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Fung A, Shafiq Y, Driker S, Rees CA, Mediratta RP, Rosenberg R, Hussaini AS, Adnan J, Wade CG, Chou R, Edmond KM, North K, Lee AC. Diagnostic Accuracy of Clinical Sign Algorithms to Identify Sepsis in Young Infants Aged 0 to 59 Days: A Systematic Review and Meta-analysis. Pediatrics 2024; 154:e2024066588D. [PMID: 39087806 DOI: 10.1542/peds.2024-066588d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 08/02/2024] Open
Abstract
CONTEXT Accurate identification of possible sepsis in young infants is needed to effectively manage and reduce sepsis-related morbidity and mortality. OBJECTIVE Synthesize evidence on the diagnostic accuracy of clinical sign algorithms to identify young infants (aged 0-59 days) with suspected sepsis. DATA SOURCES MEDLINE, Embase, CINAHL, Global Index Medicus, and Cochrane CENTRAL Registry of Trials. STUDY SELECTION Studies reporting diagnostic accuracy measures of algorithms including infant clinical signs to identify young infants with suspected sepsis. DATA EXTRACTION We used Cochrane methods for study screening, data extraction, risk of bias assessment, and determining certainty of evidence using Grading of Recommendations Assessment Development and Evaluation. RESULTS We included 19 studies (12 Integrated Management of Childhood Illness [IMCI] and 7 non-IMCI studies). The current World Health Organization (WHO) 7-sign IMCI algorithm had a sensitivity of 79% (95% CI 77%-82%) and specificity of 77% (95% CI 76%-78%) for identifying sick infants aged 0-59 days requiring hospitalization/antibiotics (1 study, N = 8889). Any IMCI algorithm had a pooled sensitivity of 84% (95% CI 75%-90%) and specificity of 80% (95% CI 64%-90%) for identifying suspected sepsis (11 studies, N = 15523). When restricting the reference standard to laboratory-supported sepsis, any IMCI algorithm had a pooled sensitivity of 86% (95% CI 82%-90%) and lower specificity of 61% (95% CI 49%-72%) (6 studies, N = 14278). LIMITATIONS Heterogeneity of algorithms and reference standards limited the evidence. CONCLUSIONS IMCI algorithms had acceptable sensitivity for identifying young infants with suspected sepsis. Specificity was lower using a reference standard of laboratory-supported sepsis diagnosis.
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Affiliation(s)
- Alastair Fung
- Division of Paediatric Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Yasir Shafiq
- Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health (CRIMEDIM), Università degli Studi del Piemonte Orientale "Amedeo Avogadro", Vercelli, Italy
- Center of Excellence for Trauma and Emergencies and Community Health Sciences, The Aga Khan University, Karachi, Pakistan
- Global Advancement of Infants and Mothers (AIM), Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Sophie Driker
- Global Advancement of Infants and Mothers (AIM), Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chris A Rees
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Rishi P Mediratta
- Division of Pediatric Hospital Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Rebecca Rosenberg
- Department of Pediatrics, School of Medicine, New York University, New York, New York
| | - Anum S Hussaini
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Jana Adnan
- American University of Beirut, Beirut, Lebanon
| | - Carrie G Wade
- Countway Library, Harvard Medical School, Boston, Massachusetts
| | - Roger Chou
- Departments of Medicine and Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | | | - Krysten North
- Global Advancement of Infants and Mothers (AIM), Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Anne Cc Lee
- Global Advancement of Infants and Mothers (AIM), Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Jahan F, Parvez SM, Rahman M, Billah SM, Yeasmin F, Jahir T, Hasan R, Darmstadt GL, Arifeen SE, Hoque MM, Shahidullah M, Islam MS, Ashrafee S, Foote EM. Acceptability and operational feasibility of community health worker-led home phototherapy treatment for neonatal hyperbilirubinemia in rural Bangladesh. BMC Pediatr 2024; 24:123. [PMID: 38360716 PMCID: PMC10868082 DOI: 10.1186/s12887-024-04584-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 01/22/2024] [Indexed: 02/17/2024] Open
Abstract
There is an unmet need for phototherapy treatment in low- and middle-income countries (LMICs) to prevent disability and death of newborns with neonatal hyperbilirubinemia. Home phototherapy deployed by community health workers (CHWs) in LMICs may help increase access to essential newborn postnatal care in a more acceptable way for families and lead to an increase in indicated treatment rates for newborns with hyperbilirubinemia. We aimed to investigate the operational feasibility and acceptability of a CHW-led home phototherapy intervention in a rural sub-district of Bangladesh for families and CHWs where home delivery was common and a treatment facility for neonatal hyperbilirubinemia was often more than two hours from households. We enrolled 23 newborns who were ≥ 2 kg in weight and ≥ 35 weeks gestational age, without clinical danger signs, and met the American Academy of Pediatric treatment criteria for phototherapy for hyperbilirubinemia. We employed a mixed-method investigation to evaluate the feasibility and acceptability of home phototherapy through surveys, in-depth interviews and focus group discussions with CHWs, mothers, and grandparents. Mothers and family members found home phototherapy worked well, saved them money, and was convenient and easy to operate. CHWs found it feasible to deploy home phototherapy and identified hands-on training, mHealth job aids, a manageable workload, and prenatal education as facilitating factors for implementation. Feasibility and acceptability concerns were limited amongst parents and included: a lack of confidence in CHWs' skills, fear of putting newborn infants in a phototherapy device, and unreliable home power supply. CHW-led home phototherapy was acceptable to families and CHWs in rural Bangladesh. Further investigation should be done to determine the impact of home phototherapy on treatment rates and on preventing morbidity associated with neonatal hyperbilirubinemia. Clinical Trial (CT) registration ID: NCT03933423, full protocol can be accessed at https://doi.org/10.1186/s13102-024-00824-6 . Name of the trial registry: clinicaltrials.gov. Clinical Trial (CT) registration Date: 01/05/2019.
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Affiliation(s)
- Farjana Jahan
- Environmental Health and WASH, Health System and Population Studies Division, International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b), Dhaka, 1212, Bangladesh.
- Environmental Interventions Unit, Infectious Disease Division, icddr,b, 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh.
| | - Sarker Masud Parvez
- Environmental Health and WASH, Health System and Population Studies Division, International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b), Dhaka, 1212, Bangladesh
- Children's Health and Environment Program, Child Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia
| | - Mahbubur Rahman
- Environmental Health and WASH, Health System and Population Studies Division, International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b), Dhaka, 1212, Bangladesh
| | - Sk Masum Billah
- Maternal and Child Health Division, International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Faculty of Medicine and Health, School of Public Health, University of Sydney, Sydney, Australia
| | - Farzana Yeasmin
- Environmental Health and WASH, Health System and Population Studies Division, International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b), Dhaka, 1212, Bangladesh
| | - Tania Jahir
- College of Medicine, Nursing & Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - Rezaul Hasan
- Environmental Health and WASH, Health System and Population Studies Division, International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b), Dhaka, 1212, Bangladesh
| | - Gary L Darmstadt
- Prematurity Research Center, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Shams El Arifeen
- Maternal and Child Health Division, International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Mahbubul Hoque
- Department of Neonatology, Bangladesh, Children Hospital & Institute, Dhaka, Bangladesh
| | | | - Muhammad Shariful Islam
- National Newborn Health Program (NNHP) and Integrated Management of Childhood Illness (IMCI), Directorate General of Health Services, Dhaka, Bangladesh
| | - Sabina Ashrafee
- National Newborn Health Program (NNHP) and Integrated Management of Childhood Illness (IMCI), Directorate General of Health Services, Dhaka, Bangladesh
| | - Eric M Foote
- Prematurity Research Center, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
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Varadharajan V, Subramaniyan B, Ramkumar V, Venkatesh L, Chandrasekar K. Field validation of an app based developmental and speech language screening (SRESHT screener) conducted by grass root workers. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2024; 26:101529. [PMID: 38623525 PMCID: PMC7615829 DOI: 10.1016/j.cegh.2024.101529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
This study validated an app-based developmental and speech language screening (SRESHT screener) conducted by Grass Roots Workers (GRWs) among children below six years of age in a rural community in the state of Tamil Nadu (the field). Method The study was carried out in two phases, first the training of GRWs and then the validation of the screening conducted by them using the app. For the training, suitable materials were developed, and the GRW's knowledge and skills were evaluated pre- and post-training. Two closed-ended questionnaires were used to evaluate the GRWs' knowledge about the screening tools. The Observed Structured Practical Examination (OSPE) method was used to evaluate their skill. All the participants were selected by convenience sampling and were screened independently by both a Speech Language Pathologist (SLP) and a GRW using the application. Cohen's kappa and percent agreement were used to determine agreement in screening results between the SLP and GRWs. Results All the GRWs scored at least 75 % and above in both the knowledge and skill assessments conducted post-training. "Substantial agreement" on kappa-based extent of agreement and "almost perfect" agreement on percent agreement were obtained between GRWs and SLP for the app-based screening. Conclusion The findings of this study imply that the app-based developmental and speech language screening performed in the community by GRWs is valid.
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Affiliation(s)
- Vasudharany Varadharajan
- Sri Ramachandra Faculty of Audiology & Speech Language Pathology, Sri Ramachandra Institute of Higher Education & Research, Chennai, India
| | - B Subramaniyan
- The Cleft & Craniofacial Centre, Department of Speech Language Pathology & Audiology, Sree Balaji Medical College and Hospital, Bharath Institute of Higher Education and Research, Chennai, India
| | - Vidya Ramkumar
- Sri Ramachandra Faculty of Audiology & Speech Language Pathology, Sri Ramachandra Institute of Higher Education & Research, Chennai, India
| | - Lakshmi Venkatesh
- Sri Ramachandra Faculty of Audiology & Speech Language Pathology, Sri Ramachandra Institute of Higher Education & Research, Chennai, India
| | - Kavyashree Chandrasekar
- Sri Ramachandra Faculty of Audiology & Speech Language Pathology, Sri Ramachandra Institute of Higher Education & Research, Chennai, India
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Fung A, Farmer J, Borkhoff CM. Young Infants Clinical Signs Study 8-sign Algorithm for Identification of Sick Infants Adapted for Routine Home Visits: A Systematic Review and Critical Appraisal of its Measurement Properties. Glob Pediatr Health 2024; 11:2333794X231219598. [PMID: 38283299 PMCID: PMC10812101 DOI: 10.1177/2333794x231219598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 10/12/2023] [Accepted: 11/23/2023] [Indexed: 01/30/2024] Open
Abstract
Objective. The 8-sign algorithm adapted from the Young Infants Clinical Signs Study (YICSS) is widely used to identify sick infants during home visits (YICSS-home algorithm). We aimed to critically appraise the development and evidence of measurement properties, including sensibility, reliability, and validity, of the YICSS-home algorithm. Methods. Relevant studies were identified through a systematic literature search. Results. The YICSS-home algorithm has good sensibility. The algorithm demonstrated at least moderate inter-rater reliability and sensitivity ranging from 69% to 80%. However, the algorithm was developed among sick infants brought for care to a health facility and not initially developed for use by community health workers (CHWs) during home visits. Some important risk factors were omitted at item generation. Inter-CHW reliability and construct validity have not been estimated. Conclusion. Future research should build on the strengths of the YICSS-home algorithm and address its limitations to develop a new algorithm with improved predictive accuracy.
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Affiliation(s)
- Alastair Fung
- Hospital for Sick Children, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | | | - Cornelia M. Borkhoff
- University of Toronto, Toronto, ON, Canada
- Hospital for Sick Children Research Institute, Toronto, ON, Canada
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Foote EM, Jahan F, Rahman M, Parvez SM, Ahmed T, Hasan R, Yeasmin F, Arifeen SE, Billah SM, Hoque MM, Shahidullah M, Shariful Islam M, Bhutani VK, Darmstadt GL. Community health worker-led household screening and management of neonatal hyperbilirubinemia in rural Bangladesh: a cluster randomized control trial protocol. Gates Open Res 2024; 7:58. [PMID: 39015822 PMCID: PMC11249711 DOI: 10.12688/gatesopenres.14033.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2024] [Indexed: 07/18/2024] Open
Abstract
Background Extreme hyperbilirubinemia leading to neurologic disability and death is disproportionately higher in low- and middle-income countries (LMIC) such as Bangladesh, and is largely preventable through timely treatment. In LMICs, an estimated half of all newborns are born at home and few receive screening or treatment for hyperbilirubinemia, leading to 6 million newborns per year who need phototherapy treatment for hyperbilirubinemia but are untreated. Household screening and treatment for neonatal hyperbilirubinemia with phototherapy administered by a trained community health worker (CHW) may increase indicated treatment for neonatal hyperbilirubinemia in comparison to the existing care system in Bangladesh. Methods 530 Bangladeshi women in their second or third trimester of pregnancy from the rural community of Sakhipur, Bangladesh will be recruited for a cluster randomized trial and randomized to the intervention arm - home screening and treatment for neonatal hyperbilirubinemia - or the comparison arm to receive usual care. In the intervention arm, CHWs will provide mothers with two prenatal visits, visit newborns by 2 days of age and then daily for 3 days to measure transcutaneous bilirubin (TcB) and monitor for clinical danger signs. Newborns without danger signs but with a TcB above the treatment threshold, but >15 mg/dL will be treated with light-emitting diode (LED) phototherapy at home. Newborns with danger signs or TcB ≥15 mg/dL will be referred to a hospital for treatment. Treatment rates for neonatal hyperbilirubinemia in each arm will be compared. Conclusion This study will evaluate the effectiveness of CHW-led home phototherapy to increase neonatal hyperbilirubinemia treatment rates in rural Bangladesh. LMICs are expanding access to postnatal care by using CHWs, and our work will give CHWs a curative treatment option for neonatal hyperbilirubinemia. Similar projects in other LMICs can be pursued to dramatically extend healthcare access to vulnerable newborns with hyperbilirubinemia.
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Affiliation(s)
- Eric M. Foote
- Prematurity Research Center, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Farjana Jahan
- Environmental Health and WASH, International Centre for Diarrheal Disease Research, Dhaka, 1212, Bangladesh
| | - Mahbubur Rahman
- Environmental Health and WASH, International Centre for Diarrheal Disease Research, Dhaka, 1212, Bangladesh
| | - Sarker Masood Parvez
- Environmental Health and WASH, International Centre for Diarrheal Disease Research, Dhaka, 1212, Bangladesh
- Children's Health and Environment Program, Child Health Research Centre, The University of Queensland, QLD, Australia
| | - Tasnim Ahmed
- Prematurity Research Center, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Rezaul Hasan
- Environmental Health and WASH, International Centre for Diarrheal Disease Research, Dhaka, 1212, Bangladesh
| | - Farzana Yeasmin
- Environmental Health and WASH, International Centre for Diarrheal Disease Research, Dhaka, 1212, Bangladesh
| | - Shams El Arifeen
- Maternal and Child Health Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, -1212, Bangladesh
| | - Sk Masum Billah
- Maternal and Child Health Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, -1212, Bangladesh
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Md. Mahbubul Hoque
- Department of Neonatology, Bangladesh Shishu Hospital & Institute Dhaka, Dhaka, Bangladesh
| | | | - Muhammad Shariful Islam
- National Newborn Health Program (NNHP) and Integrated Management of Childhood Illness (IMCI), Directorate General of Health Services, Dhaka, Bangladesh
| | - Vinod K Bhutani
- Prematurity Research Center, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Gary L Darmstadt
- Prematurity Research Center, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
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Foote EM, Jahan F, Rahman M, Parvez SM, Ahmed T, Hasan R, Yeasmin F, Arifeen SE, Billah SM, Hoque MM, Shahidullah M, Shariful Islam M, Bhutani VK, Darmstadt GL. Community health worker-led household screening and management of neonatal hyperbilirubinemia in rural Bangladesh: a cluster randomized control trial protocol. Gates Open Res 2024; 7:58. [PMID: 39015822 PMCID: PMC11249711 DOI: 10.12688/gatesopenres.14033.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Extreme hyperbilirubinemia leading to neurologic disability and death is disproportionately higher in low- and middle-income countries (LMIC) such as Bangladesh, and is largely preventable through timely treatment. In LMICs, an estimated half of all newborns are born at home and few receive screening or treatment for hyperbilirubinemia, leading to 6 million newborns per year who need phototherapy treatment for hyperbilirubinemia but are untreated. Household screening and treatment for neonatal hyperbilirubinemia with phototherapy administered by a trained community health worker (CHW) may increase indicated treatment for neonatal hyperbilirubinemia in comparison to the existing care system in Bangladesh. METHODS 530 Bangladeshi women in their second or third trimester of pregnancy from the rural community of Sakhipur, Bangladesh will be recruited for a cluster randomized trial and randomized to the intervention arm - home screening and treatment for neonatal hyperbilirubinemia - or the comparison arm to receive usual care. In the intervention arm, CHWs will provide mothers with two prenatal visits, visit newborns by 2 days of age and then daily for 3 days to measure transcutaneous bilirubin (TcB) and monitor for clinical danger signs. Newborns without danger signs but with a TcB above the treatment threshold, but >15 mg/dL will be treated with light-emitting diode (LED) phototherapy at home. Newborns with danger signs or TcB ≥15 mg/dL will be referred to a hospital for treatment. Treatment rates for neonatal hyperbilirubinemia in each arm will be compared. CONCLUSION This study will evaluate the effectiveness of CHW-led home phototherapy to increase neonatal hyperbilirubinemia treatment rates in rural Bangladesh. LMICs are expanding access to postnatal care by using CHWs, and our work will give CHWs a curative treatment option for neonatal hyperbilirubinemia. Similar projects in other LMICs can be pursued to dramatically extend healthcare access to vulnerable newborns with hyperbilirubinemia.
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Affiliation(s)
- Eric M. Foote
- Prematurity Research Center, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Farjana Jahan
- Environmental Health and WASH, International Centre for Diarrheal Disease Research, Dhaka, 1212, Bangladesh
| | - Mahbubur Rahman
- Environmental Health and WASH, International Centre for Diarrheal Disease Research, Dhaka, 1212, Bangladesh
| | - Sarker Masood Parvez
- Environmental Health and WASH, International Centre for Diarrheal Disease Research, Dhaka, 1212, Bangladesh
- Children's Health and Environment Program, Child Health Research Centre, The University of Queensland, QLD, Australia
| | - Tasnim Ahmed
- Prematurity Research Center, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Rezaul Hasan
- Environmental Health and WASH, International Centre for Diarrheal Disease Research, Dhaka, 1212, Bangladesh
| | - Farzana Yeasmin
- Environmental Health and WASH, International Centre for Diarrheal Disease Research, Dhaka, 1212, Bangladesh
| | - Shams El Arifeen
- Maternal and Child Health Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, -1212, Bangladesh
| | - Sk Masum Billah
- Maternal and Child Health Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, -1212, Bangladesh
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Md. Mahbubul Hoque
- Department of Neonatology, Bangladesh Shishu Hospital & Institute Dhaka, Dhaka, Bangladesh
| | | | - Muhammad Shariful Islam
- National Newborn Health Program (NNHP) and Integrated Management of Childhood Illness (IMCI), Directorate General of Health Services, Dhaka, Bangladesh
| | - Vinod K Bhutani
- Prematurity Research Center, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Gary L Darmstadt
- Prematurity Research Center, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
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Eltyeb E, Basheer R, Ahmed A, Al-Makramani A, Mahfouz MS, Mohamedali A, Balla A, Algadi H, Gohal G. Nursing Students' Knowledge and Attitudes toward Danger Signs in Neonatal Illnesses. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1939. [PMID: 38003988 PMCID: PMC10672865 DOI: 10.3390/medicina59111939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 10/25/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: Neonates can show subtle signs of illness that could be overlooked by their mothers and caregivers. Therefore, basic knowledge regarding neonatal health and early detection of neonatal diseases can help improve survival. We assessed nursing students' knowledge and attitudes toward the danger signs of neonatal illnesses. Materials and Methods: We performed a descriptive cross-sectional study using a structured online questionnaire based on danger signs categorized by the World Health Organization to assess knowledge of neonatal illness danger signs among nursing students. Results: We assessed 342 students, of which 67.0% (95% CI: 61.8-71.7) had good knowledge regarding neonatal illness danger signs, and 71.6% received information about neonatal care. About 33% of the participants had a basic knowledge of neonatal care, such as breastfeeding, immunization, routine postnatal care, and eye care. Students who received information on neonatal care were three times (AOR = 2.95, 95% CI: 11.59-5.47, p = 0.001) more likely to have good knowledge than those who did not. The students also showed a positive attitude towards the importance of knowledge regarding neonatal illness danger signs, teaching this subject in their college, participating in studies involving the practice and knowledge of mothers regarding neonatal illness danger signs, and the importance of knowledge in reducing neonatal mortality in the region. Conclusions: More training programs on neonatal care should be implemented to enhance knowledge and raise nursing students' awareness of the dangerous signs of neonatal illnesses.
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Affiliation(s)
- Ebtihal Eltyeb
- Faculty of Medicine, Jazan University, Jazan P.O. Box 114, Saudi Arabia; (A.A.-M.); (M.S.M.); (G.G.)
| | - Randa Basheer
- Faculty of Nursing, Jazan University, Jazan P.O. Box 114, Saudi Arabia; (R.B.); (A.A.); (A.M.); (A.B.); (H.A.)
| | - Amel Ahmed
- Faculty of Nursing, Jazan University, Jazan P.O. Box 114, Saudi Arabia; (R.B.); (A.A.); (A.M.); (A.B.); (H.A.)
| | - Ali Al-Makramani
- Faculty of Medicine, Jazan University, Jazan P.O. Box 114, Saudi Arabia; (A.A.-M.); (M.S.M.); (G.G.)
| | - Mohamed Salih Mahfouz
- Faculty of Medicine, Jazan University, Jazan P.O. Box 114, Saudi Arabia; (A.A.-M.); (M.S.M.); (G.G.)
| | - Amna Mohamedali
- Faculty of Nursing, Jazan University, Jazan P.O. Box 114, Saudi Arabia; (R.B.); (A.A.); (A.M.); (A.B.); (H.A.)
| | - Anwar Balla
- Faculty of Nursing, Jazan University, Jazan P.O. Box 114, Saudi Arabia; (R.B.); (A.A.); (A.M.); (A.B.); (H.A.)
| | - Halima Algadi
- Faculty of Nursing, Jazan University, Jazan P.O. Box 114, Saudi Arabia; (R.B.); (A.A.); (A.M.); (A.B.); (H.A.)
| | - Gassem Gohal
- Faculty of Medicine, Jazan University, Jazan P.O. Box 114, Saudi Arabia; (A.A.-M.); (M.S.M.); (G.G.)
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Khan AM, Sultana S, Ahmed S, Shi T, McCollum ED, Baqui AH, Cunningham S, Campbell H. The ability of non-physician health workers to identify chest indrawing to detect pneumonia in children below five years of age in low- and middle-income countries: A systematic review and meta-analysis. J Glob Health 2023; 13:04016. [PMID: 36730094 PMCID: PMC9894506 DOI: 10.7189/jogh.13.04016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background Non-physician health workers play a vital role in diagnosing and treating pneumonia in children in low- and middle-income countries (LMICs). Chest indrawing is a key indicator for pneumonia diagnosis, signifying the severity of the disease. We conducted this systematic review to summarize the evidence on non-physician health workers' ability to identify chest indrawing to detect pneumonia in children below five years of age in LMICs. Methods We comprehensively searched four electronic databases, including MEDLINE, Embase, Web of Science, and Scopus, and reference lists from the identified studies, from January 1, 1990, to January 20, 2022, with no language restrictions. Studies evaluating the performance of non-physician health workers in identifying chest indrawing compared to a reference standard were included. We used the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool to assess the methodological quality of the selected studies and conducted a meta-analysis following a bivariate random effects model to estimate the pooled sensitivity and specificity. Results We identified nine studies covering 4468 children that reported the accuracy of a non-physician health worker in identifying chest indrawing. Most studies were conducted in the 1990s, based at health facility settings, with children aged 2-59 months, and with pediatricians/physicians as the reference standard. Using the QUADAS-2, we evaluated most studies as having a low risk of bias and a low concern regarding applicability in all domains. The median sensitivity, specificity, positive predictive value, and negative predictive value were 44%, 97%, 55%, and 95%, respectively. We selected five studies for the meta-analysis. The pooled sensitivity was 46% (95% confidence interval (CI) = 37-56), and the pooled specificity was 95% (95% CI = 91-97). Conclusions We found the ability of non-physician health workers in LMICs in identifying chest indrawing pneumonia is relatively poor. Appropriate measures, such as targeted identification and training, supportive supervision, regular performance assessment, and feedback for those who have a poor ability to recognize chest indrawing, should be taken to improve the diagnosis of pneumonia in children. New studies are needed to assess the new generation of health workers. Registration PROSPERO (CRD42022306954).
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Affiliation(s)
- Ahad Mahmud Khan
- Usher Institute, University of Edinburgh, Edinburgh, UK,Projahnmo Research Foundation, Dhaka, Bangladesh
| | | | - Salahuddin Ahmed
- Usher Institute, University of Edinburgh, Edinburgh, UK,Projahnmo Research Foundation, Dhaka, Bangladesh
| | - Ting Shi
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Eric D McCollum
- Eudowood Division of Paediatric Respiratory Sciences, Department of Paediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Steve Cunningham
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
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Gavine A, Shinwell SC, Buchanan P, Farre A, Wade A, Lynn F, Marshall J, Cumming SE, Dare S, McFadden A. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Syst Rev 2022; 10:CD001141. [PMID: 36282618 PMCID: PMC9595242 DOI: 10.1002/14651858.cd001141.pub6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND There is extensive evidence of important health risks for infants and mothers related to not breastfeeding. In 2003, the World Health Organization recommended that infants be breastfed exclusively until six months of age, with breastfeeding continuing as an important part of the infant's diet until at least two years of age. However, current breastfeeding rates in many countries do not reflect this recommendation. OBJECTIVES 1. To describe types of breastfeeding support for healthy breastfeeding mothers with healthy term babies. 2. To examine the effectiveness of different types of breastfeeding support interventions in terms of whether they offered only breastfeeding support or breastfeeding support in combination with a wider maternal and child health intervention ('breastfeeding plus' support). 3. To examine the effectiveness of the following intervention characteristics on breastfeeding support: a. type of support (e.g. face-to-face, telephone, digital technologies, group or individual support, proactive or reactive); b. intensity of support (i.e. number of postnatal contacts); c. person delivering the intervention (e.g. healthcare professional, lay person); d. to examine whether the impact of support varied between high- and low-and middle-income countries. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (which includes results of searches of CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP)) (11 May 2021) and reference lists of retrieved studies. SELECTION CRITERIA Randomised or quasi-randomised controlled trials comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care. Support could be provided face-to-face, over the phone or via digital technologies. All studies had to meet the trustworthiness criteria. DATA COLLECTION AND ANALYSIS: We used standard Cochrane Pregnancy and Childbirth methods. Two review authors independently selected trials, extracted data, and assessed risk of bias and study trustworthiness. The certainty of the evidence was assessed using the GRADE approach. MAIN RESULTS This updated review includes 116 trials of which 103 contribute data to the analyses. In total more than 98,816 mother-infant pairs were included. Moderate-certainty evidence indicated that 'breastfeeding only' support probably reduced the number of women stopping breastfeeding for all primary outcomes: stopping any breastfeeding at six months (Risk Ratio (RR) 0.93, 95% Confidence Interval (CI) 0.89 to 0.97); stopping exclusive breastfeeding at six months (RR 0.90, 95% CI 0.88 to 0.93); stopping any breastfeeding at 4-6 weeks (RR 0.88, 95% CI 0.79 to 0.97); and stopping exclusive breastfeeding at 4-6 (RR 0.83 95% CI 0.76 to 0.90). Similar findings were reported for the secondary breastfeeding outcomes except for any breastfeeding at two months and 12 months when the evidence was uncertain if 'breastfeeding only' support helped reduce the number of women stopping breastfeeding. The evidence for 'breastfeeding plus' was less consistent. For primary outcomes there was some evidence that 'breastfeeding plus' support probably reduced the number of women stopping any breastfeeding (RR 0.94, 95% CI 0.91 to 0.97, moderate-certainty evidence) or exclusive breastfeeding at six months (RR 0.79, 95% CI 0.70 to 0.90). 'Breastfeeding plus' interventions may have a beneficial effect on reducing the number of women stopping exclusive breastfeeding at 4-6 weeks, but the evidence is very uncertain (RR 0.73, 95% CI 0.57 to 0.95). The evidence suggests that 'breastfeeding plus' support probably results in little to no difference in the number of women stopping any breastfeeding at 4-6 weeks (RR 0.94, 95% CI 0.82 to 1.08, moderate-certainty evidence). For the secondary outcomes, it was uncertain if 'breastfeeding plus' support helped reduce the number of women stopping any or exclusive breastfeeding at any time points. There were no consistent findings emerging from the narrative synthesis of the non-breastfeeding outcomes (maternal satisfaction with care, maternal satisfaction with feeding method, infant morbidity, and maternal mental health), except for a possible reduction of diarrhoea in intervention infants. We considered the overall risk of bias of trials included in the review was mixed. Blinding of participants and personnel is not feasible in such interventions and as studies utilised self-report breastfeeding data, there is also a risk of bias in outcome assessment. We conducted meta-regression to explore substantial heterogeneity for the primary outcomes using the following categories: person providing care; mode of delivery; intensity of support; and income status of country. It is possible that moderate levels (defined as 4-8 visits) of 'breastfeeding only' support may be associated with a more beneficial effect on exclusive breastfeeding at 4-6 weeks and six months. 'Breastfeeding only' support may also be more effective in reducing women in low- and middle-income countries (LMICs) stopping exclusive breastfeeding at six months compared to women in high-income countries (HICs). However, no other differential effects were found and thus heterogeneity remains largely unexplained. The meta-regression suggested that there were no differential effects regarding person providing support or mode of delivery, however, power was limited. AUTHORS' CONCLUSIONS: When 'breastfeeding only' support is offered to women, the duration and in particular, the exclusivity of breastfeeding is likely to be increased. Support may also be more effective in reducing the number of women stopping breastfeeding at three to four months compared to later time points. For 'breastfeeding plus' interventions the evidence is less certain. Support may be offered either by professional or lay/peer supporters, or a combination of both. Support can also be offered face-to-face, via telephone or digital technologies, or a combination and may be more effective when delivered on a schedule of four to eight visits. Further work is needed to identify components of the effective interventions and to deliver interventions on a larger scale.
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Affiliation(s)
- Anna Gavine
- Mother and Infant Research Unit, School of Health Sciences, University of Dundee, Dundee, UK
| | - Shona C Shinwell
- Mother and Infant Research Unit, School of Health Sciences, University of Dundee, Dundee, UK
| | | | - Albert Farre
- Mother and Infant Research Unit, School of Health Sciences, University of Dundee, Dundee, UK
| | - Angela Wade
- Centre for Paediatric Epidemiology and Biostatistics, Institute of Child Health, London, UK
| | - Fiona Lynn
- School of Nursing and Midwifery, Medical Biology Centre, Queen's University Belfast, Belfast, UK
| | - Joyce Marshall
- Division of Maternal Health, University of Huddersfield, Huddersfield, UK
| | - Sara E Cumming
- Mother and Infant Research Unit, School of Health Sciences, University of Dundee, Dundee, UK
- Mother and Infant Research Unit, University of Dundee, Dundee, UK
| | - Shadrach Dare
- Mother and Infant Research Unit, School of Health Sciences, University of Dundee, Dundee, UK
| | - Alison McFadden
- Mother and Infant Research Unit, School of Health Sciences, University of Dundee, Dundee, UK
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10
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Khan AM, O’Donald A, Shi T, Ahmed S, McCollum ED, King C, Baqui AH, Cunningham S, Campbell H. Accuracy of non-physician health workers in respiratory rate measurement to identify paediatric pneumonia in low- and middle-income countries: A systematic review and meta-analysis. J Glob Health 2022. [PMCID: PMC9037577 DOI: 10.7189/jogh.12.04037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Methods Results Conclusions
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Affiliation(s)
- Ahad M Khan
- Projahnmo Research Foundation, Dhaka, Bangladesh
- The University of Edinburgh, Edinburgh, UK
| | | | - Ting Shi
- The University of Edinburgh, Edinburgh, UK
| | - Salahuddin Ahmed
- Projahnmo Research Foundation, Dhaka, Bangladesh
- The University of Edinburgh, Edinburgh, UK
| | - Eric D McCollum
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Abdullah H Baqui
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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11
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Jahan F, Foote E, Rahman M, Shoab AK, Parvez SM, Nasim MI, Hasan R, El Arifeen S, Billah SM, Sarker S, Hoque MM, Shahidullah M, Islam MS, Ashrafee S, Darmstadt GL. Evaluation of community health worker's performance at home-based newborn assessment supported by mHealth in rural Bangladesh. BMC Pediatr 2022; 22:218. [PMID: 35459113 PMCID: PMC9027479 DOI: 10.1186/s12887-022-03282-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 03/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In low to middle-income countries where home births are common and neonatal postnatal care is limited, community health worker (CHW) home visits can extend the capability of health systems to reach vulnerable newborns in the postnatal period. CHW assessment of newborn danger signs supported by mHealth have the potential to improve the quality of danger sign assessments and reduce CHW training requirements. We aim to estimate the validity (sensitivity, specificity, positive and negative predictive value) of CHW assessment of newborn infants aided by mHealth compared to physician assessment. METHODS In this prospective study, ten CHWs received five days of theoretical and hands-on training on the physical assessment of newborns including ten danger signs. CHWs assessed 273 newborn infants for danger signs within 48 h of birth and then consecutively for three days. A physician repeated 20% (n = 148) of the assessments conducted by CHWs. Both CHWs and the physician evaluated newborns for ten danger signs and decided on referral. We used the physician's danger sign identification and referral decision as the gold standard to validate CHWs' identification of danger signs and referral decisions. RESULTS The referrals made by the CHWs had high sensitivity (93.3%), specificity (96.2%), and almost perfect agreement (K = 0.80) with the referrals made by the physician. CHW identification of all the danger signs except hypothermia showed moderate to high sensitivity (66.7-100%) compared to physician assessments. All the danger signs assessments except hypothermia showed moderate to high positive predictive value (PPV) (50-100%) and excellent negative predictive value (NPV) (99-100%). Specificity was high (99-100%) for all ten danger signs. CONCLUSION CHW's identification of neonatal danger signs aided by mHealth showed moderate to high validity in comparison to physician assessments. mHealth platforms may reduce CHW training requirements and while maintaining quality CHW physical assessment performance extending the ability of health systems to provide neonatal postnatal care in low-resource communities. TRIAL REGISTRATION clinicaltrials.gov NCT03933423 , January 05, 2019.
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Affiliation(s)
- Farjana Jahan
- Environmental Intervention Unit, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
| | - Eric Foote
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Mahbubur Rahman
- Environmental Intervention Unit, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abul Kasham Shoab
- Environmental Intervention Unit, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sarker Masud Parvez
- Environmental Intervention Unit, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Mizanul Islam Nasim
- Environmental Intervention Unit, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Rezaul Hasan
- Environmental Intervention Unit, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shams El Arifeen
- Maternal and Child Health Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sk Masum Billah
- Maternal and Child Health Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Supta Sarker
- Environmental Intervention Unit, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Mahbubul Hoque
- Department of Neonatology, Dhaka Shishu (Children) Hospital, Dhaka, Bangladesh
| | | | - Muhammad Shariful Islam
- National Newborn Health Program (NNHP) and Integrated Management of Childhood Illness (IMCI), Directorate General of Health Services, Dhaka, Bangladesh
| | - Sabina Ashrafee
- National Newborn Health Program (NNHP) and Integrated Management of Childhood Illness (IMCI), Directorate General of Health Services, Dhaka, Bangladesh
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
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12
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Azad R, Billah SM, Bhui BR, Ali NB, Herrera S, de Graft-Johnson J, Garg L, Priyanka SS, Zubair S, Rokonuzzaman SM, Rahman MM, Meena USJ, Arifeen SE. Mother's care-seeking behavior for neonatal danger signs from qualified providers in rural Bangladesh: A generalized structural equation modeling and mediation analysis. Front Pediatr 2022; 10:929157. [PMID: 36683813 PMCID: PMC9846223 DOI: 10.3389/fped.2022.929157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 11/23/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Neonatal deaths contribute to nearly half (47%) of under-five mortality globally and 67% in Bangladesh. Despite high neonatal mortality, care-seeking from qualified providers for newborn danger signs remains low. Identification of direct and indirect factors and their pathways affecting care-seeking will help to design a well-targeted intervention. This study assessed the direct, indirect, and total effect of the predictive factors on neonatal care-seeking in Bangladesh. MATERIALS AND METHODS This was a cross-sectional baseline household survey conducted in 14 districts of Bangladesh in 2019 with 17,251 recently delivered women (RDW) with a live birth outcome in the preceding 15 months. We used a two-stage stratified cluster sampling process to select the samples from 14 districts. We investigated the inter-relationship of maternal background characteristics, maternal health utilizations, child/neonate factors, health service delivery-related factors and newborn danger sign knowledge with newborn care-seeking practices and estimated the direct, indirect, and total effects using Generalized Structural Equation Modeling (GSEM) and mediation analysis. p-value = 0.05 was considered statistically significant. The result of the mediation analysis was reported in Log Odds (LOD). The positive LOD (LOD > 0) implies a positive association. RESULTS Half of the mothers (50.8%) reported a neonatal illness and among them, only 36.5% mothers of sick neonates sought care from qualified providers. Our mediation analysis showed that maternal health utilization factors, i.e., 4 + antenatal care visits (ANC) from a qualified provider (LOD: 0.63, 95% CI: 0.49, 0.78), facility delivery (LOD: 0.74, 95% CI: 0.30, 1.17) and postnatal care (PNC) from a qualified provider (LOD: 0.50, 95% CI: 0.21, 0.78) showed the highest total effect over other factors domains, and therefore, were the most important modifiable predictors for qualified neonatal care-seeking. Other important factors that directly and/or indirectly increased the chance of newborn care-seeking from qualified providers were household wealth (LOD: 0.86, 95% CI: 0.70, 1.02), maternal education (LOD: 0.48, 95% CI: 0.32, 0.63), distance to nearest health facility (LOD: 0.20, 95% CI: 0.10, 0.30), community health worker's (CHWs) home visits during ANC (LOD: 0.24, 95% CI: 0.13, 0.36), neonatal danger sign counseling after delivery (LOD: 0.20, 95% CI: 0.06, 0.34) and women's knowledge of neonatal danger signs (LOD: 0.37, 95% CI: 0.09, 0.64). CONCLUSION The inter-relationship and highest summative effect of ANC, facility delivery, and PNC on newborn care-seeking suggested the maternal care continuum altogether from ANC to facility delivery and PNC to improve care-seeking for the sick newborn. Additionally, referral training for unqualified providers, targeted intervention for poorer households, increasing CHWs home visits and neonatal danger sign counseling at the facility and community should also be considered.
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Affiliation(s)
- Rashidul Azad
- International Centre for Diarrhoeal Disease Research, Bangladesh (Icddr,b), Dhaka, Bangladesh
| | - Sk Masum Billah
- International Centre for Diarrhoeal Disease Research, Bangladesh (Icddr,b), Dhaka, Bangladesh.,The University of Sydney School of Public Health, Sydney, NSW, Australia
| | | | - Nazia Binte Ali
- International Centre for Diarrhoeal Disease Research, Bangladesh (Icddr,b), Dhaka, Bangladesh.,Harvard T.H. Chan School of Public Health, Boston, United States
| | | | | | - Lyndsey Garg
- Save the Children, Washington, DC, United States
| | | | | | - S M Rokonuzzaman
- International Centre for Diarrhoeal Disease Research, Bangladesh (Icddr,b), Dhaka, Bangladesh
| | | | | | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh (Icddr,b), Dhaka, Bangladesh
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13
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LeFevre AE, Mir F, Mitra DK, Ariff S, Mohan D, Ahmed I, Sultana S, Winch PJ, Shakoor S, Connor NE, Islam MS, El-Arifeen S, Quaiyum MA, Baqui AH, Gravett MG, Santosham M, Bhutta ZA, Zaidi A, Saha SK, Ahmed S, Soofi S, Bartlett LA. Validation of community health worker identification of maternal puerperal sepsis using a clinical diagnostic algorithm in Bangladesh and Pakistan. J Glob Health 2021; 11:04039. [PMID: 34912547 PMCID: PMC8645220 DOI: 10.7189/jogh.11.04039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Puerperal sepsis (PP sepsis) is a leading cause of maternal mortality globally. The majority of maternal sepsis cases and deaths occur at home and remain undiagnosed and under-reported. In this paper, we present findings from a nested case-control study in Bangladesh and Pakistan which sought to assess the validity of community health worker (CHW) identification of PP sepsis using a clinical diagnostic algorithm with physician assessment and classification used as the gold standard. Methods Up to 300 postpartum women were enrolled in each of the 3 sites 1) Sylhet, Bangladesh (n = 278), 2) Karachi, Pakistan (n = 278) and 3) Matiari, Pakistan (n = 300). Index cases were women with suspected PP Sepsis as diagnosed by CHWs clinical assessment of one or more of the following signs and symptoms: temperature (recorded fever ≥38.1°C, reported history of fever, lower abdominal or pelvic pain, and abnormal or foul-smelling discharge. Each case was matched with 3 control women who were diagnosed by CHWs to have no infection. Cases and controls were assessed by trained physicians using the same algorithm implemented by the CHWs. Using physician assessment as the gold standard, Kappa statistics for reliability and diagnostic validity (sensitivity and specificity) are presented with 95% CI. Sensitivity and specificity were adjusted for verification bias. Results The adjusted sensitivity and specificity of CHW identification of PP sepsis across all sites was 82% (Karachi: 78%, Matiari: 78%, Sylhet: 95%) and 90% (Karachi: 95%, Matiari: 85%, Sylhet: 90%) respectively. CHW-Physician agreement was highest for moderate and high fever (range across sites: K = 0.84-0.97) and lowest for lower abdominal pain (K = 0.30-0.34). The clinical signs and symptoms for other conditions were reported infrequently, however, the CHW-physician agreement was high for all symptoms except severe headache/ blurred vision (K = 0.13-0.38) and reported "lower abdominal pain without fever" (K = 0.39-0.57). Conclusion In all sites, CHWs with limited training were able to identify signs and symptoms and to classify cases of PP sepsis with high validity. Integrating postpartum infection screening into existing community-based platforms and post-natal visits is a promising strategy to monitor women for PP sepsis - improving delivery of cohesive maternal and child health care in low resource settings.
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Affiliation(s)
- Amnesty E LeFevre
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, Western Cape, South Africa.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Fatima Mir
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Dipak K Mitra
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Public Health, North South University, Dhaka, Bangladesh
| | - Shabina Ariff
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Diwakar Mohan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Imran Ahmed
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Shazia Sultana
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Peter J Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sadia Shakoor
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Nicholas E Connor
- The Child Health Research Foundation, Department of Microbiology, Dhaka Shishu Hospital, Dhaka, Bangladesh.,Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mohammad Shahidul Islam
- The Child Health Research Foundation, Department of Microbiology, Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Shams El-Arifeen
- Centre for Child and Adolescent Health, icddr,b, Dhaka, Bangladesh
| | - M A Quaiyum
- Centre for Child and Adolescent Health, icddr,b, Dhaka, Bangladesh
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Michael G Gravett
- University of Washington, Departments of Obstetrics & Gynecology and of Global Health, Seattle, Washington, USA
| | - Mathuram Santosham
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Zulfiqar A Bhutta
- Centre of Excellence in Women & Child Health, The Aga Khan University, Karachi, Pakistan.,Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Anita Zaidi
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Samir K Saha
- The Child Health Research Foundation, Department of Microbiology, Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Saifuddin Ahmed
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sajid Soofi
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Linda A Bartlett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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14
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Fung A, Hamilton E, Du Plessis E, Askin N, Avery L, Crockett M. Training programs to improve identification of sick newborns and care-seeking from a health facility in low- and middle-income countries: a scoping review. BMC Pregnancy Childbirth 2021; 21:831. [PMID: 34906109 PMCID: PMC8670028 DOI: 10.1186/s12884-021-04240-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 10/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most neonatal deaths occur in low- and middle-income countries (LMICs). Limited recommendations are available on the optimal personnel and training required to improve identification of sick newborns and care-seeking from a health facility. We conducted a scoping review to map the key components required to design an effective newborn care training program for community-based health workers (CBHWs) to improve identification of sick newborns and care-seeking from a health facility in LMICs. METHODS We searched multiple databases from 1990 to March 2020. Employing iterative scoping review methodology, we narrowed our inclusion criteria as we became more familiar with the evidence base. We initially included any manuscripts that captured the concepts of "postnatal care providers," "neonates" and "LMICs." We subsequently included articles that investigated the effectiveness of newborn care provision by CBHWs, defined as non-professional paid or volunteer health workers based in communities, and their training programs in improving identification of newborns with serious illness and care-seeking from a health facility in LMICs. RESULTS Of 11,647 articles identified, 635 met initial inclusion criteria. Among these initial results, 35 studies met the revised inclusion criteria. Studies represented 11 different types of newborn care providers in 11 countries. The most commonly studied providers were community health workers. Key outcomes to be measured when designing a training program and intervention to increase appropriate assessment of sick newborns at a health facility include high newborn care provider and caregiver knowledge of newborn danger signs, accurate provider and caregiver identification of sick newborns and appropriate care-seeking from a health facility either through caregiver referral compliance or caregivers seeking care themselves. Key components to consider to achieve these outcomes include facilitators: sufficient duration of training, refresher training, supervision and community engagement; barriers: context-specific perceptions of newborn illness and gender roles that may deter care-seeking; and components with unclear benefit: qualifications prior to training and incentives and remuneration. CONCLUSION Evidence regarding key components and outcomes of newborn care training programs to improve CBHW identification of sick newborns and care-seeking can inform future newborn care training design in LMICs. These training components must be adapted to country-specific contexts.
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Affiliation(s)
- Alastair Fung
- Hospital for Sick Children, Division of Paediatric Medicine, University of Toronto, 555 University Ave., Rm 10402, Black Wing, Toronto, Ontario, M5G 1X8, Canada.
| | - Elisabeth Hamilton
- Institute for Global Public Health, Rady Faculty of Health Sciences, University of Manitoba, R070 Med Rehab Bldg, 771 McDermot Avenue, Winnipeg, Manitoba, R3E 0T6, Canada
| | - Elsabé Du Plessis
- Institute for Global Public Health, Rady Faculty of Health Sciences, University of Manitoba, R070 Med Rehab Bldg, 771 McDermot Avenue, Winnipeg, Manitoba, R3E 0T6, Canada
| | - Nicole Askin
- Neil John Maclean Health Sciences Library, Rady Faculty of Health Sciences, University of Manitoba, 727 McDermot Avenue, Winnipeg, Manitoba, R3E 0T6, Canada
| | - Lisa Avery
- Institute for Global Public Health, Department Of Obstetrics, Gynecology and Reproductive Sciences, Rady Faculty of Health Sciences, University of Manitoba, R070 Med Rehab Bldg, 771 McDermot Avenue, Winnipeg, Manitoba, R3E 0T6, Canada
| | - Maryanne Crockett
- Institute for Global Public Health, Department of Pediatrics and Child Health, Medical Microbiology and Infectious Diseases, Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, R070 Med Rehab Bldg, 771 McDermot Avenue, Winnipeg, Manitoba, R3E 0T6, Canada
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15
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Prevalence of clinical signs of possible serious bacterial infection and mortality associated with them from population-based surveillance of young infants from birth to 2 months of age. PLoS One 2021; 16:e0247457. [PMID: 33626090 PMCID: PMC7904202 DOI: 10.1371/journal.pone.0247457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 02/06/2021] [Indexed: 11/19/2022] Open
Abstract
Background Community-based data on the prevalence of clinical signs of possible serious bacterial infection (PSBI) and the mortality associated with them are scarce. The aim was to examine the prevalence for each sign of infection and mortality associated with infants in the first two months of life, using community surveillance through community health workers (CHW). Methods We used population-based surveillance data of infants up to two months of age from the African Neonatal Sepsis Trial (AFRINEST). In this study, CHWs visited infants up to 10 times during the first two months of life at five sites in three sub-Saharan African countries. CHW assessed the infant for signs of infection (local or systemic) and referred infants who presented with any sign of infection to a health facility. We used a longitudinal analysis to calculate the risk of death associated with the presence of a sign of infection at the time of the visit until the subsequent visit. Results During the first two months of their life, CHWs visited 84,759 live-born infants at least twice. In 11,089 infants (13.1%), one or more signs of infection were identified, of which 237 (2.1%) died. A sign of infection was detected at 2.1% of total visits. In 52% of visits, infants had one or more sign of systemic infection, while 25% had fast breathing in 7–59 days period and 23% had a local infection. All signs of infection, including multiple signs, were more frequently seen in the first week of life. The risk of mortality was very low (0.2%) for local infections and fast breathing in 7–59 days old, it was low for fast breathing 0–6 days old (0.6%), high body temperature (0.7%) and severe chest indrawing (1.0%), moderate for low body temperature (4.9%) and stopped feeding well/not able to feed at all (5.0%) and high for movement only when stimulated or no movement at all (10%) and multiple signs of systemic infection (15.5%). The risk of death associated with most clinical signs was higher (1.5 to 9 times) in the first week of life than at later age, except for low body temperature (4 times lower) as well as high body temperature (2 times lower). Conclusion Signs of infections are common in the first two months of life. The mortality risk differs with clinical signs and can be grouped as very low (local infections, fast breathing 7–59 days), low (fever, severe chest indrawing and fast breathing 0–6 days), moderate (low body temperature and stopped feeding well/not able to feed at all) and high (for movements only on stimulation or no movements at all and multiple signs of infection). New treatment strategies that consider differential mortality risk could be developed and evaluated based on these findings. Clinical trial registration The trial was registered with Australian New Zealand Clinical Trials Registry under ID ACTRN 12610000286044.
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Incidence of postpartum and neonatal illnesses and utilization of healthcare services in rural communities in southern Ethiopia: A prospective cohort study. PLoS One 2020; 15:e0237852. [PMID: 32853242 PMCID: PMC7451546 DOI: 10.1371/journal.pone.0237852] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 08/03/2020] [Indexed: 01/02/2023] Open
Abstract
Although improving postpartum and neonatal health is a key element of the Ethiopian health extension program, the burdens of postpartum and neonatal illnesses and healthcare-seeking in rural communities in Ethiopia are poorly characterized. Therefore, we aimed to assess the incidence and risk factors for these illnesses and measure the utilization of healthcare services. We conducted a prospective cohort study of 784 postpartum women and their 772 neonates in three randomly selected kebeles in rural southern Ethiopia. Eight home follow-up visits were conducted during the first 42 postpartum days, and six neonate follow-ups were conducted at the same home over the first 28 days of life. The Prentice, Williams, and Peterson’s total time Cox-type survival model was used for analysis. We recorded 31 episodes of postpartum illness per 100 women-weeks (95% confidence interval [CI]: 30%, 32%) and 48 episodes of neonatal illness per 100 neonate-weeks (95% CI: 46%, 50%). Anemia occurred in 19% of women (95% CI: 17%, 22%) and low birth weight (<2,500g) in 15% of neonates (95% CI: 13%, 18%). However, only 5% of postpartum women (95% CI: 4%, 7%) and 4% of neonate (95% CI: 3%, 5%) reported utilizing healthcare services. Walking over 60 minutes to access healthcare was a factor of both postpartum illnesses (AHR = 2.61; 95% CI: 1.98, 3.43) and neonatal illnesses (AHR = 2.66; 95% CI: 2.12, 3.35)). Birth weight ≥2500g was identified factor of neonatal illnesses (AHR = 0.39; 95% CI: 0.33, 0.46). Compared with younger mothers, older mothers with sick newborns (AHR = 1.22; 95% CI: 1.00, 1.50) or postpartum illnesses (AHR = 1.40; 95% CI: 1.03, 1.89) were more likely to seek healthcare. Reasons for not utilizing healthcare services included a belief that the illnesses were not serious or would resolve on their own, little confidence in the healthcare institutions, and the inability to afford the cost. The burden of postpartum and neonatal illnesses in rural communities of southern Ethiopia remains high. Unfortunately, few participants utilized healthcare services. We recommend strengthening the health system that enables identifying, managing, treating, and referring maternal and neonatal illnesses and provide reasonable healthcare at the community level.
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Rono H, Bastawrous A, Macleod D, Bunywera C, Mamboleo R, Wanjala E, Burton M. Smartphone-Guided Algorithms for Use by Community Volunteers to Screen and Refer People With Eye Problems in Trans Nzoia County, Kenya: Development and Validation Study. JMIR Mhealth Uhealth 2020; 8:e16345. [PMID: 32558656 PMCID: PMC7334755 DOI: 10.2196/16345] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/17/2019] [Accepted: 12/15/2019] [Indexed: 01/18/2023] Open
Abstract
Background The provision of eye care services is currently insufficient to meet the requirements of eye care. Many people remain unnecessarily visually impaired or at risk of becoming so because of treatable or preventable eye conditions. A lack of access and awareness of services is, in large part, a key barrier to handle this unmet need. Objective This study aimed to assess whether utilizing novel smartphone-based clinical algorithms can task-shift eye screening to community volunteers (CVs) to accurately identify and refer patients to primary eye care services. In particular, we developed the Peek Community Screening app and assessed its validity in making referral decisions for patients with eye problems. Methods We developed a smartphone-based clinical algorithm (the Peek Community Screening app) using age, distance vision, near vision, and pain as referral criteria. We then compared CVs’ referral decisions using this app with those made by an experienced ophthalmic clinical officer (OCO), which was the reference standard. The same participants were assessed by a trained CV using the app and by an OCO using standard outreach equipment. The outcome was the proportion of all decisions that were correct when compared with that of the OCO. Results The required sensitivity and specificity for the Peek Community Screening app were achieved after seven iterations. In the seventh iteration, the OCO identified referable eye problems in 65.9% (378/574) of the participants. CVs correctly identified 344 of 378 (sensitivity 91.0%; 95% CI 87.7%-93.7%) of the cases and correctly identified 153 of 196 (specificity 78.1%; 95% CI 71.6%-83.6%) cases as not having a referable eye problem. The positive predictive value was 88.9% (95% CI 85.3%-91.8%), and the negative predictive value was 81.8% (95% CI 75.5%-87.1%). Conclusions Development of such an algorithm is feasible; however, it requires considerable effort and resources. CVs can accurately use the Peek Community Screening app to identify and refer people with eye problems. An iterative design process is necessary to ensure validity in the local context.
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Affiliation(s)
- Hillary Rono
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Kitale County and Referral Hospital, Kitale, Kenya
| | - Andrew Bastawrous
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Peek Vision Foundation, London, United Kingdom
| | - David Macleod
- Medical Research Council Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Cosmas Bunywera
- Kitale County and Referral Hospital, Kitale, Kenya.,Peek Vision Foundation, London, United Kingdom
| | | | | | - Matthew Burton
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Moorfields Eye Hospital NHS Trust, London, United Kingdom
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Getachew T, Mekonnen S, Yitayal M, Persson LÅ, Berhanu D. Health Extension Workers' diagnostic accuracy for common childhood illnesses in four regions of Ethiopia: a cross-sectional study. Acta Paediatr 2019; 108:2100-2106. [PMID: 31162734 PMCID: PMC7154548 DOI: 10.1111/apa.14888] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/27/2019] [Accepted: 06/03/2019] [Indexed: 01/18/2023]
Abstract
Aim The Ethiopian primary care of sick children is provided within the integrated Community Case Management of childhood illnesses by Health Extension Workers (HEW). There is limited knowledge whether this cadre correctly assess and classify common diseases. The aim was to study their ability to correctly classify common childhood illnesses. Methods A survey was conducted from December 2016 to February 2017 in four regions of Ethiopia. Observations of the HEWs‘ assessment and classification of sick children were followed by child re-examination by a trained health officer. Results The classification by the HEWs of 620 sick children as compared to the reexaminer had a sensitivity of 89% and specificity of 94% for diarrhoea, sensitivity 52% and specificity 91% for febrile disorders, and a sensitivity of 59% and specificity of 94% for acute respiratory tract infection. Malnutrition and ear infection had a sensitivity of 39 and 61%, and a specificity of 99 and 99%, respectively. Conclusion Most cases of diarrhoea were correctly classified, while other illnesses were not frequently identified. The identification of malnutrition was especially at fault. These findings suggest that a significant number of sick children were undiagnosed that could lead to absent or incorrect management and treatment.
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Affiliation(s)
- Theodros Getachew
- Health System and Reproductive Health Research Directorate Ethiopian Public Health Institute Addis Ababa Ethiopia
- College of Medicine and Health Science Institute of Public Health University of Gondar Gondar Ethiopia
| | - Solomon Mekonnen
- College of Medicine and Health Science Institute of Public Health University of Gondar Gondar Ethiopia
| | - Mezgebu Yitayal
- College of Medicine and Health Science Institute of Public Health University of Gondar Gondar Ethiopia
| | - Lars Åke Persson
- Health System and Reproductive Health Research Directorate Ethiopian Public Health Institute Addis Ababa Ethiopia
- London School of Hygiene and Tropical Medicine Bloomsbury, London UK
| | - Della Berhanu
- Health System and Reproductive Health Research Directorate Ethiopian Public Health Institute Addis Ababa Ethiopia
- London School of Hygiene and Tropical Medicine Bloomsbury, London UK
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19
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Mobbs NA, Ditai J, Abeso J, Faragher EB, Carrol ED, Gladstone M, Medina-Lara A, Olupot-Olupot P, Weeks AD. In search of a primary outcome for community-based newborn infection trials in Eastern Uganda: a nested cohort study within the BabyGel pilot trial. Pilot Feasibility Stud 2019; 5:43. [PMID: 30911406 PMCID: PMC6415494 DOI: 10.1186/s40814-019-0428-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 02/25/2019] [Indexed: 12/21/2022] Open
Abstract
Background Due to their immature immune system, neonates are at high risk of infection. This vulnerability when combined with limited resources and health education in developing countries can lead to sepsis, resulting in high global neonatal mortality rates. Many of these deaths are preventable. The BabyGel pilot trial tested the feasibility of conducting the main randomised trial, with the provision of alcohol handgel to postpartum mothers for prevention of neonatal infective morbidity in the rural community. This secondary analysis sought to evaluate the methods of detecting infections in babies up to 3 months of age. Methods The pilot two-arm cluster randomised controlled trial took place in 10 villages around Mbale, Eastern Uganda. Women were eligible and recruited antenatally if their gestation was ≥ 34 weeks. All infants of mothers participating in the BabyGel pilot trial were followed up for the first 3 months of life. Evidence for infant infection was collected using five different methods: clinician diagnosed infection, microbiologically confirmed infection, maternally reported infection, a positive infection screen using the World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) screening criteria, and reported antibiotic use identified during home and clinic visits. These methods were assessed quantitatively regarding the detection rates of suspected infections and qualitatively by exploring the challenges collecting data in the rural community setting. Results A total of 103 eligible women participated in the BabyGel pilot trial, with 1 woman delivering twins. Of the 99 mother-infant pairs who consented to participate in the study, 55 infants were identified with infection in total. Maternal report of illness provided the highest estimate, with mothers reporting suspected illness for 45 infants (81.8% of the total suspected infections identified). The WHO IMCI screening criteria identified 30 infants with suspected infection (54.5%), and evidence for antibiotic use was established in 22 infants (40%). Finally, clinician-diagnosed infection identified 19 cases (34.5%), which were also microbiologically confirmed in 5 cases (9.1%). Data collection in the rural setting was hindered by poor communication between mothers and the research team, limited staff awareness of the study in health centres resulting in reduced safeguarding of clinical notes, and widespread use of antibiotics prior to notification and clinical review. Furthermore, identification of suspected infection may not have been limited to severe infections, with ambiguity and no official clinical diagnosis being given to those identified solely by maternal report of infection. Conclusions A high rate of suspected infection was identified spanning the five sources of data collection, but no ideal method was found for detection of community neonatal infection. Although maternal self-reports of infant infection provided the highest detection rate, data collection via each source was limited and may have identified minor rather than major infections. Future studies could utilise the IMCI screening tool to detect severe community infection leading to referral for clinical confirmation. This should be combined with weekly contact with mothers to detect maternally suspected illness. Obtaining more details of the symptoms and timescale will improve the accuracy when detecting the total burden of suspected disease, and advising participants to retain medication packaging and prescriptions will improve identification of antibiotic use. Trial registration Babygel pilot trial - trial registration: ISCRCTN 67852437. Registered 02/03/2015.
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Affiliation(s)
- N A Mobbs
- 1Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool and Liverpool Women's NHS Foundation Trust, members of Liverpool Health Partners, Crown Street, Liverpool, L8 7SS UK.,2University of Liverpool, Cedar House, Ashton Street, Liverpool, L3 5PS UK
| | - J Ditai
- 1Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool and Liverpool Women's NHS Foundation Trust, members of Liverpool Health Partners, Crown Street, Liverpool, L8 7SS UK.,3Sanyu Africa Research Institute (SAfRI), Mbale Regional Referral Hospital, Pallisa-Kumi Road Junction, P.o Box 2190, Mbale, Uganda
| | - J Abeso
- 3Sanyu Africa Research Institute (SAfRI), Mbale Regional Referral Hospital, Pallisa-Kumi Road Junction, P.o Box 2190, Mbale, Uganda.,4Department of Paediatrics, Mbale Regional Referral Hospital, Mbale, Uganda
| | - E B Faragher
- 5Tropical Clinical Trials Unit, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - E D Carrol
- 6Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, 8 West Derby Street, Liverpool, L69 7BE UK
| | - M Gladstone
- 7Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool and Alder Hey NHS Foundation Trust, members of Liverpool Health Partners, Eaton Road, Liverpool, L12 2AP UK
| | - A Medina-Lara
- 8Health Economics Group, University of Exeter, Exeter, UK
| | - P Olupot-Olupot
- 9Faculty of Health Sciences, Busitema University, P.o Box 1460, Mbale, Uganda
| | - A D Weeks
- 1Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool and Liverpool Women's NHS Foundation Trust, members of Liverpool Health Partners, Crown Street, Liverpool, L8 7SS UK
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Winters N, Langer L, Geniets A. Scoping review assessing the evidence used to support the adoption of mobile health (mHealth) technologies for the education and training of community health workers (CHWs) in low-income and middle-income countries. BMJ Open 2018; 8:e019827. [PMID: 30061430 PMCID: PMC6067337 DOI: 10.1136/bmjopen-2017-019827] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES Undertake a systematic scoping review to determine how a research evidence base, in the form of existing systematic reviews in the field of mobile health (mHealth), constitutes education and training for community health workers (CHWs) who use mobile technologies in everyday work. The review was informed by the following research questions: does educational theory inform the design of the education and training component of mHealth interventions? How is education and training with mobile technology by CHWs in low-income and middle-income countries categorised by existing systematic reviews? What is the basis for this categorisation? SETTING The review explored the literature from 2000 to 2017 to investigate how mHealth interventions have been positioned within the available evidence base in relation to their use of formal theories of learning. RESULTS The scoping review found 24 primary studies that were categorised by 16 systematic reviews as supporting CHWs' education and training using mobile technologies. However, when formal theories of learning from educational research were used to recategorise these 24 primary studies, only four could be coded as such. This identifies a problem with how CHWs' education and training using mobile technologies is understood and categorised within the existing evidence base. This is because there is no agreed on, theoretically informed understanding of what counts as learning. CONCLUSION The claims made by mHealth researchers and practitioners regarding the learning benefits of mobile technology are not based on research results that are underpinned by formal theories of learning. mHealth suffers from a reductionist view of learning that underestimates the complexities of the relationship between pedagogy and technology. This has resulted in miscategorisations of what constitutes CHWs' education and training within the existing evidence base. This can be overcome by informed collaboration between the health and education communities.
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Affiliation(s)
- Niall Winters
- Department of Education, University of Oxford, Oxford, UK
| | | | - Anne Geniets
- Department of Education, University of Oxford, Oxford, UK
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21
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Okuga M, Waiswa P, Mandu R, Wachira J, Hanson C, Manzi F. Illness recognition and care-seeking for maternal and newborn complications in rural eastern Uganda. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2017; 36:47. [PMID: 29297398 PMCID: PMC5764049 DOI: 10.1186/s41043-017-0125-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND To enhance understanding of the roles of community-based initiatives in poor rural societies, we describe and explore illness recognition, decision-making, and appropriate care-seeking for mothers and newborn illnesses in two districts in eastern Uganda where in one implementation district, a facility and community quality improvement approach was implemented. METHODS This was a cross-sectional study using qualitative methods. We conducted 48 event narratives: eight maternal and newborn deaths and 16 maternal and newborn illnesses. Additionally, we conducted six FGDs with women's saving groups and community leaders. Qualitative data were analyzed thematically using Atlas.ti software. RESULTS Women and caretakers reported that community initiatives including the presence of community health workers and women's saving groups helped in enhancing illness recognition, decision-making, and care-seeking for maternal and newborn complications. Newborn illness seemed to be less well understood, and formal care was often delayed. Care-seeking was complicated by accessing several stations from primary to secondary care, and often, the hospital was reached too late. CONCLUSIONS Our qualitative study suggests that community approaches may play a role in illness recognition, decision-making, and care-seeking for maternal and newborn illness. The role of primary facilities in providing care for maternal and newborn emergencies might need to be reviewed.
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Affiliation(s)
- Monica Okuga
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda
- Center of Excellence for Maternal, Newborn and Child Health, Makerere University, Kampala, Uganda
| | - Peter Waiswa
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda
- Center of Excellence for Maternal, Newborn and Child Health, Makerere University, Kampala, Uganda
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Rogers Mandu
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda
- Center of Excellence for Maternal, Newborn and Child Health, Makerere University, Kampala, Uganda
| | - Juddy Wachira
- School of Medicine/AMPATH, Moi University, Nairobi, Kenya
| | - Claudia Hanson
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- London School of Hygiene and Tropical Medicine, London, UK
| | - Fatuma Manzi
- Ifakara Health Institute, Dar es Salaam, Tanzania
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McFadden A, Gavine A, Renfrew MJ, Wade A, Buchanan P, Taylor JL, Veitch E, Rennie AM, Crowther SA, Neiman S, MacGillivray S. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Syst Rev 2017; 2:CD001141. [PMID: 28244064 PMCID: PMC6464485 DOI: 10.1002/14651858.cd001141.pub5] [Citation(s) in RCA: 233] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND There is extensive evidence of important health risks for infants and mothers related to not breastfeeding. In 2003, the World Health Organization recommended that infants be breastfed exclusively until six months of age, with breastfeeding continuing as an important part of the infant's diet until at least two years of age. However, current breastfeeding rates in many countries do not reflect this recommendation. OBJECTIVES To describe forms of breastfeeding support which have been evaluated in controlled studies, the timing of the interventions and the settings in which they have been used.To examine the effectiveness of different modes of offering similar supportive interventions (for example, whether the support offered was proactive or reactive, face-to-face or over the telephone), and whether interventions containing both antenatal and postnatal elements were more effective than those taking place in the postnatal period alone.To examine the effectiveness of different care providers and (where information was available) training.To explore the interaction between background breastfeeding rates and effectiveness of support. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (29 February 2016) and reference lists of retrieved studies. SELECTION CRITERIA Randomised or quasi-randomised controlled trials comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach. MAIN RESULTS This updated review includes 100 trials involving more than 83,246 mother-infant pairs of which 73 studies contribute data (58 individually-randomised trials and 15 cluster-randomised trials). We considered that the overall risk of bias of trials included in the review was mixed. Of the 31 new studies included in this update, 21 provided data for one or more of the primary outcomes. The total number of mother-infant pairs in the 73 studies that contributed data to this review is 74,656 (this total was 56,451 in the previous version of this review). The 73 studies were conducted in 29 countries. Results of the analyses continue to confirm that all forms of extra support analyzed together showed a decrease in cessation of 'any breastfeeding', which includes partial and exclusive breastfeeding (average risk ratio (RR) for stopping any breastfeeding before six months 0.91, 95% confidence interval (CI) 0.88 to 0.95; moderate-quality evidence, 51 studies) and for stopping breastfeeding before four to six weeks (average RR 0.87, 95% CI 0.80 to 0.95; moderate-quality evidence, 33 studies). All forms of extra support together also showed a decrease in cessation of exclusive breastfeeding at six months (average RR 0.88, 95% CI 0.85 to 0.92; moderate-quality evidence, 46 studies) and at four to six weeks (average RR 0.79, 95% CI 0.71 to 0.89; moderate quality, 32 studies). We downgraded evidence to moderate-quality due to very high heterogeneity.We investigated substantial heterogeneity for all four outcomes with subgroup analyses for the following covariates: who delivered care, type of support, timing of support, background breastfeeding rate and number of postnatal contacts. Covariates were not able to explain heterogeneity in general. Though the interaction tests were significant for some analyses, we advise caution in the interpretation of results for subgroups due to the heterogeneity. Extra support by both lay and professionals had a positive impact on breastfeeding outcomes. Several factors may have also improved results for women practising exclusive breastfeeding, such as interventions delivered with a face-to-face component, high background initiation rates of breastfeeding, lay support, and a specific schedule of four to eight contacts. However, because within-group heterogeneity remained high for all of these analyses, we advise caution when making specific conclusions based on subgroup results. We noted no evidence for subgroup differences for the any breastfeeding outcomes. AUTHORS' CONCLUSIONS When breastfeeding support is offered to women, the duration and exclusivity of breastfeeding is increased. Characteristics of effective support include: that it is offered as standard by trained personnel during antenatal or postnatal care, that it includes ongoing scheduled visits so that women can predict when support will be available, and that it is tailored to the setting and the needs of the population group. Support is likely to be more effective in settings with high initiation rates. Support may be offered either by professional or lay/peer supporters, or a combination of both. Strategies that rely mainly on face-to-face support are more likely to succeed with women practising exclusive breastfeeding.
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Affiliation(s)
- Alison McFadden
- University of DundeeMother and Infant Research Unit, School of Nursing and Health Sciences, Dundee Centre for Health and Related Research11 Airlie PlaceDundeeTaysideUKDD1 4HJ
| | - Anna Gavine
- University of Dundeeevidence Synthesis Training and Research Group (eSTAR), School of Nursing and Health Sciences, Dundee Centre for Health and Related Research11 Airlie PlaceDundeeUKDD1 4HJ
| | - Mary J Renfrew
- University of DundeeMother and Infant Research Unit, School of Nursing and Health Sciences, Dundee Centre for Health and Related Research11 Airlie PlaceDundeeTaysideUKDD1 4HJ
| | - Angela Wade
- Institute of Child HealthCentre for Paediatric Epidemiology and Biostatistics30 Guilford StLondonUKWC1N 1 EH
| | | | | | - Emma Veitch
- Breastfeeding NetworkPaisleyRenfrewshireUKPA2 8YB
| | - Anne Marie Rennie
- NHS Grampian, Aberdeen Maternity HospitalCornhill RoadAberdeenUKAB25 2ZL
| | - Susan A Crowther
- Robert Gordon UniversityFaculty of Health and Social Care, School of Nursing and MidwiferyGarthdee RoadAberdeenUKAB10 7AQ
| | - Sara Neiman
- Breastfeeding NetworkPaisleyRenfrewshireUKPA2 8YB
| | - Stephen MacGillivray
- University of Dundeeevidence Synthesis Training and Research Group (eSTAR), School of Nursing and Health Sciences, Dundee Centre for Health and Related Research11 Airlie PlaceDundeeUKDD1 4HJ
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de Vries DH, Pool R. The Influence of Community Health Resources on Effectiveness and Sustainability of Community and Lay Health Worker Programs in Lower-Income Countries: A Systematic Review. PLoS One 2017; 12:e0170217. [PMID: 28095475 PMCID: PMC5240984 DOI: 10.1371/journal.pone.0170217] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 01/02/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Despite the availability of practical knowledge and effective interventions required to reduce priority health problems in low-income countries, poor and vulnerable populations are often not reached. One possible solution to this problem is the use of Community or Lay Health Workers (CLHWs). So far, however, the development of sustainability in CLHW programs has failed and high attrition rates continue to pose a challenge. We propose that the roles and interests which support community health work should emerge directly from the way in which health is organized at community level. This review explores the evidence available to assess if increased levels of integration of community health resources in CLHW programs indeed lead to higher program effectiveness and sustainability. METHODS AND FINDINGS This review includes peer-reviewed articles which meet three eligibility criteria: 1) specific focus on CLHWs or equivalent; 2) randomized, quasi-randomized, before/after methodology or substantial descriptive assessment; and 3) description of a community or peer intervention health program located in a low- or middle-income country. Literature searches using various article databases led to 2930 hits, of which 359 articles were classified. Of these, 32 articles were chosen for extensive review, complemented by analysis of the results of 15 other review studies. Analysis was conducted using an excel based data extraction form. Because results showed that no quantitative data was published, a descriptive synthesis was conducted. The review protocol was not proactively registered. Findings show minimal inclusion of even basic community level indicators, such as the degree to which the program is a community initiative, community input in the program or training, the background and history of CLHW recruits, and the role of the community in motivation and retention. Results show that of the 32 studies, only one includes one statistical measure of community integration. As a result of this lack of data we are unable to derive an evidence-based conclusion to our propositions. Instead, our results indicate a larger problem, namely the complete absence of indicators measuring community relationships with the programs studied. Studies pay attention only to gender and peer roles, along with limited demographic information about the recruits. The historicity of the health worker and the community s/he belongs to is absent in most studies reviewed. None of the studies discuss or test for the possibility that motivation emanates from the community. Only a few studies situate attrition and retention as an issue enabled by the community. The results were limited by a focus on low-income countries and English, peer-reviewed published articles only. CONCLUSION Published, peer-reviewed studies evaluating the effectiveness and sustainability of CLHW interventions in health programs have not yet adequately tested for the potential of utilizing existing community health roles or social networks for the development of effective and sustainable (retentive) CLHW programs. Community relationships are generally seen as a "black box" represented by an interchangeable CLHW labor unit. This disconnect from community relationships and resources may have led to a systematic and chronic undervaluing of community agency in explanations of programmatic effectiveness and sustainability.
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Affiliation(s)
- Daniel H. de Vries
- Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands
| | - Robert Pool
- Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands
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24
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Lee ACC, Mullany LC, Ladhani K, Uddin J, Mitra D, Ahmed P, Christian P, Labrique A, DasGupta SK, Lokken RP, Quaiyum M, Baqui AH. Validity of Newborn Clinical Assessment to Determine Gestational Age in Bangladesh. Pediatrics 2016; 138:peds.2015-3303. [PMID: 27313070 PMCID: PMC4925072 DOI: 10.1542/peds.2015-3303] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Gestational age (GA) is frequently unknown or inaccurate in pregnancies in low-income countries. Early identification of preterm infants may help link them to potentially life-saving interventions. METHODS We conducted a validation study in a community-based birth cohort in rural Bangladesh. GA was determined by pregnancy ultrasound (<20 weeks). Community health workers conducted home visits (<72 hours) to assess physical/neuromuscular signs and measure anthropometrics. The distribution, agreement, and diagnostic accuracy of different clinical methods of GA assessment were determined compared with early ultrasound dating. RESULTS In the live-born cohort (n = 1066), the mean ultrasound GA was 39.1 weeks (SD 2.0) and prevalence of preterm birth (<37 weeks) was 11.4%. Among assessed newborns (n = 710), the mean ultrasound GA was 39.3 weeks (SD 1.6) (8.3% preterm) and by Ballard scoring the mean GA was 38.9 weeks (SD 1.7) (12.9% preterm). The average bias of the Ballard was -0.4 weeks; however, 95% limits of agreement were wide (-4.7 to 4.0 weeks) and the accuracy for identifying preterm infants was low (sensitivity 16%, specificity 87%). Simplified methods for GA assessment had poor diagnostic accuracy for identifying preterm births (community health worker prematurity scorecard [sensitivity/specificity: 70%/27%]; Capurro [5%/96%]; Eregie [75%/58%]; Bhagwat [18%/87%], foot length <75 mm [64%/35%]; birth weight <2500 g [54%/82%]). Neonatal anthropometrics had poor to fair performance for classifying preterm infants (areas under the receiver operating curve 0.52-0.80). CONCLUSIONS Newborn clinical assessment of GA is challenging at the community level in low-resource settings. Anthropometrics are also inaccurate surrogate markers for GA in settings with high rates of fetal growth restriction.
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Affiliation(s)
- Anne CC Lee
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, Massachusetts;,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Luke C. Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Karima Ladhani
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, Massachusetts;,Department of Global Health & Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Jamal Uddin
- Child Health Research Foundation, Shishu Hospital, Dhaka, Bangladesh
| | - Dipak Mitra
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Parvez Ahmed
- International Centre for Diarrheal Disease Research, Dhaka, Bangladesh; and
| | - Parul Christian
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Alain Labrique
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sushil K. DasGupta
- International Centre for Diarrheal Disease Research, Dhaka, Bangladesh; and
| | - R. Peter Lokken
- Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Mohammed Quaiyum
- International Centre for Diarrheal Disease Research, Dhaka, Bangladesh; and
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Manu A, Hill Z, ten Asbroek AHA, Soremekun S, Weobong B, Gyan T, Tawiah-Agyemang C, Danso S, Amenga-Etego S, Owusu-Agyei S, Kirkwood BR. Increasing access to care for sick newborns: evidence from the Ghana Newhints cluster-randomised controlled trial. BMJ Open 2016; 6:e008107. [PMID: 27297006 PMCID: PMC4916576 DOI: 10.1136/bmjopen-2015-008107] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Alexander Manu
- Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Zelee Hill
- Faculty of Population Health Sciences, Institute of Global Health, University College London, London, UK
| | | | - Seyi Soremekun
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Benedict Weobong
- Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Thomas Gyan
- Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Charlotte Tawiah-Agyemang
- Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Samuel Danso
- Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Seeba Amenga-Etego
- Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Seth Owusu-Agyei
- Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Betty R Kirkwood
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Infection Surveillance Protocol for a Multicountry Population-based Study in South Asia to Determine the Incidence, Etiology and Risk Factors for Infections Among Young Infants of 0 to 59 Days Old. Pediatr Infect Dis J 2016; 35:S9-15. [PMID: 27070072 DOI: 10.1097/inf.0000000000001100] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Insufficient knowledge of the etiology and risk factors for community-acquired neonatal infection in low-income countries is a barrier to designing appropriate intervention strategies for these settings to reduce the burden and treatment of young infant infection. To address these gaps, we are conducting the Aetiology of Neonatal Infection in South Asia (ANISA) study among young infants in Bangladesh, India and Pakistan. The objectives of ANISA are to establish a comprehensive surveillance system for registering newborns in study catchment areas and collecting data on bacterial and viral etiology and associated risk factors for infections among young infants aged 0-59 days. METHODS We are conducting active surveillance in 1 peri-urban and 4 rural communities. During 2 years of surveillance, we expect to enroll an estimated 66,000 newborns within 7 days of their birth and to follow-up them until 59 days of age. Community health workers visit each young infant in the study area 3 times in the first week of life and once a week thereafter. During these visits, community health workers assess the newborns using a clinical algorithm and refer young infants with signs of suspected infection to health care facilities where study physicians reassess them and provide care if needed. On physician confirmation of suspected infection, blood and respiratory specimens are collected and tested to identify the etiologic agent. CONCLUSIONS ANISA is one of the largest initiatives ever undertaken to understand the etiology of young infant infection in low-income countries. The data generated from this surveillance will help guide evidence-based decision making to improve health care in similar settings.
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Tripathi A, Kabra SK, Sachdev HPS, Lodha R. Home visits by community health workers to improve identification of serious illness and care seeking in newborns and young infants from low- and middle-income countries. J Perinatol 2016; 36 Suppl 1:S74-82. [PMID: 27109094 PMCID: PMC4848742 DOI: 10.1038/jp.2016.34] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 11/24/2015] [Indexed: 11/20/2022]
Abstract
The objectives of this review were to evaluate the effect of home visits by trained community health workers (CHWs) to successfully identify newborns and young infants (up to 59 days of age) with serious illness and improve care seeking from a health facility. The authors searched the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE. Abstracts of all articles were read by two authors independently and relevant articles selected. Data were extracted in a pretested questionnaire by two authors independently. Statistical analysis was performed using Review Manager software. A meta-analysis of included randomized controlled trials (RCTs) was carried out. Pooled estimates (risk ratios (RRs) with 95% confidence intervals (CIs)) of the evaluated outcome measures were calculated by the generic inverse variance method. Seven articles were identified for inclusion in the review. None of them compared the diagnosis of serious illness in young infants by health workers to a 'gold standard' diagnosis. Three studies were available for evaluating the ability of CHWs to identify seriously ill young infants/signs of serious illness. These studies suggest that sensitivity to identify serious illness ranged from 33.3 to 90.5% and specificity from 75.61 to 98.4%. For the outcome of improved care seeking from a health facility, after pooling the data from six RCTs with 4760 subjects in the intervention and 4398 subjects in the control arm, there was a significant improvement in care seeking in the home visit arm (RR=1.35; 95% CI=1.15 to 1.58). Moderate quality evidence indicated that home visits by trained CHWs were associated with improved care-seeking for sick young infants from health facilities by appropriate health care providers in resource-limited settings. However, there is a lack of data regarding successful identification of serious illness. Evidence from validation studies supports the implementation of home visits by trained CHWs for improving outcomes in sick newborns and young infants in resource-limited areas. Further well-designed studies evaluating the effect of home visits by CHWs on successful identification of seriously ill newborns and young infants should include verification by a 'gold standard'.
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Affiliation(s)
- A Tripathi
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - S K Kabra
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - H P S Sachdev
- Sitaram Bhartia Institute of Science and Research, New Delhi, India
| | - R Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Johnston HB, Ganatra B, Nguyen MH, Habib N, Afework MF, Harries J, Iyengar K, Moodley J, Lema HY, Constant D, Sen S. Accuracy of Assessment of Eligibility for Early Medical Abortion by Community Health Workers in Ethiopia, India and South Africa. PLoS One 2016; 11:e0146305. [PMID: 26731176 PMCID: PMC4701452 DOI: 10.1371/journal.pone.0146305] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 12/15/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To assess the accuracy of assessment of eligibility for early medical abortion by community health workers using a simple checklist toolkit. DESIGN Diagnostic accuracy study. SETTING Ethiopia, India and South Africa. METHODS Two hundred seventeen women in Ethiopia, 258 in India and 236 in South Africa were enrolled into the study. A checklist toolkit to determine eligibility for early medical abortion was validated by comparing results of clinician and community health worker assessment of eligibility using the checklist toolkit with the reference standard exam. RESULTS Accuracy was over 90% and the negative likelihood ratio <0.1 at all three sites when used by clinician assessors. Positive likelihood ratios were 4.3 in Ethiopia, 5.8 in India and 6.3 in South Africa. When used by community health workers the overall accuracy of the toolkit was 92% in Ethiopia, 80% in India and 77% in South Africa negative likelihood ratios were 0.08 in Ethiopia, 0.25 in India and 0.22 in South Africa and positive likelihood ratios were 5.9 in Ethiopia and 2.0 in India and South Africa. CONCLUSION The checklist toolkit, as used by clinicians, was excellent at ruling out participants who were not eligible, and moderately effective at ruling in participants who were eligible for medical abortion. Results were promising when used by community health workers particularly in Ethiopia where they had more prior experience with use of diagnostic aids and longer professional training. The checklist toolkit assessments resulted in some participants being wrongly assessed as eligible for medical abortion which is an area of concern. Further research is needed to streamline the components of the tool, explore optimal duration and content of training for community health workers, and test feasibility and acceptability.
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Affiliation(s)
- Heidi Bart Johnston
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Bela Ganatra
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - My Huong Nguyen
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Ndema Habib
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Jane Harries
- Women’s Health Research Unit, School of Public Health and Family Medicine, Health Sciences Faculty, University of Cape Town, Cape Town, South Africa
| | - Kirti Iyengar
- Action Research & Training for Health, Udaipur, Rajasthan, India
| | - Jennifer Moodley
- Women’s Health Research Unit, School of Public Health and Family Medicine, Health Sciences Faculty, University of Cape Town, Cape Town, South Africa
| | | | - Deborah Constant
- Women’s Health Research Unit, School of Public Health and Family Medicine, Health Sciences Faculty, University of Cape Town, Cape Town, South Africa
| | - Swapnaleen Sen
- Action Research & Training for Health, Udaipur, Rajasthan, India
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Mbuagbaw L, Medley N, Darzi AJ, Richardson M, Habiba Garga K, Ongolo‐Zogo P. Health system and community level interventions for improving antenatal care coverage and health outcomes. Cochrane Database Syst Rev 2015; 2015:CD010994. [PMID: 26621223 PMCID: PMC4676908 DOI: 10.1002/14651858.cd010994.pub2] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The World Health Organization (WHO) recommends at least four antenatal care (ANC) visits for all pregnant women. Almost half of pregnant women worldwide, and especially in developing countries do not receive this amount of care. Poor attendance of ANC is associated with delivery of low birthweight babies and more neonatal deaths. ANC may include education on nutrition, potential problems with pregnancy or childbirth, child care and prevention or detection of disease during pregnancy.This review focused on community-based interventions and health systems-related interventions. OBJECTIVES To assess the effects of health system and community interventions for improving coverage of antenatal care and other perinatal health outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 June 2015) and reference lists of retrieved studies. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-randomised trials and cluster-randomised trials. Trials of any interventions to improve ANC coverage were eligible for inclusion. Trials were also eligible if they targeted specific and related outcomes, such as maternal or perinatal death, but also reported ANC coverage. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS We included 34 trials involving approximately 400,000 women. Some trials tested community-based interventions to improve uptake of antenatal care (media campaigns, education or financial incentives for pregnant women), while other trials looked at health systems interventions (home visits for pregnant women or equipment for clinics). Most trials took place in low- and middle-income countries, and 29 of the 34 trials used a cluster-randomised design. We assessed 30 of the 34 trials as of low or unclear overall risk of bias. Comparison 1: One intervention versus no interventionWe found marginal improvements in ANC coverage of at least four visits (average odds ratio (OR) 1.11, 95% confidence interval (CI) 1.01 to 1.22; participants = 45,022; studies = 10; Heterogeneity: Tau² = 0.01; I² = 52%; high quality evidence). Sensitivity analysis with a more conservative intra-cluster correlation co-efficient (ICC) gave similar marginal results. Excluding one study at high risk of bias shifted the marginal pooled estimate towards no effect. There was no effect on pregnancy-related deaths (average OR 0.69, 95% CI 0.45 to 1.08; participants = 114,930; studies = 10; Heterogeneity: Tau² = 0.00; I² = 0%; low quality evidence), perinatal mortality (average OR 0.98, 95% CI 0.90 to 1.07; studies = 15; Heterogeneity: Tau² = 0.01; I² = 58%; moderate quality evidence) or low birthweight (average OR 0.94, 95% CI 0.82 to 1.06; studies = five; Heterogeneity: Tau² = 0.00; I² = 5%; high quality evidence). Single interventions led to marginal improvements in the number of women who delivered in health facilities (average OR 1.08, 95% CI 1.02 to 1.15; studies = 10; Heterogeneity: Tau² = 0.00; I² = 0%; high quality evidence), and in the proportion of women who had at least one ANC visit (average OR 1.68, 95% CI 1.02 to 2.79; studies = six; Heterogeneity: Tau² = 0.24; I² = 76%; moderate quality evidence). Results for ANC coverage (at least four and at least one visit) and for perinatal mortality had substantial statistical heterogeneity. Single interventions did not improve the proportion of women receiving tetanus protection (average OR 1.03, 95% CI 0.92 to 1.15; studies = 8; Heterogeneity: Tau² = 0.01; I² = 57%). No study reported onintermittent prophylactic treatment for malaria. Comparison 2: Two or more interventions versus no interventionWe found no improvements in ANC coverage of four or more visits (average OR 1.48, 95% CI 0.99 to 2.21; participants = 7840; studies = six; Heterogeneity: Tau² = 0.10; I² = 48%; low quality evidence) or pregnancy-related deaths (average OR 0.70, 95% CI 0.39 to 1.26; participants = 13,756; studies = three; Heterogeneity: Tau² = 0.00; I² = 0%; moderate quality evidence). However, combined interventions led to improvements in ANC coverage of at least one visit (average OR 1.79, 95% CI 1.47 to 2.17; studies = five; Heterogeneity: Tau² = 0.00; I² = 0%; moderate quality evidence), perinatal mortality (average OR 0.74, 95% CI 0.57 to 0.95; studies = five; Heterogeneity: Tau² = 0.06; I² = 83%; moderate quality evidence) and low birthweight (average OR 0.61, 95% CI 0.46 to 0.80; studies = two; Heterogeneity: Tau² = 0.00; I² = 0%; moderate quality evidence). Meta-analyses for both ANC coverage four or more visits and perinatal mortality had substantial statistical heterogeneity. Combined interventions improved the proportion of women who had tetanus protection (average OR 1.48, 95% CI 1.18 to 1.87; studies = 3; Heterogeneity: Tau² = 0.01; I² = 33%). No trial in this comparison reported on intermittent prophylactic treatment for malaria. Comparison 3: Two interventions compared head to head. No trials found. Comparison 4: One intervention versus a combination of interventionsThere was no difference in ANC coverage (four or more visits and at least one visit), pregnancy-related deaths, deliveries in a health facility or perinatal mortality. No trials in this comparison reported on low birthweight orintermittent prophylactic treatment of malaria. AUTHORS' CONCLUSIONS Implications for practice - Single interventions may improve ANC coverage (at least one visit and four or more visits) and deliveries in health facilities. Combined interventions may improve ANC coverage (at least one visit), reduce perinatal mortality and reduce the occurrence of low birthweight. The effects of the interventions are unrelated to whether they are community or health system interventions. Implications for research - More details should be provided in reporting numbers of events, group totals and the ICCs used to adjust for cluster effects. Outcomes should be reported uniformly so that they are comparable to commonly-used population indicators. We recommend further cluster-RCTs of pregnant women and women in their reproductive years, using combinations of interventions and looking at outcomes that are important to pregnant women, such as maternal and perinatal morbidity and mortality, alongside the explanatory outcomes along the pathway of care: ANC coverage, the services provided during ANC and deliveries in health facilities.
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Affiliation(s)
- Lawrence Mbuagbaw
- Yaoundé Central HospitalCentre for the Development of Best Practices in Health (CDBPH)Henri Dunant AvenuePO Box 87YaoundéCameroon
- South African Medical Research CouncilSouth African Cochrane CentreTygerbergSouth Africa
| | - Nancy Medley
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Andrea J Darzi
- Clinical Research Institute (American University of Beirut Medical Center)Clinical Epidemiological UnitGefinor 4th FloorHamraBeirutLebanon
| | - Marty Richardson
- Liverpool School of Tropical MedicineCochrane Infectious Diseases GroupPembroke PlaceLiverpoolUKL3 5QA
| | - Kesso Habiba Garga
- Yaoundé Central HospitalCentre for the Development of Best Practices in Health (CDBPH)Henri Dunant AvenuePO Box 87YaoundéCameroon
| | - Pierre Ongolo‐Zogo
- Yaoundé Central HospitalCentre for the Development of Best Practices in Health (CDBPH)Henri Dunant AvenuePO Box 87YaoundéCameroon
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Cardemil CV, Gilroy KE, Callaghan-Koru JA, Nsona H, Bryce J. Comparison of methods for assessing quality of care for community case management of sick children: an application with community health workers in Malawi. Am J Trop Med Hyg 2015; 87:127-136. [PMID: 23136288 PMCID: PMC3748513 DOI: 10.4269/ajtmh.2012.12-0389] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Direct observation (DO) with re-examination (RE) by a skilled clinician is a rigorous method for assessing health worker performance, but is not always feasible. We assessed the performance of 131 community health workers in Malawi in community case management of sick children with cough and fast breathing, fever, and diarrhea. We compared estimates of correct treatment measured through DO with RE (n = 382 cases) to DO only (n = 382 cases), register review (n = 1,219 cases), and case scenarios (n = 917 cases). Estimates of correct treatment of uncomplicated fever and diarrhea measured through DO only, register review, and case scenarios were within 9 percentage points of DO with RE estimates, while estimates for uncomplicated cough and fast breathing, and severe illness were substantially higher than DO with RE (12-51 percentage points above the estimate). Those planning for community health worker assessments in community case management can use these results to make an informed choice of methods on the basis of their objectives and the local context.
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Affiliation(s)
- Cristina V. Cardemil
- *Address correspondence to Cristina V. Cardemil, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30333. E-mail:
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Gaziano TA, Abrahams-Gessel S, Denman CA, Montano CM, Khanam M, Puoane T, Levitt NS. An assessment of community health workers' ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment instrument in Bangladesh, Guatemala, Mexico, and South Africa: an observational study. LANCET GLOBAL HEALTH 2015; 3:e556-63. [PMID: 26187361 PMCID: PMC4795807 DOI: 10.1016/s2214-109x(15)00143-6] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 02/19/2015] [Accepted: 03/02/2015] [Indexed: 11/29/2022]
Abstract
Background Cardiovascular disease contributes substantially to the non-communicable disease (NCD) burden in low-income and middle-income countries, which also often have substantial health personnel shortages. In this observational study we investigated whether community health workers could do community-based screenings to predict cardiovascular disease risk as effectively as could physicians or nurses, with a simple, non-invasive risk prediction indicator in low-income and middle-income countries. Methods This observation study was done in Bangladesh, Guatemala, Mexico, and South Africa. Each site recruited at least ten to 15 community health workers based on usual site-specific norms for required levels of education and language competency. Community health workers had to reside in the community where the screenings were done and had to be fluent in that community’s predominant language. These workers were trained to calculate an absolute cardiovascular disease risk score with a previously validated simple, non-invasive screening indicator. Community health workers who successfully finished the training screened community residents aged 35–74 years without a previous diagnosis of hypertension, diabetes, or heart disease. Health professionals independently generated a second risk score with the same instrument and the two sets of scores were compared for agreement. The primary endpoint of this study was the level of direct agreement between risk scores assigned by the community health workers and the health professionals. Findings Of 68 community health worker trainees recruited between June 4, 2012, and Feb 8, 2013, 42 were deemed qualified to do fieldwork (15 in Bangladesh, eight in Guatemala, nine in Mexico, and ten in South Africa). Across all sites, 4383 community members were approached for participation and 4049 completed screening. The mean level of agreement between the two sets of risk scores was 96 8% (weighted κ =0 948, 95% CI 0 936–0 961) and community health workers showed that 263 (6%) of 4049 people had a 5-year cardiovascular disease risk of greater than 20%. Interpretation Health workers without formal professional training can be adequately trained to effectively screen for, and identify, people at high risk of cardiovascular disease. Using community health workers for this screening would free up trained health professionals in low-resource settings to do tasks that need high levels of formal, professional training. Funding US National Heart, Lung, and Blood Institute and National Institutes of Health, UnitedHealth Chronic Disease Initiative.
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Affiliation(s)
- Thomas A Gaziano
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | | | - Catalina A Denman
- Centro de Estudios en Salud y Sociedad, El Colegio de Sonora, Sonora, Mexico
| | | | - Masuma Khanam
- International Center for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Thandi Puoane
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Naomi S Levitt
- Department of Medicine, University of Cape Town, Cape Town, South Africa
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Gobezayehu AG, Mohammed H, Dynes MM, Desta BF, Barry D, Aklilu Y, Tessema H, Tadesse L, Mikulich M, Buffington ST, Sibley LM. Knowledge and skills retention among frontline health workers: community maternal and newborn health training in rural Ethiopia. J Midwifery Womens Health 2015; 59 Suppl 1:S21-31. [PMID: 24588913 DOI: 10.1111/jmwh.12146] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We examined the degree to which the skills and knowledge of health workers in Ethiopia were retained 18 months after initial maternal and newborn health training and sought to identify factors associated with 18-month skills assessment performance. METHODS A nonexperimental, descriptive design was employed to assess 18-month skills performance on the topics of Prevent Problems Before Baby Is Born and Prevent Problems After Baby Is Born. Assessment was conducted by project personnel who also received the maternal and newborn health training and additional training to reliably assess health worker performance. RESULTS Among the 732 health workers who participated in maternal and newborn health training in 6 rural districts of the Amhara and Oromia regions of Ethiopia (including pretesting before training and a posttraining posttest), 75 health extension workers (78%) and 234 guide team members (37%) participated in 18-month posttest. Among health extension workers in both regions, strong knowledge retention was noted in 10 of 14 care steps for Prevent Problems Before Baby Is Born and in 14 of 16 care steps of Prevent Problems After Baby Is Born. Lower knowledge retention was observed among guide team members in the Amhara region. Across regions, health workers scored lowest on steps that involved nonaction (eg, do not give oxytocin). Educational attainment and age were among the few variables found to significantly predict test performance, although participants varied substantially by other sociodemographic characteristics. DISCUSSION Results demonstrated an overall strong retention of knowledge and skills among health extension workers and highlighted the need for improvement among some guide team members. Refresher training and development of strategies to improve knowledge of retention of low-performing steps were recommended.
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Lassi ZS, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst Rev 2015; 2015:CD007754. [PMID: 25803792 PMCID: PMC8498021 DOI: 10.1002/14651858.cd007754.pub3] [Citation(s) in RCA: 158] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND While maternal, infant and under-five child mortality rates in developing countries have declined significantly in the past two to three decades, newborn mortality rates have reduced much more slowly. While it is recognised that almost half of the newborn deaths can be prevented by scaling up evidence-based available interventions (such as tetanus toxoid immunisation to mothers, clean and skilled care at delivery, newborn resuscitation, exclusive breastfeeding, clean umbilical cord care, and/or management of infections in newborns), many require facility-based and outreach services. It has also been stated that a significant proportion of these mortalities and morbidities could also be potentially addressed by developing community-based packaged interventions which should also be supplemented by developing and strengthening linkages with the local health systems. Some of the recent community-based studies of interventions targeting women of reproductive age have shown variable impacts on maternal outcomes and hence it is uncertain if these strategies have consistent benefit across the continuum of maternal and newborn care. OBJECTIVES To assess the effectiveness of community-based intervention packages in reducing maternal and neonatal morbidity and mortality; and improving neonatal outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2014), World Bank's JOLIS (25 May 2014), BLDS at IDS and IDEAS database of unpublished working papers (25 May 2014), Google and Google Scholar (25 May 2014). SELECTION CRITERIA All prospective randomised, cluster-randomised and quasi-randomised trials evaluating the effectiveness of community-based intervention packages in reducing maternal and neonatal mortality and morbidities, and improving neonatal outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, assessed trial quality and extracted the data. Data were checked for accuracy. MAIN RESULTS The review included 26 cluster-randomised/quasi-randomised trials, covering a wide range of interventional packages, including two subsets from three trials. Assessment of risk of bias in these studies suggests concerns regarding insufficient information on sequence generation and regarding failure to adequately address incomplete outcome data, particularly from randomised controlled trials. We incorporated data from these trials using generic inverse variance method in which logarithms of risk ratio (RR) estimates were used along with the standard error of the logarithms of RR estimates.Our review showed a possible effect in terms of a reduction in maternal mortality (RR 0.80; 95% confidence interval (CI) 0.64 to 1.00, random-effects (11 studies, n = 167,311; random-effects, Tau² = 0.03, I² 20%). However, significant reduction was observed in maternal morbidity (average RR 0.75; 95% CI 0.61 to 0.92; four studies, n = 138,290; random-effects, Tau² = 0.02, I² = 28%); neonatal mortality (average RR 0.75; 95% CI 0.67 to 0.83; 21 studies, n = 302,646; random-effects, Tau² = 0.06, I² = 85%) including both early and late mortality; stillbirths (average RR 0.81; 95% CI 0.73 to 0.91; 15 studies, n = 201,181; random-effects, Tau² = 0.03, I² = 66%); and perinatal mortality (average RR 0.78; 95% CI 0.70 to 0.86; 17 studies, n = 282,327; random-effects Tau² = 0.04, I² = 88%) as a consequence of implementation of community-based interventional care packages.Community-based intervention packages also increased the uptake of tetanus immunisation by 5% (average RR 1.05; 95% CI 1.02 to 1.09; seven studies, n = 71,622; random-effects Tau² = 0.00, I² = 52%); use of clean delivery kits by 82% (average RR 1.82; 95% CI 1.10 to 3.02; four studies, n = 54,254; random-effects, Tau² = 0.23, I² = 90%); rates of institutional deliveries by 20% (average RR 1.20; 95% CI 1.04 to 1.39; 14 studies, n = 147,890; random-effects, Tau² = 0.05, I² = 80%); rates of early breastfeeding by 93% (average RR 1.93; 95% CI 1.55 to 2.39; 11 studies, n = 72,464; random-effects, Tau² = 0.14, I² = 98%), and healthcare seeking for neonatal morbidities by 42% (average RR 1.42; 95% CI 1.14 to 1.77, nine studies, n = 66,935, random-effects, Tau² = 0.09, I² = 92%). The review also showed a possible effect on increasing the uptake of iron/folic acid supplementation during pregnancy (average RR 1.47; 95% CI 0.99 to 2.17; six studies, n = 71,622; random-effects, Tau² = 0.26; I² = 99%).It has no impact on improving referrals for maternal morbidities, healthcare seeking for maternal morbidities, iron/folate supplementation, attendance of skilled birth attendance on delivery, and other neonatal care-related outcomes. We did not find studies that reported the impact of community-based intervention package on improving exclusive breastfeeding rates at six months of age. We assessed our primary outcomes for publication bias and observed slight asymmetry on the funnel plot for maternal mortality. AUTHORS' CONCLUSIONS Our review offers encouraging evidence that community-based intervention packages reduce morbidity for women, mortality and morbidity for babies, and improves care-related outcomes particularly in low- and middle-income countries. It has highlighted the value of integrating maternal and newborn care in community settings through a range of interventions, which can be packaged effectively for delivery through a range of community health workers and health promotion groups. While the importance of skilled delivery and facility-based services for maternal and newborn care cannot be denied, there is sufficient evidence to scale up community-based care through packages which can be delivered by a range of community-based workers.
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Affiliation(s)
- Zohra S Lassi
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, The Robinson Research Institute, Discipline of Obstetrics and GynaecologyAdelaideSouth AustraliaAustralia5005
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiPakistan74800
| | - Zulfiqar A Bhutta
- Hospital for Sick ChildrenCenter for Global Child HealthTorontoONCanadaM5G A04
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Kok MC, Dieleman M, Taegtmeyer M, Broerse JEW, Kane SS, Ormel H, Tijm MM, de Koning KAM. Which intervention design factors influence performance of community health workers in low- and middle-income countries? A systematic review. Health Policy Plan 2014; 30:1207-27. [PMID: 25500559 PMCID: PMC4597042 DOI: 10.1093/heapol/czu126] [Citation(s) in RCA: 306] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2014] [Indexed: 12/21/2022] Open
Abstract
Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors influence CHW performance. A systematic review was conducted to identify intervention design related factors influencing performance of CHWs. We systematically searched six databases for quantitative and qualitative studies that included CHWs working in promotional, preventive or curative primary health services in LMICs. One hundred and forty studies met the inclusion criteria, were quality assessed and double read to extract data relevant to the design of CHW programmes. A preliminary framework containing factors influencing CHW performance and characteristics of CHW performance (such as motivation and competencies) guided the literature search and review. A mix of financial and non-financial incentives, predictable for the CHWs, was found to be an effective strategy to enhance performance, especially of those CHWs with multiple tasks. Performance-based financial incentives sometimes resulted in neglect of unpaid tasks. Intervention designs which involved frequent supervision and continuous training led to better CHW performance in certain settings. Supervision and training were often mentioned as facilitating factors, but few studies tested which approach worked best or how these were best implemented. Embedment of CHWs in community and health systems was found to diminish workload and increase CHW credibility. Clearly defined CHW roles and introduction of clear processes for communication among different levels of the health system could strengthen CHW performance. When designing community-based health programmes, factors that increased CHW performance in comparable settings should be taken into account. Additional intervention research to develop a better evidence base for the most effective training and supervision mechanisms and qualitative research to inform policymakers in development of CHW interventions are needed.
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Affiliation(s)
- Maryse C Kok
- KIT Health, Royal Tropical Institute, Amsterdam, The Netherlands,
| | | | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK and
| | | | - Sumit S Kane
- KIT Health, Royal Tropical Institute, Amsterdam, The Netherlands
| | - Hermen Ormel
- KIT Health, Royal Tropical Institute, Amsterdam, The Netherlands
| | - Mandy M Tijm
- KIT Health, Royal Tropical Institute, Amsterdam, The Netherlands
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Lee ACC, Chandran A, Herbert HK, Kozuki N, Markell P, Shah R, Campbell H, Rudan I, Baqui AH. Treatment of infections in young infants in low- and middle-income countries: a systematic review and meta-analysis of frontline health worker diagnosis and antibiotic access. PLoS Med 2014; 11:e1001741. [PMID: 25314011 PMCID: PMC4196753 DOI: 10.1371/journal.pmed.1001741] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 08/19/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Inadequate illness recognition and access to antibiotics contribute to high case fatality from infections in young infants (<2 months) in low- and middle-income countries (LMICs). We aimed to address three questions regarding access to treatment for young infant infections in LMICs: (1) Can frontline health workers accurately diagnose possible bacterial infection (pBI)?; (2) How available and affordable are antibiotics?; (3) How often are antibiotics procured without a prescription? METHODS AND FINDINGS We searched PubMed, Embase, WHO/Health Action International (HAI), databases, service provision assessments (SPAs), Demographic and Health Surveys, Multiple Indicator Cluster Surveys, and grey literature with no date restriction until May 2014. Data were identified from 37 published studies, 46 HAI national surveys, and eight SPAs. For study question 1, meta-analysis showed that clinical sign-based algorithms predicted bacterial infection in young infants with high sensitivity (87%, 95% CI 82%-91%) and lower specificity (62%, 95% CI 48%-75%) (six studies, n = 14,254). Frontline health workers diagnosed pBI in young infants with an average sensitivity of 82% (95% CI 76%-88%) and specificity of 69% (95% CI 54%-83%) (eight studies, n = 11,857) compared to physicians. For question 2, first-line injectable agents (ampicillin, gentamicin, and penicillin) had low variable availability in first-level health facilities in Africa and South Asia. Oral amoxicillin and cotrimoxazole were widely available at low cost in most regions. For question 3, no studies on young infants were identified, however 25% of pediatric antibiotic purchases in LMICs were obtained without a prescription (11 studies, 95% CI 18%-34%), with lower rates among infants <1 year. Study limitations included potential selection bias and lack of neonatal-specific data. CONCLUSIONS Trained frontline health workers may screen for pBI in young infants with relatively high sensitivity and lower specificity. Availability of first-line injectable antibiotics appears low in many health facilities in Africa and Asia. Improved data and advocacy are needed to increase the availability and appropriate utilization of antibiotics for young infant infections in LMICs. REVIEW REGISTRATION PROSPERO International prospective register of systematic reviews (CRD42013004586). Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Anne CC Lee
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Aruna Chandran
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Hadley K. Herbert
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Naoko Kozuki
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Perry Markell
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Rashed Shah
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Health and Nutrition. Save the Children, Washington (D.C.), United States of America
| | - Harry Campbell
- Global Health Academy and Centre for Population Health Sciences, The University of Edinburgh Medical School, Edinburgh, Scotland, United Kingdom
| | - Igor Rudan
- Global Health Academy and Centre for Population Health Sciences, The University of Edinburgh Medical School, Edinburgh, Scotland, United Kingdom
| | - Abdullah H. Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Gill CJ, MacLeod WB, Phiri-Mazala G, Guerina NG, Mirochnick M, Knapp AB, Hamer DH. Can traditional birth attendants be trained to accurately identify septic infants, initiate antibiotics, and refer in a rural African setting? GLOBAL HEALTH: SCIENCE AND PRACTICE 2014; 2:318-27. [PMID: 25276591 PMCID: PMC4168634 DOI: 10.9745/ghsp-d-14-00045] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 07/10/2014] [Indexed: 11/24/2022]
Abstract
Despite having limited training, these TBAs were able to accurately identify critically ill neonates, initiate treatment in the field, and refer for further care. Given their proximity to the mother/infant pair, and their role in rural communities, training and equipping TBAs in this role could be effective in reducing neonatal mortality. Background: Neonatal sepsis is a major cause of neonatal mortality. In populations with limited access to health care, early identification of bacterial infections and initiation of antibiotics by community health workers (CHWs) could be lifesaving. It is unknown whether this strategy would be feasible using traditional birth attendants (TBAs), a cadre of CHWs who typically have limited training and educational backgrounds. Methods: We analyzed data from the intervention arm of a cluster-randomized trial involving TBAs in Lufwanyama District, Zambia, from June 2006 to November 2008. TBAs followed neonates for signs of potential infection through 28 days of life. If any of 16 criteria were met, TBAs administered oral amoxicillin and facilitated referral to a rural health center. Results: Our analysis included 1,889 neonates with final vital status by day 28. TBAs conducted a median of 2 (interquartile range 2–6) home visits (51.4% in week 1 and 48.2% in weeks 2–4) and referred 208 neonates (11%) for suspected sepsis. Of referred neonates, 176/208 (84.6%) completed their referral. Among neonates given amoxicillin, 171/183 (93.4%) were referred; among referred neonates, 171/208 (82.2%) received amoxicillin. Referral and/or initiation of antibiotics were strongly associated with neonatal death (for referral, relative risk [RR] = 7.93, 95% confidence interval [CI] = 4.4–14.3; for amoxicillin administration, RR = 4.7, 95% CI = 2.4–8.7). Neonates clinically judged to be “extremely sick” by the referring TBA were at greatest risk of death (RR = 8.61, 95% CI = 4.0–18.5). Conclusion: The strategy of administering a first dose of antibiotics and referring based solely on the clinical evaluation of a TBA is feasible and could be effective in reducing neonatal mortality in remote rural settings.
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Affiliation(s)
| | | | | | | | | | - Anna B Knapp
- Boston University School of Public Health , Boston, MA , USA
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Sandberg J, Odberg Pettersson K, Asp G, Kabakyenga J, Agardh A. Inadequate knowledge of neonatal danger signs among recently delivered women in southwestern rural Uganda: a community survey. PLoS One 2014; 9:e97253. [PMID: 24824364 PMCID: PMC4019554 DOI: 10.1371/journal.pone.0097253] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 04/16/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Early detection of neonatal illness is an important step towards improving newborn survival. Every year an estimated 3.07 million children die during their first month of life and about one-third of these deaths occur during the first 24 hours. Ninety-eight percent of all neonatal deaths occur in low- and middle-income countries like Uganda. Inadequate progress has been made globally to reduce the amount of neonatal deaths that would be required to meet Millennium Development Goal 4. Poor knowledge of newborn danger signs delays care seeking. The aim of this study was to explore the knowledge of key newborn danger signs among mothers in southwestern Uganda. METHODS Results from a community survey of 765 recently delivered women were analyzed using univariate and multivariate logistic regressions. Six key danger signs were identified, and spontaneous responses were categorized, tabulated, and analyzed. RESULTS Knowledge of at least one key danger sign was significantly associated with being birth prepared (adjusted OR 1.7, 95% CI 1.2-2.3). Birth preparedness consisted of saving money, identifying transportation, identifying a skilled birth attendant and buying a delivery kit or materials. Overall, respondents had a poor knowledge of key newborn danger signs: 58.2% could identify one and 14.8% could identify two. We found no association between women attending the recommended number of antenatal care visits and their knowledge of danger signs (adjusted OR 1.0, 95% CI 0.8-1.4), or between women using a skilled birth attendant at delivery and their knowledge of danger signs (adjusted OR 1.2, 95% CI 0.9-1.7). CONCLUSIONS Our findings indicate the need to enhance education of mothers in antenatal care as well as those discharged from health facilities after delivery. Further promotion of birth preparedness is encouraged as part of the continuum of maternal care.
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Affiliation(s)
- Jacob Sandberg
- Social medicine and Global Health, Dept. of Clinical sciences, Lund University, Lund, Sweden
| | - Karen Odberg Pettersson
- Social medicine and Global Health, Dept. of Clinical sciences, Lund University, Lund, Sweden
| | - Gustav Asp
- Social medicine and Global Health, Dept. of Clinical sciences, Lund University, Lund, Sweden
| | - Jerome Kabakyenga
- Social medicine and Global Health, Dept. of Clinical sciences, Lund University, Lund, Sweden
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Anette Agardh
- Social medicine and Global Health, Dept. of Clinical sciences, Lund University, Lund, Sweden
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Bryanton J, Beck CT, Montelpare W. Postnatal parental education for optimizing infant general health and parent-infant relationships. Cochrane Database Syst Rev 2013:CD004068. [PMID: 24284872 DOI: 10.1002/14651858.cd004068.pub4] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Many learning needs arise in the early postpartum period, and it is important to examine interventions used to educate new parents about caring for their newborns during this time. OBJECTIVES The primary objective was to assess the effects of structured postnatal education delivered to an individual or group related to infant general health or care and parent-infant relationships. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2013). SELECTION CRITERIA We included randomized controlled trials of any structured postnatal education provided to individual parents or groups of parents within the first two months post-birth related to the health or care of an infant or parent-infant relationships. DATA COLLECTION AND ANALYSIS Two review authors (JB, CTB) assessed trial quality and extracted data from published reports. MAIN RESULTS Of the 27 trials (3949 mothers and 579 fathers) that met the inclusion criteria, only 15 (2922 mothers and 388 fathers) reported useable data. Educational interventions included: five on infant sleep enhancement, 12 on infant behaviour, three on general post-birth health, three on general infant care, and four on infant safety. Details of the randomization procedures, allocation concealment, blinding, and participant loss were often not reported. Of the outcomes analyzed, only 13 were measured similarly enough by more than one study to be combined in meta-analyses. Of these 13 meta-analyses, only four were found to have a low enough level of heterogeneity to provide an overall estimate of effect. Education about sleep enhancement resulted in a mean difference of 29 more night-time minutes of infant sleep in 24 hours at six weeks of age (95% confidence interval (CI) 18.53 to 39.73) than usual care. However, it had no significant effect on the mean difference in minutes of crying time in 24 hours at six weeks and 12 weeks of age. Education related to infant behaviour increased maternal knowledge of infant behaviour by a mean difference of 2.85 points (95% CI 1.78 to 3.91). AUTHORS' CONCLUSIONS The benefits of educational programs to participants and their newborns remain unclear. Education related to sleep enhancement appears to increase infant sleep but appears to have no effect on infant crying time. Education about infant behaviour potentially enhances mothers' knowledge; however more and larger, well-designed studies are needed to confirm these findings.
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Affiliation(s)
- Janet Bryanton
- School of Nursing, University of Prince Edward Island, 550 University Avenue, Charlottetown, Canada, C1A 4P3
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Waiswa P, Peterson SS, Namazzi G, Ekirapa EK, Naikoba S, Byaruhanga R, Kiguli J, Kallander K, Tagoola A, Nakakeeto M, Pariyo G. The Uganda Newborn Study (UNEST): an effectiveness study on improving newborn health and survival in rural Uganda through a community-based intervention linked to health facilities - study protocol for a cluster randomized controlled trial. Trials 2012; 13:213. [PMID: 23153395 PMCID: PMC3599589 DOI: 10.1186/1745-6215-13-213] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2012] [Accepted: 09/24/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Reducing neonatal-related deaths is one of the major bottlenecks to achieving Millennium Development Goal 4. Studies in Asia and South America have shown that neonatal mortality can be reduced through community-based interventions, but these have not been adapted to scalable intervention packages for sub-Saharan Africa where the culture, health system and policy environment is different. In Uganda, health outcomes are poor for both mothers and newborn babies. Policy opportunities for neonatal health include the new national Health Sector Strategic Plan, which now prioritizes newborn health including use of a community model through Village Health Teams (VHT). The aim of the present study is to adapt, develop and cost an integrated maternal-newborn care package that links community and facility care, and to evaluate its effect on maternal and neonatal practices in order to inform policy and scale-up in Uganda. METHODS/DESIGN Through formative research around evidence-based practices, and dialogue with policy and technical advisers, we constructed a home-based neonatal care package implemented by the responsible VHT member, effectively a Community Health Worker (CHW). This CHW was trained to identify pregnant women and make five home visits - two before and three just after birth - so that linkages will be made to facility care and targeted messages for home-care and care-seeking delivered. The project is improving care in health units to provide standardized care for the mother and the newborn in both intervention and comparison areas.The study is taking place in a new Demographic Surveillance Site in two rural districts, Iganga and Mayuge, in Uganda. It is a two-arm cluster randomized controlled design with 31 intervention and 32 control areas (villages). The comparison parishes receive the standard care already being provided by the district, but to the intervention villages are added a system for CHWs to visit the mother five times in her home during pregnancy and the neonatal period. Both areas benefit from a standardized strengthening of facility care for mothers and neonates. DISCUSSION UNEST is designed to directly feed into the operationalization of maternal and newborn care in the national VHT strategy, thereby helping to inform scale-up in rural Uganda. The study is registered as a randomized controlled trial, number ISRCTN50321130.
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Affiliation(s)
- Peter Waiswa
- Makerere University School of Public Health, College of Health Sciences, Mulago Hill, Kampala, Uganda.
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Shillcutt SD, Lefevre AE, Lee ACC, Baqui AH, Black RE, Darmstadt GL. Forecasting burden of long-term disability from neonatal conditions: results from the Projahnmo I trial, Sylhet, Bangladesh. Health Policy Plan 2012; 28:435-52. [PMID: 23002251 DOI: 10.1093/heapol/czs075] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The burden of disease resulting from neonatal conditions is substantial in developing countries. From 2003 to 2005, the Projahnmo I programme delivered community-based interventions for maternal and newborn health in Sylhet, Bangladesh. This analysis quantifies burden of disability and incorporates non-fatal outcomes into cost-effectiveness analysis of interventions delivered in the Projahnmo I programme. METHODS A decision tree model was created to predict disability resulting from preterm birth, neonatal meningitis and intrapartum-related hypoxia ('birth asphyxia'). Outcomes were defined as the years lost to disability (YLD) component of disability-adjusted life years (DALYs). Calculations were based on data from the Projahnmo I trial, supplemented with values from published literature and expert opinion where data were absent. RESULTS 195 YLD per 1000 neonates [95% confidence interval (CI): 157-241] were predicted in the main calculation, sensitive to different DALY assumptions, disability weights and alternative model structures. The Projahnmo I home care intervention may have averted 2.0 (1.3-2.8) YLD per 1000 neonates. Compared with calculations based on reductions in mortality alone, the cost-effectiveness ratio decreased by only 0.6% from $105.23 to $104.62 ($65.15-$266.60) when YLD were included, with 0.6% more DALYs averted [total 338/1000 (95% CI: 131-542)]. DISCUSSION A significant burden of disability results from neonatal conditions in Sylhet, Bangladesh. Adding YLD has very little impact on recommendations based on cost-effectiveness, even at the margin of programme adoption. This model provides guidance for collecting data on disabilities in new settings.
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Affiliation(s)
- Samuel D Shillcutt
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
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Renfrew MJ, McCormick FM, Wade A, Quinn B, Dowswell T. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Syst Rev 2012; 5:CD001141. [PMID: 22592675 PMCID: PMC3966266 DOI: 10.1002/14651858.cd001141.pub4] [Citation(s) in RCA: 201] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND There is extensive evidence of important health risks for infants and mothers related to not breastfeeding. In 2003, the World Health Organization recommended infants be exclusively breastfed until six months of age, with breastfeeding continuing as an important part of the infant's diet till at least two years of age. However, breastfeeding rates in many countries currently do not reflect this recommendation. OBJECTIVES To assess the effectiveness of support for breastfeeding mothers. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (3 October 2011). SELECTION CRITERIA Randomised or quasi-randomised controlled trials comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. MAIN RESULTS Of the 67 studies that we assessed as eligible for inclusion, 52 contributed outcome data to the review (56,451 mother-infant pairs) from 21 countries. All forms of extra support analysed together showed an increase in duration of 'any breastfeeding' (includes partial and exclusive breastfeeding) (risk ratio (RR) for stopping any breastfeeding before six months 0.91, 95% confidence interval (CI) 0.88 to 0.96). All forms of extra support together also had a positive effect on duration of exclusive breastfeeding (RR at six months 0.86, 95% CI 0.82 to 0.91; RR at four to six weeks 0.74, 95% CI 0.61 to 0.89). Extra support by both lay and professionals had a positive impact on breastfeeding outcomes. Maternal satisfaction was poorly reported. AUTHORS' CONCLUSIONS All women should be offered support to breastfeed their babies to increase the duration and exclusivity of breastfeeding. Support is likely to be more effective in settings with high initiation rates, so efforts to increase the uptake of breastfeeding should be in place. Support may be offered either by professional or lay/peer supporters, or a combination of both. Strategies that rely mainly on face-to-face support are more likely to succeed. Support that is only offered reactively, in which women are expected to initiate the contact, is unlikely to be effective; women should be offered ongoing visits on a scheduled basis so they can predict that support will be available. Support should be tailored to the needs of the setting and the population group.
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Affiliation(s)
- Mary J Renfrew
- Mother and Infant Research Unit, Department of Health Sciences, University of York, York, UK
| | - Felicia M McCormick
- Mother and Infant Research Unit, Department of Health Sciences, University of York, York, UK
| | - Angela Wade
- Centre for Paediatric Epidemiology and Biostatistics, Institute of Child Health, London, UK
| | - Beverley Quinn
- Health and Community Care Research Unit (HaCCRU), The University of Liverpool, Liverpool, UK
| | - Therese Dowswell
- Cochrane Pregnancy and Childbirth Group, Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK
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Kamath-Rayne BD, MacGuire ER, McClure EM, Goldenberg RL, Jobe AH. Clinical algorithms for the identification of sick newborns in community-based settings. Acta Paediatr 2012; 101:344-51. [PMID: 22122011 DOI: 10.1111/j.1651-2227.2011.02540.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
UNLABELLED Clinical algorithms can be powerful tools for the identification of sick newborns at risk of neonatal mortality. Several studies have evaluated clinical signs for newborns aged 0-60 days to identify severe illness; however, few studies have focused specifically on the most vulnerable time period for neonatal death, the first week of life. Therefore, we reviewed the studies that evaluated clinical signs in newborns 0-60 days, focusing on infants 0 to <7 days. Based on a comparison of relevant studies, we then identified the common, important clinical signs shown to be useful for the identification of at-risk newborns by health workers in community-based and low-resource settings. CONCLUSION We concluded that further work is urgently needed to develop a clinical algorithm for widespread validation in various community-based settings, which focuses specifically on newborns <7 days at risk of early neonatal mortality.
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Maguire JL, Kulik DM, Laupacis A, Kuppermann N, Uleryk EM, Parkin PC. Clinical prediction rules for children: a systematic review. Pediatrics 2011; 128:e666-77. [PMID: 21859912 DOI: 10.1542/peds.2011-0043] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
CONTEXT The degree to which clinical prediction rules (CPRs) for children meet published standards is unclear. OBJECTIVE To systematically review the quality, performance, and validation of published CPRs for children, compare them with adult CPRs, and suggest pediatric-specific changes to CPR methodology. METHODS Medline was searched from 1950 to 2011. Studies were selected if they included the development of a CPR involving children younger than 18 years. Two investigators assessed study quality, rule performance, and rule validation as methodologic standards. RESULTS Of 7298 titles and abstracts assessed, 137 eligible studies were identified. They describe the development of 101 CPRs addressing 36 pediatric conditions. Quality standards met in fewer than half of the studies were blind assessment of predictors (47%), reproducibility of predictors (18%), blind assessment of outcomes (42%), adequate follow-up of outcomes (36%), adequate power (43%), adequate reporting of results (49%), and 95% confidence intervals reported (36%). For rule performance, 48% had a sensitivity greater than 0.95, and 43% had a negative likelihood ratio less than 0.1. For rule validation, 76% had no validation, 17% had narrow validation, 8% had broad validation, and none had impact analysis performed. Compared with CPRs for adult health conditions, quality and rule validation seem to be lower. CONCLUSIONS Many CPRs have been derived for children, but few have been validated. Relative to adult CPRs, several quality indicators demonstrated weaknesses. Existing performance standards may prove elusive for CPRs that involve children. CPRs for children that are more assistive and less directive and include patients' values and preferences in decision-making may be helpful.
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Affiliation(s)
- Jonathon L Maguire
- Department of Pediatrics, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.
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Abstract
An estimated one million newborns die from infections in developing countries. Despite the huge burden, high-quality data from community-based epidemiologic studies on etiology, risk factors, and appropriate management are lacking from areas in which newborns experience the greatest mortality. Several planned and ongoing studies in South Asia and Africa promise to address the knowledge gaps. However, simple and low-cost interventions, such as community-based neonatal care packages supporting clean birth practices, early detection of illness through use of clinical algorithms, and home-based antibiotic therapy in areas in which hospitalization is not feasible are already available and have the potential to bring about a drastic reduction in global neonatal mortality due to infections if they are scaled up to national level. Concerted collaborative action by national governments, health professionals, civil society organizations, and international health agencies is required to reduce neonatal mortality due to infections.
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Affiliation(s)
- Hammad A Ganatra
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
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Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst Rev 2010:CD007754. [PMID: 21069697 DOI: 10.1002/14651858.cd007754.pub2] [Citation(s) in RCA: 196] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND While maternal, infant and under-five child mortality rates in developing countries have declined significantly in the past two to three decades, newborn mortality rates have reduced much more slowly. While it is recognised that almost half of the newborn deaths can be prevented by scaling up evidence-based available interventions such as tetanus toxoid immunisation to mothers; clean and skilled care at delivery; newborn resuscitation; exclusive breastfeeding; clean umbilical cord care; management of infections in newborns, many require facility based and outreach services. It has also been stated that a significant proportion of these mortalities and morbidities could also be potentially addressed by developing community-based packages interventions which should also be supplemented by developing and strengthening linkages with the local health systems. Some of the recent community-based studies of interventions targeting women of reproductive age have shown variable impacts on maternal outcomes and hence it is uncertain if these strategies have consistent benefit across the continuum of maternal and newborn care. OBJECTIVES To assess the effectiveness of community-based intervention packages in reducing maternal and neonatal morbidity and mortality; and improving neonatal outcomes. SEARCH STRATEGY We searched The Cochrane Pregnancy and Childbirth Group's Trials Register (January 2010), World Bank's JOLIS (12 January 2010), BLDS at IDS and IDEAS database of unpublished working papers (12 January 2010), Google and Google Scholar (12 January 2010). SELECTION CRITERIA All prospective randomised and quasi-experimental trials evaluating the effectiveness of community-based intervention packages in reducing maternal and neonatal mortality and morbidities; and improving neonatal outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted the data. MAIN RESULTS The review included 18 cluster-randomised/quasi-randomised trials, covering a wide range of interventional packages, including two subsets from one trial. We incorporated data from these trials using generic inverse variance method in which logarithms of risk ratio estimates were used along with the standard error of the logarithms of risk ratio estimates. Our review did not show any reduction in maternal mortality (risk ratio (RR) 0.77; 95% confidence interval (CI) 0.59 to 1.02, random-effects (10 studies, n = 144,956), I² 39%, P value 0.10. However, significant reduction was observed in maternal morbidity (RR 0.75; 95% CI 0.61 to 0.92, random-effects (four studies, n = 138,290), I² 28%; neonatal mortality (RR 0.76; 95% CI 0.68 to 0.84, random-effects (12 studies, n = 136,425), I² 69%, P value < 0.001), stillbirths (RR 0.84; 95% CI 0.74 to 0.97, random-effects (11studies, n = 113,821), I² 66%, P value 0.001) and perinatal mortality (RR 0.80; 95% CI 0.71 to 0.91, random-effects (10 studies, n = 110,291), I² 82%, P value < 0.001) as a consequence of implementation of community-based interventional care packages. It also increased the referrals to health facility for pregnancy related complication by 40% (RR 1.40; 95% CI 1.19 to 1.65, fixed-effect (two studies, n = 22,800), I² 0%, P value 0.76), and improved the rates of early breastfeeding by 94% (RR 1.94; 95% CI 1.56 to 2.42, random-effects (six studies, n = 20,627), I² 97%, P value < 0.001). We assessed our primary outcomes for publication bias, but observed no such asymmetry on the funnel plot. AUTHORS' CONCLUSIONS Our review offers encouraging evidence of the value of integrating maternal and newborn care in community settings through a range of interventions which can be packaged effectively for delivery through a range of community health workers and health promotion groups. While the importance of skilled delivery and facility-based services for maternal and newborn care cannot be denied, there is sufficient evidence to scale up community-based care through packages which can be delivered by a range of community-based workers.
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Affiliation(s)
- Zohra S Lassi
- Division of Women and Child Health, Aga Khan University Hospital, Stadium Road, PO Box 3500, Karachi, Pakistan, 74800
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