Background Mali is currently in the midst of ongoing conflicts which involve jihadist groups, rebels, and the state. This conflict has primarily centered in the North of the country. Humanitarian actors delivering services in these geographies must navigate the complex environment created by conflict. This study aimed to understand how humanitarian actors make decisions around health service delivery within this context. Methods The current case-study utilized a mixed methods approach and focused on Mopti, Mali’s fifth administrative region and fourth largest in population. Latent content analysis was used to analyze interview transcripts guided by our research objectives and new concepts as they emerged. Indicators of coverage of health interventions in the area of maternal and child health and nutrition were compiled using Mali’s National Evaluation Platform and are presented for the conflict and non-conflict regions. Development assistance estimates for Mali by year were obtained from the Developmental Assistance for Health Database compiled by the Institute for Health Metrics and Evaluation. Administrative data was compiled from the annual reports of Mali’s Système Local d’Information Sanitaire (SLIS), Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS). Results Our data suggests that the reaction of the funding mechanisms to the conflict in Mali was a major barrier to timely delivery of health services to populations in need and the nature of the conflict is likely a key modifier of such reaction patterns. Concerns have been raised about the disconnect between the very high administrative capacity of large NGOs that control the work, and the consequent burden it puts on local NGOs. Population displacement and inaccurate estimates of needs made it difficult for organizations to plan program services. Moreover, actors delivering services to populations in need had to navigate an unpredictable context and numerous security threats. Conclusions Our study highlights the need for a more flexible funding and management mechanism that can better respond to concerns and issues arising at a local level. As the conflict in Mali continues to worsen, there is an urgent need to improve service delivery to conflict-affected populations.

ObjectivesThis study aims: (1) to identify and describe similarities and differences in both adult and child COVID-19 vaccine hesitancy, and (2) to examine sociodemographic, perception-related and behavioural factors influencing vaccine hesitancy across five West African countries.DesignCross-sectional survey carried out between 5 May and 5 June 2021.Participants and setting4198 individuals from urban and rural settings in Burkina Faso, Guinea, Mali, Senegal and Sierra Leone participated in the survey.Study registrationThe general protocol is registered on clinicaltrial.gov.ResultsFindings show that in West Africa at the time only 53% of all study participants reported to be aware of COVID-19 vaccines, and television (60%, n=1345), radio (56%; n=1258), social media (34%; n=764) and family/friends/neighbours (28%; n=634) being the most important sources of information about COVID-19 vaccines. Adult COVID-19 vaccine acceptance ranges from 60% in Guinea and 50% in Sierra Leone to 11% in Senegal. This is largely congruent with acceptance levels of COVID-19 vaccinations for children. Multivariable regression analysis shows that perceived effectiveness and safety of COVID-19 vaccines increased the willingness to get vaccinated. However, sociodemographic factors, such as sex, rural/urban residence, educational attainment and household composition (living with children and/or elderly), and the other perception parameters were not associated with the willingness to get vaccinated in the multivariable regression model.ConclusionsPrimary sources of information about COVID-19 vaccines include television, radio and social media. Communication strategies addressed at the adult population using mass and social media, which emphasise COVID-19 vaccine effectiveness and safety, could encourage greater acceptance also of COVID-19 child vaccinations in sub-Saharan countries.Trial registration numberNCT04912284.

Background In malaria endemic regions, intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) is recommended for all pregnant women during prenatal consultation, from the fourth month of pregnancy up to the time of delivery. The Government of Mali is aiming for universal coverage of IPTp-SP. However, coverage is still low, estimated to be 18% for completion of three doses (IPTp-SP3). The objective of this study was to identify the factors that influence IPTp-SP adherence in the Health District of Sélingué, Mali. Methods This was a cross-sectional survey with 30 clusters, proportional to village size, with two stages of sampling. Data were collected electronically with Magpi software during face-to-face interviews/surveys. The data were analysed with SPSS version 20. A descriptive analysis and bivariate and multivariate logistic regression were performed. An equity analysis examined the effect of distance from health care facility on completion of three or more antenatal visits (ANC3 +) and three or more doses of intermittent preventive treatment (IPTp-SP3 +). Results Of the 1,021 women surveyed, 87.8% (n = 896) attended at least one ANC visit. Of these, 86.3% (n = 773) received at least one dose of IPTp-SP. Compliance with three or more doses of IPTp-SP was 63.7%. The determinants statistically related to ANC3 + were the early initiation of ANC (OR = 3.22 [1.22, 10.78]), and the presence of a community health centre (CHC) in the village (OR = 9.69 [1.09, 86.21]). The ability to read (OR = 1.60 [1.01, 2.55]), the early initiation of ANC (OR = 1.46 [1.06, 2.00], knowledge of the utility of the drug (OR = 2.38 [1.24, 4.57]), and knowledge of the recommended dose of the drug (OR = 6.11 [3.98, 9.39]) were related to completion of three or more treatments (IPTp-SP3 +). Conclusion The early initiation of ANC was a positive determinant of the completeness of both ANC3 + and IPTp-SP3 + . This study shows that a successful implementation of the IPTp strategy can be achieved by improving access to prenatal care at community health facilities, and strengthening patient-provider communication to ensure adequate knowledge on dosing of IPTp-SP and the benefits to mother and child.

Background The BRANCH Consortium recently conducted 10 mixed-methods case studies to investigate the provision of health and nutrition interventions for women and children in conflict-affected countries, aiming to better understand the dominant influences on humanitarian health actors’ programmatic decision-making and how such actors surmount intervention delivery barriers. In this paper, the research challenges encountered and the mitigating strategies employed by the case study investigators in four of the BRANCH case study contexts are discussed: Somalia, Mali, Pakistan and Afghanistan. Discussion Many of the encountered research challenges were anticipated, with investigators adopting mitigation strategies in advance or early on, but others were unexpected, with implications for how studies were ultimately conducted and how well the original study aims were met. Insecurity was a fundamental challenge in all study contexts, with restricted geographical access and concerns for personal safety affecting sampling and data collection plans, and requiring reliance on digital communications, remote study management, and off-site team meetings wherever possible. The need to navigate complex local sociopolitical contexts required maximum reliance on local partners’ knowledge, expertise and networks, and this was facilitated by early engagement with a wide range of local study stakeholders. Severe lack of reliable quantitative data on intervention coverage affected the extent to which information from different sources could be triangulated or integrated to inform an understanding of the influences on humanitarian actors’ decision-making. Conclusion Strong local partners are essential to the success of any project, contributing not only technical and methodological capacity but also the insight needed to truly understand and interpret local dynamics for the wider study team and to navigate those dynamics to ensure study rigour and relevance. Maintaining realistic expectations of data that are typically available in conflict settings is also essential, while pushing for more resources and further methodological innovation to improve data collection in such settings. Finally, successful health research in the complex, dynamic and unpredictable contexts of conflict settings requires flexibility and adaptability of researchers, as well as sponsors and donors.

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