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  • br Community based bundled health interventions are complex

    2019-05-04


    Community-based bundled health interventions are complex and challenging to implement, monitor, and assess in informal settlements (slums). Such settlements in urban areas are generally characterised by congestion, squalid conditions, deprivation, violence, crime, and poor sanitation. In Asia and Africa, the numbers of informal settlements have grown exponentially in the large and mega cities of low-income and middle-income countries in the past few decades. Their growth has been driven by rapid urbanisation and economic opportunities, leading to and prompted by rural-to-urban migration of skilled and unskilled workers. Populations in these informal settlements, particularly women, children, and, increasingly, the elderly, are vulnerable to poor and multiple physical and mental health issues that include violence-related and self-inflicted injuries. In , Neena Shah More and colleagues present evidence from a cluster-randomised, controlled trial in which they assessed the effects of community-based integrated interventions on reproductive and child health outcomes in informal settlements in Mumbai. The bundled intervention was implemented systematically by an experienced non-governmental organisation, the Society for Nutrition, Education and Health Action (SNEHA), and was designed primarily TAPI-1 to address multiple health needs of women and children (reproductive, maternal, neonatal, and child health, immunisation, nutrition, and prevention of violence). 40 clusters of similar sizes were randomly assigned to have a resource centre providing and arranging help for the TAPI-1 (n=20, 12 614 households) or to have no additional resources (control; n=20, 12 239 households). Data for the indicators used to assess change were obtained through censuses done before and 2 years after the intervention was implemented. Postintervention data were available for 8271 women and 5371 children younger than 5 years in the intervention group, and 7965 women and 5180 children in the control group. Several outcome indicators improved significantly in favour of the intervention group. For example, met need for family planning was greater in the intervention clusters than in the control clusters (odds ratio [OR] 1·31, 95% CI 1·11–1·53). Full immunisation among children aged 12–23 months was similar in the two groups when assessed by intention to treat, but improvement was seen in the per-protocol analysis (ie, children who had been resident in intervention clusters for the entire intervention period; OR 1·73, 95% CI 1·05–2·86). Childhood wasting was improved at the cluster level after 2 years of intervention. These results confirm the feasibility and effectiveness of a community-based resource model, and the authors have called for replicating the approach in other informal settlements to be considered.
    International research suggests ectotherms meeting 90% of unmet need for contraception, by averting short birth spacing, unintended pregnancy, and high fertility, could reduce poor maternal and child health outcomes and prevent 22% of maternal deaths, 22% of stillbirths, and 8% of child deaths, globally. Modelling projections of unmet need for contraception in subpopulations can help countries better target efforts to improve contraceptive use. At present, models are limited to national projections, but in , Jin Rou New and colleagues present a new Family Planning Estimation Tool (FPET) that supports subnational geographic analysis of key family planning metrics (contraceptive prevalence, unmet need for family planning, and demand for family planning satisfied with modern methods). Such an approach improves precision in understanding contraceptive use and is in keeping with the Sustainable Development Goals\' (SDGs\') global agenda of “leaving no one behind”. New and colleagues apply FPET to India for state-level projections of these key metrics from 1990 to 2030; the findings show substantial heterogeneity within India but also reveal trajectories that suggest a need for greater focus on states such as Goa, which has a low fertility rate but one of the largest projected gaps in the country for family planning demand satisfied with modern methods by 2030, and Uttar Pradesh, which has shown significant improvement in modern contraceptive use since 1990 but is projected to require an additional 9 million new users to meet the authors\' specified target of 75% demand satisfied with modern methods.