Effect of women's groups and volunteer peer counselling on rates of mortality, morbidity, and health behaviours in mothers and children in rural Malawi (MaiMwana): a factorial, cluster-randomised controlled trial

A systematic review of behaviour change interventions to improve maternal health outcomes in sub-Saharan Africa

The rate of decline in the global burden of avoidable maternal deaths has stagnated and remains an issue of concern in many sub-Saharan Africa countries. As per the most recent evidence, an average maternal mortality ratio (MMR) of 223 deaths per 100,000 live births has been estimated globally, with sub-Saharan Africa's average MMR at 536 per 100,000 live births-more than twice the global average. Despite the high MMR, there is variation in MMR between and within sub-Saharan Africa countries. Differences in the behaviour of those accessing and/or delivering maternal healthcare may explain variations in outcomes and provide a basis for quality improvement in health systems. There is a gap in describing the landscape of interventions aimed at modifying the behaviours of those accessing and delivering maternal healthcare for improving maternal health outcomes in sub-Saharan Africa. Our objective was to extract and synthesise the target behaviours, component behaviour change strategies and outcomes of behaviour change interventions for improving maternal health outcomes in sub-Saharan Africa. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Our protocol was published a priori on PROSPERO (registration number CRD42022315130). We searched ten electronic databases (PsycINFO, Cochrane Database of Systematic Reviews, International Bibliography of Social Sciences, EMBASE, MEDLINE, Scopus, CINAHL PLUS, African Index Medicus, African Journals Online, and Web of Science) and included randomised trials and quasi-experimental studies. We extracted target behaviours and specified the behavioural interventions using the Action, Actor, Context, Time, and Target (AACTT) framework. We categorised the behaviour change strategies using the intervention functions described in the Behaviour Change Wheel (BCW). We reviewed 52 articles (26 randomized trials and 26 quasi-experimental studies). They had a mixed risk of bias. Out of these, 41 studies (78.8%) targeted behaviour change of those accessing maternal healthcare services, while seven studies (13.5%) focused on those delivering maternal healthcare. Four studies (7.7%) targeted mixed stakeholder groups. The studies employed a range of behaviour change strategies, including education 37 (33.3%), persuasion 20 (18%), training 19 (17.1%), enablement 16 (14.4%), environmental restructuring 8 (7.2%), modelling 6 (5.4%) and incentivisation 5 (4.5%). No studies used restriction or coercion strategies. Education was the most common strategy for changing the behaviour of those accessing maternal healthcare, while training was the most common strategy in studies targeting the behaviour of those delivering maternal healthcare. Of the 52 studies, 40 reported effective interventions, 7 were ineffective, and 5 were equivocal. A meta-analysis was not feasible due to methodological and clinical heterogeneity across the studies. In conclusion, there is evidence of effective behaviour change interventions targeted at those accessing and/or delivering maternal healthcare in sub-Saharan Africa. However, more focus should be placed on behaviour change by those delivering maternal healthcare within the health facilities to fast-track the reduction of the huge burden of avoidable maternal deaths in sub-Saharan Africa.

Scoping review of interventions to improve continuity of postdischarge care for newborns in LMICs

INTRODUCTION

Neonatal mortality remains significant in low-income and middle-income countries (LMICs) with in-hospital mortality rates similar to those following discharge from healthcare facilities. Care continuity interventions have been suggested as a way of reducing postdischarge mortality by better linking care between facilities and communities. This scoping review aims to map and describe interventions used in LMICs to improve care continuity for newborns after discharge and examine assumptions underpinning the design and delivery of continuity.

METHODS

We searched seven databases (MEDLINE, CINAHL, Scopus, Web of Science, EMBASE, Cochrane library and (Ovid) Global health). Publications with primary data on interventions focused on continuity of care for newborns in LMICs were included. Extracted data included year of publication, study location, study design and type of intervention. Drawing on relevant theoretical frameworks and classifications, we assessed the extent to which interventions adopted participatory methods and how they attempted to establish continuity.

RESULTS

A total of 65 papers were included in this review; 28 core articles with rich descriptions were prioritised for more in-depth analysis. Most articles adopted quantitative designs. Interventions focused on improving continuity and flow of information via education sessions led by community health workers during home visits. Extending previous frameworks, our findings highlight the importance of interpersonal continuity in LMICs where communication and relationships between family members, healthcare workers and members of the wider community play a vital role in creating support systems for postdischarge care. Only a small proportion of studies focused on high-risk babies. Some studies used participatory methods, although often without meaningful engagement in problem definition and intervention implementation.

CONCLUSION

Efforts to reduce neonatal mortality and morbidity should draw across multiple continuity logics (informational, relational, interpersonal and managerial) to strengthen care after hospital discharge in LMIC settings and further focus on high-risk neonates, as they often have the worst outcomes.

Impact of health system governance on healthcare quality in low-income and middle-income countries: a scoping review

INTRODUCTION

Improving healthcare quality in low-/middle-income countries (LMICs) is a critical step in the pathway to Universal Health Coverage and health-related sustainable development goals. This study aimed to map the available evidence on the impacts of health system governance interventions on the quality of healthcare services in LMICs.

METHODS

We conducted a scoping review of the literature. The search strategy used a combination of keywords and phrases relevant to health system governance, quality of healthcare and LMICs. Studies published in English until August 2023, with no start date limitation, were searched on PubMed, Cochrane Library, CINAHL, Web of Science, Scopus, Google Scholar and ProQuest. Additional publications were identified by snowballing. The effects reported by the studies on processes of care and quality impacts were reviewed.

RESULTS

The findings from 201 primary studies were grouped under (1) leadership, (2) system design, (3) accountability and transparency, (4) financing, (5) private sector partnerships, (6) information and monitoring; (7) participation and engagement and (8) regulation.

CONCLUSIONS

We identified a stronger evidence base linking improved quality of care with health financing, private sector partnerships and community participation and engagement strategies. The evidence related to leadership, system design, information and monitoring, and accountability and transparency is limited.

Effects of Exclusive Breastfeeding Promotion Interventions on Child Outcomes: A Systematic Review and Meta-Analysis

INTRODUCTION

Interventions promoting exclusive breastfeeding (EBF) may benefit infant health outcomes, but evidence is inconsistent. The objective of this review was to assess the effect of interventions promoting EBF on health outcomes in infants and children under 7 years of age.

METHODS

A literature search was conducted using EMBASE, MEDLINE, CINAHL, Cochrane Central, Cochrane Database of Systematic Reviews, and WHO International Clinical Trials Registry Platform from inception to April 2022. Inclusion criteria were randomized or cluster-randomized controlled trials aiming to increase EBF that reported effects on offspring growth, morbidity, and/or mortality up to age 7 years. The primary outcome was infant/child growth. Secondary outcomes were infant morbidity and mortality and EBF rates. Data were pooled using a random-effects model.

RESULTS

Thirty-two studies (40 papers) were identified. No effect on infant/child growth was observed. EBF promotion interventions significantly improved EBF rates up to 6 months (n = 25; OR 3.15; 95% CI: 2.36, 4.19) and significantly reduced the odds of respiratory illness at 0-3 months by 59% (n = 2; OR 0.41; 95% CI: 0.20, 0.84) but not at later time-points. A borderline significant effect was observed for diarrhea (n = 12; OR 0.84; 95% CI: 0.70, 1.00). Effects on hospitalizations or mortality were not significant.

DISCUSSION/CONCLUSION

EBF promotion interventions improve EBF rates and might yield modest reductions in infant morbidity without affecting infant/child growth. Future studies should investigate the cost-effectiveness of these interventions and examine potential benefits on other health outcomes.

Types, reporting and acceptability of community-based interventions for stillbirth prevention in sub-Saharan Africa (SSA): a systematic review

Background

Community-based interventions are increasingly being implemented in Sub-Saharan Africa (SSA) for stillbirth prevention, but the nature of these interventions, their reporting and acceptability are poorly assessed. In addition to understanding their effectiveness, complete reporting of the methods, results and intervention acceptability is essential as it could potentially reduce research waste from replication of inadequately implemented and unacceptable interventions. We conducted a systematic review to investigate these aspects of community-based interventions for preventing stillbirths in SSA.

Methods

In this systematic review, eight databases (MEDLINE(OvidSP), Embase (OvidSP), Cochrane Central Register of Controlled Trials, Global Health, Science Citation Index and Social Science Citation index (Web of Science Core Collection), CINAHL (EBSCOhost) and Global Index Medicus) and four grey literature sources were searched from January 1, 2000 to July 7, 2023 for relevant quantitative and qualitative studies from SSA (PROSPERO-CRD42021296623). Following deduplication, abstract screening and full-text review, studies were included if the interventions were community-based with or without a health facility component. The main outcomes were types of community-based interventions, completeness of intervention reporting using the TIDier (Template for Intervention Description and replication) checklist, and themes related to intervention acceptability identified using a theoretical framework. Study quality was assessed using the Cochrane risk of bias and National Heart, Lung and Blood Institute's tools.

Findings

Thirty-nine reports from thirty-four studies conducted in 18 SSA countries were eligible for inclusion. Four types of interventions were identified: nutritional, infection prevention, access to skilled childbirth attendants and health knowledge/behaviour of women. These interventions were implemented using nine strategies: mHealth (defined as the use of mobile and wireless technologies to support the achievement of health objectives), women's groups, community midwifery, home visits, mass media sensitisation, traditional birth attendant and community volunteer training, community mobilisation and transport vouchers. The completeness of reporting using the TIDier checklist varied across studies with a very low proportion of the included studies reporting the intervention intensity, dosing, tailoring and modification. The quality of the included studies were graded as poor (n = 6), fair (n = 14) and good (n = 18). Though interventions were acceptable, only 4 (out of 7) studies explored women's perceptions, mostly focusing on perceived intervention effects and how they felt, omitting key constructs like ethicality, opportunity cost and burden of participation.

Interpretation

Different community-based interventions have been tried and evaluated for stillbirth prevention in SSA. The reproducibility and implementation scale-up of these interventions may be limited by incomplete intervention descriptions in the published literature. To strengthen impact, it is crucial to holistically explore the acceptability of these interventions among women and their families.

Funding

Clarendon/Balliol/NDPH DPhil scholarship for UGA. MN is funded by a Medical Research Council Transition Support Award (MR/W029294/1).

Effectiveness of a continuum of care in maternal health services on the reduction of maternal and neonatal mortality: Systematic review and meta-analysis

Background

Sustainable Development Goals -3 (SDG - 3) were to ensure healthy live and promote well-being by reducing global maternal and neonatal deaths. These were to be implemented through the concept of continuum of care in maternal health program framework to improve health outcomes. There is a paucity of published evidences; as such, this review is designed to assess the effectiveness of the concept of continuum of care in maternal and neonatal health services on the reduction of maternal and neonatal mortality.

Methods

A search was conducted using the key words; maternal and neonatal, health services, continuum of care, maternal and neonatal mortality. Search focused on PubMed, Cochrane, MEDLINE and Google Scholar. Extractions of articles were done based on predetermine criteria. Data were compiled, and screened, entered and analysis was done using STATA 13 and Rev. Man. software. Effects of the intervention package were determined and the result was interpreted in random effect RR with 95%CI. The publication bias was determined by using funnel plot, Egger and Bagger test, heterogeneity, and sensitivity test.

Results

A total of 4685 articles were retrieved of these 20 articles reviewed. Articles on 631,975 live births (LBs) were analyzed. Results showed the distribution as follows; 23,126 newborns died within 28 days resulting [NMR = 35/1000LBs among the intervention group whereas NMR = 39/1000LBs among the control group]. The pooled effect of the intervention was significantly reduced neonatal mortality (RR = 0.84; 95%CI: 0.77-0.91). Similarly, 1268 women died during the pregnancy period up to 42 days after childbirth that resulted [MMR = 330/100,000LBs among the intervention group whereas MMR = 460/100,000LBs among the control group]. The pooled effect of the intervention was not a statistically significant association with maternal mortality (RR = 0.64; 95%CI: 0.41-1.00).

Conclusion

Adoption of continuum of care concepts in maternal health services reduced maternal and neonatal mortality. We recommend strengthening and effective implementation of a continuum of care in maternal health services to improve maternal and neonatal health care outcomes.

What's in a name? Unpacking 'Community Blank' terminology in reproductive, maternal, newborn and child health: a scoping review

INTRODUCTION

Engaging the community as actors within reproductive, maternal, newborn and child health (RMNCH) programmes (referred to as 'community blank') has seen increased implementation in recent years. While evidence suggests these approaches are effective, terminology (such as 'community engagement,' 'community participation,' 'community mobilisation,' and 'social accountability') is often used interchangeably across published literature, contributing to a lack of conceptual clarity in practice. The purpose of this review was to describe and clarify varying uses of these terms in the literature by documenting what authors and implementers report they are doing when they use these terms.

METHODS

Seven academic databases (PubMed/MEDLINE, Embase, CINAHL, PsycINFO, Scopus, Web of Science, Global Health), two grey literature databases (OAIster, OpenGrey) and relevant organisation websites were searched for documents that described 'community blank' terms in RMNCH interventions. Eligibility criteria included being published between 1975 and 1 October 2021 and reports or studies detailing the activities used in 'community blank.' RESULTS: A total of 9779 unique documents were retrieved and screened, with 173 included for analysis. Twenty-four distinct 'community blank' terms were used across the documents, falling into 11 broader terms. Use of these terms was distributed across time and all six WHO regions, with 'community mobilisation', 'community engagement' and 'community participation' being the most frequently used terms. While 48 unique activities were described, only 25 activities were mentioned more than twice and 19 of these were attributed to at least three different 'community blank' terms.

CONCLUSION

Across the literature, there is inconsistency in the usage of 'community blank' terms for RMNCH. There is an observed interchangeable use of terms and a lack of descriptions of these terms provided in the literature. There is a need for RMNCH researchers and practitioners to clarify the descriptions reported and improve the documentation of 'community blank' implementation. This can contribute to a better sharing of learning within and across communities and to bringing evidence-based practices to scale. Efforts to improve reporting can be supported with the use of standardised monitoring and evaluation processes and indicators. Therefore, it is recommended that future research endeavours clarify the operational definitions of 'community blank' and improve the documentation of its implementation.

The effectiveness of prenatal and postnatal home visits by paramedical professionals and women's group meetings in improving maternal and child health outcomes in low and middle-income countries: a systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of prenatal and postnatal home visits (HVs) and women group meetings (WGMs) by paramedical professionals to improve maternal and child health outcomes in low- and middle-income countries (LMICs).

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

We conducted a systematic review of trials published till December 2020, as per registered protocol in The International Prospective Register of Systematic Reviews (PROSPERO) (CRD42018091968). Outcomes were neonatal mortality rate (NMR), maternal mortality ratio (MMR), the incidence of low birth weight, and still birth rate (SBR). The Cochrane Pregnancy and Childbirth Group's Trials Register, Cochrane Central Register of Controlled Trials, PubMed, and Excerpta Medica Database (EMBASE) were searched. Pooled results were estimated using random-effects meta-analysis in RevMan version 5.2.

RESULTS

Twenty-five trials met the inclusion criteria. HVs were the key intervention in 12, WGMs in 11, and both interventions in 2 trials. The pooled estimates have shown that NMR was significantly reduced by HVs (OR 0.77, confidence interval [CI]: 0.67-0.90, P = 0.0007, I² = 77%) and WGMs (OR 0.76, CI: 0.65-0.90, P = 0.001, I² = 71%). SBR was significantly reduced by HVs (OR 0.77, CI: 0.70-0.85; P < 0.001, I² = 0%). Subgroup analysis of studies in which more than 10% of pregnant women participated in the WGMs showed significant reduction in NMR (OR 0.67, CI 0.58-0.77, P = 0.00001, I² = 31%) and MMR (OR 0.55, CI 0.36-0.84, P = 0.005, I² = 27%). Two studies reported improvement in birth weight by HVs.

CONCLUSIONS

HVs and WGMs (with >10% pregnant women) by paramedical professionals are effective strategies in reducing the NMR and MMR in LMICs. HVs were also effective in reducing SBR.

Community health workers' involvement in mother-child care during the 1st year after birth, in Kaya health district, Burkina Faso: A contribution analysis

Introduction

Maternal and infant morbidity and mortality remain high in sub-Saharan Africa. However, actions to strengthen postpartum care are still weak and mainly limited to health facilities (HFs). In Kaya health district, Burkina Faso, community health workers (CHWs) were involved in mother and child care during the 1st year postpartum through home visits, outreach sessions and accompanying mothers to health facilities. The aim of this study was to assess the contribution of CHWs to postpartum women's attendance at the health facilities.

Methods

We conducted an effect assessment using Mayne and Lemire's contribution analysis framework. Qualitative and quantitative data were collected through project documents review and individual semi-structured interviews with key-informants.

Results

All the participants interviewed acknowledged that the number of women, who came to postpartum care, had increased since the implementation of the project activities. Postpartum consultation rates within the 1st week postpartum increased from 29% in 2011 to 80% in 2015 and from 19 to 50% within 6 weeks. Others interventions such as Performance based financing, Save The Children nutritional project and the health services component of Missed Opportunities in Mother and Infant Health (MOMI) were the alternative explanations.

Conclusions

CHWs involvement in women care contributed to improve their adherence to postpartum consultations in Kaya health district.

Strategies to increase rural maternal utilization of skilled health personnel for childbirth delivery in low- and middle-income countries: a narrative review

BACKGROUND

Skilled attendance at birth is considered key to accomplishing Sustainable Development Goal (SDG) 3.1 aimed at reducing maternal mortality. Many maternal deaths can be prevented if a woman receives care by skilled health personnel. Maternal utilization of skilled health delivery services in rural areas in low- and middle-income countries is 70% compared to 90% in urban areas. Previous studies have found community-based interventions may increase rural maternal uptake of skilled health delivery services, but evidence is lacking on which strategies are most effective.

OBJECTIVE

To review the effectiveness of community-based strategies to increase rural maternal utilization of skilled health personnel for childbirth delivery in low-and middle-income countries.

METHODS

We conducted a narrative review. PubMed, CINAHL, Cochrane Library, and PsycINFO databases were searched for articles from database inception through 13 November 2019. Key search terms were pre-determined. Information was extracted on studies meeting our inclusion criteria: cluster and randomized trials, rural setting, reproductive aged women, community engagement, low- and middle-income countries. Studies were considered effective if statistically significant (p < 0.05). A narrative synthesis was conducted.

RESULTS

Ten cluster randomized trials out of 5,895 candidate citations met the inclusion criteria. Strategies included home-based visits, women's groups, and combined approaches. Out of the ten articles, only three studies were found to significantly increase maternal uptake of skilled health personnel for delivery, and each used a different strategy. The results are inconclusive as to which strategies are most effective. Limitations of this review include heterogeneity and generalizability of studies.

CONCLUSIONS

This research suggests that different strategies may be effective at improving maternal utilization of skilled health personnel for delivery in certain rural settings while ineffective in others. More research is warranted to better understand the context in which strategies may be effective and under what conditions.

Health Mothers' Groups in Nepal: Barriers, Facilitators, and Recommendations

Background

Nepal's female community health volunteers (FCHVs) each lead a monthly health mothers' group (HMG) to share health-related information and engage communities in the health system. Suaahara II (SII), a US Agency for International Development-funded multisectoral nutrition program, uses social and behavior change interventions to promote HMG participation and uses its health systems interventions to strengthen HMG quality.

Objectives

This study aimed to explore HMG functionality and variation across Nepal, including barriers and facilitators to attending HMG meetings.

Methods

SII's cross-sectional annual survey data from 16 districts (n = 192 FCHVs and 1850 mothers with children <2 y) were used. Descriptive and logistic regression analyses were conducted where the outcome variable was whether mothers were active HMG members or not, with FCHV and maternal characteristics as explanatory variables. Qualitative data were obtained from 3 of 16 survey districts (n = 30 observations, n = 30 in-depth interviews with mothers, and n = 16 focus group discussions with mothers, family members, FCHVs, health workers, and SII staff).

Results

Among FCHVs, 90% reported facilitating HMG meetings, whereas 64% of mothers reported HMG availability, and only 25% reported participating actively in meetings. Household head sex, maternal age, maternal education, maternal self-efficacy, and engagement with an FCHV and SII were associated with whether mothers were active participants in HMG meetings. Qualitative findings highlighted systems-level barriers, including lack of FCHV skills, demotivation, and heavy workload. Mothers noted time as the major constraint and family support, the HMG's savings component, and active FCHVs as facilitators to participation.

Conclusions

Findings suggest that both supply- and demand-side solutions are needed to improve HMG performance and uptake in Nepal. These solutions need to include improving FCHV skills and motivating them to provide high-quality HMG services, as well as encouraging family members to support women so that they have time to participate in the HMGs.

Effectiveness of breastfeeding education compared to standard hospital information on exclusive breastfeeding among mothers: A systematic review

Breastfeeding is the single intervention with the largest impact on the health of a new-born baby. Evidence has to be generated to convince the mother as well as policy-makers for the promotion of exclusive breastfeeding (EBF) for 6 months. This study aimed to assess the evidence for the effectiveness of breastfeeding education compared with standard hospital information among mothers on the rate of EBF. The study design is systematic review. Trials which are randomized or cluster randomized which studied the effect of educational interventions for mothers on EBF were searched for. Two databases were searched, namely PubMed and Cochrane. Manual search of reference lists of all included studies in Google scholar and Clinical Trial Registry was done. Two reviewers independently assessed the quality of the included studies. Data were extracted using a table format set by the reviewers referring the previously reported high-quality systematic reviews. Out of the 12 comparisons of nine studies included for review, eight studies report that breastfeeding education has added advantage on increasing the rate of EBF. We conclude that there is evidence to support breastfeeding education versus standard hospital information across diverse settings.

Measurement of benefits in economic evaluations of nutrition interventions in low‐ and middle‐income countries: A systematic review

Economic evaluation of nutrition interventions that compares the costs to benefits is essential to priority‐setting. However, there are unique challenges to synthesizing the findings of multi‐sectoral nutrition interventions due to the diversity of potential benefits and the methodological differences among sectors in measuring them. This systematic review summarises literature on the interventions, sectors, benefit terminology and benefit types included in cost‐effectiveness, cost‐utility and benefit‐cost analyses (CEA, CUA and BCA, respectively) of nutrition interventions in low‐ and middle‐income countries. A systematic search of five databases published from January 2010 to September 2019 with expert consultation yielded 2794 studies, of which 93 met all inclusion criteria. Eighty‐seven per cent of the included studies included interventions delivered from only one sector, with almost half from the health sector (43%), followed by food/agriculture (27%), water, sanitation and hygiene (WASH) (10%), and social protection (8%). Only 9% of studies assessed programmes involving more than one sector (health, food/agriculture, social protection and/or WASH). Eighty‐one per cent of studies used more than one term to refer to intervention benefits. The included studies calculated 128 economic evaluation ratios (57 CEAs, 39 CUAs and 32 BCAs), and the benefits they included varied by sector. Nearly 60% measured a single benefit category, most frequently nutritional status improvements; other health benefits, cognitive/education gains, dietary diversity, food security, knowledge/attitudes/practices and income were included in less than 10% of all ratios. Additional economic evaluation of non‐health and multi‐sector interventions, and incorporation of benefits beyond nutritional improvements (including cost savings) in future economic evaluations is recommended.

Current economic evaluations often underestimate the total sum of benefits that can arise from nutrition interventions. Comprehensive benefit measurement of some nutrition programmes may require further methodological research.

In the near‐term, economic evaluations of multi‐sectoral nutrition interventions should include potential cost savings from improved nutrition in their calculations and assess the potential for benefits unrelated to nutrition. If the range of benefits is diverse and can be monetised, benefit‐cost analysis may be the preferred evaluation method.

Economic evaluations of nutrition‐sensitive interventions from agriculture, water, sanitation and hygiene (WASH), and gender empowerment sectors, are needed to fill an evidence gap on costs and benefits of multisectoral approaches to improved maternal and child health and nutrition.

Comprehensive Anaemia Programme and Personalized Therapies (CAPPT): protocol for a cluster-randomised controlled trial testing the effect women's groups, home counselling and iron supplementation on haemoglobin in pregnancy in southern Nepal

BACKGROUND

Anaemia in pregnancy remains prevalent in Nepal and causes severe adverse health outcomes.

METHODS

This non-blinded cluster-randomised controlled trial in the plains of Nepal has two study arms: (1) Control: routine antenatal care (ANC); (2) Home visiting, iron supplementation, Participatory Learning and Action (PLA) groups, plus routine ANC. Participants, including women in 54 non-contiguous clusters (mean 2582; range 1299-4865 population) in Southern Kapilbastu district, are eligible if they consent to menstrual monitoring, are resident, married, aged 13-49 years and able to respond to questions. After 1-2 missed menses and a positive pregnancy test, consenting women < 20 weeks' gestation, who plan to reside locally for most of the pregnancy, enrol into trial follow-up. Interventions comprise two home-counselling visits (at 12-21 and 22-26 weeks' gestation) with iron folic acid (IFA) supplement dosage tailored to women's haemoglobin concentration, plus monthly PLA women's group meetings using a dialogical problem-solving approach to engage pregnant women and their families. Home visits and PLA meetings will be facilitated by auxiliary nurse midwives. The hypothesis is as follows: Haemoglobin of women at 30 ± 2 weeks' gestation is ≥ 0.4 g/dL higher in the intervention arm than in the control. A sample of 842 women (421 per arm, average 15.6 per cluster) will provide 88% power, assuming SD 1.2, ICC 0.09 and CV of cluster size 0.27. Outcomes are captured at 30 ± 2 weeks gestation. Primary outcome is haemoglobin concentration (g/dL). Secondary outcomes are as follows: anaemia prevalence (%), mid-upper arm circumference (cm), mean probability of micronutrient adequacy (MPA) and number of ANC visits at a health facility. Indicators to assess pathways to impact include number of IFA tablets consumed during pregnancy, intake of energy (kcal/day) and dietary iron (mg/day), a score of bioavailability-enhancing behaviours and recall of one nutrition knowledge indicator. Costs and cost-effectiveness of the intervention will be estimated from a provider perspective. Using constrained randomisation, we allocated clusters to study arms, ensuring similarity with respect to cluster size, ethnicity, religion and distance to a health facility. Analysis is by intention-to-treat at the individual level, using mixed-effects regression.

DISCUSSION

Findings will inform Nepal government policy on approaches to increase adherence to IFA, improve diets and reduce anaemia in pregnancy.

TRIAL REGISTRATION

ISRCTN 12272130 .

Community Health Worker Impact on Knowledge, Antenatal Care, And Birth Outcomes: A Systematic Review

OBJECTIVES

Community health worker (CHW) interventions have been shown to be effective in areas of maternal and child health (MCH), mostly in relation to infant and neonatal mortality. The specific aims of this review were to expand outcomes to include improving knowledge related to pregnancy and infant health and the receipt of antenatal care (ANC), along with birth outcomes. We also summarized the role, characteristics and activities of CHWs in interventions conducted in settings with demonstrated improvements in key MCH outcomes.

METHODS

Articles were retrieved from: PubMed, CINAHL, Global Health, Scopus, Web of Science, and the Cochrane Library from January 2008 through 2018. We included evaluation studies that utilized CHWs as all or part of an intervention to improve outcomes, were printed in English, and published in peer-reviewed journals.

RESULTS

Initial electronic database search identified 816 studies and 123 studies met inclusion criteria for full text review. The quality assessment resulted in 0 strong-, 19 moderate-, and 25 weak-rated studies. In most interventions, CHWs were a component of a larger intervention. The majority of the studies (n = 10) found that a CHW intervention can have a positive impact on outcomes. CHW interventions showed improvements in knowledge and ANC. When combined with clinical services, the interventions positively impacted birth outcomes. Most conducted home visits and utilized CHW that were members of the community.

CONCLUSIONS FOR PRACTICE

CHWs serve an important role as health educators conducting home visits as a member of the community they serve. They should also continue to collaborate with clinical providers to address MCH outcomes.

Interventions to reduce preterm birth and stillbirth, and improve outcomes for babies born preterm in low- and middle-income countries: A systematic review

BACKGROUND

Reducing preterm birth and stillbirth and improving outcomes for babies born too soon is essential to reduce under-5 mortality globally. In the context of a rapidly evolving evidence base and problems with extrapolating efficacy data from high- to low-income settings, an assessment of the evidence for maternal and newborn interventions specific to low- and middle-income countries (LMICs) is required.

METHODS

A systematic review of the literature was done. We included all studies performed in LMICs since the Every Newborn Action Plan, between 2013 - 2018, which reported on interventions where the outcome assessed was reduction in preterm birth or stillbirth incidence and/or a reduction in preterm infant neonatal mortality. Evidence was categorised according to maternal or neonatal intervention groups and a narrative synthesis conducted.

RESULTS

179 studies (147 primary evidence studies and 32 systematic reviews) were identified in 82 LMICs. 81 studies reported on maternal interventions and 98 reported on neonatal interventions. Interventions in pregnant mothers which resulted in significant reductions in preterm birth and stillbirth were (i) multiple micronutrient supplementation and (ii) enhanced quality of antenatal care. Routine antenatal ultrasound in LMICs increased identification of fetal antenatal conditions but did not reduce stillbirth or preterm birth due to the absence of services to manage these diagnoses. Interventions in pre-term neonates which improved their survival included (i) feeding support including probiotics and (ii) thermal regulation. Improved provision of neonatal resuscitation did not improve pre-term mortality rates, highlighting the importance of post-resuscitation care. Community mobilisation, for example through community education packages, was found to be an effective way of delivering interventions.

CONCLUSIONS

Evidence supports the implementation of several low-cost interventions with the potential to deliver reductions in preterm birth and stillbirth and improve outcomes for preterm babies in LMICs. These, however, must be complemented by overall health systems strengthening to be effective. Quality improvement methodology and learning health systems approaches can provide important means of understanding and tackling implementation challenges within local contexts. Further pragmatic efficacy trials of interventions in LMICs are essential, particularly for interventions not previously tested in these contexts.

Experiences, perceptions and potential impact of community-based mentor mothers supporting pregnant and postpartum women with HIV in Kenya: a mixed-methods study

Introduction

Community‐based mentor mothers (cMMs) are women living with HIV who provide peer support to pregnant/postpartum women living with HIV (PWLWH) to enhance antiretroviral therapy (ART) adherence, retention in care and prevent perinatal transmission of HIV. The goal of this study was to explore the experiences, perceptions, mechanisms and health impact of cMMs on PWLWH in Kenya from the perspective of cMMs.

Methods

We conducted a prospective mixed‐methods study in southwestern Kenya in 2015–2018. In the qualitative phase, we completed in‐depth interviews with cMMs to explore their perceptions and experiences in supporting PWLWH. Transcripts were broad‐coded according to identified themes, then fine‐coded using an inductive approach. In the quantitative phase, we analysed medical record data from PWLWH who were randomized in the cMM intervention to examine the impact of cMM visits on optimal prevention of mother‐to‐child transmission (PMTCT). We used cluster‐adjusted generalized estimating equation models to examine relationships with a composite outcome (facility delivery, infant HIV testing, ART adherence and undetectable viral load at 6 weeks postpartum). Finally, qualitative and quantitative results were integrated.

Results

Convergence of findings from cMM interviews (n = 24) and PWLWH medical data (n = 589) revealed: (1) The cMM intervention was utilized and perceived as acceptable. PWLWH received, on average, 6.2 of 8 intended home visits through 6 weeks postpartum. (2) The cMMs reported serving as role models and confidantes, supporting PWLWH's acceptance of their HIV status, providing assurances about PMTCT and assisting with male partner disclosure and communication. cMMs also described benefits for themselves, including empowerment and increased income. (3) The cMM visits supported PWLWH's completion of PMTCT steps. Having ≥4 cMM home visits up to 6 weeks postpartum, as compared to <4 visits, was associated with higher likelihood of an optimal PMTCT composite outcome (adjusted relative risk 1.42, p = 0.044).

Conclusions

We found that peer support from cMMs during pregnancy through 6 weeks postpartum was associated with improved uptake of critical PMTCT services and health behaviours and was perceived as beneficial for cMMs themselves. CMM support of PWLWH may be valuable for other low‐resource settings to improve engagement with lifelong ART and HIV services among PWLWH.

Impact of universal home visits on child health in Bauchi State, Nigeria: a stepped wedge cluster randomised controlled trial

BACKGROUND

Nigeria is the second biggest contributor to global child mortality. Infectious diseases continue to be major killers. In Bauchi State, Nigeria, a stepped wedge cluster randomised controlled trial tested the health impacts of universal home visits to pregnant women and their spouses. We present here the findings related to early child health.

METHODS

The home visits took place in eight wards in Toro Local Government Authority, randomly allocated into four waves with a delay of 1 year between waves. Female and male home visitors visited all pregnant women and their spouses every 2 months during pregnancy, with a follow up visit 12-18 months after the birth. They presented and discussed evidence about household prevention and management of diarrhoea and immunisation. We compared outcomes among children 12-18 months old born to mothers visited during the first year of intervention in each wave (intervention group) with those among children 12-18 months old pre-intervention in subsequent waves (control group). Primary outcomes included prevalence and management of childhood diarrhoea and immunisation status, with intermediate outcomes of household knowledge and actions. Generalised Estimating Equations (GEE), with an exchangeable correlation matrix and ward as cluster, tested the significance of differences in outcomes.

RESULTS

The analysis included 1796 intervention and 5109 control children. In GEE models including other characteristics of the children, intervention children were less likely to have suffered diarrhoea in the last 15 days (Odds Ratio (OR) 0.40, 95% confidence interval (CI) 0.30-0.53) and more likely to have received increased fluids and continued feeding in their last episode of diarrhoea (OR 6.06, 95% CI 2.58-14.20). Mothers of intervention children were more likely to identify lack of hygiene as a cause of diarrhoea (OR 2.24, 95% CI 1.27-3.95) and their households had better observed hygiene (OR 3.29, 95% CI 1.45-7.45). Intervention children were only slightly more likely to be fully immunised (OR 1.67, 95% CI 0.78-3.57).

CONCLUSIONS

Evidence-based home visits to both parents stimulated household actions that improved prevention and management of childhood diarrhoea. Such visits could help to improve child health even in settings with poor access to quality health services.

TRIAL REGISTRATION

ISRCTN82954580 . Date: 11/08/2017. Retrospectively registered.

Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation

BACKGROUND

Health services have traditionally been developed to focus on specific diseases or medical specialties. Involving consumers as partners in planning, delivering and evaluating health services may lead to services that are person-centred and so better able to meet the needs of and provide care for individuals. Globally, governments recommend consumer involvement in healthcare decision-making at the systems level, as a strategy for promoting person-centred health services. However, the effects of this 'working in partnership' approach to healthcare decision-making are unclear. Working in partnership is defined here as collaborative relationships between at least one consumer and health provider, meeting jointly and regularly in formal group formats, to equally contribute to and collaborate on health service-related decision-making in real time. In this review, the terms 'consumer' and 'health provider' refer to partnership participants, and 'health service user' and 'health service provider' refer to trial participants. This review of effects of partnership interventions was undertaken concurrently with a Cochrane Qualitative Evidence Synthesis (QES) entitled Consumers and health providers working in partnership for the promotion of person-centred health services: a co-produced qualitative evidence synthesis.

OBJECTIVES

To assess the effects of consumers and health providers working in partnership, as an intervention to promote person-centred health services.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL databases from 2000 to April 2019; PROQUEST Dissertations and Theses Global from 2016 to April 2019; and grey literature and online trial registries from 2000 until September 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs of 'working in partnership' interventions meeting these three criteria: both consumer and provider participants meet; they meet jointly and regularly in formal group formats; and they make actual decisions that relate to the person-centredness of health service(s).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened most titles and abstracts. One review author screened a subset of titles and abstracts (i.e. those identified through clinical trials registries searches, those classified by the Cochrane RCT Classifier as unlikely to be an RCT, and those identified through other sources). Two review authors independently screened all full texts of potentially eligible articles for inclusion. In case of disagreement, they consulted a third review author to reach consensus. One review author extracted data and assessed risk of bias for all included studies and a second review author independently cross-checked all data and assessments. Any discrepancies were resolved by discussion, or by consulting a third review author to reach consensus. Meta-analysis was not possible due to the small number of included trials and their heterogeneity; we synthesised results descriptively by comparison and outcome. We reported the following outcomes in GRADE 'Summary of findings' tables: health service alterations; the degree to which changed service reflects health service user priorities; health service users' ratings of health service performance; health service users' health service utilisation patterns; resources associated with the decision-making process; resources associated with implementing decisions; and adverse events.

MAIN RESULTS

We included five trials (one RCT and four cluster-RCTs), with 16,257 health service users and more than 469 health service providers as trial participants. For two trials, the aims of the partnerships were to directly improve the person-centredness of health services (via health service planning, and discharge co-ordination). In the remaining trials, the aims were indirect (training first-year medical doctors on patient safety) or broader in focus (which could include person-centredness of health services that targeted the public/community, households or health service delivery to improve maternal and neonatal mortality). Three trials were conducted in high income-countries, one was in a middle-income country and one was in a low-income country. Two studies evaluated working in partnership interventions, compared to usual practice without partnership (Comparison 1); and three studies evaluated working in partnership as part of a multi-component intervention, compared to the same intervention without partnership (Comparison 2). No studies evaluated one form of working in partnership compared to another (Comparison 3). The effects of consumers and health providers working in partnership compared to usual practice without partnership are uncertain: only one of the two studies that assessed this comparison measured health service alteration outcomes, and data were not usable, as only intervention group data were reported. Additionally, none of the included studies evaluating this comparison measured the other primary or secondary outcomes we sought for the 'Summary of findings' table. We are also unsure about the effects of consumers and health providers working in partnership as part of a multi-component intervention compared to the same intervention without partnership. Very low-certainty evidence indicated there may be little or no difference on health service alterations or health service user health service performance ratings (two studies); or on health service user health service utilisation patterns and adverse events (one study each). No studies evaluating this comparison reported the degree to which health service alterations reflect health service user priorities, or resource use. Overall, our confidence in the findings about the effects of working in partnership interventions was very low due to indirectness, imprecision and publication bias, and serious concerns about risk of selection bias; performance bias, detection bias and reporting bias in most studies.

AUTHORS' CONCLUSIONS

The effects of consumers and providers working in partnership as an intervention, or as part of a multi-component intervention, are uncertain, due to a lack of high-quality evidence and/or due to a lack of studies. Further well-designed RCTs with a clear focus on assessing outcomes directly related to partnerships for patient-centred health services are needed in this area, which may also benefit from mixed-methods and qualitative research to build the evidence base.

Saving babies' lives (SBL) - a programme to reduce neonatal mortality in rural Cambodia: study protocol for a stepped-wedge cluster-randomised trial

BACKGROUND

Neonatal mortality remains unacceptably high. Many studies successful at reducing neonatal mortality have failed to realise similar gains at scale. Effective implementation and scale-up of interventions designed to tackle neonatal mortality is a global health priority. Multifaceted programmes targeting the continuum of neonatal care, with sustainability and scalability built into the design, can provide practical insights to solve this challenge. Cambodia has amongst the highest neonatal mortality rates in South-East Asia, with rural areas particularly affected. The primary objective of this study is the design, implementation, and assessment of the Saving Babies' Lives programme, a package of interventions designed to reduce neonatal mortality in rural Cambodia.

METHODS

This study is a five-year stepped-wedge cluster-randomised trial conducted in a rural Cambodian province with an estimated annual delivery rate of 6615. The study is designed to implement and evaluate the Saving Babies' Lives programme, which is the intervention. The Saving Babies' Lives programme is an iterative package of neonatal interventions spanning the continuum of care and integrating into the existing health system. The Saving Babies' Lives programme comprises two major components: participatory learning and action with community health workers, and capacity building of primary care facilities involving facility-based mentorship. Standard government service continues in control arms. Data collection covering the whole study area includes surveillance of all pregnancies, verbal and social autopsies, and quality of care surveys. Mixed methods data collection supports iteration of the complex intervention, and facilitates impact, outcome, process and economic evaluation.

DISCUSSION

Our study uses a robust study design to evaluate and develop a holistic, innovative, contextually relevant and sustainable programme that can be scaled-up to reduce neonatal mortality.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04663620 . Registered on 11th December 2020, retrospectively registered.

An innovative model for management of cardiovascular disease risk factors in the low resource setting of Cambodia

Non-communicable diseases are increasing in developing countries and control of diabetes and hypertension is needed to reduce rates of the leading causes of morbidity and mortality, stroke and ischaemic heart disease. We evaluated a programme in Cambodia, financed by a revolving drug fund, which utilizes Peer Educators to manage diabetes and hypertension in the community. We assessed clinical outcomes and retention in the programme. For all people enrolled in the programme between 2007 and 2016, the average change in blood pressure (BP) and percentage with controlled hypertension (BP < 140/<90 mmHg) or diabetes (fasting blood glucose (BG) < 7mg/dl, post-prandial BG < 130 mg/dl, or HBA1C < 7%) was calculated every 6 months from enrolment.  Attrition rate in the nth year of enrolment was calculated; associations with loss to follow-up were explored using cox regression. A total of 9139 patients enrolled between January 2007 and March 2016. For all people with hypertension, mean change in systolic and diastolic BP within the first year was −15.1 mmHg (SD 23.6, P < 0.0001) and −8.6 mmHg (SD 14.0, P < 0.0001), respectively. BP control was 50.5% at year 1, peaking at 70.6% at 5.5 years. 41.3% of people with diabetes achieved blood sugar control at 6 months and 44.4% at 6.5 years.  An average of 2.3 years [SD 1.9] was spent in programme. Attrition rate within year 1 of enrolment ranged from 29.8% to 61.5% with average of 44.1% [SD 10.3] across 2008–15. Patients with hypertension were more likely to leave the program compared to those with diabetes and males more likely than females. The programme shows a substantial and sustained rate of diabetes and hypertension control for those who remain in the program and could be a model for implementation in other low middle-income settings, however, further work is needed to improve patient retention.

Participatory learning and action cycles with women's groups to prevent neonatal death in low-resource settings: A multi-country comparison of cost-effectiveness and affordability

WHO recommends participatory learning and action cycles with women's groups as a cost-effective strategy to reduce neonatal deaths. Coverage is a determinant of intervention effectiveness, but little is known about why cost-effectiveness estimates vary significantly. This article reanalyses primary cost data from six trials in India, Nepal, Bangladesh and Malawi to describe resource use, explore reasons for differences in costs and cost-effectiveness ratios, and model the cost of scale-up. Primary cost data were collated, and costing methods harmonized. Effectiveness was extracted from a meta-analysis and converted to neonatal life-years saved. Cost-effectiveness ratios were calculated from the provider perspective compared with current practice. Associations between unit costs and cost-effectiveness ratios with coverage, scale and intensity were explored. Scale-up costs and outcomes were modelled using local unit costs and the meta-analysis effect estimate for neonatal mortality. Results were expressed in 2016 international dollars. The average cost was $203 (range: $61-$537) per live birth. Start-up costs were large, and spending on staff was the main cost component. The cost per neonatal life-year saved ranged from $135 to $1627. The intervention was highly cost-effective when using income-based thresholds. Variation in cost-effectiveness across trials was strongly correlated with costs. Removing discounting of costs and life-years substantially reduced all cost-effectiveness ratios. The cost of rolling out the intervention to rural populations ranges from 1.2% to 6.3% of government health expenditure in the four countries. Our analyses demonstrate the challenges faced by economic evaluations of community-based interventions evaluated using a cluster randomized controlled trial design. Our results confirm that women's groups are a cost-effective and potentially affordable strategy for improving birth outcomes among rural populations.

Fathers and grandmothers experiences participating in nutrition peer dialogue groups in Vihiga County, Kenya

Grandmothers and fathers are key influencers of maternal and child nutrition and are increasingly included in interventions. Yet, there is limited research exploring their experiences participating in interventions. This study reports on findings from a qualitative process evaluation of a quasi-experimental study that we conducted with grandmother and father peer dialogue groups to support maternal, infant and young child feeding practices in western Kenya. The aim was to explore grandmother and father experiences participating in interventions and how participation influences care and feeding practices. Grandmother and father peer educators received training to facilitate discussions about maternal and child nutrition, HIV and infant feeding, family communication, and family members' roles. Father peer educators also received training on gender inequities and power dynamics. In the original quasi-experimental study, the intervention was associated with increased social support and improvements in some complementary feeding practices. The process evaluation explored participants' experiences and how participation influenced infant care and feeding practices. We used Atlas.ti to thematically analyse data from 18 focus group discussions. The focus group discussions revealed that grandmothers and fathers valued their groups, the topics discussed and what they learned. Grandmothers reported improved infant feeding and hygiene practices, and fathers reported increased involvement in child care and feeding and helping with household tasks. Both described improved relationships with daughters-in-law or wives. This study highlights the importance of engaging influential family members to support child nutrition and identifies factors to build cohesion among group members, by building on grandmothers' roles as advisors and expanding fathers' roles in nutrition through gender transformative activities.

Effect of a home-based health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in Tanzania

Introduction

Evidence on the effects of community health worker (CHW) interventions and conditional cash transfers (CCTs) on child growth and development in sub-Saharan Africa remains sparse.

Methods

We conducted a single-blind, cluster-randomised controlled trial of an integrated home-visiting health, nutrition and responsive stimulation intervention alone and in combination with CCTs to promote antenatal and child clinic attendance from 2017 to 2019 in rural Morogoro Region, Tanzania. Pregnant women and caregivers with a child <1 year of age were enrolled. Twelve villages were randomised to either (1) CHW (n=200 participants), (2) CHW+CCT (n=200) or (3) control (n=193). An intention-to-treat analysis was conducted for the primary trial outcomes of child cognitive, language and motor development assessed with the Bayley Scales of Infant and Toddler Development and child length/height-for-age z-scores (HAZ) at 18 months of follow-up.

Results

The CHW and CHW+CCT interventions had beneficial effects on child cognitive development as compared with control (standardised mean difference (SMD): 0.15, 95% CI 0.05 to 0.24, and SMD: 0.18, 95% CI 0.07 to 0.28, respectively). The CHW+CCT intervention also had positive effects on language (SMD: 0.08, 95% CI 0.01 to 0.15) and motor (SMD: 0.16, 95% CI 0.03 to 0.28) development. Both CHW and CHW+CCT interventions had no effect on HAZ in the primary analysis; however, there were statistically significant positive effects in multivariable analyses. The CHW+CCT group (mean difference: 3.0 visits, 95% CI 2.1 to 4.0) and the CHW group (mean difference: 1.5 visits, 95% CI 0.6 to 2.5) attended greater number of child health and growth monitoring clinic visits as compared to the control group.

Conclusion

Integrated CHW home-visiting interventions can improve child cognitive development and may have positive effects on linear growth. Combining CHW with CCT may provide additional benefits on clinic visit attendance and selected child development outcomes.

Trial registration number

ISRCTN10323949.

Evaluation of diabetic peer support in Malawi

Background

Type 2 diabetes is a major health concern worldwide and requires urgent attention from health care providers and policy makers. Due to shortage of health care workers in low-income countries, peer support programs have been viewed as a viable option in management of diabetes and have shown to be effective in sub-Saharan Africa.

Objective

The aim of this study is to assess and evaluate the Kamuzu Central Hospital (KCH) diabetic peer support program's (DPSP) impact 4 years after its establishment by assessing knowledge, self-efficacy and behaviours of DPSP members compared to non-members.

Methodology

This is a cross-sectional study done among diabetic patients attending clinics between 12th August and 25th September 2018 at KCH. Self and interviewer-administered questionnaires (designed based on validated survey instruments) were used. The participants (n=176) were recruited consecutively after consenting.

Results

Results showed DPSP members were more knowledgeable regarding the effects of skipping meals and sweet juice on blood glucose and conditions not associated with diabetes. In terms of self-efficacy and behaviour changes, DPSP members believe that they are more able to correct hypoglycaemia, to communicate their concerns to health workers and to perform daily foot exam compared to non-members.

Conclusion

The KCH (Lilongwe) Diabetes Peer Support program has positively impacted its members and should be scaled up to engage all diabetic patients in Malawi. Ongoing training for peer supporters is necessary to update and reinforce management, knowledge and skills, and to ensure fidelity in program implementation.

Breastfeeding Education and Support to Improve Early Initiation and Exclusive Breastfeeding Practices and Infant Growth: A Cluster Randomized Controlled Trial from a Rural Ethiopian Setting

Although peer-led education and support may improve breastfeeding practices, there is a paucity of evidence on the effectiveness of such interventions in the Ethiopian context. We designed a cluster-randomized trial to evaluate the efficacy of a breastfeeding education and support intervention (BFESI) on infant growth, early initiation (EI), and exclusive breastfeeding (EBF) practices. We randomly assigned 36 clusters into either an intervention group (n = 249) receiving BFESI by trained Women's Development Army (WDA) leaders or a control group (n = 219) receiving routine care. The intervention was provided from the third trimester of pregnancy until five months postpartum. Primary study outcomes were EI, EBF, and infant growth; secondary outcomes included maternal breastfeeding knowledge and attitude, and child morbidity. The intervention effect was analysed using linear regression models for the continuous outcomes, and linear probability or logistic regression models for the categorical outcomes. Compared to the control, BFESI significantly increased EI by 25.9% (95% CI: 14.5, 37.3%; p = 0.001) and EBF by 14.6% (95% CI: 3.77, 25.5%; p = 0.010). Similarly, the intervention gave higher breastfeeding attitude scores (Effect size (ES): 0.85SD; 95% CI: 0.70, 0.99SD; p < 0.001), but not higher knowledge scores (ES: 0.15SD; 95% CI: -0.10, 0.41SD; p = 0.173). From the several growth and morbidity outcomes evaluated, the only outcomes with significant intervention effect were a higher mid-upper arm circumference (ES: 0.25cm; 95% CI: 0.01, 0.49cm; p = 0.041) and a lower prevalence of respiratory infection (ES: -6.90%; 95% CI: -13.3, -0.61%; p = 0.033). Training WDA leaders to provide BFESI substantially improves EI and EBF practices and attitude towards breastfeeding.

Relapse and regression to severe wasting in children under 5 years: A theoretical framework

Systematic reviews have highlighted that repeated severe wasting after receiving treatment is likely to be common, but standardised measurement is needed urgently. The Council of Research & Technical Advice for Acute Malnutrition (CORTASAM) released recommendations on standard measurement of relapse (wasting within 6 months after exiting treatment as per recommended discharge criteria), regression (wasting within 6 months after exiting treatment before reaching recommended discharge criteria) and reoccurrence (wasting after 6 months of exit from treatment as per recommended discharge criteria). We provide a theoretical framework of post-treatment relapse and regression to severe wasting to guide discussions, risk factor analyses, and development and evaluations of interventions. This framework highlights that there are factors that may impact risk of relapse and regression in addition to the impact of contextual factors associated with incidence and reoccurrence of severe wasting more generally. Factors hypothesised to be associated with relapse and regression relate specifically to the nutrition and health status of the child on admission to, during and exit from treatment and treatment interventions, platforms and approaches as well as type of exit from treatment (e.g., before reaching recommended criteria). These factors influence whether children reach full recovery, and poorer nutritional and immunological status at exit from treatment are more proximate determinants of risk of severe wasting after treatment, although post-treatment interventions may modify risks. The evidence base for many of these factors is weak. Our framework can guide research to improve our understanding of risks of relapse and regression and how to prevent them and inform programmes on what data to collect to evaluate relapse. Implementation research is needed to operationalise results in programmes and reduce post-treatment severe wasting at scale.

A systematic review of costing studies for implementing and scaling-up breastfeeding interventions: what do we know and what are the gaps?

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.

Promoting positive maternal, newborn, and child health behaviors through a group-based health education and microfinance program: a prospective matched cohort study in western Kenya

BACKGROUND

Chamas for Change (Chamas) is a group-based health education and microfinance program for pregnant and postpartum women that aims to address inequities contributing to high rates of maternal and infant mortality in rural western Kenya. In this prospective matched cohort study, we evaluated the association between Chamas participation and facility-based delivery. We additionally explored the effect of participation on promoting other positive maternal, newborn and child health (MNCH) behaviors.

METHODS

We prospectively compared outcomes between a cohort of Chamas participants and controls matched for age, parity, and prenatal care location. Between October-December 2012, government-sponsored community health volunteers (CHV) recruited pregnant women attending their first antenatal care (ANC) visits at rural health facilities in Busia County to participate in Chamas. Women enrolled in Chamas agreed to attend group-based health education and microfinance sessions for one year; controls received the standard of care. We used descriptive analyses, multivariable logistic regression models, and random effect models to compare outcomes across cohorts 12 months following enrollment, with α set to 0.05.

RESULTS

Compared to controls (n = 115), a significantly higher proportion of Chamas participants (n = 211) delivered in a health facility (84.4% vs. 50.4%, p < 0.001), attended at least four ANC visits (64.0% vs. 37.4%, p < 0·001), exclusively breastfed to six months (82.0% vs. 47.0%, p < 0·001), and received a CHV home visit within 48 h postpartum (75.8% vs. 38.3%, p < 0·001). In multivariable models, Chamas participants were over five times as likely as controls to deliver in a health facility (OR 5.49, 95% CI 3.12-9.64, p < 0.001). Though not significant, Chamas participants experienced a lower proportion of stillbirths (0.9% vs. 5.2%), miscarriages (5.2% vs. 7.8%), infant deaths (2.8% vs. 3.4%), and maternal deaths (0.9% vs. 1.7%) compared to controls.

CONCLUSIONS

Chamas participation was associated with increased odds of facility-based delivery compared to the standard of care in rural western Kenya. Larger proportions of program participants also practiced other positive MNCH behaviors. Our findings demonstrate Chamas' potential to achieve population-level MNCH benefits; however, a larger study is needed to validate this observed effect.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03188250 (retrospectively registered 31 May 2017).

Risk reduction of diarrhea and respiratory infections following a community health education program - a facility-based case-control study in rural parts of Kenya

Background

Diarrheal and acute respiratory infections remain a major cause of death in developing countries especially among children below 5 years of age. About 80% of all hospital attendances in Kenya can be attributed to preventable diseases and at least 50% of these preventable diseases are linked to poor sanitation. The purpose of this study was to assess the impact of a community-based health education program, called Familia Nawiri, in reducing the risk of diarrhea and respiratory infections among people living in three rural Kenyan communities.

Methods

Cases were defined as patients attending the health facility due to diarrhea or a respiratory infection while controls were patients attending the same health facility for a non-communicable disease defined as an event other than diarrhea, respiratory infection. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a logistic regression model to assess the risk of diarrheal or respiratory infection in association with exposure to the health education program.

Results

There were 324 cases and 308 controls recruited for the study with 57% of the cases and 59% of the controls being male. Overall, 13% of cases vs. 20% of control patients were exposed to the education program. Participants exposed to the program had 38% lower odds of diarrhea and respiratory infections compared to those not exposed to the program (adjusted OR 0.62, 95% CI 0.41–0.96). A similar risk reduction was observed for participants in the study who resided in areas with water improvement initiatives (adjusted OR 0.65, 95% CI 0.47–0.90). Variables in the adjusted model included water improvement projects in the area and toilet facilities.

Conclusion

Findings from this study suggest participants exposed to the education program and those residing in areas with water improvement initiatives have a reduced risk of having diarrhea or respiratory infection.

Health Outcomes of an Integrated Behaviour-Centred Water, Sanitation, Hygiene and Food Safety Intervention-A Randomised before and after Trial

Diarrhoeal disease in children under five in low income settings has been associated with multiple environmental exposure pathways, including complementary foods. Conducted from February to December 2018 in rural Malawi, this before and after trial with a control used diarrhoeal disease as a primary outcome, to measure the impact of a food hygiene intervention (food hygiene + handwashing) relative to a food hygiene and water, sanitation and hygiene (WASH) intervention (food hygiene + handwashing + faeces management + water management). The 31-week intervention was delivered by community-based coordinators through community events (n = 2), cluster group meetings (n = 17) and household visits (n = 14). Diarrhoeal disease was self-reported and measured through an end line survey, and daily diaries completed by caregivers. Difference-in-differences results show a 13-percentage point reduction in self-reported diarrhoea compared to the control group. There were also significant increases in the presence of proxy measures in each of the treatment groups (e.g., the presence of soap). We conclude that food hygiene interventions (including hand washing with soap) can significantly reduce diarrhoeal disease prevalence in children under five years in a low-income setting. Therefore, the promotion of food hygiene practices using a behaviour-centred approach should be embedded in nutrition and WASH policies and programming.

The Effects of Community Home Visit and Peer Group Nutrition Intervention Delivery Platforms on Nutrition Outcomes in Low and Middle-Income Countries: A Systematic Review and Meta-Analysis

Weak delivery systems reduce the potential of evidence-supp orted interventions to improve nutrition. We synthesized the evidence for the effectiveness of nutrition-specific intervention delivery platforms for improving nutrition outcomes in low and middle-income countries (LMIC). A systematic literature search for studies published from 1997 to June 2018 resulted in the inclusion of 83 randomized controlled trials (RCTs), quasi-randomized, and controlled before-after studies across a variety of delivery platforms. In this paper, we report on meta-analysed outcomes for community health worker (CHW) home visits and mother/peer group delivery platforms. Compared to care as usual, CHW home visits increased early initiation of breastfeeding (EIBF) (OR: 1.50; 95% CI: 1.12, 1.99; n = 10 RCTs) and exclusive breastfeeding (EBF) (OR: 4.42; 95% CI: 2.28, 8.56; n = 9 RCTs) and mother/peer groups were effective for improving children's minimum dietary diversity (OR: 2.34; 95% CI: 1.17, 4.70; n = 4) and minimum meal frequency (OR: 2.31; 95% CI: 1.61, 3.31; n = 3). Pooled estimates from studies using both home visit and group platforms showed positive results for EIBF (OR: 2.13; 95% CI: 1.12, 4.05; n = 9), EBF (OR: 2.43; 95% CI: 1.70, 3.46; n = 12), and < 5 wasting (OR: 0.77; 95% CI: 0.67, 0.89; n = 4). Our findings underscore the importance of interpersonal community platforms for improving infant and young child feeding practices and children's nutritional status in LMICs.

Effectiveness of participatory community solutions strategy on improving household and provider health care behaviors and practices: A mixed-method evaluation

Introduction

We implemented a participatory quality improvement strategy in eight primary health care units of Ethiopia to improve use and quality of maternal and newborn health services.

Methods

We evaluated the effects of this strategy using mixed-methods research. We used before-and-after (March 2016 and November 2017) cross-sectional surveys of women who had children 0–11 months to compare changes in maternal and newborn health care indicators in the 39 communities that received the intervention and the 148 communities that did not. We used propensity scores to match the intervention with the comparison communities at baseline and difference-in-difference analyses to estimate intervention effects. The qualitative method included 51 in-depth interviews of community volunteers, health extension workers, health center directors and staff, and project specialists.

Results

The difference-in-difference analyses indicated that 7.9 percentage points (95% confidence interval [CI]: 1.8–13.9%) increase in receiving skilled delivery care between baseline and follow-up surveys in the intervention area that is attributable to the strategy. The intervention effect on postnatal care in 48 hours of the mother was 15.3% (95% CI: 7.4–23.2). However, there was no evidence that the strategy affected the seven other maternal and newborn health care indicators considered. Interview participants said that the participatory design and implementation strategy helped them to realize gaps, identify real problems, and design appropriate solutions, and created a sense of ownership and shared responsibility for implementing interventions.

Conclusions

Community participation in planning and monitoring maternal and newborn health service delivery improves use of some high-impact maternal and newborn health services. The study supports the notion that participatory community strategies should be considered to foster community-responsive health systems.

Improving risk perception and uptake of voluntary medical male circumcision with peer-education sessions and incentives, in Manicaland, East Zimbabwe: study protocol for a pilot randomised trial

BACKGROUND

Voluntary medical male circumcision (VMMC) is a key component of combination HIV-prevention programmes. Several high-HIV-prevalence countries in sub-Saharan Africa, including Zimbabwe, are looking to scale up VMMC activities. There is limited evidence on how a combination of social learning from peer education by a role model with different behavioural incentives influences demand for VMMC in such settings.

METHODS/DESIGN

This matched-cluster randomised controlled trial with 1740 participants will compare two behavioural incentives against a control with no intervention. In the intervention clusters, participants will participate in an education session delivered by a circumcised young male ("role model") on the risks of HIV infection and the benefits from medical male circumcision. All participants will receive contributions towards transport costs to access medical male circumcision at participating clinics. Via blocked randomisation, in the intervention clusters participants will be randomly assigned to receive one of two types of incentives - fixed cash payment or lottery payment - both conditional on undergoing surgical VMMC. In two sites, a community-led intervention will also be implemented to address social obstacles and to increase support from peers, families and social structures. Baseline measures of endpoints will be gathered in surveys. Follow-up assessment at 6 months will include self-reported uptake of VMMC triangulated with clinic data.

DISCUSSION

This is the first trial to pilot-test social learning to improve risk perception and self-efficacy and to address the fear of pain associated with VMMC and possible present-biased preferences with front-loaded compensations as well as fixed or lottery-based cash payments. This study will generate important knowledge to inform HIV-prevention policies about the effectiveness of behavioural interventions and incentives, which could be easily scaled-up.

TRIAL REGISTRATION

This trial has been registered on ClinicalTrials.gov (identifier: NCT03565588). Registered on 21 June 2018.

Increasing utilisation of perinatal services: estimating the impact of community health worker program in Neno, Malawi

BACKGROUND

By 2015, Malawi had not achieved Millennium Development Goal 4, reducing maternal mortality by about 35% from 675 to 439 deaths per 100,000 livebirths. Hypothesised reasons included low uptake of antenatal care (ANC), intrapartum care, and postnatal care. Involving community health workers (CHWs) in identification of pregnant women and linking them to perinatal services is a key strategy to reinforce uptake of perinatal care in Neno, Malawi. We evaluated changes in uptake after deployment of CHWs between March 2014 and June 2016.

METHODS

A CHW intervention was implemented in Neno District, Malawi in a designated catchment area of about 3100 women of childbearing age. The pre-intervention period was March 2014 to February 2015, and the post-intervention period was March 2015 to June 2016. A 5-day maternal health training package was delivered to 211 paid and supervised CHWs. CHWs were deployed to identify pregnant women and escort them to perinatal care visits. A synthetic control method, in which a "counterfactual site" was created from six available control facilities in Neno District, was used to evaluate the intervention. Outcomes of interest included uptake of first-time ANC, ANC within the first trimester, four or more ANC visits, intrapartum care, and postnatal care follow-up.

RESULTS

Women enrolled in ANC increased by 18% (95% Credible Interval (CrI): 8, 29%) from an average of 83 to 98 per month, the proportion of pregnant women starting ANC in the first trimester increased by 200% (95% CrI: 162, 234%) from 10 to 29% per month, the proportion of women completing four or more ANC visits increased by 37% (95% CrI: 31, 43%) from 28 to 39%, and monthly utilisation of intrapartum care increased by 20% (95% CrI: 13, 28%) from 85 to 102 women per month. There was little evidence that the CHW intervention changed utilisation of postnatal care (- 37, 95% CrI: - 224, 170%).

CONCLUSIONS

In a rural district in Malawi, uptake of ANC and intrapartum care increased considerably following an intervention using CHWs to identify pregnant women and link them to care.

Knowledge, attitudes, and practices regarding exclusive breastfeeding among HIV-positive mothers in Uganda: A qualitative study

BACKGROUND

In Uganda, the prevalence of human immunodeficiency virus (HIV) in pregnant women was estimated at 6.1% in 2009, and in 2011, mother-to-child transmission (MTCT) of HIV resulted in 20 600 new paediatric HIV infections. A total of 50% of MTCT of HIV in Uganda occurs after birth, and this is partially attributable to poor adherence to infant feeding (IF) guidelines. Poor IF practices contribute to approximately 1.4 million deaths in children aged younger than five. In 2011, Uganda's rate of exclusive breastfeeding (EBF) was 62% for infants aged 0 to 5 months. Identifying barriers provides information on how to improve support for HIV-positive mothers' adherence to EBF, which may take the form of targeted interventions.

AIM

This study explores the knowledge, attitudes, and practices of HIV-positive mothers in Kampala, Uganda, regarding EBF of infants aged younger than 6 months.

METHODS

Five focus group discussions, each consisting of five HIV-positive mothers, were carried out at Kawempe Home Care using a semi-structured guide. Thematic content analysis was used to analyse the data.

RESULTS

The study findings showed that the main barriers to HIV-positive mothers practising EBF include a lack of IF counselling, fear of HIV transmission through breast milk, returning to work, and breastfeeding difficulties. The main factors influencing HIV-positive mothers' decisions regarding IF are IF counselling and partners' and families' recommendations.

CONCLUSION

This study recommends increasing access to couples-based HIV testing at antenatal clinics and couples-based IF counselling, while ensuring that it addresses breastfeeding difficulties.

Process evaluation of the community-based newborn care program implementation in Geze Gofa district, south Ethiopia: a case study evaluation design

Background

The Community-Based Newborn Care (CBNC) program is a comprehensive strategy designed to improve the health of newborns during pregnancy, childbirth, and the postnatal period through health extension workers at community levels, although the implementation has not been evaluated yet. Therefore, this study aimed to evaluate the process of the CBNC program implementation in Geze Gofa district, south Ethiopia.

Methods

A case study evaluation design with a mixed method was employed from May 1 to 31, 2017. A total of 321 mothers who gave birth from September 01, 2016 to February 29, 2017, were interviewed. Similarly, 27 direct observations, six-month document reviews, and 14 key informant interviews were conducted. The quantitative data were entered into Epi-Data version 3.1 and exported to SPSS version 20 for analysis. In the multivariable logistic regression analysis, variables with < 0.05 p-values and Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were used to declare factors associated with maternal satisfaction. The qualitative data were transcribed, translated, coded, and analyzed using thematic analysis. The overall process of program implementation was measured based on pre-determined judgmental criteria.

Results

The overall level of the implementation process of the CBNC program was 72.7%, to which maternal satisfaction, availability of resources, and healthcare providers’ compliance with the national guideline contributed 75.0, 81.0, and 68.0%, respectively. Essential drugs and medical equipment, like vitamin K, chlorohexidine ointment, neonatal resuscitation bags, and masks used in the program were out of stock. Very severe diseases were not treated according to the national guidelines, and the identification of neonatal sepsis cases was poor. Trading occupation (AOR: 0.16, 95% CI: 0.03–0.97) and low wealth status (AOR: 3.11, 95% CI: 1.16–8.36) were factors associated with maternal satisfaction.

Conclusion

The process of CBNC program implementation was relatively good, although the compliance of healthcare providers with the national guideline and maternal satisfaction with the services was low. Some essential drugs and medical equipment were out of stock. Merchant and low wealth status affected maternal satisfaction. Therefore, healthcare offices should provide crucial medicines and equipment for better program implementation and improve the wealth status of mothers to enhance maternal satisfaction.

Improving risk perception and uptake of pre-exposure prophylaxis (PrEP) through interactive feedback-based counselling with and without community engagement in young women in Manicaland, East Zimbabwe: study protocol for a pilot randomized trial

BACKGROUND

HIV incidence in adolescent girls and young women remains high in sub-Saharan Africa. Progress towards uptake of HIV prevention methods remains low. Studies of oral pre-exposure prophylaxis (PrEP) have shown that uptake and adherence may be low due to low-risk perception and ambivalence around using antiretrovirals for prevention. No evidence exists on whether an interactive intervention aimed at adjusting risk perception and addressing the uncertainty around PrEP will improve uptake. This pilot research trial aims to provide an initial evaluation of the impact of an interactive digital tablet-based counselling session, correcting risk perception, and addressing ambiguity around availability, usability, and effectiveness of PrEP.

METHODS/DESIGN

This is a matched-cluster randomized controlled trial which will compare an interactive tablet-based education intervention against a control with no intervention. The study will be implemented in eight sites. In each site, two matched clusters of villages will be created. One cluster will be randomly allocated to intervention. In two sites, a community engagement intervention will also be implemented to address social obstacles and to increase support from peers, families, and social structures. A total of 1200 HIV-negative young women aged 18-24 years, not on PrEP at baseline, will be eligible. Baseline measures of endpoints will be gathered in surveys. Follow-up assessment at six months will include biomarkers of PrEP uptake and surveys.

DISCUSSION

This will be the first randomized controlled trial to determine whether interactive feedback counselling leads to uptake of HIV prevention methods such as PrEP and reduces risky sexual behavior. If successful, policymakers could consider such an intervention in school-based education campaigns or as post-HIV-testing counselling for young people.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03565575. Registered on 21 June 2018.

Community-based maternal and newborn educational care packages for improving neonatal health and survival in low- and middle-income countries

BACKGROUND

In low- and middle-income countries (LMICs), health services are under-utilised, and several studies have reported improvements in neonatal outcomes following health education imparted to mothers in homes, at health units, or in hospitals. However, evaluating health educational strategy to deliver newborn care, such as one-to-one counselling or group counselling via peer or support groups, or delivered by health professionals, requires rigorous assessment of methodological design and quality, as well as assessment of cost-effectiveness, affordability, sustainability, and reproducibility in diverse health systems.

OBJECTIVES

To compare a community health educational strategy versus no strategy or the existing approach to health education on maternal and newborn care in LMICs, as imparted to mothers or their family members specifically in community settings during the antenatal and/or postnatal period, in terms of effectiveness for improving neonatal health and survival (i.e. neonatal mortality, neonatal morbidity, access to health care, and cost).

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 4), in the Cochrane Library, MEDLINE via PubMed (1966 to 2 May 2017), Embase (1980 to 2 May 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 2 May 2017). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Community-based randomised controlled, cluster-randomised, or quasi-randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted the data. We assessed the quality of evidence using the GRADE method and prepared 'Summary of findings' tables.

MAIN RESULTS

We included in this review 33 original trials (reported in 62 separate articles), which were conducted across Africa and Central and South America, with most reported from Asia, specifically India, Pakistan, and Bangladesh. Of the 33 community educational interventions provided, 16 included family members in educational counselling, most frequently the mother-in-law or the expectant father. Most studies (n = 14) required one-to-one counselling between a healthcare worker and a mother, and 12 interventions involved group counselling for mothers and occasionally family members; the remaining seven incorporated components of both counselling methods. Our analyses show that community health educational interventions had a significant impact on reducing overall neonatal mortality (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.78 to 0.96; random-effects model; 26 studies; n = 553,111; I² = 88%; very low-quality evidence), early neonatal mortality (RR 0.74, 95% CI 0.66 to 0.84; random-effects model; 15 studies that included 3 subsets from 3 studies; n = 321,588; I² = 86%; very low-quality evidence), late neonatal mortality (RR 0.54, 95% CI 0.40 to 0.74; random-effects model; 11 studies; n = 186,643; I² = 88%; very low-quality evidence), and perinatal mortality (RR 0.83, 95% CI 0.75 to 0.91; random-effects model; 15 studies; n = 262,613; I² = 81%; very low-quality evidence). Moreover, community health educational interventions increased utilisation of any antenatal care (RR 1.16, 95% CI 1.11 to 1.22; random-effects model; 18 studies; n = 307,528; I² = 96%) and initiation of breastfeeding (RR 1.56, 95% CI 1.37 to 1.77; random-effects model; 19 studies; n = 126,375; I² = 99%). In contrast, community health educational interventions were found to have a non-significant impact on use of modern contraceptives (RR 1.10, 95% CI 0.86 to 1.41; random-effects model; 3 studies; n = 22,237; I² = 80%); presence of skilled birth attendance at birth (RR 1.09, 95% CI 0.94 to 1.25; random-effects model; 10 studies; n = 117,870; I² = 97%); utilisation of clean delivery kits (RR 4.44, 95% CI 0.71 to 27.76; random-effects model; 2 studies; n = 17,087; I² = 98%); and care-seeking (RR 1.11, 95% CI 0.97 to 1.27; random-effects model; 7 studies; n = 46,154; I² = 93%). Cost-effectiveness analysis conducted in seven studies demonstrated that the cost-effectiveness for intervention packages ranged between USD 910 and USD 11,975 for newborn lives saved and newborn deaths averted. For averted disability-adjusted life-year, costs ranged from USD 79 to USD 146, depending on the intervention strategy; for cost per year of lost lives averted, the most effective strategy was peer counsellors, and the cost was USD 33.

AUTHORS' CONCLUSIONS

This review offers encouraging evidence on the value of integrating packages of interventions with educational components delivered by a range of community workers in group settings in LMICs, with groups consisting of mothers, and additional education for family members, for improved neonatal survival, especially early and late neonatal survival.

Community-led delivery of HIV self-testing to improve HIV testing, ART initiation and broader social outcomes in rural Malawi: study protocol for a cluster-randomised trial

Background

Prevention of new HIV infections is a critical public health issue. The highest HIV testing gaps are in men, adolescents 15–19 years old, and adults 40 years and older. Community-based HIV testing services (HTS) can contribute to increased testing coverage and early HIV diagnosis, with HIV self-testing (HIVST) strategies showing promise. Community-based strategies, however, are resource intensive, costly and not widely implemented. A community-led approach to health interventions involves supporting communities to plan and implement solutions to improve their health. This trial aims to determine if community-led delivery of HIVST can improve HIV testing uptake, ART initiation, and broader social outcomes in rural Malawi.

Methods

The trial uses a parallel arm, cluster-randomised design with group village heads (GVH) and their defined catchment areas randomised (1:1) to community-led HIVST or continue with the standard of the care (SOC). As part of the intervention, informal community health cadres are supported to plan and implement a seven-day HIVST campaign linked to HIV treatment and prevention. Approximately 12 months after the initial campaign, intervention GVHs are randomised to lead a repeat HIVST campaign. The primary outcome includes the proportion of adolescents 15–19 years old who have tested for HIV in their lifetime. Secondary outcomes include recent testing in adults 40 years and older and men; ART initiation; knowledge of HIV prevention; and HIV testing stigma. Outcomes will be measured through cross-sectional surveys and clinic registers. Economic evaluation will determine the cost per person tested, cost per person diagnosed, and incremental cost effectiveness ratio.

Discussion

To the best of our knowledge, this is the first trial to assess the effectiveness of community-led HTS, which has only recently been enabled by the introduction of HIVST. Community-led delivery of HIVST is a promising new strategy for providing periodic HIV testing to support HIV prevention in rural communities. Further, introduction of HIVST through a community-led framework seems particularly apt, with control over healthcare concurrently devolved to individuals and communities.

Trial registration

Clinicaltrials.gov registry (NCT03541382) registered 30 May 2018.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4430-4) contains supplementary material, which is available to authorized users.

Effect of continuum-of-care intervention package on improving contacts and quality of maternal and newborn healthcare in Ghana: a cluster randomised controlled trial

OBJECTIVE

To evaluate the effect of a continuum-of-care intervention package on adequate contacts of women and newborn with healthcare providers and their reception of high-quality care.

DESIGN

Cluster randomised controlled trial.

SETTING

32 subdistricts in 3 rural sites in Ghana.

PARTICIPANTS

The baseline survey involved 1480 women who delivered before the trial, and the follow-up survey involved 1490 women who received maternal and newborn care during the trial.

INTERVENTIONS

The intervention package included training healthcare providers, using an educational and recording tool named 'continuum-of-care card', providing the first postnatal care (PNC) by retaining women and newborns at healthcare facility or home visit by healthcare providers.

OUTCOME MEASURES

Adequate contacts were defined as at least four contacts during pregnancy, delivery with assistance of skilled healthcare providers at a healthcare facility and three timely contacts within 6 weeks postpartum. High-quality care was defined as receiving 6 care items for antenatal care (ANC), 3 for peripartum care (PPC) and 14 for PNC.

RESULTS

The difference-in-difference method was used to assess the effects of the intervention on the study outcome. The percentage of adequate contacts with high-quality care in the intervention group in the follow-up survey and the adjusted difference-in-difference estimators were 12.6% and 2.2 (p=0.61) at ANC, 31.5% and 1.9 (p=0.73) at PPC and 33.7% and 12.3 (p=0.13) at PNC in the intention-to-treat design, whereas 13.0% and 2.8 (p=0.54) at ANC, 34.2% and 2.7 (p=0.66) at PPC and 38.1% and 18.1 (p=0.02) at PNC in the per-protocol design that assigned the study sample by possession of the continuum-of-care card.

CONCLUSIONS

The interventions improved contacts with healthcare providers and quality of care during PNC. However, having adequate contact did not guarantee high-quality care. Maternal and newborn care in Ghana needs to improve its continuity and quality.

TRIAL REGISTRATION NUMBER

ISRCTN90618993. .

The revitalization and scale-up of the Baby-Friendly Hospital Initiative in Malawi

The Baby-Friendly Hospital Initiative (BFHI) has shown to strengthen health providers' skills in the provision of breastfeeding counselling and support, which have led to improvements in breastfeeding outcomes. In Malawi, where BFHI was introduced in 1993 but later languished due to losses in funding, the Maternal and Child Survival Program supported the Malawi Ministry of Health (MOH) in the revitalization and scale-up of BFHI in 54 health facilities across all 28 districts of the country. This paper describes the revitalization and scale-up process within the context of an integrated health project; successes, challenges, and lessons learned with BFHI implementation; and the future of BFHI in Malawi. More than 80,000 mothers received counselling on exclusive breastfeeding following childbirth prior to discharge from the health facility. Early initiation of breastfeeding was tracked quarterly from baseline through endline via routine MOH health facility data. Increases in early initiation of breastfeeding were seen in two of the three regions of Malawi: by 2% in the Central region and 6% in the Southern region. Greater integration of BFHI into Malawi's health system is recommended, including improved preservice and in-service trainings for health providers to include expanded BFHI content, increased country financial investments in BFHI, and integration of BFHI into national clinical guidelines, protocols, and nutrition and health policies.

On the Stability of Reported Pregnancy Intentions from Pregnancy to 1 Year Postnatally: Impact of Choice of Measure, Timing of Assessment, Women's Characteristics and Outcome of Pregnancy

OBJECTIVES

Retrospective, cross-sectional estimates of pregnancy intention, as used in the Demographic Health Survey (DHS), are the global norm. The London Measure of Unplanned Pregnancy (LMUP) is a newer, psychometrically validated measure which may be more reliable. This paper assesses the reliability of the LMUP and the DHS question over the first postnatal year and explores the effects of maternal characteristics or pregnancy outcome on reported pregnancy intention.

METHODS

We compared the test-retest reliability of the LMUP (using the AC coefficient) and DHS question (using the weighted Kappa) over the first postnatal year using data from Malawian women. We investigated the effect of maternal characteristics and pregnancy outcome using t-tests, Chi squared or Fisher's exact tests, and calculated odds ratios to estimate effect size.

RESULTS

The DHS question was associated with a statistically significant decrease in the prevalence of unplanned pregnancies from 1-to-12 months postnatally; the LMUP was not. The LMUP had moderate to substantial reliability (0.51-0.66); the DHS had moderate reliability (0.56-0.58). The LMUP's stability was not related to any of the factors examined; the stability of the DHS varied by marital status (p = 0.033), number of children (p = 0.048) and postnatal depression (p < 0.001). Both underestimated unintended pregnancy postnatally vis-à-vis the LMUP in pregnancy.

CONCLUSIONS FOR PRACTICE

The LMUP is a more reliable measure of pregnancy intention than the DHS in the first postnatal year and does not vary by maternal characteristics or pregnancy outcome. The LMUP should become the gold-standard for measuring pregnancy intention and should be collected in pregnancy or at the first postnatal opportunity.

Role-play versus lecture methods in community health volunteers

BACKGROUND

Considering the key role of health volunteers in promoting community's health, their effective training is of particular importance. Training can be more effective through cooperative and learner-centered methods. Role-play is among the cooperative methods with numerous advantages. Considering the positive impact of training via various methods, we aimed to compare training through role-play and lecture on health volunteers' health knowledge in selected comprehensive health centers of Shiraz, Iran.

METHODS

This quasi-experimental study was conducted on all health volunteers in four comprehensive health centers selected via random cluster sampling during the second half of 2017. The participants were divided into intervention and control groups and took part in the pretest based on the book entitled "Promotion of Breastfeeding". Based on the pretest results, health volunteers trained the participants in three educational sessions. The two groups were evaluated again immediately and two months after the intervention.

RESULTS

The mean age of the participants was 49.97 ± 8.1 and 46.52 ± 10.74 years in intervention and control groups, respectively. Most participants were married (94.8%) and had diplomas (92.1%).A significant difference was seen between both groups in knowledge scores at the three time points (P < 0.001). A significant difference was found between the two groups regarding knowledge scores immediately and two months after the intervention (P < 0.001), indicating the effectiveness of training through role-play.

CONCLUSION

The advantages of role-play, including development of communication skills and active listening, resulted in the learners' enthusiasm and motivation. This method was accompanied with higher educational output as well as longer knowledge persistence. Role-play increased cooperation and group discussions performed after the role-play promoted the transfer emotional experiences.

Evaluating the impact of community health volunteer home visits on child diarrhea and fever in the Volta Region, Ghana: A cluster-randomized controlled trial

BACKGROUND

Although there is mounting evidence demonstrating beneficial effects of community health workers (CHWs), few studies have examined the impact of CHW programs focused on preventing infectious diseases in children through behavior changes. We assessed the preventive effects of community health volunteers (CHVs), who receive no financial incentive, on child diarrhea and fever prevalence in Ghana.

METHODS AND FINDINGS

We conducted a cluster-randomized controlled trial in 40 communities in the Volta Region, Ghana. Twenty communities were randomly allocated to the intervention arm, and 20 to the control arm, using a computer-generated block randomization list. In the intervention arm, CHVs were deployed in their own community with the key task of conducting home visits for health education and community mobilization. The primary outcomes of the trial were diarrhea and fever prevalence at 6 and 12 months among under-5 children based on caregivers' recall. Secondary outcomes included oral rehydration treatment and rapid diagnostic testing for malaria among under-5 children, and family planning practices of caregivers. Generalized estimating equations (GEEs) with a log link and exchangeable correlation matrix were used to determine the relative risk (RR) and 95% confidence intervals (CIs) for diarrhea, fever, and secondary outcomes adjusted for clustering and stratification. Between April 18 and May 4, 2015, 1,956 children were recruited and followed up until September 20, 2016. At 6 and 12 months post-randomization, 1,660 (85%) and 1,609 (82%) participants, respectively, had outcomes assessed. CHVs' home visits had no statistically significant effect on diarrhea or fever prevalence at either time point. After a follow-up of 12 months, the prevalence of diarrhea and fever was 7.0% (55/784) and 18.4% (144/784), respectively, in the control communities and 4.5% (37/825) and 14.7% (121/825), respectively, in the intervention communities (12-month RR adjusted for clustering and stratification: diarrhea, RR 0.73, 95% CI 0.37-1.45, p = 0.37; fever, RR 0.76, 95% CI 0.51-1.14, p = 0.20). However, the following were observed: improved hand hygiene practices, increased utilization of insecticide-treated bed nets, and greater participation in community outreach programs (p-values < 0.05) in the intervention group. In a post hoc subgroup analysis, the prevalence of diarrhea and fever at 6 months was 3.2% (2/62) and 17.7% (11/62), respectively, in the intervention communities with ≥70% coverage and a ≥30-minute visit duration, and 14.4% (116/806) and 30.2% (243/806) in the control communities (RR adjusted for clustering, stratification, baseline prevalence, and covariates: diarrhea, RR 0.23, 95% CI 0.09-0.60, p = 0.003; fever, RR 0.69, 95% CI 0.52-0.92, p = 0.01). The main limitations were the following: We were unable to investigate the longer-term effects of CHVs; the trial may have been underpowered to detect small to moderate effects due to the large decline in diarrheal and fever prevalence in both the intervention and control group; and caregivers' practices were based on self-report, and the possibility of caregivers providing socially desirable responses cannot be excluded.

CONCLUSIONS

We found no effect of CHVs' home visits on the prevalence of child diarrhea or fever. However, CHV programs with high community coverage and regular household contacts of effective duration may reduce childhood infectious disease prevalence.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Registry, ISRCTN49236178.

Exploring the equity impact of a maternal and newborn health intervention: a qualitative study of participatory women's groups in rural South Asia and Africa

BACKGROUND

A consensus is developing on interventions to improve newborn survival, but little is known about how to reduce socioeconomic inequalities in newborn mortality in low- and middle-income countries. Participatory learning and action (PLA) through women's groups can improve newborn survival and home care practices equitably across socioeconomic strata, as shown in cluster randomised controlled trials. We conducted a qualitative study to understand the mechanisms that led to the equitable impact of the PLA approach across socioeconomic strata in four trial sites in India, Nepal, Bangladesh, and Malawi.

METHODS

We conducted 42 focus group discussions (FGDs) with women who had attended groups and women who had not attended, in poor and better-off communities. We also interviewed six better-off women and nine poor women who had delivered babies during the trials and had demonstrated recommended behaviours. We conducted 12 key informant interviews and five FGDs with women's group facilitators and fieldworkers.

RESULTS

Women's groups addressed a knowledge deficit in poor and better-off women. Women were engaged through visual learning and participatory tools, and learned from the facilitator and each other. Facilitators enabled inclusion of all socioeconomic strata, ensuring that strategies were low-cost and that discussions and advice were relevant. Groups provided a social support network that addressed some financial barriers to care and gave women the confidence to promote behaviour change. Information was disseminated through home visits and other strategies. The social process of learning and action, which led to increased knowledge, confidence to act, and acceptability of recommended practices, was key to ensuring behaviour change across social strata. These equitable effects were enabled by the accessibility, relevance, and engaging format of the intervention.

CONCLUSIONS

Participatory learning and action led to increased knowledge, confidence to act, and acceptability of recommended practices. The equitable behavioural effects were facilitated by the accessibility, relevance, and engaging format of the intervention across socioeconomic groups, and by reaching-out to parts of the population usually not accessed. A PLA approach improved health behaviours across socioeconomic strata in rural communities, around issues for which there was a knowledge deficit and where simple changes could be made at home.

Advice on healthy pregnancy, delivery, motherhood and information on non-communicable diseases in the maternal care programme in Myanmar: a cross-sectional study

OBJECTIVE

Pregnancy and delivery periods offer an opportunity for counselling women to improve behavioural risk and prevent complications, including non-communicable diseases (NCDs). However, little evidence is available on counselling offered during antenatal and postnatal care (PNC) in Myanmar. This study aimed to assess the contents of advice and information received by women during antenatal and postnatal counselling and to identify factors associated with receiving those advice and information.

DESIGN

Cross-sectional study.

SETTING

A predominantly rural township in the Ayeyawady region and a predominantly urban township in the Yangon region.

PARTICIPANTS

1500 women who had given birth in the last 6 weeks to 12 months prior to the survey.

OUTCOME MEASURES

Receiving advice on 18 items during antenatal counselling, 10 items during postnatal counselling and information on five major NCDs during antenatal care (ANC).

RESULTS

Nearly 52% of women received advice on 18 items during antenatal counselling, and 60% received advice on 10 items during postnatal counselling. About 28% received information on five NCDs during ANC. Women who were living in the Yangon site, who had primary school education or lower and who experienced complications were less likely to receive advice on all items during both antenatal and postnatal counselling. Women who received PNC outside of a healthcare facility and were primiparas were also less likely to receive advice on all items during postnatal counselling. Women living in the Yangon site and those who utilised a private care facility were less likely to receive information on NCDs.

CONCLUSIONS

Only 60% of women received advice on healthy pregnancy, delivery and motherhood, whereas 30% received information on NCDs. Although non-modifiable maternal factors were associated with these results, counselling practice can be improved and information on NCDs can be offered as the first step of integrated NCDs care in maternal care programme in Myanmar.