Abstract
BackgroundOshikhandass is a rural village in northern Pakistan where a 1989–1991 verbal autopsy study showed that diarrhea and pneumonia were the top causes of under-5 mortality. Intensive surveillance, active community health education and child health interventions were delivered in 1989–1996; here we assess improvements in under-5 mortality, diarrhea, and pneumonia over this period and 15 years later.MethodsTwo prospective open-cohort studies in Oshikhandass from 1989 to 1996 (Study 1) and 2011–2014 (Study 2) enrolled all children under age 60 months. Study staff trained using WHO guidelines, conducted weekly household surveillance and promoted knowledge on causes and management of diarrhea and pneumonia. Information about household characteristics and socioeconomic status was collected. Hurdle models were constructed to examine putative risk factors for diarrhea and pneumonia.ResultsAgainst a backdrop of considerable change in the socioeconomic status of the community, under-5 mortality, which declined over the course of Study 1 (from 114.3 to 79.5 deaths/1000 live births (LB) between 1989 and 1996), exceeded Sustainable Development Goal 3 by Study 2 (19.8 deaths/ 1000 LB). Reductions in diarrhea prevalence (20.3 to 2.2 days/ Child Year [CY]), incidence (2.1 to 0.5 episodes/ CY), and number of bloody diarrhea episodes (18.6 to 5.2%) seen during Study 1, were sustained in Study 2. Pneumonia incidence was 0.5 episodes /CY in Study 1 and 0.2/CY in Study 2; only 5% of episodes were categorized as severe or very severe in both studies. While no individual factors predicted a statistically significant difference in diarrhea or pneumonia episodes, the combined effect of water, toilet and housing materials was associated with a significant decrease in diarrhea; higher household income was the most protective factor for pneumonia in Study 1.ConclusionsWe report a 4-fold decrease in overall childhood mortality, and a 2-fold decrease in childhood morbidity from diarrhea and pneumonia in a remote rural village in Pakistan between 1989 and 2014. We conclude that significant, sustainable improvements in child health may be achieved through improved socioeconomic status and promoting interactions between locally engaged health workers and the community, but that continued efforts are needed to improve health worker training, supervision, and the rational use of medications.Trial registrationNot Applicable.
Highlights
Oshikhandass is a rural village in northern Pakistan where a 1989–1991 verbal autopsy study showed that diarrhea and pneumonia were the top causes of under-5 mortality
Sustainable improvements in child health may be achieved through improved socioeconomic status and promoting interactions between locally engaged health workers and the community, but that continued efforts are needed to improve health worker training, supervision, and the rational use of medications
Individual factors were not consistently associated with the risks of diarrhea or pneumonia, the combined improvements to housing materials, sanitation and water supply were predictive of lower incidence of diarrhea
Summary
Oshikhandass is a rural village in northern Pakistan where a 1989–1991 verbal autopsy study showed that diarrhea and pneumonia were the top causes of under-5 mortality. Addressing persistent health challenges, such as childhood morbidity and mortality in lower- and middle-income countries, requires sustained intervention, a key component of which is building local engagement and capacity in the community [1, 2]. At the current rates of decline in mortality [13] Pakistan will not achieve the Sustainable Development Goal 3 (SDG3) of reducing under-5 mortality to ≤25 deaths/1000 live births (LB) by 2030 [14]. Against this background, it is noteworthy that there have been successful community-level programs to improve health in some of the more remote, rural districts of GilgitBaltistan [15]
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