Development and evaluation of a subjective measurement of geographical hardness-to-reach: a survey of data collectors in a large-scale cluster randomised trial of azithromycin mass drug administration.

In 30 seconds

This sub-study within a large-scale cluster-randomised trial of azithromycin mass drug administration in Mali developed and evaluated a 14-item survey of village accessibility, completed by 25 data collectors. The survey took a mean of three minutes and showed moderate-to-strong inter-rater reliability. Subjective inaccessibility scores were associated with under-five mortality: a one standard deviation shift towards harder access corresponded to up to 8% higher under-five mortality, even after adjustment for distance to the nearest health centre. The authors judged feasibility and reliability acceptable, with moderate convergent and predictive validity.

Key findings

• Survey completion took a mean of three minutes.
• A one standard deviation shift towards harder access was associated with up to 8% higher under-five mortality, adjusted for distance to the nearest health centre.
• Average inter-rater ICCs were 0.74 for the all-item composite score and 0.69 for the two-item score.
• The all-item score correlated with distance to the nearest health facility (0.36), average monthly rainfall (0.22), and travel time by car (0.35); all P < 0.001.

Why it matters

Straight-line or measured distance may not capture the practical barriers that affect access to health services. This brief, data-collector-rated measure showed associations with objective accessibility indicators and under-five mortality, suggesting that subjective village-level assessments may add useful context when characterising access barriers in public health programmes.

What to keep in mind

This was a sub-study using assessments from 25 data collectors in Mali; the reported validity was moderate, and the mortality association is observational rather than evidence that inaccessibility causes higher mortality.