymètres de pouls (OP). La détection précoce de l'hypoxémie dès le premier niveau de la pyramide sanitaire pourrait faciliter les décisions de transfert vers des structures hospitalières équipées pour offrir des soins tels que l'oxygénothérapie. Pourtant, les OP sont souvent indisponibles à ce niveau. À ce jour, les études sur l'oxymétrie de pouls dans les soins de santé primaires dans les pays à faible ou moyen revenu restent très limitées, et de nombreuses questions sur sa mise en œuvre demeurent sans réponse (Graham et al., 2024).Cette recherche évalue l'introduction des OP lors des consultations de routine pour les enfants de moins de cinq ans dans 202 centres de santé primaires (CSP) de quatre pays d'Afrique de l'Ouest : le Burkina Faso, la Guinée, le Mali et le Niger. Nous mobilisons la littérature théorique et empirique sur la diffusion des innovations en santé ainsi qu'une démarche d'évaluation réaliste pour analyser l'adoption individuelle des OP au niveau décentralisé. L'approche d'évaluation réaliste, développée par Pawson et Tilley (1997), se concentre sur la compréhension des mécanismes explicatifs du fonctionnement d'une intervention et sur les contextes spécifiques dans lesquels ils sont déclenchés. Elle permet de comprendre non seulement si l'intervention est efficace, mais également pourquoi, comment et dans quels contextes elle fonctionne.Notre thèse apporte deux contributions principales. La première est la mise en relation de l'approche réaliste, encore peu exploitée par les sciences économiques, avec l'économie politique. Nous abordons ce rapprochement sous deux angles. D'un point de vue ontologique, nous avons mis en évidence les liens entre le réalisme critique (Bhaskar, 1975) et les approches hétérodoxes en économie, en nous appuyant notamment sur les travaux de Lawson (1997). Dans le domaine de l'évaluation de programme, nous avons démontré comment l'évaluation réaliste peut constituer une alternative à la méthode dominante des expérimentations aléatoires.La seconde concerne la production de données probantes sur la mise en œuvre des OP au niveau décentralisé dans des pays à faible revenu. Notre étude repose principalement sur 100 entretiens, réalisés dans 16 CSP des quatre pays, avec les agents de santé responsables des consultations pour les enfants de moins de cinq ans. Une analyse transversale a permis d'identifier des régularités comportementales dans des contextes spécifiques, influençant l'utilisation, puis l'adoption des OP. Deux facteurs clés facilitent l'adoption. D'abord, l'utilisation de l'appareil rassure les agents dans leurs diagnostics et renforce leur confiance dans leurs décisions, surtout dans un contexte où les outils de diagnostic sont rares. Ensuite, l'adoption est favorisée lorsque les agents sont informés des effets positifs de leurs diagnostics sur la santé des patients référés à des structures de niveau supérieur. Néanmoins, l'adoption individuelle des OP peut être compromise par des obstacles structurels et par le manque d'adoption institutionnelle. Cette recherche met en lumière les défis et les facteurs de succès liés à l'introduction de technologies médicales de diagnostic dans des structures de santé décentralisées.

Introduction: Extreme heat has always been a public health challenge in the Sahel, with growing evidence of its adverse effects on maternal, newborn, and child health (MNCH), including mental health. In Senegal’s Matam region, high seasonal temperatures may affect exclusive breastfeeding (EBF) practices and maternal mental health through direct effects of heat perceptions and knowledge. SPRINT-Sen aims to co-design, implement, and evaluate a community-based, population health intervention to improve EBF and maternal mental health under a hot and arid climate. Methods: SPRINT-Sen is a population health intervention research (PHIR) study using a quasi-experimental longitudinal design with four independent cross-sectional surveys in an open cohort. The impact evaluation follows a pre–post design using a mixed-method approach for acceptability and process evaluation. Eligible participants are pregnant women and mothers of infants aged 0–12 months. The co-designed intervention will combine (1) EBF promotion adapted to extreme heat conditions; (2) maternal mental health support through promotion and psychosocial activities; and (3) continuous temperature monitoring to inform a heat warning system. The primary outcome is EBF at six months. Secondary outcomes include maternal mental health impacts such as anxiety, stress, and interpersonal conflict. Meteorological and thermal mapping will assess environmental exposure. Results: The study will generate evidence on the mechanisms and implementation of heat-EBF interventions and heat-related mental health impacts among MNCH. Findings will inform efforts to strengthen a heat-resilient health system through community-based solutions. Knowledge transfer will be supported through co-dissemination with stakeholders and integration into maternal health and climate adaptation policies. Conclusions: SPRINT-Sen will provide novel and context-specific evidence on the feasibility, implementation and effectiveness of an integrated intervention addressing both maternal mental health and EBF in the context of extreme heat. The findings will inform adaptation strategies for MNCH programmes and contribute to global discussions on PHIR in Sahelian contexts.

Introduction: To better identify severe hypoxaemia as a major risk factor for specific illnesses in children aged under 5 years, the Améliorer l’Identification des détresses Respiratoires chez l’Enfant (AIRE) project implemented routine use of pulse oximetry within implementation of Integrated Management of Childhood Illness (IMCI) guidelines at primary health centres (PHCs) in Burkina Faso, Guinea, Mali and Niger. We aimed to measure and understand the acceptability of pulse oximeter (PO) use among healthcare workers (HCWs) and children’s families (CFs). Methods: Based on an original conceptual framework, we conducted a convergent mixed methods study to assess acceptability. We conducted repeated cross-sectional studies among all HCWs on duty within the 202 PHCs involved in the AIRE project, using quantitative Likert-scale questionnaires. These were administered at four key time points: (1) just before the PO use training, (2) immediately after the training, (3) 6 months after the introduction of PO devices in PHCs and (4) 2 months after the completion of all AIRE project activities. We also conducted semistructured interviews with HCWs (n=100) and CFs (n=59). Quantitative data were analysed using descriptive statistics and multivariable ordinal logistic regression. Qualitative data were thematically analysed with NVivo, and both were interpreted in light of the conceptual framework to explore convergence and divergence across acceptability dimensions. Results: From March 2021 to December 2022, 486, 537, 538 and 476 HCWs completed the four acceptability surveys. Overall, 31% of HCWs had mixed feelings about PO use before the training, 46% found it somewhat acceptable and 23% strongly acceptable. At the end of the project, it was respectively 15%, 34% and 51%. PO training was consistently associated with greater HCWs acceptability. HCWs reported many advantages in using PO, such as a more accurate diagnosis and a boost in their confidence in sick child management. Nevertheless, challenges reported by HCWs included perceived increased workload and consultation time, as well as difficulties in referring children to hospital. CFs did not necessarily understand the device’s purpose, but their opinions of the technology were generally positive. Conclusion: PO use, integrated into IMCI consultations, was reported to be accepted by HCWs and CFs, although sustainable challenges in implementation remain.

Background: The Integrated Management of Childhood Illness (IMCI) guidelines are symptom-based algorithms used to identify critically ill children under five in primary health centres (PHC) in resource-limited countries. Hypoxaemia, a life-threatening event, is clinically underdiagnosed. The Amélioration de l'Identification des détresses Respiratoires de l'Enfant/Improving Identification of Respiratory Distress in Children (AIRE) project implemented the routine use of pulse oximetry (PO) within IMCI consultations to improve the diagnosis and management of severe hypoxaemia (pulse blood oxygen saturation 2 days, home to PHC travel time >30 min. Conclusion: The prevalence of seriously ill children under five, including severe hypoxaemia, was high in PHC, particularly in neonates. The high between-country heterogeneity may be explained by differences in case definitions (Guinea) and structural factors (accessibility). Improving early access to primary care could be an actionable lever to improve the health of West African children.

Introduction: Out-of-pocket payments limit access to care in Africa. The Amélioration de l'Identification des détresses Respiratoires de l'Enfant/Improving Identification of Respiratory Distress in Children (AIRE) project evaluated the implementation of pulse oximetry within Integrated Management of Childhood Illness (IMCI) guidelines at primary health centres (PHCs) in Burkina Faso and Niger (with total exemption policies) and in Mali and Guinea (with partial exemption policies). We measured households’ out-of-pocket expenditures for treating children under 5 years of age and analysed the associated factors. Methods: Between June 2021 and May 2022, all children under 5 years of age attending IMCI consultations, excluding simple non-respiratory cases, aged 2–59 months, were enrolled in the AIRE study with parental consent. Five non-severe cases and five severe cases (followed up over 14 days) per PHC were randomly selected every month. We collected medical and non-medical direct costs and indirect costs. We described the median costs and investigated the factors associated with medical direct costs (MDCs) using two-part models for countries with total exemption and a general linear model for those with partial exemption. Results: Overall, 940 non-severe cases and 745 severe cases were selected. The median MDCs were US$0.0, US$7.1, US$5.0 and US$3.6 for non-severe cases and US$1.6, US$8.6, US$7.4 and US$14.4 for severe cases, in Burkina Faso, Guinea, Mali and Niger, respectively. Medicine expenditures were the main MDC items, accounting for 79% of costs for non-severe cases and 59% for severe cases. In all countries, disease severity and the unavailability of prescribed medicines at PHCs or referral hospital depots were associated with out-of-pocket payments and higher expenses. Conclusion: With the exception of Burkina Faso, household out-of-pocket payments for children under five remain high despite free care policies, particularly for treating severe cases. This is mainly explained by medicines expenditures. Action is needed to identify efficient financing systems that ensure the regular and adequate supply of medicines in public health facilities and to support free healthcare policies.

Background: The Integrated Management of Childhood Illness (IMCI) guidelines are implemented within primary health centres (PHCs) in resource-limited settings. These symptom-based algorithms under-diagnose severe hypoxemia, which contributes to the under-five’mortality in sub-Saharan Africa. To improve the diagnosis and management of severe hypoxaemia, the Améliorer l’Identification des détresses Respiratoires chez l’Enfant (AIRE) project implemented the routine use of pulse oximetry (PO) within IMCI consultations in Burkina Faso, Guinea, Mali and Niger. We described the intervention sites and measured their capacity to offer IMCI care prior to project implementation. Methods: A cross-sectional quantitative survey was conducted in all the AIRE PHCs and their district hospitals (DHs) from March to July 2020. Results: Overall, 215 PHCs and 8 DHs were surveyed. Almost all the PHCs were public structures, mainly managed by nurses. At least one healthcare worker was IMCI trained in >99% of PHCs. At baseline, PO was available in only 2/215 (1%) PHCs and 4/8 (50%) DH. Median referral rate was estimated to 1.5% per PHC; 35/215 (16%) PHCs had functional ambulances for managing referrals to DHs, including two with mobile oxygen. IMCI consultations were free of fees in Burkina Faso and Niger, but charged for in Guinea and Mali (from US$0.5 to US$1). All the DHs had capacities to provide specialised paediatric care, although the use of PO was not systematic. Oxygen was available at all DHs except one. Parents of children requiring hospitalisation had to pay out of pocket costs ranging from US$1.7 to US$8.4 per day. Conclusions: This survey highlights the weak adoption of IMCI guidelines in these settings, the absence of PO’s at PHC level and their low use at hospital level, as well as difficulties in managing severe cases, referral to hospital and accessing oxygen. It has guided the choice of the AIRE research PHCs and the upgrading of PHCs including IMCI training.

Introduction: Hypoxaemia is an important contributor to child mortality, particularly in low-resource settings where diagnostic tools are scarce. The Améliorer l'Identification des détresses Respiratoires chez l'Enfant project introduced pulse oximeters (POs) into 202 primary healthcare centres (PHCs) in Burkina Faso, Guinea, Mali and Niger, integrating them into the Integrated Management of Childhood Illness guidelines. This initiative aimed to strengthen diagnostic capacities for identifying hypoxaemia and to improve care management for critically ill children under 5. This study examined how healthcare workers (HCWs) adopted POs and explored the contexts and mechanisms influencing their adoption. Methods: We conducted a realist evaluation to analyse adoption patterns, focusing on interactions between the Intervention, Contexts, Actors, Mechanisms and Outcomes (ICAMO configurations). Data collection included 299 interviews with HCWs, patients’ families and institutional actors, conducted in 16 selected PHCs, at the institutional level and in district hospitals, complemented by site observations. Analysis was performed using NVivo software, identifying ICAMO configurations as demi-regularities to explain variations in PO use and adoption. Results: Training enabled HCWs to recognise the utility of POs, further motivating their use. Support-focused supervision fostered a sense of support, while control-focused approaches sometimes resulted in mechanical use driven by external pressure. In contexts of high workloads and children’s agitation, difficulties in using POs were observed. In settings with limited diagnostic tools, POs increased HCWs’ diagnostic confidence, encouraging adoption and improving decision-making. Observing or knowing the benefits of POs on children’s health provided HCWs with a sense of relief and pride, further reinforcing PO adoption. However, structural barriers and challenges related to institutional adoption may threaten long-term use. Conclusions: This study sheds light on the contexts and mechanisms that influence the use and adoption of the PO in PHCs. While widely used by HCWs, addressing challenges related to training, supply chain logistics and referral systems to hospitals is essential to ensure long-term sustainability and improve child health outcomes.

Background: In line with the Integrated Management of Childhood Illness (IMCI) guidelines, healthcare workers (HCWs) should refer all severe pneumonia among children under 5 seen in primary care in resource-limited settings. We investigated the frequency and correlates of missed opportunities for hospital referral (MOHR) of clinical severe pneumonia. Our study was embedded within the Améliorer l'Identification des détresses Respiratoires chez l'Enfant project, which involved the routine implementation of pulse oximetry (PO) within IMCI consultations at primary healthcare centres (PHCs) in West Africa: Burkina Faso, Guinea, Mali and Niger. Methods: All children aged 2–59 months attending IMCI consultations in 16 PHCs and classified as severe cases using IMCI+PO were enrolled into a prospective cohort for 14 days, with parental consent. We estimated the rate of MOHR for IMCI-defined severe pneumonia, which was either not referred, or referred but did not make it to hospital. Correlates of MOHR at day 14 were investigated using logistic mixed regression with random effect for PHCs. Results: From June 2021 to June 2022, among the 1786 children aged 2–59 months classified as severe cases by IMCI+PO, 682 (38.2%) were severe pneumonia. Of these, 35 (5.1%) also had severe anaemia, 47 (6.9%) severe hypoxaemia (SpO ₂ 2 between 90% and 93% (aOR: 12.16; 95% CI 3.47 to 42.61) or greater than 94% (aOR: 11.81; 95% CI 3.98 to 35.02) or severe malaria (aOR:2.55; 95% CI 1.04 to 6.26) significantly increased it. Conclusion: MOHR for severe pneumonia was extremely high at PHC level in these settings, mainly explained by HCW’s decisions. Strengthening the referral system and training HCW to reinforce their adherence to IMCI guidelines remains essential to improve the management of severe pneumonia. Trial registration number: PACTR202206525204526; Pan African Clinical Trials Registry on 15 June 2022.

Background: The Amélioration de l'Identification des détresses Respiratoires de l'Enfant (AIRE) project introduced the routine use of pulse oximetry (PO) into Integrated Management of Childhood Illness (IMCI) consultations within primary health centres (PHCs) in Burkina Faso, Guinea, Mali and Niger. We analysed how severe cases were managed and 14-day mortality by hypoxaemia severity. Methods: All children aged under 5 years attending IMCI consultations integrating PO use at 16 research PHCs and classified as severe cases (severe IMCI cases or severe hypoxemia: SpO ₂ <90%) were eligible for referral and enrolled in a 14-day prospective cohort with parental consent. Referral decisions, admissions, access to oxygen therapy and Kaplan-Meier probability of death were compared by hypoxaemia severity. An adjusted mixed-effects Cox regression model with a random effect for PHC estimated adjusted ORs (aORs) and 95% CIs of mortality by day 14. Results: From July 2021 to July 2022, 1998 severe cases were enrolled, including 10.6% aged <2 months; 7.1% had severe hypoxaemia, and 10.5% had moderate hypoxaemia (90%≤oxygen saturation≤93%). By day 14, 625 (31.3%) were referred, 463 (23.2%) hospitalised, and 95 children (4.8%) had died. Referral decisions, hospitalisations and oxygen therapy rates were significantly higher for severe hypoxaemic cases (83.8%, 82.3% and 34.5%, respectively) than for moderate hypoxaemic cases (32.7%, 26.5% and 7.1%, respectively) and cases without hypoxaemia (26.3%, 17.5% and 1.4%, respectively). Similarly, day 14 mortality rates were 26.1%, 7.5% and 2.3%, respectively. The aORs for mortality were severe hypoxaemia (9.34, 95% CI 5.08 to 17.16), moderate hypoxaemia (2.32, 95% CI 1.16 to 4.64), age <2 months (3.68, 95% CI 1.67 to 8.13), severe malaria (2.02, 95% CI 1.03 to 3.97) and living in Niger (4.06, 95% CI 1.41 to 11.67). Conclusion: Regardless of severity, hypoxaemia was common among outpatients screened using PO and meeting criteria for severity. Its presence was associated with mortality risk. Incorporating PO within IMCI prompted care management of severely hypoxaemic cases, but hospital referrals and access to oxygen remain sub-optimal and are crucial levers for reducing under-five mortality. Study registration number: PACTR202206525204526 registered retrospectively on 15 June 2022.