Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 5. equity effects for neonates and children

Background

The degree to which investments in health programs improve the health of the most disadvantaged segments of the population—where utilization of health services and health status is often the worst—is a growing concern throughout the world. Therefore, questions about the degree to which community–based primary health care (CBPHC) can or actually does improve utilization of health services and the health status of the most disadvantaged children in a population is an important one.

Methods

Using a database containing information about the assessment of 548 interventions, projects or programs (referred to collectively as projects) that used CBPHC to improve child health, we extracted evidence related to equity from a sub–set of 42 projects, identified through a multi–step process, that included an equity analysis. We organized our findings conceptually around a logical framework matrix.

Results

Our analysis indicates that these CBPHC projects, all of which implemented child health interventions, achieved equitable effects. The vast majority (87%) of the 82 equity measurements carried out and reported for these 42 projects demonstrated “pro–equitable” or “equitable” effects, meaning that the project’s equity indicator(s) improved to the same degree or more in the disadvantaged segments of the project population as in the more advantaged segments. Most (78%) of the all the measured equity effects were “pro–equitable,” meaning that the equity criterion improved more in the most disadvantaged segment of the project population than in the other segments of the population.

Conclusions

Based on the observation that CBPHC projects commonly provide services that are readily accessible to the entire project population and that even often reach down to all households, such projects are inherently likely to be more equitable than projects that strengthen services only at facilities, where utilization diminishes greatly with one’s distance away. The decentralization of services and attention to and tracking of metrics across all phases of project implementation with attention to the underserved, as can be done in CBPHC projects, are important for reducing inequities in countries with a high burden of child mortality. Strengthening CBPHC is a necessary strategy for reducing inequities in child health and for achieving universal coverage of essential services for children.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 4. child health findings

Background

This paper assesses the effectiveness of community–based primary health care (CBPHC) in improving child health beyond the neonatal period. Although there has been an accelerated decline in global under–5 mortality since 2000, mortality rates remain high in much of sub–Saharan Africa and in some south Asian countries where under–5 mortality is also decreasing more slowly. Essential interventions for child health at the community level have been identified. Our review aims to contribute further to this knowledge by examining how strong the evidence is and exploring in greater detail what specific interventions and implementation strategies appear to be effective.

Methods

We reviewed relevant documents from 1950 onwards using a detailed protocol. Peer reviewed documents, reports and books assessing the impact of one or more CBPHC interventions on child health (defined as changes in population coverage of one or more key child survival interventions, nutritional status, serious morbidity or mortality) among children in a geographically defined population was examined for inclusion. Two separate reviews took place of each document followed by an independent consolidated summative review. Data from the latter review were transferred to electronic database for analysis.

Results

The findings provide strong evidence that the major causes of child mortality in resource–constrained settings can be addressed at the community level largely by engaging communities and supporting community–level workers. For all major categories of interventions (nutritional interventions; control of pneumonia, diarrheal disease and malaria; HIV prevention and treatment; immunizations; integrated management of childhood diseases; and comprehensive primary health care) we have presented randomized controlled trials that have consistently produced statistically significant and operationally important effects.

Conclusions

This review shows that there is strong evidence of effectiveness for CBPHC implementation of an extensive range of interventions to improve child health and that four major strategies for delivering these interventions are effective.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 3. neonatal health findings

Background

As the number of deaths among children younger than 5 years of age continues to decline globally through programs to address the health of older infants, neonatal mortality is becoming an increasingly large proportion of under–5 deaths. Lack of access to safe delivery care, emergency obstetric care and postnatal care continue to be challenges for reducing neonatal mortality. This article reviews the available evidence regarding the effectiveness of community–based primary health care (CBPHC) and common components of programs aiming to improve health during the first 28 days of life.

Methods

A database comprising evidence of the effectiveness of projects, programs and field research studies (referred to collectively as projects) in improving maternal, neonatal and child health through CBPHC has been assembled and described elsewhere in this series. From this larger database (N = 548), a subset was created from assessments specifically relating to newborn health (N = 93). Assessments were excluded if the primary project beneficiaries were more than 28 days of age, or if the assessment did not identify one of the following outcomes related to neonatal health: changes in knowledge about newborn illness, care seeking for newborn illness, utilization of postnatal care, nutritional status of neonates, neonatal morbidity, or neonatal mortality. Descriptive analyses were conducted based on study type and outcome variables. An equity assessment was also conducted on the articles included in the neonatal subset.

Results

There is strong evidence that CBPHC can be effective in improving neonatal health, and we present information about the common characteristics shared by effective programs. For projects that reported on health outcomes, twice as many reported an improvement in neonatal health as did those that reported no effect; only one study demonstrated a negative effect. Of those with the strongest experimental study design, almost three–quarters reported beneficial neonatal health outcomes. Many of the neonatal projects assessed in our database utilized community health workers (CHWs), home visits, and participatory women’s groups. Several of the interventions used in these projects focused on health education (recognition of danger signs), and promotion of and support for exclusive breastfeeding (sometimes, but not always, including early breastfeeding). Almost all of the assessments that included a measurable equity component showed that CBPHC produced neonatal health benefits that favored the poorest segment of the project population. However, the studies were quite biased in geographic scope, with more than half conducted in South Asia, and many were pilot studies, rather than projects at scale.

Conclusions

CBPHC can be effectively employed to improve neonatal health in high–mortality, resource–constrained settings. CBPHC is especially important for education and support for pregnant and postpartum mothers and for establishing community–facility linkages to facilitate referrals for obstetrical emergencies; however, the latter will only produce better health outcomes if facilities offer timely, high–quality care. Further research on this topic is needed in Africa and Latin America, as well as in urban and peri–urban areas. Additionally, more assessments are needed of integrated packages of neonatal interventions and of programs at scale.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 6. strategies used by effective projects

BACKGROUND

As part of our review of the evidence of the effectiveness of community-based primary health care (CBPHC) in improving maternal, neonatal and child health (MNCH), we summarize here the common delivery strategies of projects, programs and field research studies (collectively referred to as projects) that have demonstrated effectiveness in improving child mortality. Other articles in this series address specifically the effects of CBPHC on improving MNCH, while this paper explores the specific strategies used.

METHODS

We screened 12 166 published reports in PubMed of community-based approaches to improving maternal, neonatal and child health in high-mortality, resource-constrained settings from 1950-2015. A total of 700 assessments, including 148 reports from other publicly available sources (mostly unpublished evaluation reports and books) met the criteria for inclusion and were reviewed using a data extraction form. Here we identify and categorize key strategies used in project implementation.

RESULTS

Six categories of strategies for program implementation were identified, all of which required working in partnership with communities and health systems: (a) program design and evaluation, (b) community collaboration, (c) education for community-level staff, volunteers, beneficiaries and community members, (d) health systems strengthening, (e) use of community-level workers, and (f) intervention delivery. Four specific strategies for intervention delivery were identified: (a) recognition, referral, and (when possible) treatment of serious childhood illness by mothers and/or trained community agents, (b) routine systematic visitation of all homes, (c) facilitator-led participatory women's groups, and (d) health service provision at outreach sites by mobile health teams.

CONCLUSIONS

The strategies identified here provide useful starting points for program design in strengthening the effectiveness of CBPHC for improving MNCH.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 7. shared characteristics of projects with evidence of long-term mortality impact

Background

There is limited evidence about the long–term effectiveness of integrated community–based primary health care (CBPHC) in improving maternal, neonatal and child health. However, the interventions implemented and the approaches used by projects with such evidence can provide guidance for ending preventable child and maternal deaths by the year 2030.

Methods

A database of 700 assessments of the effectiveness of CBPHC in improving maternal, neonatal and child health has been assembled, as described elsewhere in this series. A search was undertaken of these assessments of research studies, field project and programs (hereafter referred to as projects) with more than a single intervention that had evidence of mortality impact for a period of at least 10 years. Four projects qualified for this analysis: the Matlab Maternal Child Health and Family Planning (MCH–FP) P in Bangladesh; the Hôpital Albert Schweitzer in Deschapelles, Haiti; the Comprehensive Rural Health Project (CRHP) in Jamkhed, India; and the Society for Education, Action and Research in Community Health (SEARCH) in Gadchiroli, India.

Results

These four projects have all been operating for more than 30 years, and they all have demonstrated reductions in infant mortality, 1– to 4–year mortality, or under–5 mortality for at least 10 years. They share a number of characteristics. Among the most notable of these are: they provide comprehensive maternal, child health and family planning services, they have strong community–based programs that utilize community health workers who maintain regular contact with all households, they have develop strong collaborations with the communities they serve, and they all have strong referral capabilities and provide first–level hospital care.

Conclusions

The shared features of these projects provide guidance for how health systems around the world might improve their effectiveness in improving maternal, neonatal and child health. Strengthening these features will contribute to achieving the goal of ending preventable child and maternal deaths by the year 2030.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 2. maternal health findings

BACKGROUND

We summarize the findings of assessments of projects, programs, and research studies (collectively referred to as projects) included in a larger review of the effectiveness of community-based primary health care (CBPHC) in improving maternal, neonatal and child health (MNCH). Findings on neonatal and child health are reported elsewhere in this series.

METHODS

We searched PUBMED and other databases through December 2015, and included assessments that underwent data extraction. Data were analyzed to identify themes in interventions implemented, health outcomes, and strategies used in implementation.

RESULTS

152 assessments met inclusion criteria. The majority of assessments were set in rural communities. 72% of assessments included 1-10 specific interventions aimed at improving maternal health. A total of 1298 discrete interventions were assessed. Outcome measures were grouped into five main categories: maternal mortality (19% of assessments); maternal morbidity (21%); antenatal care attendance (50%); attended delivery (66%) and facility delivery (69%), with many assessments reporting results on multiple indicators. 15 assessments reported maternal mortality as a primary outcome, and of the seven that performed statistical testing, six reported significant decreases. Seven assessments measured changes in maternal morbidity: postpartum hemorrhage, malaria or eclampsia. Of those, six reported significant decreases and one did not find a significant effect. Assessments of community-based interventions on antenatal care attendance, attended delivery and facility-based deliveries all showed a positive impact. The community-based strategies used to achieve these results often involved community collaboration, home visits, formation of participatory women's groups, and provision of services by outreach teams from peripheral health facilities.

CONCLUSIONS

This comprehensive and systematic review provides evidence of the effectiveness of CBPHC in improving key indicators of maternal morbidity and mortality. Most projects combined community- and facility-based approaches, emphasizing potential added benefits from such holistic approaches. Community-based interventions will be an important component of a comprehensive approach to accelerate improvements in maternal health and to end preventable maternal deaths by 2030.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 1. rationale, methods and database description

BACKGROUND

Community-based primary health care (CBPHC) is an approach used by health programs to extend preventive and curative health services beyond health facilities into communities and even down to households. Evidence of the effectiveness of CBPHC in improving maternal, neonatal and child health (MNCH) has been summarized by others, but our review gives particular attention to not only the effectiveness of specific interventions but also their delivery strategies at the community level along with their equity effects. This is the first article in a series that summarizes and analyzes the assessments of programs, projects, and research studies (referred to collectively as projects) that used CBPHC to improve MNCH in low- and middle-income countries. The review addresses the following questions: (1) What kinds of projects were implemented? (2) What were the outcomes of these projects? (3) What kinds of implementation strategies were used? (4) What are the implications of these findings?

METHODS

12 166 reports were identified through a search of articles in the National Library of Medicine database (PubMed). In addition, reports in the gray literature (available online but not published in a peer-reviewed journal) were also reviewed. Reports that describe the implementation of one or more community-based interventions or an integrated project in which an assessment of the effectiveness of the project was carried out qualified for inclusion in the review. Outcome measures that qualified for inclusion in the review were population-based indicators that defined some aspect of health status: changes in population coverage of evidence-based interventions or changes in serious morbidity, in nutritional status, or in mortality.

RESULTS

700 assessments qualified for inclusion in the review. Two independent reviewers completed a data extraction form for each assessment. A third reviewer compared the two data extraction forms and resolved any differences. The maternal interventions assessed concerned education about warning signs of pregnancy and safe delivery; promotion and/or provision of antenatal care; promotion and/or provision of safe delivery by a trained birth attendant, screening and treatment for HIV infection and other maternal infections; family planning, and; HIV prevention and treatment. The neonatal and child health interventions that were assessed concerned promotion or provision of good nutrition and immunizations; promotion of healthy household behaviors and appropriate utilization of health services, diagnosis and treatment of acute neonatal and child illness; and provision and/or promotion of safe water, sanitation and hygiene. Two-thirds of assessments (63.0%) were for projects implementing three or fewer interventions in relatively small populations for relatively brief periods; half of the assessments involved fewer than 5000 women or children, and 62.9% of the assessments were for projects lasting less than 3 years. One-quarter (26.6%) of the projects were from three countries in South Asia: India, Bangladesh and Nepal. The number of reports has grown markedly during the past decade. A small number of funders supported most of the assessments, led by the United States Agency for International Development. The reviewers judged the methodology for 90% of the assessments to be adequate.

CONCLUSIONS

The evidence regarding the effectiveness of community-based interventions to improve the health of mothers, neonates, and children younger than 5 years of age is growing rapidly. The database created for this review serves as the basis for a series of articles that follow this one on the effectiveness of CBPHC in improving MNCH published in the Journal of Global Health. These findings, together with recommendations provided by an Expert Panel which has guided this review, that are included as the last paper in this series, will help to provide the rationale for building stronger community-based platforms for delivering evidence-based interventions in high-mortality, resource-constrained settings.