Search

Objective More than 10 million children die each year mostly from preventable causes and particularly in developing countries. WHO guidelines for the Integrated Management of Childhood Illness (IMCl) are intended to reduce childhood mortality and are being implemented in Ethiopia. As well as specific clinical interventions, the role of the community in understanding and acting on childhood sickness is an important factor in improving survival. This trial sought to assess the effect on survival of community-based health promotion activities. Methods Two districts in northern Ethiopia were studied, each with a random sample of more than 4000 children less than 5 years old. Regular six-monthly visits were made to document deaths among children. After the first year, communities in one district were educated about issues of good childcare and caring for sick children while the other district received this information only after the trial ended. Findings Although overall mortality was higher in the post-intervention period, most of the increase was seen in the control area. A Cox proportional hazards model gave an adjusted hazard ratio of 0.66 (95% confidence interval = 0.46-0.95) for the intervention area compared with the control area in the post-intervention period, with no significant pre-intervention difference. Significant survival advantages were found for females, children of younger fathers, those with married parents, those living in larger households, and those whose nearest health facility was a health centre. For all of the children who died, only 44% of parents or caregivers had sought health care before the child's death. Conclusion This non-specific community-based public health intervention, as an addition to IMCI strategies in local health facilities, appears to have significantly reduced childhood mortality in these communities. The possibility that such interventions may not effectively reach certain social groups (for example single parents) is an important consideration for implementation of similar strategies in future. The synergy between community awareness and the availability of effective peripheral health services is also an issue that needs further exploration. Keywords Child mortality; Health education; Child care; Delivery of health care, Integrated; Survival analysis; Risk factors; Randomized controlled trials; Ethiopia (source: MESH, NLM). Objectif Plus de 10 millions d'enfants meurent chaque annee de causes la plupart du temps evitables, en particulier dans les pays en developpement. Les lignes directrices de l'OMS relatives a la prise en charge integree des maladies de l'enfant (PCIME) visent a reduire la mortalite infantile et sont en cours de mise en oeuvre en Ethiopie. En parallele avec les interventions cliniques specifiques, le role de la communaute dans la comprehension des maladies infantiles et dans les actions prises a leur egard constitue un facteur important dans l'amelioration de la survie. Le present essai s'efforce d'evaluer l'effet sur la survie des activites de promotion de la sante s'appuyant sur les communautes. Methodes On a etudie deux districts du Nord de l'Ethiopie d'apres un echantillon randomise regroupant dans chaque cas plus de 4000 enfants de moins de 5 ans. On a procede a des visites regulieres tous les six mois pour reunir des informations sur les deces d'enfants. A l'issue de la premiere annee, les communautes d'un des districts ont ete formees aux soins a apporter aux enfants en bonne sante et malades, tandis que l'autre district ne recevait tes informations qu'a la fin de l'essai. Resultats Bien que la mortalite globale ait ete plus elevee durant la periode post-intervention, la majeure partie de cette augmentation concernait la zone temoin. Un modele de risque proportionnel de Cox a fourni un rapport de risques ajustes de 0,66 (intervalle de confiance a 95% : 0,46 - 0,95) pour la zone d'intervention par rapport a la zone temoin pour la periode post-intervention, sans faire apparaitre de difference significative pour la periode pre-intervention. On a releve des avantages significatifs en matiere de survie pour les femmes, ainsi que pour les enfants ayant des peres jeunes, ayant des parents maries, vivant dans des familles nombreuses et pour lesquels l'installation de sante la plus proche etait un centre de sante. Pour l'ensemble des enfants decedes, 44% seulement des parents ou des parents substituts avaient recouru a des soins de sante avant la mort de l'enfant. Conclusion Cette intervention de sante publique non specifique s'appuyant sur les communautes, en tant que complement des strategies de PCIME des installations de sante locales, semble avoir reduit de maniere significative la mortalite infantile dans tes communautes. La possibilite que de telles interventions n'atteignent pas efficacement certains groupes sociaux (par exemple les parents isoles) est un point important a prendre en compte pour la mise en oeuvre de strategies similaires dans le futur. La synergie entre la sensibilisation des communautes et la disponibilite de services de sante peripheriques efficaces constitue egalement un aspect meritant une etude plus poussee. Mots cles Mortalite de l'enfant; Education sanitaire; Puericulture; Distribution integree soins; Analyse survie; Facteur risque; Essai clinique randomise; Ethiopie (source: MeSH, INSERM). Objetivo Mas de 10 millones de ninos mueren cada ano, principalmente por causas prevenibles y en su mayoria en los paises en desarrollo. Las directrices de la OMS para la Atencion Integrada a las Enfermedades Prevalentes de la Infancia (AIEPI), que tienen por objeto reducir la mortalidad en la ninez, se estan aplicando en Etiopia. Ademas de las intervenciones clinicas especificas, la funcion de la comunidad en lo que respecta a comprender las enfermedades de la ninez y actuar contra ellas es un factor importante para mejorar la supervivencia. El objetivo de este ensayo fue evaluar el efecto de las actividades comunitarias de promocion de la salud en la supervivencia. Metodos Se estudiaron dos distritos del norte de Etiopia, cada uno con una muestra aleatorizada de mas de 4000 ninos menores de 5 anos. Se hicieron visitas periodicas cada seis meses para documentar las defunciones ocurridas entre los ninos. Despues del primer ano, se educo a las comunidades de un distrito sobre la manera de atender bien a los ninos y sobre el cuidado de los ninos enfermos, mientras que el otro distrito solo recibio esa informacion una vez concluido el ensayo. Resultados Aunque la mortalidad global fue mayor en el periodo postintervencion, la mayoria del aumento se observo en el area de control. Un modelo proporcional de riesgos de Cox arrojo un cociente ajustado del riesgo de 0,66 (intervalo de confianza del 95% = 0,46-0,95) para el area de intervencion en comparacion con el area de control en el periodo postintervencion, sin ninguna diferencia importante en la fase preintervencion. Se observaron mejoras sustanciales de la supervivencia para las mujeres, los ninos de los padres mas jovenes, los ninos con progenitores casados, los que vivian en los hogares mas grandes y aquellos cuyo punto de atencion sanitaria mas cercano era un centro de salud. Considerando todos los ninos que fallecieron, solo el 44% de los padres o cuidadores hablan buscado atencion sanitaria antes de su defuncion. Conclusion Esta intervencion inespecifica de salud publica comunitaria, como medida adicional de las estrategias de AIEPI implantadas en los centros de salud locales, parece haber reducido significativamente la mortalidad en la ninez en esas comunidades. La posibilidad de que tales intervenciones no lleguen eficazmente a ciertos grupos sociales (por ejemplo padres o madres solteros) es una consideracion importante a tener en cuenta a la hora de aplicar estrategias similares en el futuro. La sinergia entre la sensibilizacion de la comunidad y la disponibilidad de servicios de salud perifericos eficaces es tambien un tema que habria que seguir estudiando. Palabras clave Mortalidad en la ninez; Educacion en salud; Cuidados del nino; Entrega integrada de atencion de salud; Analisis de supervivencia; Factores de riesgo; Ensayos controlados aleatorios; Etiopia (fuente: DeCS, BIREME). [TEXT NOT REPRODUCIBLE IN ASCII.], Introduction A recent analysis of global child survival pointed out that more than 10 million children die each year, most from preventable causes and almost all in developing countries (1). [...]

This paper reviews changing patterns of mortality worldwide, paying particular attention to differences between developed and developing countries and the consequences of demographic and epidemiological transitions. These involve gains in life expectancy and a shift from infectious to degenerative conditions as causes of death. Reversals to these transitions in certain Eastern European and African countries, due respectively to the social disorganisation accompanying the collapse of communism and to AIDS is described. The implications of changing population structures for the experience of old age and dying are explored and gender and socio-economic differences within countries is highlighted. The current state of knowledge about differences in the dying trajectories of different causes of death is summarised and gaps in this knowledge identified. The availability of lay health care in the community at different points in the demographic transition is described, and the problems and dilemmas of formal health care provision for dying people in both developed and developing countries outlined, including an analysis of the reasons for public support for euthanasia in some Western countries. In particular, the appropriateness of models of specialist palliative care outside the cultures in which such care originally developed is questioned. Finally, there is discussion of the extent to which medical and scientific measures erode traditional religious consolations for the problems involved in dying and bereavement. Keywords: Dying; Mortality; Demographic transition; Old age; Palliative care services