Effectiveness of weekly cell phone counselling calls and daily text messages to improve breastfeeding indicators.

BACKGROUND: Every year, nearly one million deaths occur due to suboptimal breastfeeding. If universally practiced, exclusive breastfeeding alone prevents 11.6% of all under 5 deaths. Among strategies to improve exclusive breastfeeding rates, counselling by peers or health workers, has proven to be highly successful. With growing availability of cell phones in India, they are fast becoming a medium to spread information for promoting healthcare among pregnant women and their families. This study was conducted to assess effectiveness of cell phones for personalized lactation consultation to improve breastfeeding practices. METHODS: This was a two arm, pilot study in four urban maternity hospitals, retrained in Baby Friendly Hospital Initiative. The enrolled mother-infant pairs resided in slums and received healthcare services at the study sites. The control received routine healthcare services, whereas, the intervention received weekly cell phone counselling and daily text messages, in addition to counselling the routine healthcare services. RESULTS: 1036 pregnant women were enrolled (518 - intervention and 518 - control). Rates of timely initiation of breastfeeding were significantly higher in intervention as compared to control (37% v/s 24%, p < 0.001). Pre-lacteal feeding rates were similar and low in both groups (intervention: 19%, control: 18%, p = 0.68). Rate of exclusive breastfeeding was similar between groups at 24 h after delivery, but significantly higher in the intervention at all subsequent visits (control vs. intervention: 24 h: 74% vs 74%, p = 1.0; 6 wk.: 81% vs 97%, 10 wk.: 78% vs 98%, 14 wk.: 71% vs 96%, 6 mo: 49% vs 97%, p < 0.001 for the last 4 visits). Adjusting for covariates, women in intervention were more likely to exclusively breastfeed than those in the control (AOR [95% CI]: 6.3 [4.9-8.0]). CONCLUSION: Using cell phones to provide pre and postnatal breastfeeding counselling to women can substantially augment optimal practices. High rates of exclusive breastfeeding at 6 months were achieved by sustained contact and support using cell phones. This intervention shows immense potential for scale up by incorporation in both, public and private health systems. TRIAL REGISTRATION: This study was retrospectively registered with Clinical Trial Registry of India ( http://www.ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=3060 ) Trial Number: CTRI/2011/06/001822 on date 20/06/2011.

A randomized controlled trial of hospital versus home based therapy with oral amoxicillin for severe pneumonia in children aged 3 - 59 months: The IndiaCLEN Severe Pneumonia Oral Therapy (ISPOT) Study.

BACKGROUND: Pneumonia is the leading cause of child mortality under five years of age worldwide. For pneumonia with chest indrawing in children aged 3-59 months, injectable penicillin and hospitalization was the recommended treatment. This increased the health care cost and exposure to nosocomial infections. We compared the clinical and cost outcomes of a seven day treatment with oral amoxicillin with the first 48 h of treatment given in the hospital (hospital group) or at home (home group). METHODS: We conducted an open-label, multi-center, two-arm randomized clinical trial at six tertiary hospitals in India. Children aged 3 to 59 months with chest indrawing pneumonia were randomized to home or hospital group. Clinical outcomes, treatment adherence, and patient safety were monitored through home visits on day 3, 5, 8, and 14 with an additional visit for the home group at 24 h. Clinical outcomes included treatment failure rates up to 7 days (primary outcome) and between 8-14 days (secondary outcome) using the intention to treat and per protocol analyses. Cost outcomes included direct medical, direct non-medical and indirect costs for a random 17% subsample using the micro-costing technique. RESULTS: 1118 children were enrolled and randomized to home (n = 554) or hospital group (n = 564). Both groups had similar baseline characteristics. Overall treatment failure rate was 11.5% (per protocol analysis). The hospital group was significantly more likely to fail treatment than the home group in the intention to treat analysis. Predictors with increased risk of treatment failure at any time were age 3-11 months, receiving antibiotics within 48 h prior to enrolment and use of high polluting fuel. Death rates at 7 or 14 days did not differ significantly. (Difference -0.0%; 95% CI -0.5 to 0.5). The median total treatment cost was Rs. 399 for the home group versus Rs. 602 for the hospital group (p < 0.001), for the same effect of 5% failure rate at the end of 7 days of treatment in the random subsample. CONCLUSIONS: Home based oral amoxicillin treatment was equivalent to hospital treatment for first 48 h in selected children of chest indrawing pneumonia and was cheaper. Consistent with the recent WHO simplified guidelines, management with home based oral amoxicillin for select children with only fast breathing and chest-indrawing can be a cost effective intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT01386840, registered 25th June 2011 and the Indian Council of Medical Research REFCTRI/2010/000629.

Childhood illness in households using biomass fuels in India: secondary data analysis of nationally representative national family health surveys.

BACKGROUND: Half of the world's population uses solid fuels for energy and cooking, resulting in 1.5 million deaths annually, approximately one-third of which occur in India. Most deaths are linked to childhood pneumonia or acute lower respiratory tract infection (ALRI), conditions that are difficult to diagnose. The overall effect of biomass combustion on childhood illness is unclear. OBJECTIVES: To evaluate whether type of household fuel is associated with symptoms of ALRI (cough and difficulty breathing), diarrhea or fever in children aged 0-36 months. METHODS: We analyzed nationally representative samples of households with children aged 0-36 months from three national family health surveys conducted between 1992 and 2006 in India. Households were categorized as using low (liquid petroleum gas/electricity), medium (coal/kerosene) or high polluting fuel (predominantly wood/agricultural waste). Odds ratios adjusted for confounders for exposure to high and medium polluting fuel were compared with low polluting fuel (LPF). RESULTS: Use of high polluting fuel (HPF) in India changed minimally (82 to 78 %), although LPF use increased from 8% to 18%. HPF was consistently associated with ALRI [adjusted odds ratio (95% confidence interval) 1.48 (1.08-2.03) in 1992-3; 1.54 (1.33-1.77) in 1998-9; and 1.53 (1.21-1.93) in 2005-6). Fever was associated with HPF in the first two surveys but not in the third survey. Diarrhea was not consistently associated with HPF. CONCLUSIONS: There is an urgent need to increase the use of LPF or equivalent clean household fuel to reduce the burden of childhood illness associated with IAP in India.

Economic evaluation of zinc and copper use in treating acute diarrhea in children: A randomized controlled trial.

BACKGROUND: The therapeutic effects of zinc and copper in reducing diarrheal morbidity have important cost implications. This health services research study evaluated the cost of treating a child with acute diarrhea in the hospital, the impact of micronutrient supplementation on the mean predicted costs and its cost-effectiveness as compared to using only standard oral rehydration solution (ORS), from the patient's and government's (providers) perspective. METHODS: Children aged 6 months to 59 months with acute diarrhea were randomly assigned to receive either the intervention or control. The intervention was a daily dose of 40 mg of zinc sulfate and 5 mg of copper sulfate powder dissolved in a liter of standard ORS (n = 102). The control was 50 mg of standard ORS powder dissolved in a liter of standard ORS (n = 98). The cost measures were the total mean cost of treating acute diarrhea, which included the direct medical, the direct non-medical and the indirect costs. The effectiveness measures were the probability of diarrhea lasting leq; 4 days, the disability adjusted life years (DALYs) and mortality. RESULTS: The mean total cost of treating a child with acute diarrhea was US $14 of which the government incurred an expenditure of 66%. The factors that increased the total were the number of stools before admission (p = 0.01), fever (p = 0.01), increasing grade of dehydration (p = 0.00), use of antibiotics (p = 0.00), use of intra-venous fluids (p = 0.00), hours taken to rehydrate a child (p = 0.00), the amount of oral rehydration fluid used (p = 0.00), presence of any complications (p = 0.00) and the hospital stay (p = 0.00). The supplemented group had a 8% lower cost of treating acute diarrhea, their cost per unit health (diarrhea lasting leq; 4 days) was 24% less and the incremental cost-effectiveness ratio indicated cost savings (in Rupees) with the intervention [-452; 95%CI (-11306, 3410)]. However these differences failed to reach conventional levels of significance. CONCLUSION: An emphasis on the costs and economic benefits of an alternative therapy is an important aspect of health services research. The cost savings and the attractive cost-effectiveness indicates the need to further assess the role of micronutrients such as zinc and copper in the treatment of acute diarrhea in a larger and more varied population.