AIM: To accelerate progress in reducing child mortality, many countries in sub-Saharan Africa have adopted and scaled-up integrated community case management (iCCM) programs targeting the three major infectious killers of children under-five. The programs train lay community health workers to assess, classify and treat uncomplicated cases of pneumonia with antibiotics, malaria with antimalarial drugs and diarrhea with Oral Rehydration Salts (ORS) and zinc. Although management of these conditions with the respective appropriate drugs has proven efficacious in randomized trials, the effectiveness of large iCCM scale-up programs in reducing child mortality is yet to be demonstrated. This paper reviews recent experience in documenting and attributing changes in under-five mortality to the specific interventions of a variety of iCCM programs.
METHODS: Eight recent studies have been identified and assessed in terms of design, mortality measurement and results. Impact of the iCCM program on mortality among children age 2-59 months was assessed through a difference in differences approach using random effect Poisson regression.
RESULTS: Designs used by these studies include cluster randomized trials, randomized stepped-wedge and quasi-experimental trials. Child mortality is measured through demographic surveillance or household survey with full birth history conducted at the end of program implementation. Six of the eight studies showed a higher decline in mortality among children 2-59 months in program areas compared to comparison areas, although this acceleration was statistically significant in only one study with a decline of 76% larger in intervention than in comparison areas.
CONCLUSION: Studies that evaluate large scale iCCM programs and include assessment of mortality impact must ensure an appropriate design. This includes required sample sizes and sufficient number of program and comparison districts that allow adequate inference and attribution of impact. In addition, large-scale program utilization, and a significant increase in coverage of care seeking and treatment of targeted childhood illnesses are preconditions to measurable mortality impact. Those issues need to be addressed before large investments in assessing changes in child mortality is undertaken, or the results of mortality impact evaluation will most likely be inconclusive.
BACKGROUND: Geography poses serious challenges to delivery of health services and is a well documented marker of inequity. Maternal, newborn and child health (MNCH) outcomes are poorer in mountainous regions of low and lower-middle income countries due to geographical inaccessibility combined with other barriers: poorer quality services, persistent cultural and traditional practices and lower socioeconomic and educational status. Reaching universal coverage goals will require attention for remote mountain settings. This study aims to identify strategies to address barriers to reproductive MNCH (RMNCH) service utilisation in difficult-to-reach mountainous regions in low and lower-middle income settings worldwide.
METHODS: A systematic literature review drawing from MEDLINE, Web of Science, Scopus, Google Scholar, and Eldis. Inclusion was based on; testing an intervention for utilisation of RMNCH services; remote mountain settings of low- and lower-middle income countries; selected study designs. Studies were assessed for quality and analysed to present a narrative review of the key themes.
FINDINGS: From 4,130 articles 34 studies were included, from Afghanistan, Bolivia, Ethiopia, Guatemala, Indonesia, Kenya, Kyrgyzstan, Nepal, Pakistan, Papua New Guinea and Tajikistan. Strategies fall into four broad categories: improving service delivery through selected, trained and supported community health workers (CHWs) to act alongside formal health workers and the distribution of critical medicines to the home; improving the desirability of existing services by addressing the quality of care, innovative training and supervision of health workers; generating demand by engaging communities; and improving health knowledge for timely care-seeking. Task shifting, strengthened roles of CHWs and volunteers, mobile teams, and inclusive structured planning forums have proved effective.
CONCLUSIONS: The review highlights where known evidence-based strategies have increased the utilisation of RMNCH services in low income mountainous areas. While these are known strategies in public health, in such disadvantaged settings additional supports are required to address both supply and demand barriers.
INTRODUCTION: Diarrhea and pneumonia are the two leading causes of mortality in children under five. Improvements have occurred over the past two decades but the progress is slow to meet the MDG-4.
METHODS: We conducted a systematic review of the randomized controlled trials, quasi-experimental and observational studies to estimate the effect of community based interventions including community case management on the coverage of various commodities and on mortality due to diarrhea and pneumonia. We used a standardized abstraction and grading format and performed meta-analyses for all the relevant outcomes. The estimated effect of community based interventions was determined by applying the standard Child Health Epidemiology Reference Group (CHERG) rules.
RESULTS: We included twenty four studies in this review. Community based interventions led to significant rise in care seeking behaviors with 13% and 9% increase in care seeking for pneumonia and diarrhea respectively. These interventions were associated with 160% increase in the use of ORS and 80% increase in the use of zinc for diarrhea. There was a 75% decline in the unnecessary use of antibiotics for diarrhea and a 40% decrease in treatment failure rates for pneumonia. Community case management for diarrhea and pneumonia is associated with a 32% reduction in pneumonia specific mortality, while the evidence on diarrhea related mortality is weak.
CONCLUSION: Community based interventions have the potential to scale up care seeking and the use of essential commodities and significantly decrease morbidity and mortality burden due to diarrhea and pneumonia in children under the age of five years.
BACKGROUND: Each year almost one million newborns die from infections, mostly in low-income countries. Timely case management would save many lives but the relative mortality effect of varying strategies is unknown. We have estimated the effect of providing oral, or injectable antibiotics at home or in first-level facilities, and of in-patient hospital care on neonatal mortality from pneumonia and sepsis for use in the Lives Saved Tool (LiST).
METHODS: We conducted systematic searches of multiple databases to identify relevant studies with mortality data. Standardized abstraction tables were used and study quality assessed by adapted GRADE criteria. Meta-analyses were undertaken where appropriate. For interventions with biological plausibility but low quality evidence, a Delphi process was undertaken to estimate effectiveness.
RESULTS: Searches of 2876 titles identified 7 studies. Among these, 4 evaluated oral antibiotics for neonatal pneumonia in non-randomised, concurrently controlled designs. Meta-analysis suggested reductions in all-cause neonatal mortality (RR 0.75 95% CI 0.64- 0.89; 4 studies) and neonatal pneumonia-specific mortality (RR 0.58 95% CI 0.41- 0.82; 3 studies). Two studies (1 RCT, 1 observational study), evaluated community-based neonatal care packages including injectable antibiotics and reported mortality reductions of 44% (RR = 0.56, 95% CI 0.41-0.77) and 34% (RR = 0.66, 95% CI 0.47-0.93), but the interpretation of these results is complicated by co-interventions. A third, clinic-based, study reported a case-fatality ratio of 3.3% among neonates treated with injectable antibiotics as outpatients. No studies were identified evaluating injectable antibiotics alone for neonatal pneumonia. Delphi consensus (median from 20 respondents) effects on sepsis-specific mortality were 30% reduction for oral antibiotics, 65% for injectable antibiotics and 75% for injectable antibiotics on pneumonia-specific mortality. No trials were identified assessing effect of hospital management for neonatal infections and Delphi consensus suggested 80%, and 90% reductions for sepsis and pneumonia-specific mortality respectively.
CONCLUSION: Oral antibiotics administered in the community are effective for neonatal pneumonia mortality reduction based on a meta-analysis, but expert opinion suggests much higher impact from injectable antibiotics in the community or primary care level and even higher for facility-based care. Despite feasibility and low cost, these interventions are not widely available in many low income countries.
FUNDING: This work was supported by the Bill & Melinda Gates Foundation through a grant to the US Fund for UNICEF, and to Saving Newborn Lives Save the Children, through Save the Children US.
BACKGROUND: Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. Little is known, however, about the effectiveness of LHW interventions.
OBJECTIVES: To assess the effects of LHW interventions in primary and community health care on maternal and child health and the management of infectious diseases.
SEARCH STRATEGY: For the current version of this review we searched The Cochrane Central Register of Controlled Trials (including citations uploaded from the EPOC and the CCRG registers) (The Cochrane Library 2009, Issue 1 Online) (searched 18 February 2009); MEDLINE, Ovid (1950 to February Week 1 2009) (searched 17 February 2009); MEDLINE In-Process & Other Non-Indexed Citations, Ovid (February 13 2009) (searched 17 February 2009); EMBASE, Ovid (1980 to 2009 Week 05) (searched 18 February 2009); AMED, Ovid (1985 to February 2009) (searched 19 February 2009); British Nursing Index and Archive, Ovid (1985 to February 2009) (searched 17 February 2009); CINAHL, Ebsco 1981 to present (searched 07 February 2010); POPLINE (searched 25 February 2009); WHOLIS (searched 16 April 2009); Science Citation Index and Social Sciences Citation Index (ISI Web of Science) (1975 to present) (searched 10 August 2006 and 10 February 2010). We also searched the reference lists of all included papers and relevant reviews, and contacted study authors and researchers in the field for additional papers.
SELECTION CRITERIA: Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community health care and intended to improve maternal or child health or the management of infectious diseases. A 'lay health worker' was defined as any health worker carrying out functions related to healthcare delivery, trained in some way in the context of the intervention, and having no formal professional or paraprofessional certificate or tertiary education degree. There were no restrictions on care recipients.
DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data using a standard form and assessed risk of bias. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the study results were combined and an overall estimate of effect obtained.
MAIN RESULTS: Eighty-two studies met the inclusion criteria. These showed considerable diversity in the targeted health issue and the aims, content, and outcomes of interventions. The majority were conducted in high income countries (n = 55) but many of these focused on low income and minority populations. The diversity of included studies limited meta-analysis to outcomes for four study groups. These analyses found evidence of moderate quality of the effectiveness of LHWs in promoting immunisation childhood uptake (RR 1.22, 95% CI 1.10 to 1.37; P = 0.0004); promoting initiation of breastfeeding (RR = 1.36, 95% CI 1.14 to 1.61; P < 0.00001), any breastfeeding (RR 1.24, 95% CI 1.10 to 1.39; P = 0.0004), and exclusive breastfeeding (RR 2.78, 95% CI 1.74 to 4.44; P <0.0001); and improving pulmonary TB cure rates (RR 1.22 (95% CI 1.13 to 1.31) P <0.0001), when compared to usual care. There was moderate quality evidence that LHW support had little or no effect on TB preventive treatment completion (RR 1.00, 95% CI 0.92 to 1.09; P = 0.99). There was also low quality evidence that LHWs may reduce child morbidity (RR 0.86, 95% CI 0.75 to 0.99; P = 0.03) and child (RR 0.75, 95% CI 0.55 to 1.03; P = 0.07) and neonatal (RR 0.76, 95% CI 0.57 to 1.02; P = 0.07) mortality, and increase the likelihood of seeking care for childhood illness (RR 1.33, 95% CI 0.86 to 2.05; P = 0.20). For other health issues, the evidence is insufficient to draw conclusions regarding effectiveness, or to enable the identification of specific LHW training or intervention strategies likely to be most effective.
AUTHORS' CONCLUSIONS: LHWs provide promising benefits in promoting immunisation uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared to usual care. For other health issues, evidence is insufficient to draw conclusions about the effects of LHWs.
BACKGROUND: With the aim of populating the Lives Saved Tool (LiST) with parameters of effectiveness of existing interventions, we conducted a systematic review of the literature assessing the effect of pneumonia case management on mortality from childhood pneumonia.
METHODS: This review covered the following interventions: community case management with antibiotic treatment, and hospital treatment with antibiotics, oxygen, zinc and vitamin A. Pneumonia mortality outcomes were sought where available but data were also recorded on secondary outcomes. We summarized results from randomized controlled trials (RCTs), cluster RCTs, quasi-experimental studies and observational studies across outcome measures using standard meta-analysis methods and used a set of standardized rules developed for the purpose of populating the LiST with required parameters, which dealt with the issues of comparability of the studies in a uniform way across a spectrum of childhood conditions.
RESULTS: We estimate that community case management of pneumonia could result in a 70% reduction in mortality from pneumonia in 0-5-year-old children. In contrast treatment of pneumonia episodes with zinc and vitamin A is ineffective in reducing pneumonia mortality. There is insufficient evidence to make a quantitative estimate of the effect of hospital case management on pneumonia mortality based on the published data.
CONCLUSION: The available evidence reinforces the effectiveness of community and hospital case management with World Health Organization-recommended antibiotics and the lack of effect of zinc and vitamin A supportive treatment for children with pneumonia. Evidence from one trial demonstrates the effectiveness of oxygen therapy but further research is required to give higher quality evidence so that an effect estimate can be incorporated into the LiST model. We identified no trials that separately evaluated the effectiveness of other supportive care interventions. The summary estimates of effect on pneumonia mortality will inform the LiST model.
This article assesses 36 peer-reviewed studies of the impact of primary healthcare (PHC) on health outcomes in low- and middle-income countries. Studies were abstracted and assessed according to where they took place, the research design used, target population, primary care measures, and overall conclusions. Results indicate that the bulk of evidence for PHC effectiveness is focused on infant and child health, but there is also evidence of the positive role PHC has on population health over time. Although the peer-reviewed literature is lacking in rigorous experimental studies, a small number of relatively well-designed observational studies and the consistency of findings generally support the contention that an integrated approach to primary care can improve health. A few large-scale experiences also help identify elements of good practice. The review concludes with several recommendations for future studies, including a focus on better conceptualizing and measuring PHC, further investigation into the advantages of comprehensive over selective PHC, need for experimental or quasi-experimental research designs that allow testing of the independent effect of primary care on outcomes over time, and a more detailed conceptual framework guiding overall evaluation design that places limits on the parameters under consideration and describes relationships among different levels and types of data likely to be collected in the evaluation process.
A disproportionate burden of infant and under-five childhood mortality occurs during the neonatal period, usually within a few days of birth and against a backdrop of socio-economic deprivation in developing countries. To guide programmes aimed at averting these 4 million annual deaths, recent reviews have evaluated the efficacy and cost-effectiveness of individual interventions during the antenatal, intrapartum and postnatal periods in reducing neonatal mortality, and packages of interventions have been proposed for wide-scale implementation. However, no systematic review of the empirical data on packages of interventions, including consideration of community-based intervention packages, has yet been performed. To address this gap, we reviewed peer-reviewed journals and grey literature to evaluate the content, impact, efficacy (implementation under ideal circumstances), effectiveness (implementation within health systems), type of provider, and cost of packages of interventions reporting neonatal health outcomes. Studies employing more than one biologically plausible neonatal health intervention (i.e. package) and reporting neonatal morbidity or mortality outcomes were included. Studies were ordered by study design and mortality stratum, and their component interventions classified by time period of delivery and service delivery mode. We found 41 studies that implemented packages of interventions and reported neonatal health outcomes, including 19 randomized controlled trials. True effectiveness trials conducted at scale in health systems were completely lacking. No study targeted women prior to conception, antenatal interventions were largely micronutrient supplementation studies, and intrapartum interventions were limited principally to clean delivery. Few studies approximated complete packages recommended in The Lancet's Neonatal Survival Series. Interventions appeared largely bundled out of convenience or funding requirements, rather than based on anticipated synergistic effects, like service delivery mode or cost-effectiveness. Only two studies reported cost-effectiveness data. The evidence base for the impact of neonatal health intervention packages is a weak foundation for guiding effective implementation of public health programmes addressing neonatal health. Significant investment in effectiveness trials carefully tailored to local health needs and conducted at scale in developing countries is required.
To appraise the effectiveness of the pneumonia case-management strategy in improving child survival, we have done a meta-analysis of six published intervention trials. The results of a seventh published study and two unpublished studies were also reviewed. The six published studies satisfied our criteria for methodological soundness. The reduction in mortality rate (control group minus intervention group) was estimated for each study, and for all the studies together. For total infant mortality, the overall reduction was 15.9 (95% confidence interval 10.6-21.1) deaths per 1000 livebirths; infant mortality due to acute lower respiratory infection was reduced by 10.7 (4.8-16.7) deaths/1000 livebirths. Mortality among children under 5 years was decreased by 36 deaths/1000 livebirths. The pooled estimates of relative risk are consistent with a 20% reduction in infant mortality and a 25% reduction in under-5 mortality. There was no clear association across the studies between the effect of the pneumonia case-management and extent of co-interventions such as immunisation and oral rehydration therapy. The consistency of findings of all the studies, despite differences in design and methods, shows that the case-management strategy has a substantial effect on infant and under-5 mortality, at least in settings with infant mortality rates of 90/1000 livebirths or more. It is important to find out the most efficient ways of implementing this strategy and integrating it into primary health care.
To accelerate progress in reducing child mortality, many countries in sub-Saharan Africa have adopted and scaled-up integrated community case management (iCCM) programs targeting the three major infectious killers of children under-five. The programs train lay community health workers to assess, classify and treat uncomplicated cases of pneumonia with antibiotics, malaria with antimalarial drugs and diarrhea with Oral Rehydration Salts (ORS) and zinc. Although management of these conditions with the respective appropriate drugs has proven efficacious in randomized trials, the effectiveness of large iCCM scale-up programs in reducing child mortality is yet to be demonstrated. This paper reviews recent experience in documenting and attributing changes in under-five mortality to the specific interventions of a variety of iCCM programs.
METHODS:
Eight recent studies have been identified and assessed in terms of design, mortality measurement and results. Impact of the iCCM program on mortality among children age 2-59 months was assessed through a difference in differences approach using random effect Poisson regression.
RESULTS:
Designs used by these studies include cluster randomized trials, randomized stepped-wedge and quasi-experimental trials. Child mortality is measured through demographic surveillance or household survey with full birth history conducted at the end of program implementation. Six of the eight studies showed a higher decline in mortality among children 2-59 months in program areas compared to comparison areas, although this acceleration was statistically significant in only one study with a decline of 76% larger in intervention than in comparison areas.
CONCLUSION:
Studies that evaluate large scale iCCM programs and include assessment of mortality impact must ensure an appropriate design. This includes required sample sizes and sufficient number of program and comparison districts that allow adequate inference and attribution of impact. In addition, large-scale program utilization, and a significant increase in coverage of care seeking and treatment of targeted childhood illnesses are preconditions to measurable mortality impact. Those issues need to be addressed before large investments in assessing changes in child mortality is undertaken, or the results of mortality impact evaluation will most likely be inconclusive.
