Community-based Package Research Articles

Differentiated care for youth in Zimbabwe: Outcomes across the HIV care cascade.

Youth living with HIV are at higher risk than adults of disengaging from HIV care. Differentiated models of care such as community delivery of antiretroviral therapy (ART) may improve treatment outcomes. We investigated outcomes across the HIV cascade among youth accessing HIV services in a community-based setting. This study was nested in a cluster-randomised controlled trial (CHIEDZA: Clinicaltrials.gov, Registration Number: NCT03719521) conducted in three provinces in Zimbabwe and aimed to investigate the impact of a youth-friendly community-based package of HIV services, integrated with sexual and reproductive health services for youth (16-24 years), on population-level HIV viral load (VL). HIV services included HIV testing, ART initiation and continuous care, VL testing, and adherence support. Overall 377 clients were newly diagnosed with HIV at CHIEDZA, and linkage to HIV care was confirmed for 265 (70.7%, 234 accessed care at CHIEDZA and 31 with other providers); of these 250 (94.3%) started ART. Among those starting ART at CHIEDZA who did not transfer out and had enough follow up time (>6 months), 38% (68/177) were lost-to-follow-up within six months. Viral suppression (HIV Viral Load <1000 copies/ml) among those who had a test at 6 months was 90% (96/107). In addition 1162 clients previously diagnosed with HIV accessed CHIEDZA; 714 (61.4%) had a VL test, of whom 565 (79.1%) were virally suppressed. This study shows that provision of differentiated services for youth in the community is feasible. Linkage to care and retention during the initial months of ART was the main challenge and needs concerted attention to achieve the ambitious 95-95-95 UNAIDS targets.

Family-led rehabilitation in India (ATTEND)-Findings from the process evaluation of a randomized controlled trial.

Training family carers to provide evidence-based rehabilitation to stroke patients could address the recognized deficiency of access to stroke rehabilitation in low-resource settings. However, our randomized controlled trial in India (ATTEND) found that this model of care was not superior to usual care alone. This process evaluation aimed to better understand trial outcomes through assessing trial implementation and exploring patients', carers', and providers' perspectives. Our mixed methods study included process, healthcare use data and patient demographics from all sites; observations and semi-structured interviews with participants (22 patients, 22 carers, and 28 health providers) from six sampled sites. Intervention fidelity and adherence to the trial protocol was high across the 14 sites; however, early supported discharge (an intervention component) was not implemented. Within both randomized groups, some form of rehabilitation was widely accessed. ATTEND stroke coordinators provided counseling and perceived that sustaining patients' motivation to continue with rehabilitation in the face of significant emotional and financial stress as a key challenge. The intervention was perceived as an acceptable community-based package with education as an important component in raising the poor awareness of stroke. Many participants viewed family-led rehabilitation as a necessary model of care for poor and rural populations who could not access rehabilitation. Difficulty in sustaining patient and carer motivation for rehabilitation without ongoing support, and greater than anticipated access to routine rehabilitation may explain the lack of benefit in the trial. Nonetheless, family-led rehabilitation was seen as a concept worthy of further development.

Health extension workers improve tuberculosis case finding and treatment outcome in Ethiopia: a large-scale implementation study

BackgroundTuberculosis (TB) is a major cause of death in Ethiopia. One of the main barriers for TB control is the lack of access to health services.MethodsWe evaluated a diagnostic and...

Intensive case management for severe mental illness.

Intensive case management for severe mental illness.

Impact of a community-based package of interventions on child development in Zambia: a cluster-randomised controlled trial

BackgroundCommunity-based programmes are a critical platform for improving child health and development. We tested the impact of a community-based early childhood intervention package in rural Zambia.MethodsWe conducted a non-blinded cluster...

Effect of community-based newborn care on cause-specific neonatal mortality in Sylhet district, Bangladesh: findings of a cluster-randomized controlled trial

Community-based maternal and newborn intervention packages have been shown to reduce neonatal mortality in resource-constrained settings. This analysis uses data from a large community-based cluster-randomized trial to assess the impact of a community-based package on cause-specific neonatal mortality and draws programmatic and policy implications. In addition, the study shows that cause-specific mortality estimates vary substantially based on the hierarchy used in assigning cause of death, which also has important implications for program planning. Therefore, understanding the methods of assigning causes of deaths is important, as is the development of new methodologies that account for multiple causes of death. The objective of this study was to estimate the effect of two service delivery strategies (home care and community care) for a community-based package of maternal and neonatal health interventions on cause-specific neonatal mortality rates in a rural district of Bangladesh. Within the general community of the Sylhet district in rural northeast Bangladesh. Pregnancy histories were collected from a sample of women in the study area during the year preceding the study (2002) and from all women who reported a pregnancy outcome during the intervention in years 2004 to 2005. All families that reported a neonatal death during these time periods were asked to complete a verbal autopsy interview. Expert algorithms with two different hierarchies were used to assign causes of neonatal death, varying in placement of the preterm/low birth weight category within the hierarchy (either third or last). The main outcome measure was cause-specific neonatal mortality. Deaths because of serious infections in the home-care arm declined from 13.6 deaths per 1000 live births during the baseline period to 7.2 during the intervention period according to the first hierarchy (preterm placed third) and from 23.6 to 10.6 according to the second hierarchy (preterm placed last). This study confirms the high burden of neonatal deaths because of infection in low resource rural settings like Bangladesh, where most births occur at home in the absence of skilled birth attendance and care seeking for newborn illnesses is low. The study demonstrates that a package of community-based neonatal health interventions, focusing primarily on infection prevention and management, can substantially reduce infection-related neonatal mortality.

Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes.

Background While maternal, infant and under-five child mortality rates in developing countries have declined significantly in the past two to three decades, newborn mortality rates have reduced much more slowly. While it is recognised that almost half of the newborn deaths can be prevented by scaling up evidence-based available interventions such as tetanus toxoid immunisation to mothers; clean and skilled care at delivery; newborn resuscitation; exclusive breastfeeding; clean umbilical cord care; management of infections in newborns, many require facility based and outreach services. It has also been stated that a significant proportion of these mortalities and morbidities could also be potentially addressed by developing community-based packages interventions which should also be supplemented by developing and strengthening linkages with the local health systems. Some of the recent community-based studies of interventions targeting women of reproductive age have shown variable impacts on maternal outcomes and hence it is uncertain if these strategies have consistent benefit across the continuum of maternal and newborn care. The objective of this review is to assess the effectiveness of community-based intervention packages in reducing maternal and neonatal morbidity and mortality; and improving neonatal outcomes.

Cost-effectiveness of community-based strategies to strengthen the continuum of HIV care in rural South Africa: a health economic modelling analysis

SummaryBackgroundHome HIV counselling and testing (HTC) achieves high coverage of testing and linkage to care compared with existing facility-based approaches, particularly among asymptomatic individuals. In a modelling analysis we aimed to assess the effect on population-level health and cost-effectiveness of a community-based package of home HTC in KwaZulu-Natal, South Africa.MethodsWe parameterised an individual-based model with data from home HTC and linkage field studies that achieved high coverage (91%) and linkage to antiretroviral therapy (80%) in rural KwaZulu-Natal, South Africa. Costs were derived from a linked microcosting study. The model simulated 10 000 individuals over 10 years and incremental cost-effectiveness ratios were calculated for the intervention relative to the existing status quo of facility-based testing, with costs discounted at 3% annually.FindingsThe model predicted implementation of home HTC in addition to current practice to decrease HIV-associated morbidity by 10–22% and HIV infections by 9–48% with increasing CD4 cell count thresholds for antiretroviral therapy initiation. Incremental programme costs were US$2·7 million to $4·4 million higher in the intervention scenarios than at baseline, and costs increased with higher CD4 cell count thresholds for antiretroviral therapy initiation; antiretroviral therapy accounted for 48–87% of total costs. Incremental cost-effectiveness ratios per disability-adjusted life-year averted were $1340 at an antiretroviral therapy threshold of CD4 count lower than 200 cells per μL, $1090 at lower than 350 cells per μL, $1150 at lower than 500 cells per μL, and $1360 at universal access to antiretroviral therapy.InterpretationCommunity-based HTC with enhanced linkage to care can result in increased HIV testing coverage and treatment uptake, decreasing the population burden of HIV-associated morbidity and mortality. The incremental cost-effectiveness ratios are less than 20% of South Africa's gross domestic product per person, and are therefore classed as very cost effective. Home HTC can be a viable means to achieve UNAIDS' ambitious new targets for HIV treatment coverage.FundingNational Institutes of Health, Bill & Melinda Gates Foundation, Wellcome Trust.

Can Available Interventions End Preventable Deaths in Mothers, Newborn Babies, and Stillbirths, and at What Cost?

Despite progress in lowering death rates in children younger than 5 years, progress in reducing newborn deaths has been slower and should focus on effective interventions, intentional investment, and implementation. This report offers an update of the evidence for interventions, the potential for lives saved, and running costs of implementation. Specific interventions across the continuum of pregnancy care were evaluated along with delivery platforms for these interventions and methods to improve care. All major databases were searched to identify quality systematic reviews in various domains using standardized methodology. Interventions before and between pregnancies include delaying the age at the first pregnancy, family planning, optimal interpregnancy intervals, and enhancement of prepregnancy nutrition. Antenatal interventions include maternal immunization, management of infections and preexisting chronic diseases or pregnancy-induced disorders, detection and management of significant in utero growth retardation, prevention of RhD alloimmunization, improvements in nutrition and psychosocial health, and treatment of drug misuse. Interventions during or close to labor include obstetric care with labor monitoring, skilled delivery and provision of emergency obstetric care as needed, and management of preterm labor and postterm pregnancy, as well as clean/sterile birth practices to reduce neonatal sepsis and tetanus deaths and use of antenatal steroids. Interventions at birth for every newborn include immediate drying and stimulation, provision of warmth, delaying of cord clamping, hygienic care, support for immediate breast-feeding, and administration of vitamin K. Neonatal resuscitation is crucial for babies who do not breathe immediately and could include prevention and management of meconium aspiration. Beginning breast-feeding within 1 hour of birth, exclusive breast-feeding of infants until age 6 months, and continuation of breast-feeding until age 2 years are strongly recommended. Interventions for small and ill newborn babies include prevention of hypothermia; management of respiratory distress syndrome, neonatal pneumonia, sepsis, and hyperbilirubinemia; and skin care with emollient and massage therapy. Kangaroo mother care involves early and continuous skin-to-skin contact, breast-feeding support, early discharge from hospital, and supportive care in stable neonates. Use of continuous positive airway pressure, anticonvulsants, and animal-derived surfactant can reduce neonatal morbidity and mortality. Care of neonates in intensive care units has become increasingly sophisticated in high-income countries, and creation of neonatal intensive care units is being implemented in low- and middle-income countries. Delivery platforms and strategies to reach mothers and neonates are important for delivery of high-quality care to underserved populations. Community-based delivery platforms, especially if linked to local health facilities, can increase coverage of essential interventions and reduce inequities. Changes in household behaviors and practices, tetanus immunization, use of clean birth kits, facility births, early initiation of breast-feeding, and seeking of health care for neonatal illnesses are all factors in reaching mothers and neonates. Community mobilization and antenatal and postnatal home visits by health workers can complement facility-based care and promote family contact with the health system at crucial times. Community-based packages of preventive and basic care, promoted by outreach workers and women's groups, empower women to facilitate these vital changes. One method to enhance these improvements is to create financial incentives as strategies to ease poverty, reduce financial barriers, and improve health outcomes in poor populations. To determine the financial aspects of these major changes to health care delivery in underserved populations, the Lives Saved Tool was used to model the effects of these interventions within the health systems of 75 countries that account for more than 95% of maternal, neonatal, and child deaths worldwide. The Lives Saved Tool estimates the country-by-country cause-specific effects of increasing coverage of individual interventions from baseline levels of 2012 on stillbirth and neonatal and maternal mortality. With high coverage by 2025, 71% (56%-76%) of neonatal mortality, 33% (23%-38%) of stillbirths, and 51% (44%-53%) of maternal deaths could be averted. If 90% of all women giving birth in facilities in 2020 received highly effective interventions, an estimated 113,000 maternal deaths (84% of the total deaths averted by 2020), 531,000 stillbirths (76%), and 1.325 million neonatal deaths (77%), including 300,000 preterm deaths, would be prevented. The incremental annual costs (in US dollars) of providing these care packages would be approximate to$4.5 billion ($0.91/person) by 2020, rising to $5.65 billion ($1.15/person) in 2025 (or $1928 for each maternal and infant life saved). Increased coverage and quality of preconception, antenatal, intrapartum, and postnatal interventions by 2025 could avert 71% of neonatal deaths (1.9 million [1.6-2.1 million]), 33% of stillbirths (0.82 million [0.60-0.93 million]), and 54% of maternal deaths (0.16 million [0.14-0.17 million]) annually. Available interventions can reduce preterm, intrapartum, and infection-related deaths by 58%, 79%, and 84%, respectively. Closing the quality gap for facility births is imperative. Many of the current differentials in quality relate to ethnicity, geography, and other forms of social marginalization. Strategies to overcome these obstacles are required to create and maintain health systems to benefit women, babies, development outcomes, and economic capital.

Engaging new migrants in infectious disease screening: a qualitative semi-structured interview study of UK migrant community health-care leads.

Migration to Europe - and in particular the UK - has risen dramatically in the past decades, with implications for public health services. Migrants have increased vulnerability to infectious diseases (70% of TB cases and 60% HIV cases are in migrants) and face multiple barriers to healthcare. There is currently considerable debate as to the optimum approach to infectious disease screening in this often hard-to-reach group, and an urgent need for innovative approaches. Little research has focused on the specific experience of new migrants, nor sought their views on ways forward. We undertook a qualitative semi-structured interview study of migrant community health-care leads representing dominant new migrant groups in London, UK, to explore their views around barriers to screening, acceptability of screening, and innovative approaches to screening for four key diseases (HIV, TB, hepatitis B, and hepatitis C). Participants unanimously agreed that current screening models are not perceived to be widely accessible to new migrant communities. Dominant barriers that discourage uptake of screening include disease-related stigma present in their own communities and services being perceived as non-migrant friendly. New migrants are likely to be disproportionately affected by these barriers, with implications for health status. Screening is certainly acceptable to new migrants, however, services need to be developed to become more community-based, proactive, and to work more closely with community organisations; findings that mirror the views of migrants and health-care providers in Europe and internationally. Awareness raising about the benefits of screening within new migrant communities is critical. One innovative approach proposed by participants is a community-based package of health screening combining all key diseases into one general health check-up, to lessen the associated stigma. Further research is needed to develop evidence-based community-focused screening models - drawing on models of best practice from other countries receiving high numbers of migrants.

The Effect of Community Maternal and Newborn Health Family Meetings on Type of Birth Attendant and Completeness of Maternal and Newborn Care Received During Birth and the Early Postnatal Period in Rural Ethiopia

Maternal and newborn deaths occur predominantly in low-resource settings. Community-based packages of evidence-based interventions and skilled birth attendance can reduce these deaths. The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) used community-level health workers to conduct prenatal Community Maternal and Newborn Health family meetings to build skills and care-seeking behaviors among pregnant women and family caregivers. Baseline and endline surveys provided data on a random sample of women with a birth in the prior year. An intention-to-treat analysis, plausible net effect calculation, and dose-response analysis examined increases in completeness of care (mean percentage of 17 maternal and newborn health care elements performed) over time and by meeting participation. Regression models assessed the relationship between meeting participation, completeness of care, and use of skilled providers or health extension workers for birth care-controlling for sociodemographic and health service utilization factors. A 151% increase in care completeness occurred from baseline to endline. At endline, women who participated in 2 or more meetings had more complete care than women who participated in fewer than 2 meetings (89% vs 76% of care elements; P < .001). A positive dose-response relationship existed between the number of meetings attended and greater care completeness (P < .001). Women with any antenatal care were nearly 3 times more likely to have used a skilled provider or health extension worker for birth care. Women who had additionally attended 2 or more meetings with family members were over 5 times as likely to have used these providers, compared to women without antenatal care and who attended fewer than 2 meetings (odds ratio, 5.19; 95% confidence interval, 2.88-9.36; P < .001). MaNHEP's family meetings complemented routine antenatal care by engaging women and family caregivers in self-care and care-seeking, resulting in greater completeness of care and more highly skilled birth care.

Newborn survival in Nepal: a decade of change and future implications

Nepal is on target to meet the Millennium Development Goals for maternal and child health despite high levels of poverty, poor infrastructure, difficult terrain and recent conflict. Each year, nearly 35,000 Nepali children die before their fifth birthday, with almost two-thirds of these deaths occurring in the first month of life, the neonatal period. As part of a multi-country analysis, we examined changes for newborn survival between 2000 and 2010 in terms of mortality, coverage and health system indicators as well as national and donor funding. Over the decade, Nepal's neonatal mortality rate reduced by 3.6% per year, which is faster than the regional average (2.0%) but slower than national annual progress for mortality of children aged 1-59 months (7.7%) and maternal mortality (7.5%). A dramatic reduction in the total fertility rate, improvements in female education and increasing change in skilled birth attendance, as well as increased coverage of community-based child health interventions, are likely to have contributed to these mortality declines. Political commitment and support for newborn survival has been generated through strategic use of global and national data and effective partnerships using primarily a selective newborn-focused approach for advocacy and planning. Nepal was the first low-income country to have a national newborn strategy, influencing similar strategies in other countries. The Community-Based Newborn Care Package is delivered through the nationally available Female Community Health Volunteers and was piloted in 10 of 75 districts, with plans to increase to 35 districts in mid-2013. Innovation and scale up, especially of community-based packages, and public health interventions and commodities appear to move relatively rapidly in Nepal compared with some other countries. Much remains to be done to achieve high rates of effective coverage of community care, and especially to improve the quality of facility-based care given the rapid shift to births in facilities.

An effectiveness study of an integrated, community-based package for maternal, newborn, child and HIV care in South Africa: study protocol for a randomized controlled trial

BackgroundProgress towards MDG4 in South Africa will depend largely on scaling up effective prevention against mother to child transmission (PMTCT) of HIV and also addressing neonatal mortality. This imperative drives increasing focus on the neonatal period and particularly on the development and testing of appropriate models of sustainable, community-based care in South Africa in order to reach the poor. A number of key implementation gaps affecting progress have been identified. Implementation gaps for HIV prevention in neonates; implementation gaps for neonatal care especially home postnatal care; and implementation gaps for maternal mental health support. We have developed and are evaluating and costing an integrated and scaleable home visit package delivered by community health workers targeting pregnant and postnatal women and their newborns to provide essential maternal/newborn care as well as interventions for Prevention of Mother to Child Transmission (PMTCT) of HIV.MethodsThe trial is a cluster randomized controlled trial that is being implemented in Umlazi which is a peri-urban settlement with a total population of 1 million close to Durban in KwaZulu Natal, South Africa. The trial consists of 30 randomized clusters (15 in each arm). A baseline survey established the homogeneity of clusters and neither stratification nor matching was performed. Sample size was based on increasing HIV-free survival from 74% to 84%, and calculated to be 120 pregnant women per cluster. Primary outcomes are higher levels of HIV free survival and levels of exclusive and appropriate infant feeding at 12 weeks postnatally. The intervention is home based with community health workers delivering two antenatal visits, a postnatal visit within 48 hours of birth, and a further four visits during the first two months of the infants life. We are undertaking programmatic and cost effectiveness analysis to cost the intervention.DiscussionThe question is not merely to develop an efficacious package but also to identify and test delivery strategies that enable scaling up, which requires effectiveness studies in a health systems context, adapting and testing Asian community-based studies in various African contexts.Trial registrationISRCTN: ISRCTN41046462

Using formative research to develop MNCH programme in urban slums in Bangladesh: experiences from MANOSHI, BRAC

BackgroundMANOSHI, an integrated community-based package of essential Maternal, Neonatal and Child Health (MNCH) services is being implemented by BRAC in the urban slums of Bangladesh since 2007. The objective of the formative research done during the inception phase was to understand the context and existing resources available in the slums, to reduce uncertainty about anticipated effects, and develop and refine the intervention components.MethodsData were collected during Jan-Sept 2007 in one of the earliest sites of programme intervention in the Dhaka metropolitan area. A conceptual framework guided data collection at different stages. Besides exploring slum characteristics, studies were done to map existing MNCH service providing facilities and providers, explore existing MNCH-related practices, and make an inventory of community networks/groups with a stake in MNCH service provision. Also, initial perception and expectations regarding the community delivery centres launched by the programme was explored. Transect walk, observation, pile sorting, informal and focus group discussions, in-depth interviews, case studies, network analysis and small quantitative surveys were done to collect data.ResultsFindings reveal that though there are various MNCH services and providers available in the slums, their capacity to provide rational and quality services is questionable. Community has superficial knowledge of MNCH care and services, but this is inadequate to facilitate the optimal survival of mothers and neonates. Due to economic hardships, the slum community mainly relies on cheap informal sector for health care. Cultural beliefs and practices also reinforce this behaviour including home delivery without skilled assistance. Men and women differed in their perception of pregnancy and delivery: men were more concerned with expenses while women expressed fear of the whole process, including delivering at hospitals. People expected 'one-stop' MNCH services from the community delivery centres by skilled personnel. Social support network for health was poor compared to other networks. Referral linkages to higher facilities were inadequate, fragmentary, and disorganised.ConclusionsFindings from formative research reduced contextual uncertainty about existing MNCH resources and care in the slum. It informed MANOSHI to build up an intervention which is relevant and responsive to the felt needs of the slum population.