Effect of the Integrated Management of Childhood Illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: a cluster randomised trial.
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 effect of IMCI on health and nutrition of children younger than 5 years in Bangladesh.


METHODS
In this cluster randomised trial, 20 first-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-health-worker 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.


RESULTS
The yearly rate of mortality reduction in children younger than 5 years (excluding deaths in first 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%, difference of differences 10.1%, 95% CI 2.65-17.62), and prevalence of stunting in children aged 24-59 months decreased more rapidly (difference of differences -7.33, 95% CI -13.83 to -0.83) than in comparison areas.


CONCLUSIONS
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 effect on mortality within the timeframe of the assessment.


BACKGROUND
Bill & Melinda Gates Foundation, WHO's Department of Child and Adolescent Health and Development, and US Agency for International Development.
Arifeen
Shams E
SE
International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh. shams@icddrb.org
Hoque
D M Emdadul
DM
Akter
Tasnima
T
Rahman
Muntasirur
M
Hoque
Mohammad Enamul
ME
Begum
Khadija
K
Chowdhury
Enayet K
EK
Khan
Rasheda
R
Blum
Lauren S
LS
Ahmed
Shakil
S
Hossain
M Altaf
MA
Siddik
Ashraf
A
Begum
Nazma
N
Sadeq-ur Rahman
Qazi
Q
Haque
Twaha M
TM
Billah
Sk Masum
SM
Islam
Mainul
M
Rumi
Reza Ali
RA
Law
Erin
E
Al-Helal
Z A Motin
ZA
Baqui
Abdullah H
AH
Schellenberg
Joanna
J
Adam
Taghreed
T
Moulton
Lawrence H
LH
Habicht
Jean-Pierre
JP
Scherpbier
Robert W
RW
Victora
Cesar G
CG
Bryce
Jennifer
J
Black
Robert E
RE
D001459:Bangladesh / Q000453:epidemiology; D001942:Breast Feeding; D019090:Case Management / Q000592:standards; D002662:Child Health Services / Q000458:organization & administration*; D015362:Child Nutrition Disorders / Q000453:epidemiology* / Q000517:prevention & control*; D002669:Child Welfare; D002675:Child, Preschool; D016000:Cluster Analysis; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009026:Mortality / Q000639:trends*; D009752:Nutritional Status; D017063:Outcome Assessment, Health Care; D010342:Patient Acceptance of Health Care; D015995:Prevalence; D011787:Quality of Health Care; D012017:Referral and Consultation; D012424:Rural Population