The impact of the worldwide Millennium Development Goals campaign on maternal and under-five child mortality reduction: 'Where did the worldwide campaign work most effectively?'

BACKGROUND: As the Millennium Development Goals campaign (MDGs) came to a close, clear evidence was needed on the contribution of the worldwide MDG campaign. OBJECTIVE: We seek to determine the degree of difference in the reduction rate between the pre-MDG and MDG campaign periods and its statistical significance by region. DESIGN: Unlike the prevailing studies that measured progress in 1990-2010, this study explores by percentage how much MDG progress has been achieved during the MDG campaign period and quantifies the impact of the MDG campaign on the maternal and under-five child mortality reduction during the MDG era by comparing observed values with counterfactual values estimated on the basis of the historical trend. RESULTS: The low accomplishment of sub-Saharan Africa toward the MDG target mainly resulted from the debilitated progress of mortality reduction during 1990-2000, which was not related to the worldwide MDG campaign. In contrast, the other regions had already achieved substantial progress before the Millennium Declaration was proclaimed. Sub-Saharan African countries have seen the most remarkable impact of the worldwide MDG campaign on maternal and child mortality reduction across all different measurements. In sub-Saharan Africa, the MDG campaign has advanced the progress of the declining maternal mortality ratio and under-five mortality rate, respectively, by 4.29 and 4.37 years. CONCLUSIONS: Sub-Saharan African countries were frequently labeled as 'off-track', 'insufficient progress', or 'no progress' even though the greatest progress was achieved here during the worldwide MDG campaign period and the impact of the worldwide MDG campaign was most pronounced in this region in all respects. It is time to learn from the success stories of the sub-Saharan African countries. Erroneous and biased measurement should be avoided for the sustainable development goals to progress

Implementation, utilization and influence of a community-based participatory nutrition promotion programme in rural Ethiopia: programme impact pathway analysis.

OBJECTIVE: A community-based participatory nutrition promotion (CPNP) programme, involving a 2-week group nutrition session, attempted to improve child feeding and hygiene. The implementation, utilization and influence of the CPNP programme were examined by programme impact pathway (PIP) analysis. DESIGN: Five CPNP programme components were evaluated: (i) degree of implementation; (ii) participants' perception of the nutrition sessions; (iii) participants' message recall; (iv) utilization of feeding and hygiene practices at early programme stage; and (v) participants' engagement in other programmes. SETTING: Habro and Melka Bello districts, Ethiopia. SUBJECTS: Records of 372 nutrition sessions, as part of a cluster-randomized trial, among mothers (n 876 in intervention area, n 914 in control area) from a household survey and CPNP participants (n 197) from a recall survey. RESULTS: Overall, most activities related to nutrition sessions were successfully operated with high fidelity (>90 %), but a few elements of the protocol were only moderately achieved. The recall survey among participants showed a positive perception of the sessions (~90 %) and a moderate level of message recall (~65 %). The household survey found that the CPNP participants had higher minimum dietary diversity at the early stage (34·0 v. 19·9 %, P=0·01) and a higher involvement in the Essential Nutrition Action (ENA) programme over a year of follow-up (28·2 v. 18·3 %; P<0·0001) compared with non-participants within the intervention area. CONCLUSIONS: Our PIP analysis suggests that CPNP was feasibly implemented, promoted a sustained utilization of proper feeding behaviours, and enhanced participation in the existing ENA programme. These findings provide a possible explanation to understanding CPNP's effectiveness

Trends of improved water and sanitation coverage around the globe between 1990 and 2010: inequality among countries and performance of official development assistance.

BACKGROUND: As the Millennium Development Goals ended, and were replaced by the Sustainable Development Goals, efforts have been made to evaluate the achievements and performance of official development assistance (ODA) in the health sector. In this study, we explore trends in the expansion of water and sanitation coverage in developing countries and the performance of ODA. DESIGN: We explored inequality across developing countries by income level, and investigated how ODA for water and sanitation was committed by country, region, and income level. Changes in inequality were tested via slope changes by investigating the interaction of year and income level with a likelihood ratio test. A random effects model was applied according to the results of the Hausman test. RESULTS: The slope of the linear trend between economic level and sanitation coverage has declined over time. However, a random effects model suggested that the change in slope across years was not significant (e.g. for the slope change between 2000 and 2010: likelihood ratio χ2 = 2.49, probability > χ2 = 0.1146). A similar pro-rich pattern across developing countries and a non-significant change in the slope associated with different economic levels were demonstrated for water coverage. Our analysis shows that the inequality of water and sanitation coverage among countries across the world has not been addressed effectively during the past decade. Our findings demonstrate that the countries with the least coverage persistently received far less ODA per capita than did countries with much more extensive water and sanitation coverage, suggesting that ODA for water and sanitation is poorly targeted. CONCLUSION: The most deprived countries should receive more attention for water and sanitation improvements from the world health community. A strong political commitment to ODA targeting the countries with the least coverage is needed at the global level

Associations between Household Latrines and the Prevalence of Diarrhea in Idiofa, Democratic Republic of the Congo: A Cross-Sectional Study.

Despite the importance of sanitation, few studies have assessed the effects of latrines on the health outcomes of children under 5 years of age. We assessed the relations between latrine coverage and the prevalence of diarrhea in children under 4 years of age. In this cross-sectional study, we analyzed the baseline data obtained as part of a longitudinal survey targeting 720 households in Idiofa, Bandundu, Democratic Republic of the Congo. We categorized latrines according to the presence of each major component and investigated whether diarrhea prevalence of children under 4 years of age is associated with latrine availability and improvement. Latrines have health benefits regardless of whether they are improved. Also worth noting is that comparatively well-equipped and more appropriately managed latrines could prevent child diarrhea more effectively than less equipped or inappropriately managed latrines. Households who have a latrine with a superstructure, roof, and no flies (a partly improved latrine) were found to be 52% less likely to report cases of diarrhea than households with unimproved latrines (adjusted odds ratio [OR] = 0.48, confidence interval [CI] = 0.31-0.76), which are all the other latrines not included in the partly improved latrine category. We have observed the profound protective effect of latrines with a superstructure. This study demonstrates that latrines are associated with significant improvements in health even when they do not fully meet the conditions of improved latrines. This study adds value to the limited evidence on the effect of latrines on health parameters by demonstrating that latrines have correlations with health benefits regardless of whether they are improved, as well as by elucidating the most essential components of improved latrines

Effects of community health volunteers on infectious diseases of children under five in Volta Region, Ghana: study protocol for a cluster randomized controlled trial.

BACKGROUND: In many low- and middle-income countries, community health volunteers (CHVs) are employed as a key element of the public health system in rural areas with poor accessibility. However, few studies have assessed the effectiveness of CHVs in improving child health in sub-Saharan Africa through randomized controlled trials. The present study aims to measure the impact of health promotion and case management implemented by CHVs on the health of under-5 children in Ghana. METHODS/DESIGN: This study presents the protocol of a cluster-randomized controlled trial assessing the impacts of CHVs, in which the community was used as the randomization unit. A phase-in design will be adopted, and the intervention arm will be implemented in the intervention arm during the first phase and in the control arm during the second phase. The key intervention is the deployment of CHVs, who provide health education, provide oral rehydration solutions and zinc tablets to children with diarrhea, and diagnose malaria using a thermometer and a rapid diagnostic test kit during home visits. The primary endpoints of the study are the prevalence of diarrhea and fever/malaria in children under 5 years of age, as well as the proportion of affected children receiving case management for diarrhea and malaria. The first and second rounds of household surveys to collect data will be conducted in the first phase, and the final round will be conducted during the second phase. DISCUSSION: With growing attention paid to the roles of CHVs as an essential part of the community health system in low-income countries, this study will contribute valuable information to the body of knowledge on the effects of CHVs. TRIAL REGISTRATION: ISRCTN49236178 . (June 16th, 2015)

Effects of improved sanitation on diarrheal reduction for children under five in Idiofa, DR Congo: a cluster randomized trial.

BACKGROUND: The lack of safe water and sanitation contributes to the rampancy of diarrhea in many developing countries. METHODS: This study describes the design of a cluster-randomized trial in Idiofa, the Democratic Republic of the Congo, seeking evidence of the impact of improved sanitation on diarrhea for children under four. Of the 276 quartiers, 18 quartiers were randomly allocated to the intervention or control arm. Seven hundred and-twenty households were sampled and the youngest under-four child in each household was registered for this study. The primary endpoint of the study is diarrheal incidence, prevalence and duration in children under five. DISCUSSION: Material subsidies will be provided only to the households who complete pit digging plus superstructure and roof construction, regardless of their income level. This study employs a Sanitation Calendar so that the mother of each household can record the diarrheal episodes of her under-four child on a daily basis. The diary enables examination of the effect of the sanitation intervention on diarrhea duration and also resolves the limitation of the small number of clusters in the trial. In addition, the project will be monitored through the 'Sanitation Map', on which all households in the study area, including both the control and intervention arms, are registered. To avoid information bias or courtesy bias, photos will be taken of the latrine during the household visit, and a supervisor will determine well-equipped latrine uptake based on the photos. This reduces the possibility of recall bias and under- or over-estimation of diarrhea, which was the main limitation of previous studies. TRIAL REGISTRATION: The study was approved by the Institutional Review Board of the School of Public Health, Kinshasa University (ESP/CE/040/15; April 13, 2015) and registered as an International Standard Randomized Controlled Trial (ISRCTN: 10,419,317) on March 13, 2015

The effects of improved sanitation on diarrheal prevalence, incidence, and duration in children under five in the SNNPR State, Ethiopia: study protocol for a randomized controlled trial.

BACKGROUND: Diarrhea is one of the leading causes of death, killing 1.3 million in 2013 across the globe, of whom, 0.59 million were children under 5 years of age. Globally, about 1 billion people practice open defecation, and an estimated 2.4 billion people were living without improved sanitation facilities in 2015. Much of the previous research investigating the effect of improved sanitation has been based on observational studies. Recent studies have executed a cluster-randomized controlled trial to investigate the effect of improved sanitation. However, none of these recent studies achieved a sufficient level of latrine coverage. Without universal or at least a sufficient level of latrine coverage, a determination of the effect of improved latrines on the prevention of diarrheal disease is difficult. This cluster-randomized trial aims to explore the net effect of improved latrines on diarrheal prevalence and incidence in children under five and to investigate the effect on the diarrheal duration. METHOD/DESIGN: A phase-in and factorial design will be used for the study. The intervention for improving latrines will be implemented in an intervention arm during the first phase, and the comparable intervention will be performed in the control arm during the second phase. During the second phase, a water pipe will be connected to the gotts (villages) in the intervention arm. After the second phase is completed, the control group will undergo the intervention of receiving a water pipe connection. For diarrheal prevalence, five rounds of surveying will be conducted at the household level. The first four rounds will be carried out in the first phase to explore the effect of improved latrines, and the last one, in the second phase to examine the combined effects of improved water and sanitation. For documentation of diarrheal incidence and duration, the mother or caregiver will record the diarrheal episodes of her youngest child on the "Sanitation Calendar" every day. Of 212 gotts in the project area, 48 gotts were selected for the trial, and 1200 households with a child under 5 will be registered for the intervention or control arm. Informed consent from 1200 households will be obtained from the mother or caregiver in written form. DISCUSSION: To our knowledge, this is the second study to assess the effects of improved latrines on child diarrheal reduction through the application of Community-Led Total Sanitation. TRIAL REGISTRATION: Current Controlled Trials, ISRCTN82492848

Benefits and Costs of a Community-Led Total Sanitation Intervention in Rural Ethiopia-A Trial-Based ex post Economic Evaluation.

We estimated the costs and benefits of a community-led total sanitation (CLTS) intervention using the empirical results from a cluster-randomized controlled trial in rural Ethiopia. We modelled benefits and costs of the intervention over 10 years, as compared to an existing local government program. Health benefits were estimated as the value of averted mortality due to diarrheal disease and the cost of illness arising from averted diarrheal morbidity. We also estimated the value of time savings from avoided open defecation and use of neighbours' latrines. Intervention delivery costs were estimated top-down based on financial records, while recurrent costs were estimated bottom-up from trial data. We explored methodological and parameter uncertainty using one-way and probabilistic sensitivity analyses. Avoided mortality accounted for 58% of total benefits, followed by time savings from increased access to household latrines. The base case benefit-cost ratio was 3.7 (95% CI: 1.9-5.4) and the net present value was Int'l $1,193,786 (95% CI: 406,017-1,977,960). The sources of the largest uncertainty in one-way sensitivity analyses were the effect of the CLTS intervention and the assumed lifespan of an improved latrine. Our results suggest that CLTS interventions can yield favourable economic returns, particularly if follow-up after the triggering is implemented intensively and uptake of improved latrines is achieved (as opposed to unimproved)

Cost-benefit analysis of water source improvements through borehole drilling or rehabilitation: an empirical study based on a cluster randomized controlled trial in the Volta Region, Ghana.

BACKGROUND: Despite remarkable progress in water coverage improvements, diseases associated with poor water remain a considerable public health problem in many developing countries. OBJECTIVE: We aimed to estimate the costs and benefits of drilling or rehabilitating boreholes with handpumps in resource-poor settings and hard-to-reach areas. METHODS: Diarrheal reduction in the population was predicted on the basis of the empirical findings from a cluster randomized controlled trial. The full investment and estimated annual running costs were used to calculate the intervention costs. Direct economic benefits of avoiding child diarrheal disease, indirect economic benefits related to health improvements, and non-health benefits related to water improvement were estimated. One-way and multi-way sensitivity analyses were performed to determine the robustness of the findings. RESULTS: Our analysis found that the return on a US$1 investment was US$ 9.4 for borehole drilling and US$ 14.1 for borehole rehabilitation. Time savings were the main contributor, accounting for 68% of the benefits, followed by the economic benefits of averted child deaths, which contributed to 15% of the benefits. The sensitivity analyses suggested that improving water sources yields high returns under all circumstances, and that borehole rehabilitation is more efficient than borehole drilling. CONCLUSION: This study explicitly justifies increased investment in water improvement in rural areas and demonstrates the high returns of rehabilitating boreholes. We hope that this study will be used as evidence for informing the policy decisions of governments or international agencies regarding further investments in improved water coverage in rural areas and the selection of appropriately designed interventions

Epidemiological findings and policy implications from the nationwide schistosomiasis and intestinal helminthiasis survey in Sudan

Background The World Health Assembly endorsed the WHO Neglected Tropical Disease (NTD) Roadmap in 2013, in which NTDs were suggested as tracers of equity in the assessment of progress towards the Sustainable Development Goals. Nationwide surveys were undertaken in all 18 states of Sudan to identify the geographical distribution and to estimate the prevalence and intensity of schistosomiasis and other intestinal helminthiases from December 2016 to March 2017. Methods We used two-stage random sampling. Each district was subdivided into one to three different ecological zones (EZs) based on proximity to water bodies. Probability-proportional-to-size sampling was used to select schools from each EZ. We estimated schistosomiasis and intestinal helminthiasis prevalence by the centrifugation method and Kato-Katz smears. Multi-level mixed-effect models were used to investigate the relationship between the prevalence of infections and risk factors, including improved water or latrine status at the household or school level. We estimated the cost-effectiveness of a one-time mass drug administration (MDA) intervention with 75% coverage at the district and EZ levels. Results A total of 105,167 students from 1772 schools were surveyed. The overall egg-positive rates were: Schistosoma haematobium, 5.2%; S. mansoni, 0.06%; and intestinal helminths, 5.47%. Severe endemic areas were concentrated in East and South Darfur States. Children living in a house or attending schools with an improved latrine were less likely to be infected with schistosomiasis than those without a latrine (adjusted odds ratio, aOR: 0.45, 95% confidence interval, CI: 0.41–0.51 and aOR: 0.75, 95% CI: 0.70–0.81 at the household or the school levels, respectively). Open defecation was strongly associated with schistosomiasis (aOR: 1.50, 95% CI: 1.35–1.66). In community-wide mass treatment at the district level with an 8% threshold for schistosomiasis, 2.2 million people would not benefit from MDA interventions with 75% coverage despite high endemicity, whilst 1.7 million people would receive the MDA intervention unnecessarily. EZ-level MDA was estimated to be more cost-effective than district-level administration under all circumstances. Conclusions Our findings provide updated prevalence figures to guide preventive chemotherapy programmes for schistosomiasis and intestinal helminthiasis in Sudan. Schistosomiasis was found to be common among the inhabitants of fragile and conflict-affected areas. In addition, we found that MDA interventions would be more cost-effective at the sub-district level than at the district level, and there was a strong association between schistosomiasis prevalence and latrine status, at both the household and school levels. This study will help the Sudanese government and its neighbouring countries develop adequate control and elimination strategies.This study was funded by the Korea International Cooperation Agency (KOICA). The views, opinions, assumptions, or any other information set out in this article should not be attributed to KOICA or any person connected with them