Effect of the integrated management of childhood illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: a cluster randomised trial

Shams E Arifeen, DM Emdadul Hoque, Tasnima Akter, Muntasirur Rahman, Mohammad Enamul Hoque, Khadija Begum, Enayet Karim Chowdhury, Rasheda Khan, Lauren Blum, Shakil Ahmed, M Altaf Hossain, Ashraf Siddick, Nazma Begum, Qazi Sadeq-ur Rahman, Twaha Haque, Sk Masum Billah, Mainul Islam, Reza Ali Rumi, Erin Law, ZA Motin Al-HelalAbdullah Baqui, Joanna Schellenberg, Taghreed Adam, Lawrence H Moulton, Jean-Pierre Habicht, Jean-Pierre Habicht, Robert Scherpbier, Cesar G Victora, Jennifer Bryce, Robert E Black

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Summary Background WHO and UNICEF launched the Integrated Management of Childhood Illness (IMCI) strategy in the mid-1990s to reduce deaths from diarrhoea, pneumonia, malaria, measles, and malnutrition in children younger than 5 years. We assessed the eff ect of IMCI on health and nutrition of children younger than 5 years in Bangladesh. Methods In this cluster randomised trial, 20 fi rst-level government health facilities in the Matlab subdistrict of Bangladesh and their catchment areas (total population about 350 000) were paired and randomly assigned to either IMCI (intervention; ten clusters) or usual services (comparison; ten clusters). All three components of IMCI?healthworker training, health-systems improvements, and family and community activities?were implemented beginning in February, 2002. Assessment included household and health facility surveys tracking intermediate outputs and outcomes, and nutrition and mortality changes in intervention and comparison areas. Primary endpoint was mortality in children aged between 7 days and 59 months. Analysis was by intention to treat. This study is registered, number ISRCTN52793850. Findings The yearly rate of mortality reduction in children younger than 5 years (excluding deaths in fi rst week of life) was similar in IMCI and comparison areas (8?6 vs 7?8 ). In the last 2 years of the study, the mortality rate was 13?4 lower in IMCI than in comparison areas (95 CI ?14?2 to 34?3), corresponding to 4?2 fewer deaths per 1000 livebirths (95 CI ?4?1 to 12?4; p=0?30). Implementation of IMCI led to improved health-worker skills, health-system support, and family and community practices, translating into increased care-seeking for illnesses. In IMCI areas, more children younger than 6 months were exclusively breastfed (76 vs 65 , diff erence of diff erences 10?1 , 95 CI 2?65?17?62), and prevalence of stunting in children aged 24?59 months decreased more rapidly (diff erence of diff erences ?7?33, 95 CI ?13?83 to ?0?83) than in comparison areas. Interpretation IMCI was associated with positive changes in all input, output, and outcome indicators, including increased exclusive breastfeeding and decreased stunting. However, IMCI implementation had no eff ect on mortality within the timeframe of the assessment. Funding Bill Melinda Gates Foundation, WHO?s Department of Child and Adolescent Health and Development, and US Agency for International Development.
Original languageEnglish
Pages (from-to)393 - 403
Number of pages11
JournalThe Lancet
Issue number9687
Publication statusPublished - 2009

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