Care-seeking for fatal illnesses in young children in Indramayu, west Java, Indonesia

Associations of single versus multiple anthropometric failure with mortality in children under 5 years: A prospective cohort study

Background/objectives

Stunting, underweight, and wasting are used to monitor nutritional status in children, but they do not identify children with concurrent anthropometric failures (AF). Our study estimates the association between AF and mortality in children with single versus multiple failures, then calculates the percentage of child deaths attributable to AF.

Subjects/methods

Using data from a prospective, longitudinal study of 3605 children from age 1 to age 5 years in Ethiopia and India, we estimate the association between AF and mortality using conventional definitions (stunting, underweight, and wasting) and the mutually exclusive categories of stunted only underweight only, wasted only, stunted and underweight (SU), underweight and wasted, and stunted, underweight, and wasted (SUW), adjusting for socioeconomic status and other demographic variables. Last, we calculate the population attributable fraction.

Results

Children who were SU and SUW had 3.20 (95% CI: 1.69, 6.06; p < 0.001) and 5.52 (95% CI: 2.25, 13.56; p < 0.001) times the odds of death in fully adjusted models by Round 2 compared to children with no failure, while no increased mortality risk was found among children with other categories of failure. We estimate that 42.69% of child deaths can be attributed to children who are SUW (17.02%) or SU (25.67%), accounting for nearly 80% of child deaths from AF.

Conclusions

This study provides new insight to programs and policy to better identify children most at risk of malnutrition-related mortality.

Health-Seeking Behavior of People in Indonesia: A Narrative Review

This review aims to locate existing studies on health-seeking behavior of people in Indonesia, identify gaps, and highlight important findings. Articles were retrieved from Medline, Scopus, Web of Science, Academic Search Complete (via Ebsco), and ProQuest with a number of key words and various combinations. Articles from Indonesian journals were also searched for with Google Scholar. A total of 56 articles from peer-reviewed journal databases and 19 articles from Indonesian journals were reviewed. Quantitative designs were applied more frequently than qualitative, and mixed methods designs were used in some studies. The majority gathered retrospective information about people's behaviors. Communicable diseases and maternity care were the most frequently studied conditions, in contrast to noncommunicable diseases. In terms of geographical distribution, most research was conducted on Java island, with very few in outside Java. Important findings are a model of Indonesian care-seeking pathways, an understanding of determinants of people's care choices, and the role of sociocultural beliefs. The findings from this narrative review provide insight to what and how Indonesians make decisions to manage their illness and why. This makes an important contribution to understanding the problem of underutilization of medical services despite the government's extensive efforts to improve accessibility.

Management of fast breathing pneumonia in young infants aged 7 to 59 days by community level health workers: protocol for a multi-centre cluster randomized controlled trial

Background:

WHO does not recommend community-level health workers (CLHWs) using integrated community case management (iCCM) to treat 7–59 days old infants with fast breathing with oral amoxicillin, whereas World Health Organization (WHO) integrated management of childhood illness (IMCI) recommends it. We want to collect evidence to help harmonization of both protocols.

Methods:

A cluster, randomized, open-label trial will be conducted in Africa and Asia (Ethiopia, Malawi, Bangladesh and India) using a common protocol with the same study design, inclusion criteria, intervention, comparison, and outcomes to contribute to the overall sample size. This trial will also identify hypoxaemia in young infants with fast breathing. CLHWs will assess infants for fast breathing, which will be confirmed by a study supervisor. Enrolled infants in the intervention clusters will be treated with oral amoxicillin, whereas in the control clusters they will be managed as per existing iCCM protocol. An independent outcome assessor will assess all enrolled infants on days 6 and 14 of enrolment for the study outcomes in both intervention and control clusters. Primary outcome will be clinical treatment failure by day 6. This trial will obtain approval from the WHO and site institutional ethics committees.

Conclusions:

If the research shows that CLHWs can effectively and safely treat fast breathing pneumonia in 7–59 days old young infants, it will increase access to pneumonia treatment substantially for infants living in communities with poor access to health facilities. Additionally, this evidence will contribute towards the review of the current iCCM protocol and its harmonization with IMCI protocol.

Trial Registration:

The trial is registered at AZNCTR International Trial Registry as ACTRN12617000857303.

NON-INVASIVE PREDICTION MODEL FOR DEVELOPING COUNTRIES TO PREDICT SEPSIS IN NEONATES

Majority of global neonatal deaths is due to sepsis. A vast portion of these deaths occurs in developing countries due to inaccessibility of hospitals or lack of resources. Blood culture is the test to confirm sepsis, but it requires the presence of laboratory and is time-consuming. Therefore, we require simple, easy to use methods to predict sepsis in homes. Majority of the available prediction models need invasive parameters and hence become useless in the rural areas of developing countries where laboratory facilities do not exist. Non-invasive prediction models overcome these challenges to predict neonatal sepsis in places where there is a scarcity of laboratories. The aim and objective of this study are as follows: (i) to develop a practical, non-invasive prediction-model for neonatal sepsis which can be used in the rural areas of developing countries and to validate its performance. (ii) To compare the prognostic performance of the non-invasive prediction model with invasive prediction model and (iii) to create a prototype of the hardware which calculates the probability of the sepsis in neonates and sends the real-time data to the cloud. For this retrospective analysis, we extracted the data of 1446 neonates from Medical Information Mart for Intensive care III (MIMIC) database. Using stepwise logistic regression analysis, we developed and validated two prediction models. These two models were named as model NI and model O. Model O contains invasive as well as non-invasive parameters whereas model NI contains only non-invasive parameters. Model NI performed equally well in comparison to Model O despite using different predictors. The area under ROC curves for model NI and model O were 0.879 (95% CI: 0.857 to 0.899) and 0.861 (95% CI: 0.838 to 0.881) respectively. Both models were statistically significant with [Formula: see text]-value[Formula: see text].

Health care seeking for maternal and newborn illnesses in low- and middle-income countries: a systematic review of observational and qualitative studies

Background: In low- and middle-income countries, a large number of maternal and newborn deaths occur due to delays in health care seeking. These delays occur at three levels i.e. delay in making decision to seek care, delay in access to care, and delay in receiving care. Factors that cause delays are therefore need to be understand to prevent and avoid these delays to improve health and survival of mothers and babies.   

Methods: A systematic review of observational and qualitative studies to identify factors and barriers associated with delays in health care seeking.

Results: A total of 159 observational and qualitative studies met the inclusion criteria. The review of observational and qualitative studies identified social, cultural and health services factors that contribute to delays in health care seeking, and influence decisions to seek care. Timely recognition of danger signs, availability of finances to arrange for transport and affordability of health care cost, and accessibility to a health facility were some of these factors.

Conclusions: Effective dealing of factors that contribute to delays in health care seeking would lead to significant improvements in mortality, morbidity and care seeking outcomes, particularly in countries that share a major brunt of maternal and newborn morbidity and mortality.

Registration: PROSPERO CRD42012003236.

Illness recognition and appropriate care seeking for newborn complications in rural Oromia and Amhara regional states of Ethiopia

Background

Ethiopia has made significant progress in reducing child mortality but newborn mortality has stagnated at around 29 deaths per 1000 births. The Maternal Health in Ethiopia Partnership (MaNHEP) was a 3.5-year implementation project aimed at developing a community-oriented model of maternal and newborn health in rural Ethiopia and to position it for scale up. In 2014, we conducted a case study of the project focusing on recognition of and timely biomedical care seeking for maternal and newborn complications. In this paper, we detail the main findings from one component of the case study – the narrative interviews on newborn complications.

Methods

The study area, comprised of six districts in which MaNHEP had been implemented, was located in the two most populous federal regions of Ethiopia, Oromia and Amhara. The final purposive sample consisted of 16 cases in which the newborn survived to 28 days of life, and 13 cases in which the newborn died within 28 days of life, for a total sample size of 29 cases. Narrative interview were conducted with the main caregiver and several witnesses to the event. Analysis of the data included thematic content analysis and the determination of care seeking pathways and levels and timeliness of biomedical care seeking.

Results

Mothers and other witnesses do recognize certain symptoms of newborn illness which they often mentioned in clusters. The majority considered the symptoms to be serious and in some case hopeless. Perceived causes were mostly natural. Forty-one percent of care seekers sought timely biomedical care in the neonatal period. Surprisingly, perceived severity did not necessarily trigger care seeking. Facilitators of biomedical care seeking included accessibility of health facilities and counseling by health workers, whereas barriers included perceived vulnerability of newborns, post-partum restrictions on movements, hopelessness, wait-and-see atttitudes, poor communication and physical inaccessibility of health facilities.

Conclusions

Symptom recognition and care seeking patterns indicate the need to strengthen focused locally relevant health messages which target mothers, fathers and other community members, to further enhance access to health care and to improve referral and quality of care.

Responses to hypothetical health scenarios overestimate healthcare utilization for common infectious syndromes: a cross-sectional survey, South Africa, 2012

Background

Asking people how they would seek healthcare in a hypothetical situation can be an efficient way to estimate healthcare utilization, but it is unclear how intended healthcare use corresponds to actual healthcare use.

Methods

We performed a cross-sectional survey between August and September 2012 among households in Soweto and Klerksdorp, South Africa, to compare healthcare seeking behaviors intended for hypothetical common infectious syndromes (pneumonia, influenza-like illness [ILI], chronic respiratory illness, meningitis in persons of any age, and diarrhea in a child < 5 years old) with the self-reported healthcare use among patients with those syndromes.

Results

For most syndromes, the proportion of respondents who intended to seek healthcare at any facility or provider (99–100%) in a hypothetical scenario exceeded the proportion that did seek care (78–100%). More people intended to seek care for a child < 5 years old with diarrhea (186/188 [99%]) than actually did seek care (32/41 [78%], P < 0.01). Although most people faced with hypothetical scenarios intended to seek care with licensed medical providers such as hospitals and clinics (97–100%), patients who were ill reported lower use of licensed medical providers (55–95%).

Conclusions

People overestimated their intended healthcare utilization, especially with licensed medical providers, compared with reported healthcare utilization among patients with these illnesses. Studies that measure intended healthcare utilization should consider that actual use of healthcare facilities may be lower than intended use.

Leveraging the private sector for child health: a qualitative examination of caregiver and provider perspectives on private sector care for childhood pneumonia in Uttar Pradesh, India

BACKGROUND

The private health sector is a primary source of curative care for childhood illnesses in many low- and middle-income countries. Therefore ensuring appropriate private sector care is an important step towards improving outcomes from illnesses like pneumonia, which is the leading infectious cause of childhood mortality worldwide. This study aimed to provide evidence on private sector care for childhood pneumonia in Uttar Pradesh, India, by simultaneously exploring providers' knowledge and practices and caregivers' experiences.

METHODS

We conducted in-depth interviews with a purposive sample of 36 practitioners and 34 caregivers in two districts. Practitioners included allopathic doctors, AYUSH providers, and drug sellers. Caregivers were mothers of children under the age of five with symptoms consistent with pneumonia who had seen one of those practitioners. Interview transcripts were analyzed thematically.

RESULTS

Caregivers were generally prompt in seeking care outside the home, but many initially favored local informal providers based on access and cost. Drug sellers were not commonly consulted for treatment. Formal providers had imperfect, but reasonable, knowledge of pneumonia and followed appropriate steps for diagnosis, though some gaps were noticed that were primarily related to lack of (or failure to use) diagnostic tools. Most practitioners prescribed antibiotics and supportive symptomatic treatment. Relational and structural factors encouraged overuse of antibiotics and treatment interruption. Caregivers often had a limited understanding of treatment but wanted rapid symptomatic improvements, frequently leading to sequentially consulting multiple providers and interrupting treatment when symptoms improved. Providers were confronted with these expectations and care-seeking patterns.

CONCLUSIONS

This study contributes in-depth evidence on private sector care for childhood pneumonia in UP. Achieving appropriate care requires an enriched perspective that simultaneously considers the critical role of provider-caregiver interactions and of the context in which they occur in shaping treatment outcomes.

Increasing access to care for sick newborns: evidence from the Ghana Newhints cluster-randomised controlled trial

OBJECTIVES

To evaluate the impact of Newhints community-based surveillance volunteer (CBSV) assessments and referrals on access to care for sick newborns and on existing inequities in access.

DESIGN

We evaluated a prospective cohort nested within the Newhints cluster-randomised controlled trial.

SETTING

Community-based intervention involving more than 750 000, predominantly rural, population in seven contiguous districts in the Brong-Ahafo Region, Ghana.

PARTICIPANTS

Participants were recently delivered women (from more than 120 000 women under surveillance) and their 16 168 liveborn babies. Qualitative in-depth interviews with referral narratives (IDIs) were conducted with 92 mothers, CBSVs and health facility front-desk and maternity/paediatrics ward staff.

INTERVENTIONS

Newhints trained and effectively supervised 475 CBSVs (existing within the Ghana Health Service) in 49 of 98 supervisory zones (clusters) to assess and refer newborns with any of the 10-key-danger signs to health facilities within the first week after birth; promote independent care seeking for sick newborns and problem-solve around barriers between November 2008 and December 2009.

PRIMARY OUTCOMES

The main evaluation outcomes were rates of compliance with referrals and independent care seeking for newborn illnesses.

RESULTS

Of 4006 sampled, 2795 (69.8%) recently delivered women received CBSV assessment visits and 279 (10.0%) newborns were referred with danger signs. Compliance with referrals was unprecedentedly high (86.0%) with women in the poorest quintile (Q1) complying better than the least poor (Q5):87.5%(Q1) vs 69.7%(Q5); p=0.038. Three-quarters went to hospitals; 18% were admitted and 58% received outpatient treatment. Some (24%) mothers were turned away at facilities and follow-on IDIs showed that some of these untreated babies subsequently died. Independent care seeking for severe newborn illness increased from 55.4% in control to 77.3% in Newhints zones, especially among Q1 where care seeking almost doubled (95.0% vs 48.6%; RR=1.94 (1.32, 2.84); p=0.001). Rates were the highest among rural residents but urban residents complied quicker.

CONCLUSIONS

Home visits are feasible and a potentially pro-poor approach to link sick newborns to facilities. Its effectiveness in improving survival hinges on matched improvement in facility quality of care.

TRIAL REGISTRATION NUMBER

NCT00623337.

Taken to Health Care Provider or Not, Under-Five Children Die of Preventable Causes: Findings from Cross-Sectional Survey and Social Autopsy in Rural India

Background:

Under-five children in India continue to die from causes that can either be treated or prevented. The data regarding causes of death, community care-seeking practices, and events prior to death are needed to guide and refine health policies for achieving national goals and targets.

Materials and Methods:

A cross-sectional survey covering rural areas of 16 districts from eight states across India was conducted to understand the causes of deaths and the health-seeking patterns of caregivers prior to the death of such children. Mothers of the deceased children were interviewed. The physician review process was used to assign cause of death. The qualitative data were analyzed as per standard methods, while STATA version 10 was used for analysis of quantitative data.

Findings:

A total of 1,488 death histories were captured through verbal autopsy. Neonatal etiologies, acute respiratory infection (ARI), and diarrhea accounted for approximately 63.1% of all deaths in the under-five age group. The causes of death in neonates showed that birth asphyxia, prematurity, and neonatal infections contributed to more than 67.5% of all neonatal deaths, while in children aged 29 days to 59 months, ARI and diarrhea accounted for 54.3% of deaths. Care providers of 52.6% of the neonates and 21.7% of infants and under-five children did not seek any medical care before the death of the child. Substantial delays in seeking care occurred at home and during transit. For those who received medical care, there was an apparent amongst in their caregivers toward private health providers.

Conclusion:

The deaths of neonates and postneonates taken to any health facilities highlight the need for providing equitable and high-quality health services in India. The findings could be used for policy planning and program refinement in India.

Simplified antibiotic regimens compared with injectable procaine benzylpenicillin plus gentamicin for treatment of neonates and young infants with clinical signs of possible serious bacterial infection when referral is not possible: a randomised, open-label, equivalence trial

BACKGROUND

WHO recommends hospital-based treatment for young infants aged 0-59 days with clinical signs of possible serious bacterial infection, but most families in resource-poor settings cannot accept referral. We aimed to assess whether use of simplified antibiotic regimens to treat young infants with clinical signs of severe infection was as efficacious as an injectable procaine benzylpenicillin-gentamicin combination for 7 days for situations in which hospital referral was not possible.

METHODS

In a multisite open-label equivalence trial in DR Congo, Kenya, and Nigeria, community health workers visited all newborn babies at home, identifying and referring unwell young infants to a study nurse. We stratified young infants with clinical signs of severe infection whose parents did not accept referral to hospital by age (0-6 days and 7-59 days), and randomly assigned each individual within these strata to receive one of the four treatment regimens. Randomisation was stratified by age group of infants. An age-stratified randomisation scheme with block size of eight was computer-generated off-site at WHO. The outcome assessor was masked. We randomly allocated infants to receive injectable procaine benzylpenicillin-gentamicin for 7 days (group A, reference group); injectable gentamicin and oral amoxicillin for 7 days (group B); injectable procaine benzylpenicillin-gentamicin for 2 days, then oral amoxicillin for 5 days (group C); or injectable gentamicin for 2 days and oral amoxicillin for 7 days (group D). Trained health professionals gave daily injections and the first dose of oral amoxicillin. Our primary outcome was treatment failure by day 8 after enrolment, defined as clinical deterioration, development of a serious adverse event (including death), no improvement by day 4, or not cured by day 8. Independent outcome assessors, who did not know the infant's treatment regimen, assessed study outcomes on days 4, 8, 11, and 15. Primary analysis was per protocol. We used a prespecified similarity margin of 5% to assess equivalence between regimens. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12610000286044.

FINDINGS

In Kenya and Nigeria, we started enrolment on April 4, 2011, and we enrolled the necessary number of young infants aged 7 days or older from Oct 17, 2011, to April 30, 2012. At these sites, we continued to enrol infants younger than 7 days until March 29, 2013. In DR Congo, we started enrolment on Sept 17, 2012, and continued until June 28, 2013. We randomly assigned 3564 young infants to either group A (n=894), group B (n=884), group C (n=896), or group D (n=890). We excluded 200 randomly assigned infants, who did not fulfil the predefined criteria of adherence to treatment and adequate follow-up. In the per-protocol analysis, 828 infants were included in group A, 826 in group B, 862 in group C, and 848 in group D. 67 (8%) infants failed treatment in group A compared with 51 (6%) infants in group B (risk difference -1·9%, 95% CI -4·4 to 0·1), 65 (8%) in group C (-0·6%, -3·1 to 2·0), and 46 (5%) in group D (-2·7%, -5·1 to 0·3). Treatment failure in groups B, C, and D was within the similarity margin compared with group A. During the 15 days after random allocation, 12 (1%) infants died in group A, compared with ten (1%) infants in group B, 20 (2%) infants in group C, and 11 (1%) infants in group D. An infant in group A had a serious adverse event other than death (injection abscess).

INTERPRETATION

The three simplified regimens were as effective as injectable procaine benzylpenicillin-gentamicin for 7 days on an outpatient basis in young infants with clinical signs of severe infection, without signs of critical illness, and whose caregivers did not accept referral for hospital admission.

FUNDING

Bill & Melinda Gates Foundation grant to WHO.

Development and formative evaluation of an innovative mHealth intervention for improving coverage of community-based maternal, newborn and child health services in rural areas of India

Background

A new cadre of village-based frontline health workers, called Accredited Social Health Activists (ASHAs), was created in India. However, coverage of selected community-based maternal, newborn and child health (MNCH) services remains low.

Objective

This article describes the process of development and formative evaluation of a complex mHealth intervention (ImTeCHO) to increase the coverage of proven MNCH services in rural India by improving the performance of ASHAs.

Design

The Medical Research Council (MRC) framework for developing complex interventions was used. Gaps were identified in the usual care provided by ASHAs, based on a literature search, and SEWA Rural's1 three decades of grassroots experience. The components of the intervention (mHealth strategies) were designed to overcome the gaps in care. The intervention, in the form of the ImTeCHO mobile phone and web application, along with the delivery model, was developed to incorporate these mHealth strategies. The intervention was piloted through 45 ASHAs among 45 villages in Gujarat (population: 45,000) over 7 months in 2013 to assess the acceptability, feasibility, and usefulness of the intervention and to identify barriers to its delivery.

Results

Inadequate supervision and support to ASHAs were noted as a gap in usual care, resulting in low coverage of selected MNCH services and care received by complicated cases. Therefore, the ImTeCHO application was developed to integrate mHealth strategies in the form of job aid to ASHAs to assist with scheduling, behavior change communication, diagnosis, and patient management, along with supervision and support of ASHAs. During the pilot, the intervention and its delivery were found to be largely acceptable, feasible, and useful. A few changes were made to the intervention and its delivery, including 1) a new helpline for ASHAs, 2) further simplification of processes within the ImTeCHO incentive management system and 3) additional web-based features for enhancing value and supervision of Primary Health Center (PHC) staff.

Conclusions

The effectiveness of the improved ImTeCHO intervention will be now tested through a cluster randomized trial.

The recognition of and care seeking behaviour for childhood illness in developing countries: a systematic review

BACKGROUND

Pneumonia, diarrhoea, and malaria are among the leading causes of death in children. These deaths are largely preventable if appropriate care is sought early. This review aimed to determine the percentage of caregivers in low- and middle-income countries (LMICs) with a child less than 5 years who were able to recognise illness in their child and subsequently sought care from different types of healthcare providers.

METHODS AND FINDINGS

We conducted a systematic literature review of studies that reported recognition of, and/or care seeking for episodes of diarrhoea, pneumonia or malaria in LMICs. The review is registered with PROSPERO (registration number: CRD42011001654). Ninety-one studies met the inclusion criteria. Eighteen studies reported data on caregiver recognition of disease and seventy-seven studies on care seeking. The median sensitivity of recognition of diarrhoea, malaria and pneumonia was low (36.0%, 37.4%, and 45.8%, respectively). A median of 73.0% of caregivers sought care outside the home. Care seeking from community health workers (median: 5.4% for diarrhoea, 4.2% for pneumonia, and 1.3% for malaria) and the use of oral rehydration therapy (median: 34%) was low.

CONCLUSIONS

Given the importance of this topic to child survival programmes there are few published studies. Recognition of diarrhoea, malaria and pneumonia by caregivers is generally poor and represents a key factor to address in attempts to improve health care utilisation. In addition, considering that oral rehydration therapy has been widely recommended for over forty years, its use remains disappointingly low. Similarly, the reported levels of care seeking from community health workers in the included studies are low even though global action plans to address these illnesses promote community case management. Giving greater priority to research on care seeking could provide crucial evidence to inform child mortality programmes.

Infant illness spanning the antenatal to early neonatal continuum in rural northern Ghana: local perceptions, beliefs and practices

OBJECTIVE

To explore community understanding of perinatal illness in northern Ghana.

STUDY DESIGN

A cross-sectional descriptive study design.

RESULT

253 community members participated in in-depth interviews and focus group discussions, including women with newborn infants, grandmothers and health care providers. Four overarching themes emerged: (1) Local understanding of illness affects treatment practices. Respondents recognized danger signs of illness spanning antenatal to early neonatal periods. Understanding of causation often had a distinctly local flavor, and thus treatment sometimes differed from mainstream recommendations; (2) Mothers are frequently blamed for their infant's illness; (3) Healthcare decisions regarding infant care are often influenced by community members aside from the infant's mother and (4) Confidence in healthcare providers is issue-specific, and many households use a blended approach to meet their health needs.

CONCLUSION

Despite widespread recognition of danger signs and reported intentions to treat ill infants through the formal health care system, traditional approaches to perinatal illness remain common. Interventions need to be aligned with community perceptions if they are to succeed.

Barriers to neonatal care in developing countries: parents' and providers' perceptions

AIM

Hospital care and advanced medical technologies for sick neonates are increasingly available, but not always readily accessible, in many countries. We characterised parents' and providers' perceptions of barriers to neonatal care in developing countries.

METHODS

We interviewed parents whose infant was hospitalised within the first month of life in Cambodia, Malaysia, Laos and Vietnam, asking about perceived barriers to obtaining newborn care. We also surveyed health-care providers about perceived barriers to providing care.

RESULTS

We interviewed 198 parents and 212 newborn care providers (physicians, nurses, midwives, paediatric and nursing trainees). Most families paid all costs of newborn care, which they reported as a hardship. Although newborn care is accessible, 39% reported that hospitals are too distant; almost 20% did not know where to obtain care. Parents cited lack of cleanliness (46%), poor availability of medications (42%) or services (36%), staff friendliness (42%), poor infant outcome (45%), poor communications with staff (44%) and costs of care (34%) as significant problems during prior newborn care. Providers cited lack of equipment (74%), lack of staff training (61%) and poor infrastructure (51%) as barriers to providing neonatal care. Providers identified distance to hospital, lack of transportation, care costs and low parental education as barriers for families.

CONCLUSIONS

Improving cleanliness, staff friendliness and communication with parents may diminish some barriers to neonatal care in developing countries. Costs of newborn care, hospital infrastructure, distance to hospital, staffing shortages, limited staff training and limited access to medications pose more difficult barriers to remedy.

Neonatal deaths in rural southern Tanzania: care-seeking and causes of death

Introduction. We report cause of death and care-seeking prior to death in neonates based on interviews with relatives using a Verbal Autopsy questionnaire. Materials and Methods. We identified neonatal deaths between 2004 and 2007 through a large household survey in 2007 in five rural districts of southern Tanzania. Results. Of the 300 reported deaths that were sampled, the Verbal Autopsy (VA) interview suggested that 11 were 28 days or older at death and 65 were stillbirths. Data was missing for 5 of the reported deaths. Of the remaining 219 confirmed neonatal deaths, the most common causes were prematurity (33%), birth asphyxia (22%) and infections (10%). Amongst the deaths, 41% (90/219) were on the first day and a further 20% (43/219) on day 2 and 3. The quantitative results matched the qualitative findings. The majority of births were at home and attended by unskilled assistants. Conclusion. Caregivers of neonates born in health facility were more likely to seek care for problems than caregivers of neonates born at home. Efforts to increase awareness of the importance of early care-seeking for a premature or sick neonate are likely to be important for improving neonatal health.

Why do families of sick newborns accept hospital care? A community-based cohort study in Karachi, Pakistan

OBJECTIVE

Sick young infants are at high risk of mortality in developing countries, but families often decline hospital referral. Our objective was to identify the predictors of acceptance of referral for hospital care among families of severely ill newborns and infants <59 days old in three low-income communities of Karachi, Pakistan.

STUDY DESIGN

A cohort of 541 newborns and infants referred from home by community health workers conducting household surveillance, and diagnosed with a serious illness at local community clinics between 1 January and 31 December 2007, was followed-up within 1 month of referral to the public hospital.

RESULT

Only 24% of families accepted hospital referral. Major reasons for refusal were financial difficulties (67%) and father/elder denying permission (65%). Religious/cultural beliefs were cited by 20% of families. Referral acceptance was higher with recognition of severity of the illness by mother (odds ratio=12.7; 95% confidence interval=4.6 to 35.2), family's ability to speak the dominant language at hospital (odds ratio=2.0; 95% confidence interval=1.3-3.1), presence of grunting in the infant (odds ratio=3.3; 95% confidence interval=1.2-9.0) and infant temperature <35.5 °C (odds ratio=4.1; 95% confidence interval=2.3 to 7.4). No gender differential was observed.

CONCLUSION

Refusal of hospital referral for sick young infants is very common. Interventions that encourage appropriate care seeking, as well as community-based management of young infant illnesses when referral is not feasible are needed to improve neonatal survival in low-income countries.

Social autopsy: INDEPTH Network experiences of utility, process, practices, and challenges in investigating causes and contributors to mortality

BACKGROUND

Effective implementation of child survival interventions depends on improved understanding of cultural, social, and health system factors affecting utilization of health care. Never the less, no standardized instrument exists for collecting and interpreting information on how to avert death and improve the implementation of child survival interventions.

OBJECTIVE

To describe the methodology, development, and first results of a standard social autopsy tool for the collection of information to understand common barriers to health care, risky behaviors, and missed opportunities for health intervention in deceased children under 5 years old.

METHODS

Under the INDEPTH Network, a social autopsy working group was formed to reach consensus around a standard social autopsy tool for neonatal and child death. The details around 434 child deaths in Iganga/Mayuge Health and Demographic Surveillance Site (HDSS) in Uganda and 40 child deaths in Dodowa HDSS in Ghana were investigated over 12 to 18 months. Interviews with the caretakers of these children elicited information on what happened before death, including signs and symptoms, contact with health services, details on treatments, and details of doctors. These social autopsies were used to assess the contributions of delays in care seeking and case management to the childhood deaths.

RESULTS

At least one severe symptom had been recognized prior to death in 96% of the children in Iganga/Mayuge HDSS and in 70% in Dodowa HDSS, yet 32% and 80% of children were first treated at home, respectively. Twenty percent of children in Iganga/Mayuge HDSS and 13% of children in Dodowa HDSS were never taken for care outside the home. In both countries most went to private providers. In Iganga/Mayuge HDSS the main delays were caused by inadequate case management by the health provider, while in Dodowa HDSS the main delays were in the home.

CONCLUSION

While delay at home was a main obstacle to prompt and appropriate treatment in Dodowa HDSS, there were severe challenges to prompt and adequate case management in the health system in both study sites in Ghana and Uganda. Meanwhile, caretaker awareness of danger signs needs to improve in both countries to promote early care seeking and to reduce the number of children needing referral. Social autopsy methods can improve this understanding, which can assist health planners to prioritize scarce resources appropriately.

Social autopsy for maternal and child deaths: a comprehensive literature review to examine the concept and the development of the method

"Social autopsy" refers to an interview process aimed at identifying social, behavioral, and health systems contributors to maternal and child deaths. It is often combined with a verbal autopsy interview to establish the biological cause of death. Two complementary purposes of social autopsy include providing population-level data to health care programmers and policymakers to utilize in developing more effective strategies for delivering maternal and child health care technologies, and increasing awareness of maternal and child death as preventable problems in order to empower communities to participate and engage health programs to increase their responsiveness and accountability.Through a comprehensive review of the literature, this paper examines the concept and development of social autopsy, focusing on the contributions of the Pathway Analysis format for child deaths and the Maternal and Perinatal Death Inquiry and Response program in India to social autopsy's success in meeting key objectives. The Pathway Analysis social autopsy format, based on the Pathway to Survival model designed to support the Integrated Management of Childhood Illness approach, was developed from 1995 to 2001 and has been utilized in studies in Asia, Africa, and Latin America. Adoption of the Pathway model has enriched the data gathered on care seeking for child illnesses and supported the development of demand- and supply-side interventions. The instrument has recently been updated to improve the assessment of neonatal deaths and is soon to be utilized in large-scale population-representative verbal/social autopsy studies in several African countries. Maternal death audit, starting with confidential inquiries into maternal deaths in Britain more than 50 years ago, is a long-accepted strategy for reducing maternal mortality. More recently, maternal social autopsy studies that supported health programming have been conducted in several developing countries. From 2005 to 2009, 10 high-mortality states in India conducted community-based maternal verbal/social autopsies with participatory data sharing with communities and health programs that resulted in the implementation of numerous data-driven maternal health interventions.Social autopsy is a powerful tool with the demonstrated ability to raise awareness, provide evidence in the form of actionable data and increase motivation at all levels to take appropriate and effective actions. Further development of the methodology along with standardized instruments and supporting tools are needed to promote its wide-scale adoption and use.

Socio-demographic factors and appropriate health care-seeking behavior for childhood illnesses

The objective of the study was to determine the influence of socio-demographic factors on healthcare-seeking behaviors for childhood illnesses. This cross-sectional survey was conducted among consecutively admitted acutely ill children in the Children Emergency Room of a Nigerian tertiary care hospital. A total of 168 respondents were surveyed out of which only 12 (7.1%) performed well with regard to all the four indicators of appropriate healthcare-seeking behaviors. Bivariate analysis showed significant association between high maternal education and early care-seeking, utilization of orthodox health facilities, and drug use at home (p < 0.001 in each case). Similarly, age of child <1 year was associated with early care-seeking, care-seeking outside home, and utilization of orthodox health services (p < 0.001 in each case). Logistic regression showed that high maternal education and high family socioeconomic status were strong predictors of early care-seeking and care-seeking outside the home. It is concluded that maternal age, maternal education, and family socioeconomic status are predictors of appropriate healthcare-seeking behaviors for childhood illnesses.

Can interventions improve health services from informal private providers in low and middle-income countries?: a comprehensive review of the literature

BACKGROUND There is a growing interest in the role of private health providers in low- and middle-income countries (LMICs). Informal private providers (IPPs) provide a significant portion of health care in many LMICs, but they have not received training in allopathic medicine. Interventions have been developed to take advantage of their potential to expand access to essential health services, although their success is not well measured. This paper addresses this information gap through a review of interventions designed to improve the quality, coverage, or costs of health services provided by IPPs in LMICs. METHODS A search for published literature in the last 15 years for any intervention dealing with IPPs in a LMIC, where at least one outcome was measured, was conducted through electronic databases PubMed and Global Health, as well as Google for grey literature from the Internet. RESULTS A total of 1272 articles were retrieved, of which 70 separate studies met inclusion criteria. The majority (70%) of outcomes measured proximate indicators such as provider knowledge (61% were positive) and behaviour (56% positive). Training IPPs was the most common intervention tested (77% of studies), but the more effective strategies did not involve training alone. Interventions that changed the institutional relationships and contributed to changing the incentives and accountability environment were most successful, and often required combinations of interventions. CONCLUSION Although there are documented interventions among IPPs, there are few good quality studies. Strategies that change the market conditions for IPPs-by changing incentives and accountability-appear more likely to succeed than those that depend on building individual capacities of IPPs. Understanding the effectiveness of these and other strategies will also require more rigorous research designs that assess contextual factors and document outcomes over longer periods.

Effectiveness of home-based management of newborn infections by community health workers in rural Bangladesh

BACKGROUND

: Infections account for about half of neonatal deaths in low-resource settings. Limited evidence supports home-based treatment of newborn infections by community health workers (CHW).

METHODS

: In one study arm of a cluster randomized controlled trial, CHWs assessed neonates at home, using a 20-sign clinical algorithm and classified sick neonates as having very severe disease or possible very severe disease. Over a 2-year period, 10,585 live births were recorded in the study area. CHWs assessed 8474 (80%) of the neonates within the first week of life and referred neonates with signs of severe disease. If referral failed but parents consented to home treatment, CHWs treated neonates with very severe disease or possible very severe disease with multiple signs, using injectable antibiotics.

RESULTS

: For very severe disease, referral compliance was 34% (162/478 cases), and home treatment acceptance was 43% (204/478 cases). The case fatality rate was 4.4% (9/204) for CHW treatment, 14.2% (23/162) for treatment by qualified medical providers, and 28.5% (32/112) for those who received no treatment or who were treated by other unqualified providers. After controlling for differences in background characteristics and illness signs among treatment groups, newborns treated by CHWs had a hazard ratio of 0.22 (95% confidence interval [CI] = 0.07-0.71) for death during the neonatal period and those treated by qualified providers had a hazard ratio of 0.61 (95% CI = 0.37-0.99), compared with newborns who received no treatment or were treated by untrained providers. Significantly increased hazards ratios of death were observed for neonates with convulsions (hazard ratio [HR] = 6.54; 95% CI = 3.98-10.76), chest in-drawing (HR = 2.38, 95% CI = 1.29-4.39), temperature <35.3 degrees C (HR = 3.47, 95% CI = 1.30-9.24), and unconsciousness (HR = 7.92, 95% CI = 3.13-20.04).

CONCLUSIONS

: Home treatment of very severe disease in neonates by CHWs was effective and acceptable in a low-resource setting in Bangladesh.

Care-seeking practices in rural Rajasthan: barriers and facilitating factors

Poor care seeking contributes significantly to high neonatal mortality in developing countries. The study was conducted to identify care-seeking patterns for sick newborns in rural Rajasthan, India, and to understand family perceptions and circumstances that explain these patterns. Of the 290 mothers interviewed when the infant was 1 to 2 months of age, 202 (70%) reported at least one medical condition during the neonatal period that would have required medical care, and 106 (37%) reported a danger sign during the illness. However, only 63 (31%) newborns with any reported illness were taken to consult a care provider outside home, about half of these to an unqualified modern or traditional care provider. In response to hypothetical situations of neonatal illness, families preferred home treatment as the first course of action for almost all conditions, followed by modern treatment if the child did not get better. For babies born small and before time, however, the majority of families does not seem to have any preference for seeking modern treatment even as a secondary course of action. Perceptions of 'smallness', not appreciating the conditions as severe, ascribing the conditions to the goddess or to evil eye, and fatalism regarding surviving newborn period were the major reasons for the families' decision to seek care. Mothers were often not involved in taking this critical decision, especially first-time mothers. Decision to seek care outside home almost always involved the fathers or another male member. Primary care providers (qualified or unqualified) do not feel competent to deal with the newborns. The study findings provide important information on which to base newborn survival interventions in the study area: need to target the communication initiatives on mothers, fathers and grandmothers, need for tailor-made messages based on specific perceptions and barriers, and for building capacity of the primary care providers in managing sick newborns.

Delayed care seeking for fatal pneumonia in children aged under five years in Uganda: a case-series study

OBJECTIVE

To review individual case histories of children who had died of pneumonia in rural Uganda and to investigate why these children did not survive.

METHODS

This case-series study was done in the Iganga/Mayuge demographic surveillance site, Uganda, where 67 000 people were visited once every 3 months for population-based data and vital events. Children aged 1-59 months from November 2005 to August 2007 were included. Verbal and social autopsies were done to determine likely cause of death and care-seeking actions.

FINDINGS

Cause of death was assigned for 164 children, 27% with pneumonia. Of the pneumonia deaths, half occurred in hospital and one-third at home. Median duration of pneumonia illness was 7 days, and median time taken to seek care outside the home was 2 days. Most first received drugs at home: 52% antimalarials and 27% antibiotics. Most were taken for care outside the home, 36% of whom first went to public hospitals. One-third of those reaching the district hospital were referred to the regional hospital, and 19% reportedly improved after hospital treatment. The median treatment cost for a child with fatal pneumonia was US$ 5.8.

CONCLUSION

There was mistreatment with antimalarials, delays in seeking care and likely low quality of care for children with fatal pneumonia. To improve access to and quality of care, the feasibility and effect on mortality of training community health workers and drug vendors in pneumonia and malaria management with prepacked drugs should be tested.

The relative contribution of case management and inadequate care-seeking behaviour to childhood deaths from diarrhoea and acute respiratory infections in Hidalgo, Mexico

Objective To investigate the contribution of poor case management and care-seeking behaviour to childhood deaths from acute respiratory infections (ARI) and diarrhoeal diseases in rural Mexico. Methods Eighty-nine deaths from ARI and diarrhoea in under-fives from Hidalgo over a 7-month period were identified from registered death certificates. We interviewed the carers of 75 of these children, eliciting what happened before death, including signs and symptoms, contact with health services, details on treatments and details of doctors. These death narratives were used to assess the contributions of care seeking and case management to the childhood deaths. We conducted an independent investigation of the clinical competence of doctors mentioned in the death narratives using standard case scenarios and compared this with results obtained from neighbourhood control doctors. Results Late care seeking and/or poor case management contributed to 68% of deaths. The estimated contribution of care seeking alone was 32%, of case management alone 17% and of both care seeking and case management 18% of deaths. Doctors implicated as having contributed to a child's death had significantly lower clinical competence scores than those who were not. Private doctors accounted for 1.4 times more consultations prior to death than public doctors, but were implicated in 1.8 times the number of deaths. Conclusion Efforts to reduce child mortality need to improve both care seeking for childhood illnesses and quality of case management. It is essential that doctors in the private sector be included, as in Mexico and many other countries they provide a large proportion of care, often with adverse outcomes.

Has the 2005 measles mortality reduction goal been achieved? A natural history modelling study

BACKGROUND

In 2002, the UN General Assembly Special Session on Children adopted a goal to reduce deaths owing to measles by half by the end of 2005, compared with 1999 estimates. We describe efforts and progress made towards this goal.

METHODS

We assessed trends in immunisation against measles on the basis of national implementation of the WHO/UNICEF comprehensive strategy for measles mortality reduction, and the provision of a second opportunity for measles immunisation. We used a natural history model to evaluate trends in mortality due to measles.

RESULTS

Between 1999 and 2005, according to our model mortality owing to measles was reduced by 60%, from an estimated 873,000 deaths (uncertainty bounds 634,000-1,140,000) in 1999 to 345,000 deaths (247,000-458,000) in 2005. The largest percentage reduction in estimated measles mortality during this period was in the western Pacific region (81%), followed by Africa (75%) and the eastern Mediterranean region (62%). Africa achieved the largest total reduction, contributing 72% of the global reduction in measles mortality. Nearly 7.5 million deaths from measles were prevented through immunisation between 1999 and 2005, with supplemental immunisation activities and improved routine immunisation accounting for 2.3 million of these prevented deaths.

INTERPRETATION

The achievement of the 2005 global measles mortality reduction goal is evidence of what can be accomplished for child survival in countries with high childhood mortality when safe, cost-effective, and affordable interventions are backed by country-level political commitment and an effective international partnership.

Care seeking behaviour for childhood illness--a questionnaire survey in western Nepal

BACKGROUND

The World Health Organization estimates that seeking prompt and appropriate care could reduce child deaths due to acute respiratory infections by 20%. The purpose of our study was to assess care seeking behaviour of the mothers during childhood illness and to determine the predictors of mother's care seeking behaviour.

METHODS

A cross-sectional survey was conducted in the immunization clinics of Pokhara city, Kaski district, western Nepal. A trained health worker interviewed the mothers of children suffering from illness during the preceding 15 days.

RESULTS

A total of 292 mothers were interviewed. Pharmacies (46.2%) were the most common facilities where care was sought followed by allopathic medical practitioners (26.4%). No care was sought for 8 (2.7%) children and 26 (8.9%) children received traditional/home remedies. 'Appropriate', 'prompt' and 'appropriate and prompt' care was sought by 77 (26.4%), 166 (56.8%) and 33 (11.3%) mothers respectively. The mothers were aware of fever (51%), child becoming sicker (45.2%) and drinking poorly (42.5%) as the danger signs of childhood illness. By multiple logistic regression analysis total family income, number of symptoms, mothers' education and perceived severity of illness were the predictors of care seeking behaviour.

CONCLUSION

The results of the present study show that the mothers were more likely to seek care when they perceived the illness as 'serious'. Poor maternal knowledge of danger signs of childhood illness warrants the need for a complementary introduction of community-based Integrated Management of Childhood Illness programmes to improve family's care seeking behaviour and their ability to recognize danger signs of childhood illness. Socioeconomic development of the urban poor may overcome their financial constraints to seek 'appropriate' and 'prompt' care during the childhood illness.

Local understandings of vulnerability and protection during the neonatal period in Sylhet District, Bangladesh: a qualitative study

BACKGROUND

Understanding of local knowledge and practices relating to the newborn period, as locally defined, is needed in the development of interventions to reduce neonatal mortality. We describe the organisation of the neonatal period in Sylhet District, Bangladesh, the perceived threats to the well-being of neonates, and the ways in which families seek to protect them.

METHODS

We did 39 in-depth, unstructured, qualitative interviews with mothers, fathers, and grandmothers of neonates, and traditional birth attendants. Data on neonatal knowledge and practices were also obtained from a household survey of 6050 women who had recently given birth.

FINDINGS

Interviewees defined the neonatal period as the first 40 days of life (chollish din). Confinement of the mother and baby is most strongly observed before the noai ceremony on day 7 or 9, and involves restriction of movement outside the home, sleeping where the birth took place rather than in the mother's bedroom, and sleeping on a mat on the floor. Newborns are seen as vulnerable to cold air, cold food or drinks (either directly or indirectly through the mother), and to malevolent spirits or evil eye. Bathing, skin care, confinement, and dietary practices all aim to reduce exposure to cold, but some of these practices might increase the risk of hypothermia.

INTERPRETATION

Although fatalism and cultural acceptance of high mortality have been cited as reasons for high levels of neonatal mortality, Sylheti families seek to protect newborns in several ways. These actions reflect a set of assumptions about the newborn period that differ from those of neonatal health specialists, and have implications for the design of interventions for neonatal care.

Reduced incidence of neonatal morbidities: effect of home-based neonatal care in rural Gadchiroli, India

OBJECTIVE

We found a high burden of morbidities in a cohort of neonates observed in rural Gadchiroli, India. We hypothesised that interventions would reduce the incidence of neonatal morbidities, including the seasonal increase observed in many of them. This article reports the effect of home-based neonatal care on neonatal morbidities in the intervention arm of the field trial by comparing the early vs late periods, and the possible explanation for this effect.

METHODS

During 3 years (1995 to 1998), trained village-health-workers (VHWs) in 39 villages prospectively collected data by making home visits during pregnancy, home-delivery and during neonatal period. We estimated the incidence and burden of neonatal morbidities over the 3 years from these data. In the first year, the VHWs made home visits only to observe. From the second year, they assisted mothers in neonatal care and managed the sick neonates at home. Health education of mothers and family members, individually and in group, was added in the third year. We measured the coverage of interventions over the 3 years and evaluated maternal knowledge and practices on 21 indicators in the third year. The effect on 17 morbidities was estimated by comparing the incidence in the first year with the third year.

RESULTS

The VHWs observed 763 neonates in the first year, 685 in the second and 913 in the third year. The change in the percent incidence of morbidities was (i) infections, from 61.6 to 27.5 (-55%; p<0.001), (ii) care-related morbidities (asphyxia, hypothermia, feeding problems) from 48.2 to 26.3 (-45%; p<0.001); (iii) low birth weight from 41.9 to 35.2 (-16%; p<0.05); (iv) preterm birth and congenital anomalies remained unchanged. The mean number of morbidities/100 neonates in the 3 years was 228, 170 and 115 (a reduction of 49.6%; p<0.001). These reductions accompanied an increasing percent score of interventions during 3 years: 37.9, 58.4 and 81.3, thus showing a dose-response relationship. In the third year, the proportion of correct maternal knowledge was 78.7% and behaviours was 69.7%. The significant seasonal increase earlier observed in the incidence of five morbidities reduced in the third year.

CONCLUSION

The home-based care and health education reduced the incidence and burden of neonatal morbidities by nearly half. The effect was broad, but was especially pronounced on infections, care-related morbidities and on the seasonal increase in morbidities.

Home-based neonatal care: summary and applications of the field trial in rural Gadchiroli, India (1993 to 2003)

High levels of neonatal mortality and lack of access to neonatal health care are widespread problems in developing countries. A field trial of home-based neonatal care (HBNC) was conducted in rural Gadchiroli, India to develop and test the feasibility of a low-cost approach of delivering primary neonatal care by using the human potential available in villages, and to evaluate its effect on neonatal mortality. In the first half of this article we summarize various aspects of the field trial, presented in the previous 11 articles in this issue of the journal supplement. The background, objectives, study design and interventions in the field trial and the results over 10 years (1993 to 2003) are presented. Based on these results, the hypotheses are tested and conclusions presented. In the second half, we discuss the next questions: can it be replicated? Can this intervention become a part of primary health-care services? What is the cost and the cost-effectiveness of HBNC? The limitations of the approach, the settings where HBNC might be relevant and the management pre-requisites for its scaling up are also discussed. The need to develop an integrated approach is emphasized. A case for newborn care in the community is made for achieving equity in health care.

Impact of counselling on careseeking behaviour in families with sick children: cluster randomised trial in rural India

OBJECTIVE

To assess whether training doctors in counselling improves careseeking behaviour in families with sick children.

DESIGN

Pair matched, community randomised trial conducted in 12 primary health centres (six pairs). Doctors in intervention centres were trained in counselling, communication, and clinical skills, using the integrated management of childhood illness approach.

SETTING

Rural district in Rajasthan, India.

PARTICIPANTS

Children aged under 5 years presenting for curative care and their mothers were recruited and visited monthly at home for six months. A total of 2460 children were recruited (1248 intervention, 1212 control).

MAIN OUTCOME MEASURES

Careseeking behaviour of mothers for sick children; mothers' knowledge and perceptions of seeking care; counselling performance of doctors.

RESULTS

For episodes of illness with at least one reported danger sign, 15% of intervention group mothers and 10% of control group mothers reported having sought care from an appropriate provider promptly; this difference was not statistically significant (relative risk reduction 5%, 95% confidence interval -0.4% to 11%; P = 0.07). One month after training, intervention site doctors counselled more effectively than control group doctors, but at six months their performance had declined. A greater proportion of mothers in the intervention group than in the control group recalled having had at least one danger sign explained (45% v 8%; P = 0.02).

CONCLUSIONS

Mothers' appreciation of the need to seek prompt and appropriate care for severe episodes of childhood illness increased, but their careseeking behaviour did not improve significantly.

Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles

BACKGROUND

Previous analyses derived the relative risk (RR) of dying as a result of low weight-for-age and calculated the proportion of child deaths worldwide attributable to underweight.

OBJECTIVES

The objectives were to examine whether the risk of dying because of underweight varies by cause of death and to estimate the fraction of deaths by cause attributable to underweight.

DESIGN

Data were obtained from investigators of 10 cohort studies with both weight-for-age category (<-3 SDs, -3 to <-2 SDs, -2 to <-1 SD, and >-1 SD) and cause of death information. All 10 studies contributed information on weight-for-age and risk of diarrhea, pneumonia, and all-cause mortality; however, only 6 studies contributed information on deaths because of measles, and only 3 studies contributed information on deaths because of malaria or fever. With use of weighted random effects models, we related the log mortality rate by cause and anthropometric status in each study to derive cause-specific RRs of dying because of undernutrition. Prevalences of each weight-for-age category were obtained from analyses of 310 national nutrition surveys. With use of the RR and prevalence information, we then calculated the fraction of deaths by cause attributable to undernutrition.

RESULTS

The RR of mortality because of low weight-for-age was elevated for each cause of death and for all-cause mortality. Overall, 52.5% of all deaths in young children were attributable to undernutrition, varying from 44.8% for deaths because of measles to 60.7% for deaths because of diarrhea.

CONCLUSION

A significant proportion of deaths in young children worldwide is attributable to low weight-for-age, and efforts to reduce malnutrition should be a policy priority.

Recognizing childhood illnesses and their traditional explanations: exploring options for care-seeking interventions in the context of the IMCI strategy in rural Ghana

OBJECTIVES

Interventions that promote appropriate care-seeking for severely ill children have the potential to substantially reduce child mortality in developing countries, but little is known about the best approach to address the issue. This paper explores the relative importance of illness recognition as a barrier to care-seeking and the feasibility and potential impact of improving recognition.

METHODS

The study combined qualitative and quantitative methods including in-depth interviews exploring the local illness classification system, a Rapid Anthropological Assessment (RAA) recording narratives of recent episodes of child illness and a survey designed to test the hypotheses that emerged from the RAA.

RESULTS

Several danger symptoms were not recognized by caregivers. There were recognition problems which may not be feasibly addressed in an intervention. Other significant care-seeking barriers included classifying certain illnesses as 'not-for-hospital' and untreatable by modern medicine; problems of access; and frequent use of traditional medicines.

CONCLUSION

The recognition component of any care-seeking intervention should identify the type of recognition problem present in the community. Many of the care-seeking barriers identified in the study revolved around the local illness classification system, which should be explored and built on as part of any care-seeking intervention.

Factors constraining adherence to referral advice for severely ill children managed by the Integrated Management of Childhood Illness approach in Imbabura Province, Ecuador

AIM

Low referral completion rates in developing countries undermine the Integrated Management of Childhood Illness (IMCI) strategy for lowering child mortality. This study sought to identify factors constraining adherence to referral advice in a health system using the IMCI approach.

METHODS

Caregivers of 160 children urgently referred to hospital were prospectively interviewed. Caregivers who accessed and did not access hospital were compared for potential referral constraining factors, including demographics, family dynamics, the severity of their child's illness, their interaction with the health system, self-perceived problems, and physical and financial access.

RESULTS

67/160 (42%) referred children did not access hospital. Six factors were associated with non-access, including two health worker actions: not being given a referral slip [adjusted odds ratio (OR)= 15.3, 95% confidence interval (95% CI) 4.4-64.6] and not being told to go to the hospital immediately (adjusted OR = 5.3, 95% CI 1.9-16.3). Receiving both of these interventions reduced the risk of not accessing hospital to 19%, from 96% for those who received neither intervention. Several indicators of illness severity, including caregivers' ranking of their children's illness severity, the presence of severe illness signs and mortality, were investigated and found not to be important explanatory factors.

CONCLUSION

Providing a referral slip and counseling the caregivers of severely ill children to go to the hospital immediately appear to be powerful tools for increasing successful referral outcomes.

Circumstances of post-neonatal deaths in Ceara, Northeast Brazil: mothers' health care-seeking behaviors during their infants' fatal illness

Promotion of oral rehydration therapy (ORT) for the treatment of diarrheal diseases and the WHO case management strategy for acute respiratory infections (ARI) have contributed to significant reductions in infant mortality, but these two conditions remain the leading causes of infant deaths in most developing countries. Identification of the factors contributing to these deaths may contribute to reduce infant mortality from preventable causes. To gain insight into the circumstances and maternal and health services factors that may contribute to infant deaths we used a verbal autopsy method to interview mothers of all infants who died during the previous 12 months (June 1995-May 1996) in 11 municipalities in the State of Ceara, Northeast Brazil. Our results revealed that one-third of the deaths occurred in a hospital and two-thirds at home. Almost all the infants who died at home, however, had been examined one or more times by a doctor, and 36% of them had been hospitalized during the disease episode that resulted in death. For most (85%) of these children the causes of death were diarrhea or acute respiratory infection, and it is likely that death could have been averted if appropriate treatment had been initiated promptly. Three major groups of factors that alone or in combination appeared to contribute to most deaths were delays in seeking medical care on behalf of the parents, medical interventions reported as ineffective by mothers and delays in providing medical care to children who arrived at the hospital too late in the day to be scheduled for consultation. Our findings suggest that government efforts to further reduce infant mortality in Ceara should focus on health education interventions that address quality of home care, recognition of signs of severity and danger and importance of seeking timely medical care: and on improving the quality of care provided at community health centers and hospitals. Measures likely to improve infants' chance of survival include: ensuring prompt access to medical consultation for young children brought to health centers or hospitals with potentially life-threatening symptoms related to infections, health education to mothers on the need for continued home care after discharge and to return to the medical care facility if the child does not recover, and that they have access to medicine prescribed by hospital physicians. Further benefits could be obtained by using community health workers, now integrated into the Family Medicine Program (PSF) health teams, to provide health education, supervise home care, refer mothers to health centers and facilitate their access to hospitals.

Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India

BACKGROUND

Neonatal care is not available to most neonates in developing countries because hospitals are inaccessible and costly. We developed a package of home-based neonatal care, including management of sepsis (septicaemia, meningitis, pneumonia), and tested it in the field, with the hypothesis that it would reduce the neonatal mortality rate by at least 25% in 3 years.

METHODS

We chose 39 intervention and 47 control villages in the Gadchiroli district in India, collected baseline data for 2 years (1993-95), and then introduced neonatal care in the intervention villages (1995-98). Village health workers trained in neonatal care made home visits and managed birth asphyxia, premature birth or low birthweight, hypothermia, and breast-feeding problems. They diagnosed and treated neonatal sepsis. Assistance by trained traditional birth attendants, health education, and fortnightly supervisory visits were also provided. Other workers recorded all births and deaths in the intervention and the control area (1993-98) to estimate mortality rates.

FINDINGS

Population characteristics in the intervention and control areas, and the baseline mortality rates (1993-95) were similar. Baseline (1993-95) neonatal mortality rate in the intervention and the control areas was 62 and 58 per 1000 live births, respectively. In the third year of intervention 93% of neonates received home-based care. Neonatal, infant, and perinatal mortality rates in the intervention area (net percentage reduction) compared with the control area, were 25.5 (62.2%), 38.8 (45.7%), and 47.8 (71.0%), respectively (p<0.001). Case fatality in neonatal sepsis declined from 16.6% (163 cases) before treatment, to 2.8% (71 cases) after treatment by village health workers (p<0.01). Home-based neonatal care cost US$5.3 per neonate, and in 1997-98 such care averted one death (fetal or neonatal) per 18 neonates cared for.

INTERPRETATION

Home-based neonatal care, including management of sepsis, is acceptable, feasible, and reduced neonatal and infant mortality by nearly 50% among our malnourished, illiterate, rural study population. Our approach could reduce neonatal mortality substantially in developing countries.

Careseeking for illness in young infants in an urban slum in India

Illness in infants in the first two months of life can take a precipitous life-threatening course, and requires timely and appropriate medical assessment and management. We conducted a focused ethnographic study of illness in young infants and associated careseeking practices in an urban slum in New Delhi, India, in order to identify the constraints in securing effective care for severe illness in this age group. The findings suggest that maternal recognition of illness is not a limiting factor in the use of health care services for sick young infants in this setting. Mothers respond to a number of important signs of illness, including changes in the young infant's sleeping or feeding behavior, and they are usually prompt in seeking care outside the home. They are not able, however, to discriminate among the many sources of health care available in this setting, and give preference to local unqualified private practitioners. Most practitioners, including qualified medical practitioners, display critical failures in the assessment and management of sick young infants. The continuity and effectiveness of care is further compromised by the caretakers' expectations of rapid cure, which result in discontinued treatment courses and frequent changes in practitioners, and by their reluctance to seek hospital care. The implications of these findings for the design of programs to reduce young infant mortality are discussed. In particular, the feasibility and acceptability of hospital referrals according to current program guidelines are called into question.

Developing strategies to encourage appropriate care-seeking for children with acute respiratory infections: an example from Egypt

Determinants of care-seeking and patterns of referral for acute respiratory infections (ARIs) in children were studied in two communities in Ismailia, Egypt. A video was used to assess mothers' recognition and interpretation of clinical signs of serious illness. Mothers were questioned about which of the locally available provider options they would choose for four different locally-defined ARI illnesses; they were also read brief descriptions of hypothetical cases, and asked how they would recommend treating children in those situations. These results were compared with reported care-seeking practices during past ARI episodes that occurred in their own children. The results indicate that mothers generally recognize rapid or difficult breathing, but do not use the recognition to take appropriate actions. The data suggest that a substantial proportion of children in the study area, who are perceived to have severe respiratory illnesses, may not be brought to the government health facilities for treatment. Implications of the findings for the training policies and strategies of the Egyptian national ARI program are considered.

Acute respiratory illnesses in children under five years in Indramayu, west Java, Indonesia: a rapid ethnographic assessment

A rapid, focused ethnographic study was carried out in a rural area of West Java, Indonesia to identify local beliefs, perceptions, and practices surrounding acute respiratory infections (ARI) in infants and young children. The study incorporates key informant interviews, open-ended interviews, and structured data collection from fifty mothers of young children selected to represent the geographical settlement pattern in the area: structured interviews with biomedical and indigenous health care providers; and structured interviews with fifty mothers who sought health care for an infant or young child with a respiratory illness. The most commonly perceived cause for ARI in children was air entering the body through some type of chill, exposure to draft or breeze, or change of weather. When fever or difficult breathing was present, mothers tended to increase the number and diversity the types of medicines used. Mothers recognized difficult as well as rapid breathing, both being described as "difficult breathing." More concern was expressed about fever than about difficulty in breathing. Effective medical care was more likely to be delayed for infants than for older children; infants were also more likely to be taken to an indigenous healer as the first-choice provider. Infants were less likely to receive an effective drug regimen even if appropriate medication was prescribed, because mothers commonly take the drugs in order to deliver them to the infant through breast milk.