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A Systematic Review of the Effectiveness of Community-Based Primary Health Care in Improving Child Health


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Title: A Systematic Review of the Effectiveness of Community-Based Primary Health Care in Improving Child Health

A Systematic Review of the Effectiveness of
Community-Based Primary Health Care in Improving
Child Health
  • Sponsored by the Working Group on CBPHC of the
    International Health Section of APHA in
    collaboration with UNICEF, WHO, the World Bank
    and with support from Future Generations

  • Describe the review and methods
  • A few observations about specific interventions
  • Evidence concerning integrated approaches
  • Cross-cutting themes scaling up/CHWs
  • Findings, recommendations and conclusions

Study Questions
  • How strong is the evidence that CBPHC can improve
    child health?
  • What are the conditions needed for
    community-based interventions to be effective?
  • What lessons have been learned?
  • What additional research needed is need?
  • What are the policy implications?

Study Outcomes
  • Report to Expert Panel
  • Journal supplement
  • Consensus statement of Expert Review Panel
  • Summary publication of key findings in
    high-profile journal
  • Book

Identification of Documents for the Review
  • One or more interventions with outcome
  • Main outcome measures
  • -Change in mortality
  • -Change in nutritional status
  • -Change in coverage of a key child survival
  • intervention

Sources and Selection Criteria
  • Computerized database searches Pubmed
  • Broadcasts to global health listserves
  • Knowledgeable persons
  • Reviews of studies also included where
  • Documents from grey literature included

Document Review Process
  • PUBMED search produced 3,224 documents
    (community health AND infant/child morbidity
    or mortality AND developing countries)
  • Each document assessed for inclusion by two
  • independent reviewers
  • Each document which qualified for inclusion was
    reviewed by 2 independent reviewers
  • Standardized data extraction forms used for
    single studies
  • Each pair of reviews consolidated by a third
    senior reviewer into a single data sheet created
    as an EPI INFO questionnaire for further analysis
  • 380 studies and 50 review articles

Study Personnel
  • Directors Henry Perry and Paul Freeman
  • Coordinators Sundeep Gupta and Bahie Rassekh
  • 70 reviewers (mostly volunteer, including many
    Hopkins students)

Members of the Expert Review Panel
  • Dr. Carl Taylor, Chairperson, Johns Hopkins
    University, Baltimore, MD
  • Dr. Raj Arole, Comprehensive Rural Health
    Project, Jamkhed, India
  • Dr. Rajiv Bahl, World Health Organization, Geneva
  • Dr. Abhay Bang, Society for Education, Action and
    Education (SEARCH), Gadchiroli, India
  • Dr. Robert Black, Johns Hopkins University,
    Baltimore, MD, USA
  • Dr. Anthony Costello, University College of
    London, London, UK

Members of the Expert Review Panel (cont.)
  • Betty Kirkwood, London School of Hygiene and
    Tropical Medicine, London, UK
  • Rudolph Knippenberg, UNICEF, New York, NY
  • Claudio Lanata, Institute of Nutritional
    Research, Lima, Peru
  • Dr. Adetokumbo Lucas, Harvard University, Ibidan,
  • Dr. Pang Ruyan, WHO, Manila, Philippines
  • Dr. David Sanders, University of Western Cape,
    Capetown, South Africa
  • Dr. Agnes Soucat, World Bank, Washington, DC
  • Dr. Mary Taylor, Gates Foundation

What Is CBPHC?
  • Broad-based definition
  • Any interventions(s) outside of health facilities
    or in coordination with health facilities with a
    direct or indirect effect on health

Main Findings CBPHC Interventions for Improving
Child Health
CBPHC Interventions for Improving Child Health
CBPHC Interventions for Improving Child Health
Selected Findings from the Review Effective
CBPHC Interventions
  • Community-based treatment of pneumonia is
  • Water and sanitation interventions are effective
  • Handwashing reduces rates of childhood diarrhea
    AND pneumonia
  • Womens empowerment, cash transfers,
    micro-credit, overall social/political
    environment each contribute to child health

Some Comments on the Evidence for Specific
Interventions Family and community practices
that promote child survival, growth and
development. A REVIEWOF THE EVIDENCE http//whql
Meta-Analysis of Studies to Improve the Quality
of Drinking Water (33 studies)
  • Types household-based (chlorination, filtration,
    flocculation/ disinfection, solar disinfection)
    and source-based chlorination
  • Overall, 39 reduced risk of childhood diarrhea
  • Addition of other interventions (e.g., hygiene
    instruction, improved water vessel storage,
    improved sanitation, or improved water supply)
    does not increase effectiveness
  • (Clasen et al., British Medical
    Journal, 2007)

Review of Potential Effectiveness of Nutrition
Interventions (thousands of studies)
-- In the 36 countries with the 90 of children
with stunting -- All interventions are
Bhutta et al., Lancet, 2008
Evidence for Integrated Approaches Analysis of
Integrated Projects Included in the Review
  • Review of studies with at least 3 child survival
    interventions and at least 4 years of
  • 40 studies/projects identified

Characteristics of 40 Integrated Projects
Community Processes Used in Intervention
Common Methods of Outreach
  • Censuses/mapping/family registration common
  • Routine home visitation common
  • Drama/dance/ songs/puppet shows used to attract
    the community for health education events

Examples of Types of Community Involvement/Partici
  • At community leadership level
  • Village health committees
  • Associations of village health committees
  • Village development committees
  • Health action committees
  • Community leadership committees
  • Meetings with chiefs/mayors/ elders/imams
  • Imams as community mobilizers
  • Community meetings/assemblies
  • Community pharmacies
  • Self-sufficient maternity homes
  • At household level
  • Health days (for community clean up)
  • Model mothers
  • Competitions among mothers for healthiest babies
  • Breastfeeding support groups
  • Husbands and mothers-in-law as targets for
  • Pregnant womens groups
  • Mothers clubs
  • Child clubs

Outcomes of 40 Integrated Projects
Review of Studies of the Effectiveness of
Packages of Community-based Neonatal Health
Interventions (41 studies)
  • Packages of interventions which had more than 1
    plausible biological effect
  • Few studies of any complete packages
    (antenatal, intrapartum and postpartum) which
    were recommended in the Lancet neonatal series
  • Interventions appeared t o be bundled on basis of
    convenience or funding requirements
  • No studies of true effectiveness of packages (in
    routine conditions) at scale
  • Haws et al., Health Policy and
    Planning 2007

Matlab (Bangladesh) Infant and 1-4-Year Mortality
Rates in Intervention and Comparison Areas
Jamkhed CRHP Infant Mortality Rates Compared to
Estimated Rates for Rural Maharahstra
Note Rates for rural Maharashtra are the infant
mortality rates among mothers with less than 5
years of education for the entire state inflated
by 10 since rural rates in general are 10
greater than rates for the overall population.
  • Freedom from Want
  • The Remarkable Success Story of BRAC, the Global
    Grassroots Organization Thats Winning the Fight
    Against Poverty
  • Ian Smillie
  • Learning to Reach Health for All Thirty Years of
    Instructive Experience at BRAC
  • Jon E Rohde

Hospital Albert Schweitzer (Haiti), Imesi
Ile/Wesley Guild (Nigeria), Matlab (Bangladesh),
Jamkhed (India), BRAC (Bangladesh), SEARCH
(India), and Navrongo (Ghana)
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