Effect of capacity-building in infectious disease on mortality among children under-5: a cluster randomised trial

Abstract

BackgroundDue to shortage of health personnel in sub-Saharan Africa, WHO advocates shifting some tasks traditionally performed by doctors to mid-level practitioners (MLPs). The effect on under-5 (U5) mortality of an on-site support (OSS) intervention for MLPs after an Integrated Management of Infectious Disease training programme was estimated. Methods36 health centres were randomised 1:1 to staggered implementation arms, with the intervention group receiving OSS during phase 1 (April to December, 2010) and both groups receiving OSS during phase 2 (March to October, 2011). Mortality was assessed by a household survey employing a novel sampling design; 300 enumeration areas (EAs) per arm were randomly selected among all within 5 km of the health centres. Key informants assisted in identifying all households with a U5 death in each EA for interviews. A random sample of 30 households was also selected for interviews to provide denominator person-time information. Birth histories were collected from all female residents aged 15–49 years or proxies, and survival data were collected on children whose mothers were not residents. Mortality risk was compared in intervention and control arms during baseline (August, 2008, to March, 2010), phase 1, and phase 2 using discrete-time survival analysis. FindingsA total of 87 189 households in 597 EAs were listed; 20 546 were selected; and 17% reported a U5 death. For 68% of children in the sample, their resident birth mother was interviewed. During phase 1, unadjusted odds of death were 1·09 (95% CI 0·81–1·39) times higher than baseline in the intervention arm and 1·23 (1·05–1·46) in the control. During phase 2, odds rose to 1·77 (1·31–2·40) times higher than baseline in the intervention arm and 1·67 (1·42–1·97) in the control. Adjusted results were similar. Differences between arms were not statistically significant during any time period. InterpretationU5 mortality increased in both arms, but timing of the increase was delayed in the OSS arm during intervention. FundingThe Infectious Disease Capacity Building Evaluation (IDCAP) was funded by grant 49298 to Accordia Global Health Foundation from the Bill & Melinda Gates Foundation.