Effective Intervention, Centre for Economic Performance, London School of Economics, London, UK.
Medical Statistics Department, London School of Hygiene & Tropical Medicine, London, UK.
Lancet Glob Health. 2016 May;4(5):e328-35. doi: 10.1016/S2214-109X(16)30048-1.
Evidence suggests that community-based interventions that promote improved home-based practices and care-seeking behaviour can have a large impact on maternal and child mortality in regions where rates are high. We aimed to assess whether an intervention package based on the WHO Integrated Management of Childhood Illness handbook and community mobilisation could reduce under-5 mortality in rural Guinea-Bissau, where the health service infrastructure is weak.
We did a non-masked cluster-randomised controlled trial (EPICS) in the districts of Tombali and Quinara in Guinea-Bissau. Clusters of rural villages were stratified by ethnicity and distance from a regional health centre, and randomly assigned (1:1) to intervention or control using a computerised random number generator. Women were eligible if they lived in one of the clusters at baseline survey prior to randomisation and if they were aged 15-49 years or were primary caregivers of children younger than 5 years. Their children were eligible if they were younger than 5 years or were liveborn after intervention services could be implemented on July 1, 2008. In villages receiving the intervention, community health clubs were established, community health workers were trained in case management, and traditional birth attendants were trained to care for pregnant women and newborn babies, and promote facility-based delivery. Registered nurses supervised community health workers and offered mobile clinic services. Health centres were not improved. The control group received usual services. The primary outcome was the proportion of children dying under age 5 years, and was analysed in all eligible children up to final visits to villages between Jan 1 and March 31, 2011. This trial is registered with ISRCTN, number ISRCTN52433336.
On Aug 30, 2007, we randomly assigned 146 clusters to intervention (73 clusters, 5669 women, and 4573 children) or control (73 clusters, 5840 women, and 4675 children). From randomisation until the end of the trial (last visit by June 30, 2011), the intervention clusters had 3093 livebirths and the control clusters had 3194. 6729 children in the intervention group and 6894 in the control group aged 0-5 years on July 1, 2008, or liveborn subsequently were analysed for mortality outcomes. 311 (4·6%) of 6729 children younger than 5 years died in the intervention group compared with 273 (4·0%) of 6894 in the control group (relative risk 1·16 [95% CI 0·99-1·37]).
Our package of community-based interventions did not reduce under-5 mortality in rural Guinea-Bissau. The short timeframe and other trial limitations might have affected our results. Community-based health promotion and basic first-line services in fragile contexts with weak secondary health service infrastructure might be insufficient to reduce child deaths.
Effective Intervention.
有证据表明，在那些母婴死亡率较高的地区，以促进改善家庭护理实践和寻求医疗服务为目标的社区干预措施可能会产生巨大影响。本研究旨在评估以世界卫生组织《儿童疾病综合管理》手册和社区动员为基础的干预方案是否能降低几内亚比绍农村地区的 5 岁以下儿童死亡率，因为该地区的卫生服务基础设施薄弱。
我们在几内亚比绍的通巴利和基纳拉地区进行了一项非盲、整群随机对照试验（EPICS）。根据种族和距地区卫生中心的距离对农村村庄进行分层，使用计算机随机数生成器以 1:1 的比例随机分配（干预组或对照组）。如果女性在随机分组前的基线调查中居住在一个集群中，并且年龄在 15-49 岁或为 5 岁以下儿童的主要照顾者，则有资格参加研究。如果他们的孩子年龄小于 5 岁或在 2008 年 7 月 1 日可以实施干预服务后活产，他们的孩子也有资格参加研究。在接受干预的村庄中，成立了社区卫生俱乐部，培训了社区卫生工作者进行病例管理，培训了传统助产士照顾孕妇和新生儿，并促进了以设施为基础的分娩。注册护士监督社区卫生工作者，并提供流动诊所服务。卫生中心没有得到改善。对照组接受常规服务。主要结局是 5 岁以下儿童的死亡率比例，并对截至 2011 年 1 月 1 日至 3 月 31 日最后一次访问村庄时所有符合条件的儿童进行分析。本试验在 ISRCTN 注册，编号为 ISRCTN52433336。
2007 年 8 月 30 日，我们将 146 个集群随机分配到干预组（73 个集群，5669 名妇女，4573 名儿童）或对照组（73 个集群，5840 名妇女，4675 名儿童）。从随机分组到试验结束（最后一次访问时间为 2011 年 6 月 30 日），干预组有 3093 例活产，对照组有 3194 例。2008 年 7 月 1 日，干预组有 6729 名 0-5 岁儿童和 6894 名儿童，或随后活产的儿童被纳入死亡率结局分析。在干预组，有 311（4·6%）名 5 岁以下儿童死亡，而对照组有 273（4·0%）名儿童死亡（相对风险 1·16 [95%CI 0·99-1·37]）。
我们的社区为基础的干预方案并没有降低几内亚比绍农村地区的 5 岁以下儿童死亡率。较短的时间框架和其他试验限制可能影响了我们的结果。在脆弱的环境中，以社区为基础的健康促进和基本的一线服务，以及薄弱的二级卫生服务基础设施，可能不足以降低儿童死亡人数。
有效干预。
