Linkage to Care Intervention to Improve Post-hospital Outcomes Among Children with Sickle Cell Anemia in Tanzania: A Pilot Study

Background: Of the 300,000 infants born with sickle cell anemia (SCA) yearly, 75% are born in sub-Saharan Africa. Approximately 50%-80% of these children will die before adulthood. The period after hospitalization carries significant risk for mortality. A previous observational study in Tanzania showed that children with SCA have a 20% chance of dying in the year following hospitalization. Attendance at a SCA clinic lowers mortality for children with SCA. We conducted a pilot study to determine the effectiveness of a social worker intervention at improving post-hospital outcomes. The primary objective was to compare 12-month post-hospital mortality rates between children with SCA receiving a social worker intervention and historical controls and to identify factors associated with failure to link to clinic.

Methods: The study was conducted at Bugando Medical Center (BMC) in Mwanza, Tanzania from June 2018 - October 2019. Eligible participants were children with SCA hospitalized at BMC. Children enrolled into the study underwent a social worker intervention that consisted of five meetings over a 3-month period after hospitalization. Meetings occurred on average every two weeks either at the child’s home, clinic site or a designated convenient location. The sessions focused on identifying strengths/barriers to accessing care, goal settings, and transitioning the social worker’s responsibilities to a clinic.

The primary study outcome was mortality. Secondary study outcomes were clinic attendance (defined as 2 visits within past 3 months) and cumulative rate of readmission. These outcomes were measured at 3, 6 and 12 months after hospitalization. We also interviewed families and healthcare workers to identify factors associated with failure to link to clinic.

Results: Fifty-nine children were enrolled in the interventional cohort. One-hundred percent completed all five social work sessions. The post-hospital mortality at 12 months was 4/59 (6.7%) (Table 1). This was significantly lower than the 19.2% mortality observed in the historical cohort (adjusted Hazard Ratio (aHR) 0.26, 95% CI 0.08 to 0.83; p=0.023). Clinic attendance improved from 45.6% in the historical cohort to 93.2% in the interventional cohort (aHR 7.05, 95% CI 2.39 to 20.77; p<0.001), and the cumulative rate of readmission was 50.8% in the historical cohort compared with 70.4% in the interventional cohort (aHR, 1.17; 95% CI, 0.73-1.87; P = 0.543).

Sixty-two interviews were performed with families or healthcare workers. Using the Gelberg and Andersen Behavioral Model for Health Care Utilization for Vulnerable Populations, key factors identified as influencing linkage to care are listed in Figure 1.

Conclusion: Implementing a social worker intervention during the first 3 months after hospitalization for children with SCA may improve clinic attendance and reduce post-hospital mortality. Further research should be directed at interventions to reduce barriers to linkage to care.