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Christian CS, Nkonki L, Desmond C, Hoegfeldt C, Dube S, Rochat T, Stein A. Protocol of a cost-effectiveness analysis of a combined intervention for depression and parenting compared with enhanced standard of care for perinatally depressed, HIV-positive women and their infants in rural South Africa. BMJ Open 2024; 14:e082977. [PMID: 39097310 DOI: 10.1136/bmjopen-2023-082977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2024] Open
Abstract
INTRODUCTION Poverty, HIV and perinatal depression represent a triple threat to public health in sub-Saharan Africa because of their combined negative effects on parenting and child development. In the resource-constrained context of low-income and middle-income countries, a lay-counsellor-delivered intervention that combines a psychological and parenting intervention could offer the potential to mitigate the consequences of perinatal depression while also optimising scarce resources for healthcare.Measuring the cost-effectiveness of such a novel intervention will help decision-makers to better understand the relative costs and effects associated with replicating the intervention, thereby supporting evidence-based decision-making. This protocol sets out the methodological framework for analysing the cost-effectiveness of a cluster randomised controlled trial (RCT) that compares a combined intervention to enhanced standard of care when treating depressed, HIV-positive pregnant women and their infants in rural South Africa. METHODS AND ANALYSIS This cost-effectiveness analysis (CEA) protocol complies with the Consolidated Health Economic Evaluation Reporting Standards 2022 checklist. A societal perspective will be chosen.The proposed methods will determine the cost and efficiency of implementing the intervention as per the randomised control trial protocol, as well as the cost of replicating the intervention in a non-research setting. The costs will be calculated using an appropriately adjusted version of the Standardised Early Childhood Development Costing Tool.Primary health outcomes will be used in combination with costs to determine the cost per improvement in maternal perinatal depression at 12 months postnatal and the cost per improvement in child cognitive development at 24 months of age. To facilitate priority setting, the incremental cost-effectiveness ratios for improvements in child cognitive development will be ranked against six other child cognitive-development interventions according to Verguet et al's methodology (2022).A combination of activity-based and ingredient-based costing approaches will be used to identify, measure and value activities and inputs for all alternatives. Outcomes data will be sourced from the RCT team. ETHICS AND DISSEMINATION The University of Oxford is the sponsor of the CEA. Ethics approval has been obtained from the Human Sciences Research Council (HSRC, #REC 5/23/08/17), South Africa and the Oxford Tropical Research Ethics Committee (OxTREC #31-17), UK.Consent for publication is not applicable since no participant data are used in this protocol.We plan to disseminate the CEA results to key policymakers and researchers in the form of a policy brief, meetings and academic papers. TRIAL REGISTRATION DETAILS ISRCTN registry #11 284 870 (14/11/2017) and SANCTR DOH-27-102020-9097 (17/11/2017).
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Affiliation(s)
- Carmen Sue Christian
- Department of Economics, Faculty of Economics and Management Sciences, University of the Western Cape, Bellville, South Africa
| | - Lungiswa Nkonki
- Health Systems and Public Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Chris Desmond
- School of Economics and Finance, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Tamsen Rochat
- Department of Psychology, Faculty of Health and Education, Manchester Metropolitan University, Manchester, UK
- SAMRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand Johannesburg, Johannesburg, South Africa
| | - Alan Stein
- Department of Psychiatry, University of Oxford, Oxford, UK
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, Johannesburg, South Africa
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Gavine A, Farre A, Lynn F, Shinwell S, Buchanan P, Marshall J, Cumming S, Wallace L, Wade A, Ahern E, Hay L, Cranwell M, McFadden A. Lessons for the UK on implementation and evaluation of breastfeeding support: evidence syntheses and stakeholder engagement. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-206. [PMID: 39054917 DOI: 10.3310/dgtp5702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Background Breastfeeding impacts positively on multiple health outcomes, but < 50% of UK women breastfeed at 8 weeks. Women with long-term conditions face additional challenges in breastfeeding. Objectives To synthesise global and UK evidence to co-create an implementation and evaluation toolkit for cost-effective breastfeeding support in the NHS. Design Evidence syntheses with stakeholder engagement. Review methods Systematic reviews examined effectiveness of breastfeeding support for (1) healthy women and (2) women with long-term conditions using Cochrane Pregnancy and Childbirth Group methods. Mixed-methods systematic reviews synthesised process evaluations of effective breastfeeding support interventions for healthy women and experiences of receiving/providing support for breastfeeding women with long-term conditions. Cross-study synthesis integrated qualitative and quantitative findings. Systematic reviews synthesised evidence on the incremental costs and cost-effectiveness of breastfeeding support following National Institute for Health and Care Excellence guidance. All searches were conducted from May 2021 to October 2022. Stakeholder engagement and toolkit development comprised online discussions, a modified Delphi study, focus groups and four workshops. Participants were 23 stakeholders, 16 parents in the parents' panels, 15 women in the focus groups and 87 stakeholders who attended the workshops. Results We found considerably more interventions designed for healthy women (review 1) than aimed at women with long-term conditions (reviews 1 and 4); approximately half of the studies were targeted at groups at higher risk of poor breastfeeding outcomes, and the impact of support may be different in these populations. Despite this, studies from review 2 found that women perceived the provision of support as positive, important and needed. Studies from review 5 echoed a range of suggestions from participants regarding potential strategies to improve breastfeeding support, with the most widely reported being the need to acknowledge the role and influence of other sources of support (e.g. partners, family, friends, peers, external professionals, web-based resources) and involving these sources in the provision of breastfeeding support for women with long-term conditions. In reviews 3 and 6, there was uncertainty about the cost-effectiveness of breastfeeding support interventions due to the limited number of studies and lack of good-quality evidence. Limitations There was a lack of evidence for the effectiveness and cost-effectiveness of breastfeeding interventions in the UK. There was often insufficient information reported about intervention characteristics. Conclusions 'Breastfeeding only' support probably reduces the number of women stopping any or exclusive breastfeeding. The evidence for 'breastfeeding plus' interventions is less consistent, but these may reduce the number of women stopping exclusive breastfeeding at 4-6 weeks and at 6 months. We found no evidence of differential intervention effects regarding mode of provision or provider. Cost-effectiveness is uncertain due to the lack of good-quality evidence. Key enablers of successful implementation were responsiveness and tailoring of interventions to both women's and supporters' needs. Breastfeeding support as delivered in the included studies probably has little to no effect on breastfeeding outcomes for women with long-term conditions. The mixed-methods synthesis and stakeholder work identified that existing interventions may not address the complex needs of these women. The main study output is a co-produced toolkit to guide implementation and evaluation of breastfeeding support services in the UK. Future work Evaluation of breastfeeding support for all women, particularly those at risk of poor breastfeeding outcomes (e.g. long-term conditions, deprivation). This could involve tailoring the toolkit to local contexts via implementation and effectiveness studies or using quality improvement studies. Study registration This study is registered as PROSPERO CRD42022337239, CRD42021229769 and CRD42022374509. The reviews of economic evidence were not registered; however, the review protocol can be accessed via the repository held by Queen's University Belfast Research Portal (https://pure.qub.ac.uk/). Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130995) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 20. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Anna Gavine
- School of Health Sciences, University of Dundee, Dundee, UK
| | - Albert Farre
- School of Health Sciences, University of Dundee, Dundee, UK
| | - Fiona Lynn
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Shona Shinwell
- School of Health Sciences, University of Dundee, Dundee, UK
| | | | - Joyce Marshall
- Department of Nursing and Midwifery, University of Huddersfield, Huddersfield, UK
| | - Sara Cumming
- School of Health Sciences, University of Dundee, Dundee, UK
| | - Louise Wallace
- School of Health, Wellbeing and Social Care, The Open University, Milton Keynes, UK
| | - Angie Wade
- Population, Policy and Practice, Great Ormond Street Institute of Child Health, London, UK
| | - Elayne Ahern
- Department of Psychology, University of Limerick, Castletroy, Ireland
| | - Laura Hay
- School of Health Sciences, University of Dundee, Dundee, UK
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Modjadji P, Seabela ES, Ntuli B, Madiba S. Beliefs and Norms Influencing Initiation and Sustenance of Exclusive Breastfeeding: Experiences of Mothers in Primary Health Care Facilities in Ermelo, South Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1513. [PMID: 36674268 PMCID: PMC9864642 DOI: 10.3390/ijerph20021513] [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: 10/04/2022] [Revised: 01/10/2023] [Accepted: 01/11/2023] [Indexed: 06/17/2023]
Abstract
Exclusive breastfeeding (EBF) is not a norm in many communities in South Africa despite the World Health Organizations' recommendations for EBF in the first six months of infant's life. Thus, South Africa continues to observe suboptimal and poor practices of EBF. The purpose of the study was to explore the experiences of mothers who are HIV-positive and negative on EBF and examine the extent to which initiation and sustenance of EBF is influenced by cultural beliefs, societal norms, and family norms and practices in Mpumalanga Province. Three focus group discussions and twelve in-depth interviews were conducted among thirty mothers who were purposively selected during their visits to the facilities for childcare services. Interviews were audiotaped, transcribed verbatim, and transcripts were analysed through thematic analysis using NVivo version 10. Mothers were aged between 18 and 42 years, most were unemployed and were living in poor sociodemographic backgrounds in extended family households. We found evidence of factors that influence the decision to EBF and mix feed infants among mothers. Traditional and cultural beliefs and norms that exist within their communities informed decisions mothers took to EBF. These beliefs existed alongside mothers' opinions on breastfeeding (BF) and HIV infection, as well as the fears of harming the baby through HIV infection, leading to early cessation of BF. Mothers were also advised by family members, friends, and even some healthcare workers to use traditional medicines while BF. The association of EBF with sagging breasts and weight loss as well as discomfort with public BF are personal beliefs that influenced initiation and early cessation of EBF. Breastfeeding messages ought to be context specific to improve the knowledge, understanding, acceptance and practice of EBF among HIV-positive and negative mothers. Culturally appropriate counselling messages that address the known cultural practices of the populations affected are essential to changing the beliefs and norms of the communities including extended families of EBF mothers.
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Affiliation(s)
- Perpetua Modjadji
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town 7505, South Africa
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, 1 Molotlegi Street, Ga-Rankuwa, Pretoria 0208, South Africa
| | - Ethel Sekori Seabela
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, 1 Molotlegi Street, Ga-Rankuwa, Pretoria 0208, South Africa
| | - Busisiwe Ntuli
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, 1 Molotlegi Street, Ga-Rankuwa, Pretoria 0208, South Africa
| | - Sphiwe Madiba
- Faculty of Health Sciences, University of Limpopo, Polokwane 0700, South Africa
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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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5
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Oyelana O, Kamanzi J, Richter S. A critical look at exclusive breastfeeding in Africa: Through the lens of diffusion of innovation theory. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2021. [DOI: 10.1016/j.ijans.2020.100267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Carroll G, Safon C, Buccini G, Vilar-Compte M, Teruel G, Pérez-Escamilla R. A systematic review of costing studies for implementing and scaling-up breastfeeding interventions: what do we know and what are the gaps? Health Policy Plan 2020; 35:461-501. [PMID: 32073628 DOI: 10.1093/heapol/czaa005] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2020] [Indexed: 12/17/2022] Open
Abstract
Despite the well-established evidence that breastfeeding improves maternal and child health outcomes, global rates of exclusive breastfeeding remain low. Cost estimates can inform stakeholders about the financial resources needed to scale up interventions to ultimately improve breastfeeding outcomes in low-, middle- and high-income countries. To inform the development of comprehensive costing frameworks, this systematic review aimed to (1) identify costing studies for implementing or scaling-up breastfeeding interventions, (2) assess the quality of identified costing studies and (3) examine the availability of cost data to identify gaps that need to be addressed through future research. Peer-reviewed and grey literature were systematically searched using a combination of index terms and relevant text words related to cost and the following breastfeeding interventions: breastfeeding counselling, maternity leave, the World Health Organization International Code of Marketing of Breastmilk Substitutes, the Baby-Friendly Hospital Initiative, media promotion, workplace support and pro-breastfeeding social policies. Data were extracted after having established inter-rater reliability among the first two authors. The quality of studies was assessed using an eight-item checklist for key costing study attributes. Forty-five studies met the inclusion criteria, with the majority including costs for breastfeeding counselling and paid maternity leave. Most cost analyses included key costing study attributes; however, major weaknesses among the studies were the lack of clarity on costing perspectives and not accounting for the uncertainty of reported cost estimates. Costing methodologies varied substantially, standardized costing frameworks are needed for reliably estimating the costs of implementing and scaling-up breastfeeding interventions at local-, national- or global-levels.
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Affiliation(s)
- Grace Carroll
- Department of Social and Behavioral Sciences, Yale School of Public Health, 135 College St. Suite 200, New Haven, CT 06510, USA
| | - Cara Safon
- Department of Social and Behavioral Sciences, Yale School of Public Health, 135 College St. Suite 200, New Haven, CT 06510, USA.,Department of Health Law, Policy, and Management, Boston University School of Public Health, Talbot Building, 715 Albany Street, Boston, MA 02118, USA
| | - Gabriela Buccini
- Department of Social and Behavioral Sciences, Yale School of Public Health, 135 College St. Suite 200, New Haven, CT 06510, USA
| | - Mireya Vilar-Compte
- EQUIDE Research Institute for Equitable Development, Universidad Iberoamericana, Prolongacion Paseo de la Reforma 880, Santa Fe, Zedec Sta Fé, Álvaro Obregón, 01219 Ciudad de México, CDMX, Mexico
| | - Graciela Teruel
- EQUIDE Research Institute for Equitable Development, Universidad Iberoamericana, Prolongacion Paseo de la Reforma 880, Santa Fe, Zedec Sta Fé, Álvaro Obregón, 01219 Ciudad de México, CDMX, Mexico
| | - Rafael Pérez-Escamilla
- Department of Social and Behavioral Sciences, Yale School of Public Health, 135 College St. Suite 200, New Haven, CT 06510, USA
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Pretorius CE, Asare H, Genuneit J, Kruger HS, Ricci C. Impact of breastfeeding on mortality in sub-Saharan Africa: a systematic review, meta-analysis, and cost-evaluation. Eur J Pediatr 2020; 179:1213-1225. [PMID: 32592027 DOI: 10.1007/s00431-020-03721-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 06/10/2020] [Accepted: 06/15/2020] [Indexed: 10/24/2022]
Abstract
Sub-Saharan Africa has lower breastfeeding rates compared to other low- and middle-income countries, and globally holds the highest under-five mortality rates. The aims of this study were to estimate mortality risk for inappropriate breastfeeding, prevalence of breastfeeding, population attributable fraction, and the economic impact of breastfeeding on child mortality, in sub-Saharan Africa. The systematic review included databases from Medline and CINAHL. Meta-analysis of mortality risk estimates was conducted using random effect methods. The prevalence of breastfeeding in Sub-Saharan African countries was determined using UNICEF's database. Population attributable fraction was derived from the prevalence and relative risk data. The cost attributable to child deaths in relation to inappropriate breastfeeding was calculated using the World Health Statistics data. The pooled relative mortality risk to any kind of infant feeding compared to exclusive and early breastfeeding initiation were 5.71 (95%CI: 2.14, 15.23) and 3.3 (95%CI: 2.49, 4.46), respectively. The overall exclusive and early initiation of breastfeeding prevalence were 35%(95%CI: 32%;37%) and 47%(95%CI: 44%;50%), respectively. The population attributable fraction for non-exclusive and late breastfeeding initiation breastfeeding were 75.7% and 55.3%, respectively. The non-health gross domestic product loss resulted in about 19.5 USB$.Conclusion: Public health interventions should prioritize appropriate breastfeeding practices to decrease the under-five mortality burden and its related costs in sub-Saharan Africa. What is Known: • Globally, sub-Saharan Africa holds the highest under five mortality rates and still has lower breastfeeding rates compared to other low- and middle-income countries. • There is a significant association between child mortality and inappropriate breastfeeding practices. What is New: • A five-fold and three-fold increased risks for under-five mortality were estimated with regard to non-exclusive breastfeeding and delayed breastfeeding initiation, respectively. • 55-75% of under-five deaths can be attributable to inappropriate breastfeeding practices and at least part of them could be potentially prevented with breastfeeding promotion interventions, saving a non-health gross domestic product loss of 19.5 USB$.
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Affiliation(s)
- Cianté E Pretorius
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa.
| | - Hannah Asare
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
| | - Jon Genuneit
- Pediatric Epidemiology, Department of Pediatrics, Medical Faculty, Leipzig University, Leipzig, Germany
| | - Herculina S Kruger
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa.,Medical Research Council Hypertension and Cardiovascular Disease Research Unit, North-West University, Potchefstroom, South Africa
| | - Cristian Ricci
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa.,Pediatric Epidemiology, Department of Pediatrics, Medical Faculty, Leipzig University, Leipzig, Germany
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8
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Nepal P, Schwarz R, Citrin D, Thapa A, Acharya B, Acharya Y, Aryal A, Baum A, Bhandari V, Bhatt L, Bhattarai D, Choudhury N, Dangal B, Dhimal M, Dhungana SK, Gauchan B, Halliday S, Kalaunee SP, Kunwar LB, Maru D, Nirola I, Paudel R, Raut A, Rayamazi HJ, Sapkota S, Schwarz D, Thapa P, Thapa P, Tiwari A, Tuitui R, Walter E, Maru S. Costing Analysis of a Pilot Community Health Worker Program in Rural Nepal. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:239-255. [PMID: 32606093 PMCID: PMC7326517 DOI: 10.9745/ghsp-d-19-00393] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 05/19/2020] [Indexed: 01/01/2023]
Abstract
Data from a retrospective costing analysis offers insights and practical considerations for policy makers and locally elected officials for designing and implementing a new community health work cadre as a mechanism to achieve SDG targets in Nepal. Community health workers (CHWs) are essential to primary health care systems and are a cost-effective strategy to achieve the Sustainable Development Goals (SDGs). Nepal is strongly committed to universal health coverage and the SDGs. In 2017, the Nepal Ministry of Health and Population partnered with the nongovernmental organization Nyaya Health Nepal to pilot a program aligned with the 2018 World Health Organization guidelines for CHWs. The program includes CHWs who: (1) receive regular financial compensation; (2) meet a minimum education level; (3) are well supervised; (4) are continuously trained; (5) are integrated into local primary health care systems; (6) use mobile health tools; (7) have consistent supply chain; (8) live in the communities they serve; and (9) provide service without point-of-care user fees. The pilot model has previously demonstrated improved institutional birth rate, antenatal care completion, and postpartum contraception utilization. Here, we performed a retrospective costing analysis from July 16, 2017 to July 15, 2018, in a catchment area population of 60,000. The average per capita annual cost is US$3.05 (range: US$1.94 to US$4.70 across 24 villages) of which 74% is personnel cost. Service delivery and administrative costs and per beneficiary costs for all services are also described. To address the current discourse among Nepali policy makers at the local and federal levels, we also present 3 alternative implementation scenarios that policy makers may consider. Given the Government of Nepal’s commitment to increase health care spending (US$51.00 per capita) to 7.0% of the 2030 gross domestic product, paired with recent health care systems decentralization leading to expanded fiscal space in municipalities, this CHW program provides a feasible opportunity to make progress toward achieving universal health coverage and the health-related SDGs. This costing analysis offers insights and practical considerations for policy makers and locally elected officials for deploying a CHW cadre as a mechanism to achieve the SDG targets.
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Affiliation(s)
| | - Ryan Schwarz
- Possible, New York, NY, USA. .,Brigham and Women's Hospital, Department of Medicine, Division of Global Health Equity, Boston, MA, USA.,Harvard Medical School, Department of Medicine, Boston, MA, USA.,Massachusetts General Hospital, Department of Medicine, Division of General Internal Medicine, Boston, MA, USA
| | - David Citrin
- Possible, New York, NY, USA.,University of Washington, Department of Global Health, Seattle, WA, USA.,University of Washington, Department of Anthropology, Seattle, WA, USA.,University of Washington, Henry M. Jackson School of International Studies, Seattle, WA, USA.,Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA
| | | | - Bibhav Acharya
- Possible, New York, NY, USA.,University of California, San Francisco, Department of Psychiatry, San Francisco, CA, USA
| | - Yubraj Acharya
- Pennsylvania State University, College of Health and Human Development, Department of Health Policy and Administration, University Park, PA, USA
| | - Anu Aryal
- Nyaya Health Nepal, Kathmandu, Nepal
| | - Aaron Baum
- Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA
| | | | | | | | - Nandini Choudhury
- Possible, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA
| | | | | | | | - Bikash Gauchan
- Nyaya Health Nepal, Kathmandu, Nepal.,University of California, San Francisco, Health Equity Action Leadership Initiative, San Francisco, CA, USA
| | - Scott Halliday
- Possible, New York, NY, USA.,University of Washington, Department of Global Health, Seattle, WA, USA.,University of Washington, Department of Anthropology, Seattle, WA, USA.,University of Washington, Henry M. Jackson School of International Studies, Seattle, WA, USA
| | - S P Kalaunee
- Nyaya Health Nepal, Kathmandu, Nepal.,Eastern University, College of Leadership and Development, St. Davids, PA, USA
| | | | - Duncan Maru
- Possible, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Department of Health Systems Design and Global Health, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Department of Internal Medicine, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Department of Pediatrics, New York, NY, USA
| | - Isha Nirola
- Possible, New York, NY, USA.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | | | | | - Dan Schwarz
- Possible, New York, NY, USA.,Brigham and Women's Hospital, Department of Medicine, Division of Global Health Equity, Boston, MA, USA.,Harvard Medical School, Department of Medicine, Boston, MA, USA.,Beth Israel Deaconess Medical Center, Department of Medicine, Boston, MA, USA.,Ariadne Labs, Harvard T.H. Chan School of Public Health and Brigham and Women's Hospital, Boston, MA, USA
| | - Poshan Thapa
- University of New South Wales, School of Public Health and Community Medicine, Sydney, NSW, Australia
| | | | | | - Roshani Tuitui
- Nursing and Social Security Division, Dept of Health Services, Kathmandu, Nepal
| | - Eric Walter
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.,University of Pennsylvania, The Wharton School, Healthcare Management Department, Philadelphia, PA, USA
| | - Sheela Maru
- Possible, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Department of Health Systems Design and Global Health, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology and Reproductive Science, New York, NY, USA
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9
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George G, Mudzingwa T, Horwood C. The cost of the training and supervision of community health workers to improve exclusive breastfeeding amongst mothers in a cluster randomised controlled trial in South Africa. BMC Health Serv Res 2020; 20:76. [PMID: 32013946 PMCID: PMC6998150 DOI: 10.1186/s12913-020-4913-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 01/16/2020] [Indexed: 11/11/2022] Open
Abstract
Background Interventions targeting community health workers (CHWs) aim to optimise the delivery of health services to underserved rural areas. Whilst interventions are evaluated against their objectives, there remains limited evidence on the economic costs of these interventions, and the practicality and value of scale up. The aim of this paper is to undertake a cost analysis on a CHW training and supervision intervention using exclusive breastfeeding rates amongst mothers as an outcome measure. Methods This is a retrospective cost analysis, from an implementer’s perspective, of a cluster randomised controlled trial investigating the effectiveness of a continuous quality improvement (CQI) intervention aimed at CHWs providing care and support to pregnant women and women with babies aged < 1 year in South Africa. Results One of the outcomes of the RCT revealed that the prevalence of exclusive breastfeeding (EBF) significantly improved, with the cost per mother EBF in the control and intervention arm calculated at US$760,13 and US$1705,28 respectively. The cost per additional mother practicing EBF was calculated to be US$7647, 88, with the supervision component of the intervention constituting 64% of the trial costs. In addition, women served by the intervention CHWs were more likely to have received a CHW visit and had significantly better knowledge of childcare practices. Conclusion Whilst the cost of this intervention is high, adapted interventions could potentially offer an economical alternative for achieving selected maternal and child health (MCH) outcomes. The results of this study should inform future programmes aimed at providing adapted training and supervision to CHWs with the objective of improving community-level health outcomes.
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Affiliation(s)
- Gavin George
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa.
| | - Takunda Mudzingwa
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Christiane Horwood
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
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10
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Nkonki LL, Chola LL, Tugendhaft AA, Hofman KK. Modelling the cost of community interventions to reduce child mortality in South Africa using the Lives Saved Tool (LiST). BMJ Open 2017; 7:e011425. [PMID: 28851766 PMCID: PMC5577872 DOI: 10.1136/bmjopen-2016-011425] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 01/18/2017] [Accepted: 03/17/2017] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE To estimate the costs and impact on reducing child mortality of scaling up interventions that can be delivered by community health workers at community level from a provider's perspective. SETTING In this study, we used the Lives Saved Tool (LiST), a module in the spectrum software. Within the spectrum software, LiST interacts with other modules, the AIDS Impact Module, Family Planning Module and Demography Projections Module (Dem Proj), to model the impact of more than 60 interventions that affect cause-specific mortality. PARTICIPANTS DemProj Based on National South African Data. INTERVENTIONS A total of nine interventions namely, breastfeeding promotion, complementary feeding, vitamin supplementation, hand washing with soap, hygienic disposal of children's stools, oral rehydration solution, oral antibiotics for the treatment of pneumonia, therapeutic feeding for wasting and treatment for moderate malnutrition. PRIMARY AND SECONDARY OUTCOME MEASURES Reducing child mortality. RESULTS A total of 9 interventions can prevent 8891 deaths by 2030. Hand washing with soap (21%) accounts for the highest number of deaths prevented, followed by therapeutic feeding (19%) and oral rehydration therapy (16%). The top 5 interventions account for 77% of all deaths prevented. At scale, an estimated cost of US$169.5 million (US$3 per capita) per year will be required in community health worker costs. CONCLUSION The use of community health workers offers enormous opportunities for saving lives. These programmes require appropriate financial investments. Findings from this study show what can be achieved if concerted effort is channelled towards the identified set of life-saving interventions.
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Affiliation(s)
- Lungiswa Ll Nkonki
- Division of Community Health, Centre for Health Systems and Services Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Lumbwe L Chola
- Population Health, Health Systems and Innovation, Human Science Research Council, Pretoria, South africa
| | - Aviva A Tugendhaft
- PRICELESS SA-MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South africa
| | - Karen K Hofman
- PRICELESS SA-MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South africa
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11
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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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12
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Maredza M, Chola L, Hofman K. Economic evaluations of interventions to reduce neonatal morbidity and mortality: a review of the evidence in LMICs and its implications for South Africa. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2016; 14:2. [PMID: 26819571 PMCID: PMC4728765 DOI: 10.1186/s12962-015-0049-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 12/09/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Newborn mortality, comprising a third of all under-5 deaths, has hardly changed in low and middle income countries (LMICs) including South Africa over the past decade. To attain the MDG 4 target, greater emphasis must be placed on wide-scale implementation of proven, cost-effective interventions. This paper reviews economic evidence on effective neonatal health interventions in LMICs from 2000-2013; documents lessons for South African policy on neonatal health; and identifies gaps and areas for future research. METHODS A narrative review was performed in leading public health databases for full economic evaluations conducted between 2000 and 2013. Data extraction from the articles included in the review was guided by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist, and the quality of the included economic evaluations was assessed using the Quality of Health Economics Studies Instrument (QHES). RESULTS Twenty-seven economic evaluations were identified, from South East Asia and sub-Saharan Africa, with those from sub-Saharan Africa primarily focused on HIV/AIDS. Packages of care to prevent neonatal mortality were more cost-effective than vertical interventions. A wide variability in methodological approaches challenges the comparability of study results between countries. In South Africa, there is limited cost-effectiveness evidence for the interventions proposed by the National Perinatal Morbidity and Mortality Committee. CONCLUSIONS Neonatal strategies have a strong health system focus but this review suggests that strengthening community care could be an additional component for averting neonatal deaths. While some evidence exists, having a more complete understanding of how to most effectively deploy scarce resources for neonatal health in South Africa in the post-2015 era is essential.
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Affiliation(s)
- Mandy Maredza
- />Priority Cost-Effective Lessons for Systems Strengthening-South Africa (PRICELESS SA), Medical Research Council/Wits Rural Public Health and Health Transition Research Unit (Agincourt), Johannesburg, South Africa
- />School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lumbwe Chola
- />Priority Cost-Effective Lessons for Systems Strengthening-South Africa (PRICELESS SA), Medical Research Council/Wits Rural Public Health and Health Transition Research Unit (Agincourt), Johannesburg, South Africa
- />School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen Hofman
- />Priority Cost-Effective Lessons for Systems Strengthening-South Africa (PRICELESS SA), Medical Research Council/Wits Rural Public Health and Health Transition Research Unit (Agincourt), Johannesburg, South Africa
- />School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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13
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Chola L, Fadnes LT, Engebretsen IMS, Nkonki L, Nankabirwa V, Sommerfelt H, Tumwine JK, Tylleskar T, Robberstad B. Cost-Effectiveness of Peer Counselling for the Promotion of Exclusive Breastfeeding in Uganda. PLoS One 2015; 10:e0142718. [PMID: 26619338 PMCID: PMC4664391 DOI: 10.1371/journal.pone.0142718] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 10/26/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Community based breastfeeding promotion programmes have been shown to be effective in increasing breastfeeding prevalence. However, there is limited data on the cost-effectiveness of these programmes in sub-Saharan Africa. This paper evaluates the cost-effectiveness of a breastfeeding promotion intervention targeting mothers and their 0 to 6 month old children. METHODS Data were obtained from a community randomized trial conducted in Uganda between 2006-2008, and supplemented with evidence from several studies in sub-Saharan Africa. In the trial, peer counselling was offered to women in intervention clusters. In the control and intervention clusters, women could access standard health facility breastfeeding promotion services (HFP). Thus, two methods of breastfeeding promotion were compared: community based peer counselling (in addition to HFP) and standard HFP alone. A Markov model was used to calculate incremental cost-effectiveness ratios between the two strategies. The model estimated changes in breastfeeding prevalence and disability adjusted life years. Costs were estimated from a provider perspective. Uncertainty around the results was characterized using one-way sensitivity analyses and a probabilistic sensitivity analysis. FINDINGS Peer counselling more than doubled the breastfeeding prevalence as reported by mothers, but there was no observable impact on diarrhoea prevalence. Estimated incremental cost-effectiveness ratios were US$68 per month of exclusive or predominant breastfeeding and U$11,353 per disability adjusted life year (DALY) averted. The findings were robust to parameter variations in the sensitivity analyses. CONCLUSIONS Our strategy to promote community based peer counselling is unlikely to be cost-effective in reducing diarrhoea prevalence and mortality in Uganda, because its cost per DALY averted far exceeds the commonly assumed willingness-to-pay threshold of three times Uganda's GDP per capita (US$1653). However, since the intervention significantly increases prevalence of exclusive or predominant breastfeeding, it could be adopted in Uganda if benefits other than reducing the occurrence of diarrhoea are believed to be important.
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Affiliation(s)
- Lumbwe Chola
- Population Health, Health Systems and Innovation (PHHSI), Human Sciences Research Council, Pretoria, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Box 7804, N-5020, Bergen, Norway
| | - Lars T. Fadnes
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Box 7804, N-5020, Bergen, Norway
- Department of Clinical Dentistry, University of Bergen, Bergen, Norway
| | - Ingunn M. S. Engebretsen
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Box 7804, N-5020, Bergen, Norway
- Department of Clinical Dentistry, University of Bergen, Bergen, Norway
| | - Lungiswa Nkonki
- Health Systems and Services Research Unit, Division of Community Health, University of Stellenbosch, Cape Town, South Africa
| | - Victoria Nankabirwa
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Box 7804, N-5020, Bergen, Norway
- Department of Paediatrics and Child Health, School of Medicine, Makerere University, Box 7072, Kampala, Uganda
| | - Halvor Sommerfelt
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Box 7804, N-5020, Bergen, Norway
- Department of International Public Health, Norwegian Institute of Public Health, Oslo, Norway
| | - James K. Tumwine
- Department of Paediatrics and Child Health, School of Medicine, Makerere University, Box 7072, Kampala, Uganda
| | - Thorkild Tylleskar
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Box 7804, N-5020, Bergen, Norway
| | - Bjarne Robberstad
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Box 7804, N-5020, Bergen, Norway
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