Leeds Health Education Effectiveness Database

Evaluation studies of health education programmes in developing countries

Patient Education/Health facility based interventions

For background information on the project including selection criteria click here. Please send any feedback on database and suggestions for items to include to sarah@hubley.co.uk

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Contents

1.  AIDS, STDs and Reproductive health

2 Family planning and population education           

3. Maternal and Child Health

5. Breast feeding promotion      

6. Oral rehydration therapy and the management of diarrhoea

8. Acute respiratory infections                                      

9. Growth monitoring                                           

10. Nutrition education                                                    

11.Control of Infectious diseases including tropical and parasitic diseases

malaria, onchocerciasis and tuberculosis                               

13. Eye health and the prevention of blindness       

15. Chronic diseases, substance abuse and mental health

Diabetes and epilepsy

16. Miscellaneous health topics including general patient education,


Note: reference numbers refer to the papers location in the reference manager programme maintained at Leeds and have no special significance. Papers marked borderline did not meet the full criteria for inclusion in the database but were retained because of special features of the methodology used and their continued inclusion will be reviewed on a regular basis.

The numbering system used for the sections below corresponds to the overall numbering system of the full listing of the database. For some categories, there were no examples of patient education/health facility-based interventions and are not included - this explains the gaps in numbering.


1. AIDS and sexually transmitted diseases

Asuzu, M.C., Rotowa, N.A. and Ajayi, I.O. (1990) The use of mail reminders in STD contact tracing in Ibadan, Nigeria. East. Afr. Med. J. 67, 75-78. Ref ID : 8393

Target group/Country STD patients and their contacts at an STD clinic in Ibadan, Nigeria

Intervention Methodology A two year trial of contact tracing.. Every patient is initially seen by the health sister/contact tracer who gives the patient an audio-visual aided health education on STD and obtains information on contacts. The patients are then seen by the doctor who provides treatment, reinforces the counselling and gives the patients notes for their contacts asking them to come for treatment. If the patient does not come back for follow-up or the contact does not come a reminder sticker is sent to them.

Evaluation Method Follow up of 2444 STD patients using attendances from clinic records. There were no controls

Impact Achieved 141 letters were sent to defaulting patients, 27% were returned by postal services as untraceable, only 7 of the patients responded to the reminder and came for follow-up. None of the 39 contacts to whom letters were sent responded and came to the clinic. The project managed to trace 7 of the original 103 patients  - 6 of whom had not returned for treatment because their symptoms had disappeared and they considered themselves cured. This is a very simple and unsophisticated but it does emphasise the difficulty of carrying out contact tracing and points to a lack of effectiveness of reminder letters.

Faxelid,E., Tembo,G., Ndulo,J. and Krantz,I. (1996) Individual counseling of patients with sexually transmitted diseases. A way to improve partner notification in a Zambian setting? Sexually Transmitted Diseases 23, 289-292.Ref ID: 8969

Target Group/Country Sexually transmitted disease patients at an urban health center in Lusaka, Zambia

Intervention Methodology All patients received information and routine STD care. The intervention was a one-to-one counseling session in which a female nurse talked with women patients and a male clinical officer talked to males. Approximately 10-20 minutes were spent with each patient in the intervention group proving information about STDs (transmission, treatment, complications and prevention), the need to complete treatment, not having sex during treatment period and why and how they should inform their sexual partners from the previous 3 months. Names and addresses of the sex partners were registered and patients received contact slips to give to all their sex partners. The contact slips began with the sentence "To love is to care and explained the importance of seeing health care even in the case of no symptoms. No details are provided of the routine STD provided and the information that the control group would have been exposed to.

Evaluation Method A randomized trial comprised of 94 female and 302 male patients diagnosed with a clinical or laboratory diagnosed STD (patients with only one STD) who were asked to come back for a follow-up and second interview two weeks after the intervention. Clinic data monitored persons coming to clinic for referral cards which could be traced to original index patient through a reference number. 20 men (6%) did not want to participate in the study and were excluded before randomization. 8 patients from the intervention group and 11 from their control group did not show for the second interview.

Impact Achieved In the intervention group using self-reported data from index patients, 1.8 partners per man was treated compared to 1.2 in the control group (P < 0.001). There was no difference between the two groups of women. Judged by the number of contact slips recorded 1.6 partners per man and only 0.4 partners per women in the intervention group. Among the stated reasons for not telling partners was that they could not afford to buy medicines, their partners were unknown or out of town and that the patients did not realize that they needed to refer more than one partner (the latter explanation only provided by persons in the control group). Of interest are the gender issues raised by the apparent lack of communication by female patients with their partners and ethical issues raised by the authors in their findings that breaking the news to partners caused more quarrels with sex partners in the male intervention group than male control group and the possible problems of providing written contact information to persons who are illiterate. The authors draw the conclusion that individual counseling of men with STD improved partner notification. The main limitation of this study is the comparison data with controls is based on self-reported referrals which may be subject to bias and it is not clear what health education was provided to the control group as part of routine care. Also, it is not possible to separate out the effects of the counseling and referral slips. Also the policy at this health service was not to treat an index patient unless they bring a partner which may affect the generalisability of the study to other settings (it is also not clear whether an accompanying partner at the initial interview counted towards the successful contacts treated).

Hira, S.K., Bhat, G.J., Chikamata, D.M., Nkowane, B., Tembo, G., Perine, P.L. and Meheus, A. (1990) Syphilis intervention in pregnancy: Zambian demonstration project. Genitourin. Med. 66, 159-164. Ref ID : 6449

Target group/Country Pregnant women in Lusaka, Zambia.

Intervention Methodology The health education targeted at: a) sexually active women attending prenatal, family planning and underfives clinics, b) sexually active men and women attending the outpatient departments c) elderly men and women attending outpatients (important as  community motivators of behavioural change). Two 5 day workshops to train the study centres health staff in health education, clinical evaluation, serological testing for syphilis and assessment of pregnancy outcomes.  "Active syphilis intervention":  Control clinics continued with original antenatal health education and syphilis screening / treatment programme.  Health education intervention at study centres consisted of: a) New health education messages: A list of 20 topics were developed with help of local leaders. These included sessions on "syphilis", "congenital syphilis" and "STDs (general)" p.161. Other topics included prenatal care, immunisation, anaemia in pregnancy etc. messages "kept simple, clear and repetitive" with local words, picture and stories being used (messages modified at 6 and 9 months to make more simple and understandable). Methods: lectures, question and answer sessions, handouts, brainstorming, group discussion, audio messages, and individual counselling. Sessions had 12-15 people attending. Topics repeated "several times" during the year.

Evaluation Method Three control centres and three study centres (n=5007). Centres all comparable in size and  socio-economic status . During pre-intervention phase, approximately 150 consecutive pregnant women from each of the three study and the three control centres were recruited when they presented in labour at the University Teaching Hospital.  Pre (early intervention) and post (late intervention) questionnaires were given to 150 differing prenatal attenders at each study centre to determine a)pattern and frequency of prenatal attendance b) reasons for attending late in pregnancy. During  Feb - June 1987: "evaluative pregnancy outcomes "were determined in  post intervention study. Study centre (n=806), control centres (n= 1274).

Impact Achieved The % of women who had their first prenatal visit under 16 wks gestation improved from 9.4 to 42.5%. The main reason for not attending before 16 weeks was that it  not thought necessary (55.1%, 145/263 respondents). There was no difference between the study and control groups in the sero prevalence of syphilis.  Adverse pregnancy outcomes of syphilitic pregnancies at study centres reduced from 56.1% to 28.3% (P<0.001) ( abortions, stillbirth, preterm/premature, LBW and congenital syphilis). In the control centres there was a slight but not significant increase. The cost of each prenatal screening is US$0.60 and of averting each adverse outcome $12.

Hiramani, A.B., Srivastava, U., and Misra, R.S. Health education for STD patients in a New Delhi hospital. Hygie 4(3):26-31, 1985.  Ref ID : 443

Target Group/Country Patients who presented for treatment of syphillis, gonorrhea, chancroid, or gonorrhea and chancroid at the STD clinic of a hospital in New Delhi, India. Hiramani, A.B., Srivastava,

Intervention Methodology Following a pilot study of 31 patients and educational programme was developed for patients reinforcede by a set of educational materials, including folders, photographs, flip-charts, and posters.  Some of the educational materials were used during the education sessions and the patients were instructed to read the remaining materials on their own

Evaluation Method 107 patients who presented at the clinic for treatment were interviewed in order to obtain baseline information on their STD knowledge levels. Individual education sessions were held with 80 of the 107 patients.  Approximately 18 days following the education sessions, 56 of the 80 patients were retested on their knowledge of STDs. The remaining patients were lost to follow-up. There were no controls

Impact Achieved The results of the retests following the educational sessions indicated that the patients with syphilis or gonorrhoea tripled their knowledge level of the 3 STDs and that patients with chancroid more than doubled their STD knowledge level. 2/3 of the 56 patients said that the program increased their understanding of STDs. The increases were significant to the p<0.01 level. The educational method preferred by the largest proportion of respondents (64%) was the individual educational sessions. The folders and photographs were ranked as 2nd and 3rd in preference. Many of the patients had delayed seeking treatment for their condition. The major reason for the delay was that the patient did not understand the seriousness of the disease. Lack of controls and the small sample size  limit the value of this study.

Jackson, D.J., Rakwar, J.P., Richardson, B.A., Mandliya, K., Chohan, B.H., Bwayo, J.J., Ndinya-Achola, J.O., Martin, H.L., Moses, S. and Kreiss, J.K. (1997) Decreased incidence of sexually transmitted diseases among trucking company workers in Kenya: results of a behavioural risk-reduction programme. AIDS 11, 903-909.. Ref ID : 7275

Target group/Country Male employees of trucking companies in Mombasa, Kenya

Intervention Methodology A behavioural intervention programme was implemented at rotating on-site clinics held weekly in the depots of each of six of the largest trucking companies in Mombasa. The educational intervention was carried out by health workers and a health educator included initial informal group discussions, pre- and post-HIV test counselling and condom promotion. This pre-test counselling took place at the point of enrolment and at each 3 month follow-up visit. Post-test counselling took place one week later when the test results were available.

Evaluation Method A prospective cohort study was conducted among 556 male HIV-seronegative employees. At each 3 month follow-up visit a questionnaire on recent sexual behaviour and medical history was complete, physical examination performed and a 10 ml blood sample was drawn for HIV testing.

Impact Achieved Using time-trend modelling, significant declines in self-reported high-risk sexual behaviour were demonstrated during a 1-year follow-up. The percentage of men reporting any extramarital sex during the 3-month period prior to a follow-up visit decreased from 49% during the first quarter of follow-up to 36% during the last quarter (P <0.001). The decline in reported female sex worker contact was from 12% to 6% (P = 0.001). Approximately 30% of men reported consistent condom use during extramarital sex and this percentage remained unchanged during the study period. The incidence of STD declined from 34 per 100 person years (PY) during the first quarter to 10 per 100 PY during the last quarter (P = 0.001). Significant reductions in gonorrhoea (15 to 5 cases per 100 PY, P = 0.04), non-gonococcal urethritis (10 to 2 cases per 100 PY, P = 0.05), and genital ulcer disease (9 to 2 cases per 100 PY, P = 0.02) were observed. The intervention concluded that among truck company workers who participated in a cohort study in Mombasa, Kenya, there was a significant decrease in sex with high-risk partners, but no change in condom use. The change in heterosexual risk behaviour was accompanied by a significant decrease in incidence of gonorrhoea, non-gonococcal urethritis, and genital ulcer disease. Note the fact that the number of sexual contacts was reduced but there was no change in condom use is an interesting observation.

Kaleeba, N., Kalibala, S., Kaseje, M., Ssebbanja, P., Anderson, S., Praag, E.v., Tembo, G., and Katabira, E. Participatory evaluation of counselling, medical and social services of The AIDS Support Organization (TASO) in Uganda. AIDS Care 9(1):13-26, 1997. . Ref ID : 6029

Target group/Country People living with HIV/AIDS in Uganda

Intervention Methodology The AIDS Support Organization (TASO) is an indigenous non-governmental organization (NGO) of HIV-infected and affected people in Uganda. TASO provides counselling, social support, medical and nursing care for opportunistic infections at 7 centres affiliated to district hospitals in Uganda.

Evaluation Method Over three months beginning August 1993 the services provided by TASO were evaluated through a participatory  approach in which staff and clients carried out interviews with 324 clients currently attending  7 TASO clinics, 322 clients who were visited at home, 74 client drop-outs who no longer used TASO services and 232 family care-givers of clients. This was supplemented with 24 key informant interviews and observation of 49 counselling sessions. There were no controls.

Impact Achieved TASO counselling services helped clients and their families to cope with HIV and AIDS, with 90.4% of clients revealing their serostatus, and 57.2% reporting consistent use of condoms in the past 3 months (higher than surveys of the general population in Uganda reported in other recent studies). TASO was also the main source of medical care for clients with opportunistic infections in the last 6 months (63. 8%). As a result of counselling, over half of the clients (56. 9%) made plans for the future and 51.3% wished to make wills. There was a high level of acceptance of people living with HIV/AIDS (PWAs) by families (79%) and the community (76%). Of clients sampled at home 49.4% were on medication and 57% of these appeared to be taking medicines correctly. 50.&% of family care givers know how to make up sugar-salt oral rehydration while 78.6% knew how to use ready-made sachets of ORS. Of the 49 counselling sessions observed, 39 (79.6%) addressed safer sex practices. Note this is a useful process evaluation of a well known programme. Interpretation of impact is limited by lack of controls and the fact that raw data and details of analysis of qualitative and observational data are not always provided.

Matthews,C., Ellison,G., Guttmacher,S., Reisch,N. and Goldstein,S. (1999)  Can audiovisual presentations be used to provide health education at primary care facilities in South Africa?  Health Education Journal  58, 146-156. Ref ID8740

Target group/Country Patients at waiting rooms four primary health care clinics serving large, poor peri-urban townships in South Africa

Educational Methodology A 24-minute episode of South Africa's popular soap opera, Soul City was played continuously during three consecutive days in the clinic waiting areas. The storyline of the episode chosen was intended to convey key health messages regarding the prevention and treatment of STDs..

Evaluation Method Observations of patient behaviour were made, and a random selection of about  25 male and 25 female patients were interviewed from each of the four clinics (total n=187 patients) patients were interviewed on exit. A focus-group discussion was held with all of the clinic staff at each clinic site, to assess staff attitudes towards the use of such audiovisual presentations as part of their future routine duties.

Impact Achieved The mean proportion of patients who were observed watching the video at any one time varied from 34 to 64 per cent at all four clinics. Based on "it interviews, the presentation was seen by 88.2 per cent of patients attending all four clinics, and its STD content was recognised by 91.5 per cent of those who had seen it. Over 90 per cent of patients found the presentation helpful and interesting. Clinic staff described the use of video-mediated education as a solution to the problem of inadequate health education, and there was unanimous support for it.

Ogunbanjo, B.O., Azulu, M.C., Edet, E. and Osoba, A.O. (1986) Reinforcement of health education and counselling by doctors in treatment and control of sexually transmitted disease. Genitourin. Med. 62, 53-55.. Ref ID : 6842

Target group/Country STD patients in a clinic in Nigeria.

Intervention Methodology Male patients treated for acute gonococcal urethritis received standard STD counselling by a social worker, treatment by a doctor and contact tracing. Without the knowledge of the social worker, half the patients were given 5-7 minutes extra counselling and STD health education by a doctor covering transmission of STD, importance for follow-up and the need to bring sexual contacts for treatment.

Evaluation Method A randomised controlled trial. 64  patients were randomised into two groups of 32. Both groups received the counselling but the experimental group received reinforcement from the doctor. Each group attended three follow-up examinations

Impact Achieved There were 20 defaults from attending follow-up interviews in the control group (8, 4 and 8 defaults from each round of follow-up visits) of whom 4 became reinfected. For the group receiving counselling, none defaulted from attending the first follow-up visit, one from the second and 3 from the third (p<0.01) and ther were no cases of reinfection (p<0.061). This simple study shows that even a small additional educational input can have an influence on patient compliance. Details of the health education provided by the social worker and doctor are not provided so it is not clear whether the  impact from the additional educational input was achieved because of the increased educational activity, an improved quality of delivery of education or greater credibility of education delivered by a doctor

Temmerman, M., Kiragu, D., Fusallah, S., Piot, P. and Wamola, I.A. (1990) Impact of single session post-partum counselling of HIV infected women on their subsequent reproductive behaviour. AIDS Care 2, 247-252.. Ref ID : 3772

Target group/Country Mothers at a large maternity hospital in Nairobi, Kenya Temmerman, M., Kiragu, D., Fusallah, S.,

Intervention Methodology Asymptomatic HIV-positive women who had recently delivered were informed of their HIV sero-status and counselled by a trained nurse regarding contraception and reproductive behaviour in a single session.

Evaluation Method 94 infected women and 94 uninfected women matched for pregnancy outcome were followed up after 1 yr.

Impact Achieved Contraceptive use, condom use, and pregnancy rates were similar in both groups. Only 37.5% of infected subjects  had informed their partners of their sero-status, and the single session of counselling did not influence decisions on subsequent condom use or reproductive behaviour. Results suggest that more intensive counseling of HIV-positive individuals should be developed and evaluated.

Wilkins, H.A., Alonso, P., Baldeh, S., Cham, M.K., Corrah, T., Hughes, A., Jaiteh, K.O., Oelman, B., and Pickering, H. Knowledge of AIDS, use of condoms and results of counselling subjects with asymptomatic HIV2 infection in The Gambia. AIDS Care 1(3):247-256, 1989. Ref ID : 2669

Target group/Country Rural and urban populations in The Gambia

Intervention Methodology A counsellor met with 31 asymptomatic, HIV-positive subjects in their homes on 2 occasions during the survey.

Evaluation Method Follow-up of 31 persons 1-2 months after receiving initial counselling. There were no controls. (Programme incidental to a large scale survey).

Impact Achieved By the 2nd interview, only 3 subjects had discussed AIDS and HIV infection with their partner and only one. Only 8 of the 14 subjects who had taken condoms at the first visit had used any by the time of the second visit. 21 of the persons appeared very worried by their serostatus at the second visit. Condoms were offered again on the second visit but only 5 subjects wanted a supply. Limited information is provided of the counselling sessions which is disappointing as some were tape-recorded. The data bear out the authors' conclusions on the need for a more sustained and intensive counselling process.

Wynendaele, B., Bomba, W., M'Manga, W., Bhart, S., and Fransen, L. Impact of counselling on safer sex and STD occurrence among STD patients in Malawi. International Journal of STD and AIDS 6(2):105-109, 1995. l. Ref ID : 7321

Target group/Country STD patients in hospital clinics in Malawi

Intervention Methodology Counselling as part of STD treatment.. Trained counsellors discussed modes of transmission and prevention of STD/AIDS including a condom demonstration; symptoms and treatment of STDs; partner notification; risk taking and reasons for doing so; and motivations for behaviour change

Evaluation Method Increases in safer sex practices are used as indicators of prevention behaviour. A pre-test (n=155 intervention and n=154 control)  post-test (n=75 intervention and n=70 control)  group design over a 4-month interval was conducted in 1991 in 2 comparable hospitals approximately 100 km apart. STD was diagnosed symptomatically and Knowledge Attitude Practice and Behaviour (KAPB) data collected using a structured questionnaire..

Impact Achieved ( half the test and control sample dropped out over the four months).The group receiving counselling were more likely to have used a condom (11%73% compared with 1126% in controls p<0.05%), more likely to have reported fewer partners in the previous month (1.31.1 compared with 1.32.1in controls P<0.05) and less likely to have an STD on their follow-up visit (100%12% compared with 100%77% p.05). Note very little information is provided on the counselling process used also there was a very high drop-out from the original sample.

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2. Family planning

Bossyns,P., Miye,H. and vLerberghe,W. (2015) Supply-level measures to increase uptake of family planning services in Niger: the effectiveness of improving responsiveness. Tropical Medicine and International Health 7, 383-390. Ref ID: 9003

Target Group/Country Clients at rural health centres in a district in Nigeria.

Intervention Methodology Previously family planning was only offered to clients at specific family planning clinics operated by health centres. The intervention was set up in 1999 and involved a 4 day training session for staff to introduce the 3 measures: (1) family planning services were integrated , special family planning clinics were abolished and staff were instructed to make contraceptives available during any working session including curative consultations, under-fives clinics and post-natal care; (2) Health staff were asked to propose family planning to all eligible women rather than waiting until women initiated requests. There were also asked to improve communication; ((family planning procedures were made more flexible and the strict schedule for repeat visits no longer demanded with the message to come back whenever they felt necessary.

Evaluation Method The study measured in 3 health centres and whole district the number of new acceptors, number of oral contraceptive cycles and progesterone injections administered as well as the couple-years of protection before the measures were introduced and the year following the introduction. There was no control.

Impact Achieved In the year after the intervention the number of new acceptors increased by a factor of 4.5 in the 3 health centres and 3 times for the district as a whole. Staff were originally sceptical about the feasibility of the package of measures and wary of the extra workload but became enthusiastic only after the first positive results were obtained and also realized that this would stabilize as the pool of eligible new candidates for the contraception would diminish and that it is much less than the workload of training for and following-up that would be involved in a community-based distribution strategy. It is disappointing that information on coverage of potential target couples is not provided. The authors conclude service barriers are more important than cultural barriers which they feel are over-emphasized in the literature. That cultural barriers may still play a role is indicated by data presented on reasons for refusals recorded by the health workers which were: need for contraception was not felt as husband was away working (25%), preferred natural spacing through breast feeding (22%); women wanted to ask the opinion of their husband (19%), religious reasons and fear of side effects such as sterility (14%), assumed that husband would refuse (6%); lacked information about family planning (4%); reasons not given (10%). Unfortunately the number and proportion of refusals is not given. While improved communication was part of the package, training in communication skills did not appear to be in the training and the authors comment in their discussion that improvements in the quality of communication might increase the responsiveness of the services even further. The authors argue that improving the quality of existing services would be a cheaper and more feasible than launching community-based distribution programmes.

Omu, A.E., Weir, S.S., Janowitz, B., Covington, D.L., Lamptey, P.R. and Burton, N.N. (1989) The effect of counseling on sterilization acceptance by high-parity women in Nigeria. International Family Planning Perspectives 15, 66-71. Ref ID : 6809

Target Group /Country Women with four or more children at ante-natal clinics

Intervention Methodology University of Benin Teaching Hospital launched a family planning and education program for pregnant women who had had 4 or more previous deliveries. This consisted of 4 individualized counselling sessions on family planning methods and the health risks associated with high parity.

Evaluation Method  ore than 1000 high-parity women ( 4or more children) admitted for prenatal care during a 19-month period were randomly allocated either to a treatment group exposed to the education or to a control group that received only the standard family planning information provided at the prenatal clinic. More than 99% of the women were interviewed at admission and almost 90% were interviewed at six weeks post-partum.

Impact Achieved   Overall, 71% of the women in the treatment group were using an effective method of birth control at 6 weeks postpartum, compared with 51% of the women in the control group (p<0.001). About 40% of women in both groups had indicated at admission that they did not want more children, but women in the treatment group were significantly more likely to choose female sterilization as their postpartum contraceptive method than women in the control group--13%, compared with 3% (p<0.001). At admission, only 45% of the women in the study had heard of sterilization and most of them did not fully understand it. At 6 weeks post partum, however all of the treatment patients said that they had heard of sterilization and women who had had the operation were the most informed. 6% of women in the treatment group who had 4 living children underwent sterilization, compared with 46% of those with 7 or more living children. Among control patients, the proportions were 0 and 5%, respectively. This study provides both a demonstration of the impact of counselling as well as evidence for the achievement of informed consent

Ward, W.B., Sam, M., Nicholas, D.D., and Pappoe, M.E. Impact of family planning information on acceptance at a Ghanaian rural health post. International Journal of Health Education 21(4):273-281, 1978.  Ref ID : 543

Target Group /Country Communities in Rural Southern Ghana.

Intervention Methodology A clinic-based educational programme by health education assistants to groups of women at a family planning clinic. The family planning presentation took about 10 minutes and was followed by a question and answer period. There were between thee to  four presentations per session. At the beginning of each session the HEAs were given the results of the previous session's interviews so that they could improve on their practice.

Evaluation Method  The study was limited to female clinic attendees aged 15-44. Ten sessions were investigated  in the study, five with family planning information (N=210) and a control group of five sessions (N=236) with educational session on nutrition. Health clinic attendees were directed to interviewers after they had been seen by the nurse and were waiting to receive their medication

Impact Achieved   There were significantly more (p<0.005) acceptors on days when family planning information was offered. In general, it would appear that family planning education provided in a health facility adjacent to a family planning clinic can have a significant impact on initial adoption of family planning methods.

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3.  Maternal and Child Health


Bhalerao, V.R., Galwankar, M., Kowli, S.S., Kumar, R., and Chaturvedi, R.M. Contribution of the education of the prospective fathers to the success of maternal health care programme. Journal of Postgraduate Medicine 30(1):10-12, 1984.. Ref ID : 1374

Target Group/Country .Prospective fathers of pregnant women attending the mothercraft clinic of the Malavani Health Centre, Bombay, India

Intervention Methodology The husbands who attended the centre were educated individually and in groups about their role in nutrition and the health of their wives during pregnancy and their responsibility in the subsequent child rearing. They were explained in details the physiology of pregnancy, complications of pregnancy and the possible ways and means of preventing the complications. They were also told to encourage their wives to attend the antenatal clinic of the centre as frequently as possible. All this information was imparted by the resident medical officer to the prospective fathers in one single visit to the centre

The attendance at the antenatal clinic and the outcome of pregnancy were compared in two groups: (a)

Evaluation Method 270 women whose husbands participated in the programme and (b) 405 whose husbands did not. Allocation was not through random process but subsequent assessment of characteristics of the sample showed that Group I and II were similar with respect to economic, educational, cultural and religious background as well as parity

Impact Achieved 223 (n=270) made 4 or more ante-natal visits in the first group (fathers involved) and 248 (n=405) paid 4 or more visits in the second group (p<0.001). There were 4 perinatal deaths in the first group and 14 in the second (p<0.001).

Mohan, P., Iyengar, S. D., Martines, J., Cousens, S., & Sen, K. (2013), Impact of counselling on careseeking behaviour in families with sick children: cluster randomised trial in rural India, British Medical Journal, 329, no. 7460, . 266-0. Ref ID: 9220

Target Group/Country Rural district in Rajasthan, India

Intervention Methodology Doctors were trained in counselling to improve careseeking behaviour in families with sick children according to the strategy for WHO's integrated management of childhood illness. Doctors in intervention centres were trained in counselling, communication, and clinical skills, using the generic training modules of the integrated management of childhood illness strategy, strengthening the sections on counselling and communication with material from the breastfeeding counselling training course prepared by WHO and UNICEF. Local terms for illnesses and danger signs were determined and used. A card with pictures and messages was developed to assist in counselling and copies of these cards were given to intervention site doctors to distribute to mothers. Control doctors were trained over a period of one to three days in clinical skills alone. The training provided and the content of the counselling is poorly described.

Evaluation Method Pair matched, community randomised trial conducted in 12 primary health centres (six pairs).. A total of 2460 children aged under 5 years presenting for curative care and their mothers were recruited and visited monthly at home for six months (1248 intervention, 1212 control). Main outcome measures Care seeking behaviour of mothers for sick children; mothers' knowledge and perceptions of seeking care; counselling performance of doctors. One and 6 months after training each doctor was observed in 10 consultations with children and details of their counselling performance recorded. The scale consisted of the following 6 criteria: plays with the child, praises the mother, asks open ended checking questions, advises on feeding, checks immunization status and explains at least one danger sign. There was no baseline prior to the intervention.

Impact Achieved For episodes of illness with at least one reported danger sign, 15% of intervention group mothers and 10% of control group mothers reported having sought care from an appropriate provider promptly; this difference was not statistically significant (relative risk reduction 5%, 95% confidence interval -0.4% to 11%; P = 0.07). One month after training, intervention site doctors counselled more effectively than control group doctors, but at six months their performance had declined. A greater proportion of mothers in the intervention group than in the control group recalled having had at least one danger sign explained (45% v 8%; P = 0.02). The authors concluded that mothers' appreciation of the need to seek prompt and appropriate care for severe episodes of childhood illness increased, but their care seeking behaviour did not improve significantly. In discussing reasons for fall-off of counselling behaviour, doctors pointed to their high level of field and administrative difficulties and also the organization of patient flow which made it difficult to find time for counselling. The authors point out that the criteria for selection of sample is that mothers selected for the intervention were those presenting for health care hence the sample under-represents women who do not utilize health care. This study is interesting in that shows that the counselling improves knowledge but does not increase actual care but the reasons for this are not clear. The authors suggest that other channels of communication could be used to increase exposure to educational messages. However, it is disappointing that more information is not available on the actual process of care seeking and the influences e.g. the role of cultural and economic barriers and influence of other members of the household e.g. husbands.

5. Breast feeding programme

Alvarado, M., R, Atalah, S., E, Diaz, F., S, Rivero, V., S, Labbe, D., M and Escudero, P., Y (1996) Evaluation of a breastfeeding-support programme with health promoters' participation. Food and Nutrition Bulletin 17, 49-53. Ref ID : 6627

Target Group /Country Families of low socio-economic level living in the Northern district of Santiago in Conchali in Northern Chile

Intervention Methodology  Women living in the same geographic area with experience in health promotion activities were trained as breastfeeding and general health care promoters. They were involved in enrolling, educating (through both individual and group instruction) and following the mothers. Mothers in the intervention group received home visits from health promoters in the last three months of pregnancy. The health promoters also visited the maternity ward in the immediate postpartum period. Further follow-up was given in the health centre. Education was a combination of individual and group sessions.

Evaluation Method   The results obtained in a non-governmental health centre (experimental group) were compared with those obtained in a health centre of the same geographic area (control group), in a cohort of 62 and 66 infants, respectively.. Data were obtained from mothers' and children's records for both groups. Dietary information was obtained from a one week dietary history. The variables analysed were the type of feeding at the first, second, fourth and sixth moths; the child's weight and length at the same periods and the monthly weight gain.

Impact Achieved  The prevalence of exclusive breast-feeding was significantly greater in the experimental group during the entire period. At 6 months, 41.9% of the children in the experimental group and none of the children in the control group were exclusively breast-fed (P<0.01) and the percentages of children weaned were 1.6 and 37.8%, respectively. Height and weight were higher in the experimental group from the fourth to the sixth month, with a lower level of malnutrition (P<0.05).

Barros, F.C., Semer, T.C., Tonioli Filho, S., Tomasi, E., and Victora, C.G. The impact of lactation centres on breastfeeding patterns, morbidity and growth: a birth cohort study. Acta Paediatr. 84(11):1221-1226, 1995. Ref ID : 7583

Target Group /Country Women participating in lactation centres in Guaruja, Sao Paulo, Brazil

Intervention Methodology  The two lactation centres assist around 40 mothers and infants a day and group consultations (four mothers and babies) are offered when problems with breastfeeding are presented by the mothers and solutions are discussed by the group based on their own experience supervised by a paediatrician. Babies are schedule to attend once a week during th first month of life, each fortnight in the second month and once a month from the third to the sixth months of life

Evaluation Method   A longitudinal cohort study from birth up to the age of 6 months among 605 mothers and newborns at a maternity hospital. The sample were recruited in the maternity hospital between January and February, 1993. All babies kept with their mothers  in rooming-in were considered eligible. For ethical reasons a control was not used, however mothers that of their own volition decided to come to the lactation centres were considered the intervention group and those mothers who decided against it were the controls. Taking into account the families who dropped out and could not be contacted, at four months 289 (54%)children had attended the centre with the remaining 246 children who had never attended the centre. A baseline questionnaire was administered was collected at the maternity hospital and mothers were visited and given questionnaires at home and the babies weighed when the babies were 1, 4 and 6 months.

Impact Achieved  Children recruited in the perinatal period who subsequently attended the lactation centres (54%) were exclusively breastfed significantly more at 4 months (43 versus 18% p<0.001) and at 6 months of age (15 versus 6% p<0.001), than non-attenders, even after adjusting for confounders. Also, attenders presented less diarrhoea in the last fortnight than non-attenders (10 versus 17%, p=0.02), and their weight for age was significantly better (mean z-scores of 0.26 and 0.02, respectively p<0.01). The authors conclude that lactation centres are effective in promoting breastfeeding, and their use in areas with short breastfeeding duration should be considered. However, it should be noted (and the authors accept this) that subjects were not allocated at random to control and lactation centre and it is possible that the mothers attending the lactation centres were more highly motivated in their first instance to breastfeed.

Davies-Adetugbo, A.A. (1996) Promotion of breast feeding in the community: impact of health education programme in rural communities in Nigeria. Journal of Diarrhoeal Diseases Rese arch 14, 5-11. Ref ID : 6514

Davies-Adetegbu,A.A. and Adebawa,H.A. (1997)  The Ife South Breastfeeding Project: training community health extension workers to promote and manage breastfeeding in rural communities.  Bull. World Health Organ.  75, 323-332. Ref ID:7242

Target Group /Country Rural communities in Nigeria

Intervention Methodology  Project: training community health extension workers to promote and manage breastfeeding in rural communities. The intervention consisted of the training of the community health workers on UNICEF’s concept of baby friendly hospitals. The breast feeding education for the women included promotional posters in antenatal clinics and distributed to mothers for display in their homes, handouts on breastfeeding , breast feeding talks at the clinics and in their homes. One-to-one counselling was given by community health workers and their supervisors in the antenatal clinics and during the follow up home visits after delivery.

Evaluation Method   Late trimester pregnant women were enrolled into the study and given a questionnaire on knowledge, attitudes, and practices (KAP) about breast feeding. Women in the study group (n = 126) received breast feeding counselling before and after delivery, while those in control group (n = 130) did not receive any counselling. Both groups were monitored after delivery and followed with the KAP questionnaire.

Impact Achieved  32% of the deliveries reported early initiation of breastfeeding (within 30 minutes) in the intervention group compared to 6% in the control group (p<0.001). The prevalence of exclusive breast feeding at 4 months was 39.8% in the intervention group compared to 13.9% for the controls. Multivariate analysis showed that the intervention was a powerful and the only significant predictor of the increase in breast feeding behaviours (p = 0.0000), and that an early initiation of breast feeding is a strong predictor of exclusive breast feeding at 4 months of age. Note that it is of interest that there was no significant difference in the averaged knowledge scores of intervention and control women (although there were significant differences for knowledge of benefits of colostrums and expressing milk -=p=0.0000). The study showed substantial increases in health worker knowledge towards breastfeeding suggesting that the crucial factor was encouragement and support by health workers rather than specific changes in knowledge of the health workers that was critical to success)

Flores,M. and Filteau,S. (2015) Effect of lactation counselling on subclinical mastitis among Bangladeshi women. Annals of Tropical Paediatrics 22, 85-88.Ref. ID: 8978

Target Group/Country Ante-natal women in rural Chittagong, Bangladesh

Intervention Methodology Sub-clinical mastitis, defined as raised milk sodium/potassium (Na/K) in the absence of clinical symptoms, is associated with poor infant weight gain and increased risk of mother-to-child HIV transmission. Similarly to clinical mastitis, sub-clinical mastitis appears to have multiple causes, one being poor lactation practice. Two female field workers were trained to counsel women and assess practice afterwards. Counseling consisted of a single session of lactation counseling around the time of delivery. The counseling messages included the importance of giving colostrum, exclusive breastfeeding, feeding on demand and how to achieve good positioning and attachment.

Evaluation Method The intervention group was an opportunistic sample of antenatal women attending the local hospital. Women for the control group (n=66) were contacted at a vaccination clinic at the hospital. At 4 weeks post-partum, all women were administered questionnaire about infant feeding practices and were observed during a feed and asked to donate an approximately 5ml spot milk sample from each breast. These were analysed by flame photometry for sodium and potassium and by ELISA for interleukin-8 (IL8) by a technician who was unaware which samples were control and intervention. According to the report the non-counseled women differed from the counseled women only in that a higher percentage deliverd at home (83% vs. 70%; p=0.084) and their infants had been delivered a month before the intervention took place. However comparison data on education and economic status are not provided to support this.

Impact Achieved At 1 month postpartum, sodium and potassium were measured in spot milk samples from each breast by flame photometry. Geometric mean Na/K ratios and the proportion of milk samples with raised Na/K ratio were significantly (p < 0.05) lower in the counseled group [mean 0.42, 95% confidence interval (CI) 0.39-0.45, n = 116 samples; 10% Na/K ratio > 0.6] than in the non-counseled group [mean 0.49, 95% CI 0.45-0.53, n = 127; 25% Na/K ratio > 0.6]. Milk IL8 concentration did not differ between groups. The results show that among Bangladeshi women a simple lactation counseling intervention reduced sub-clinical mastitis. An important point in the validity of these findings is the assumption that the control and intervention group are equivalent and the higher proportion of birts at home in the control group is not indicative of other differences which could affect the outcome.

Garcia-Montrone, V. and Rose, J.C.,de Education in the promotion of breast feeding and infant stimulation by women of low socioeconomic level - a preliminary study. Cadernos de Saude Publica 12(1):61-68, 1996. Ref ID : 6519 (in Portuguese)

Target Group /Country Women of low socioeconomic status living in Sao Paulo State, Brazil.

Intervention Methodology  The educational programme on breast-feeding and infant stimulation.  The programme which was

covered in 5 sessions lasting about 1 h once weekly.

Evaluation Method   Women , who had been pregnant for 17-29 weeks, when the programme started, were divided into experimental and control groups of ten each matched for age, educational level and experience in breast feeding. The programme was evaluated by direct observation of mother-infant interactions and interviews with mothers up to 6 months after childbirth. One pair dropped out from the control and experimental group.

Impact Achieved  By the time the infants had reached 6 months old, 5 of the experimental and 2 of the control mothers were still breast feeding. The experimental mothers are claimed to show a 'significantly' higher frequency of stimulation of their infant during and after feeding than did the controls but no statistical tests are provided. This study is of interest in that it extends the evaluation of a breastfeeding education programme beyond breastfeeding performance to consider stimulation of the baby. However the sample size in this preliminary study is very small which severely limits the value of the publication.

Haider, R., Kabir, I., Hamadani, J.D. and Habte, D. (1997) Reasons for failure of breast-feeding counselling: mothers' perspectives in Bangladesh. Bull. World Health Organ. 75, 191-196. 7297 Ref ID: 7297

Target Group/Country Urban mothers of children aged 1-12 weeks hospitalised for diarrhoea in Dacca, Bangladesh

Intervention Methodology  During the hospitalization in the Dhaka hospital of the international Centre for Diarrhoeal Disease Research, Bangladesh, of a group of partially breast-fed infants aged 1-12 weeks who had been admitted with acute diarrhoea, their mothers were individually counselled by breast- feeding counsellors to start exclusive breast-feeding. The counselling was repeated 1 week later at home.

Evaluation Method   The infant-feeding practices of 104 mother-infant pairs were evaluated 2 weeks after their infants had been discharged from hospital. There were no controls. Note that 19 of the original 125 recruited could not be traced for follow-up)

Impact Achieved  75% of the mothers exclusively breast fed their babies. There was not significant difference between the mothers who had received two and three counselling sessions. A total of 25% of the mothers failed to breast-feed exclusively despite having been counselled. The case studies of these mothers illustrate that although they generally complained about having "insufficient breast milk" various factors such as domineering grandmothers, lack of financial support by their husbands, too much housework, or disinterest contributed to their failure to breast-feed exclusively. This study provides a useful and practical follow-up to a counselling programme. Limitations of this study are the absence of information on the breast-feeding practices prior to admission to the hospital for diarrhoea and the lack of a control (though the latter might be justified on ethical grounds). The authors comment that anxiety of the mothers over the health of their sick children may have distracted their attention from the counselling ( an argument for including such counselling as part of normal maternity care).

Hardy, E.E., Vichi, A.M., Sarmento, R.C., Moreira,L.E. and Bosquerio,C.M. Breastfeeding promotion: effect of an educational programme in Brazil. Stud.Fam.Plann. 13(3):79-86, 1982. Ref ID : 968

Target Group/Country Women in Brazil

Intervention Methodology  Educational material was presented to intervention groups (36 colour slides and a tape recording, presented over 15 minutes) followed by group discussion. Topics: importance of breastfeeding, care of breasts and nipples, characteristics of colostrum and milk, ejection reflex,  breastfeeding techniques, differences in breast and bottle fed babies. 48% of women attended one presentation, 36% attended two and 16% three or more. Training of health workers: lecture and discussion

Evaluation Method   Intervention study with control (n= 200 women) and intervention groups (n= 200 women) at different hospitals. Women interviewed re breastfeeding at postpartum check up 40 days after hospital discharge and then followed up until breast feeding stopped or until 9 months of age (same percentage of women followed up in both groups, 56.5%). Women in intervention group were also advised re breastfeeding but women in the control group "not  given any special instruction/ advice".

Impact Achieved  Any breastfeeding (A) and full breastfeeding (B) continuation rates: were significantly larger in intervention group at each month of age of child than control group. (A: Chi squared p<0.023, B: Chi squared p < 0.001). The influence of the program was significant for women over 25, for those whose partners were aged 30 or more, and for those with less education. The program failed to produce a significantly longer duration of breastfeeding among the younger women and among those with a relatively higher education and with younger partners.

Hoffman, M.N., Durcan, N.M., and Disler, P.B. Breast-feeding in a socio-economically disadvantaged area of Cape Town. Part II The introduction of an educational and support programme. S.Afr.Med.J. 66(14 July):66-67, 1984. Ref ID : 7860

Target Group/Country Mothers, the community, health professionals in a socially disadvantaged area of Cape Town Hoffman,

Intervention Methodology  Breastfeeding clinics introduced and conducted at the same time as antenatal clinics. Prospective mothers could see breastfeeding in action and learn by example. The name of volunteers who would help mothers with breastfeeding problems provided. Talks given in the community on the advantages of breastfeeding. Lectures, demonstrations and a symposium for local clinic staff. Letters sent to local doctors to encourage them to promote breastfeeding.

Evaluation Method   Evaluation of breastfeeding among mothers 2 years after the initiation of an intervention. Pre intervention questionnaire used. Mothers attending the clinic with infants < 6 weeks of age classified as fully breastfed or mixed/bottle fed. Breastfeeding mothers interviewed after 6 weeks. Pre and post intervention data compared.

Impact Achieved  Breastfeeding at < 6 weeks: significant increase over the two year period from 52.7% to 75.8% (P < 0.01). Breastfeeding in the following 6 week period: significant increase over the two year period from 23.7% to 38.7% (P < 0.01). While there was an overall increase in the numbers of women breastfeeding after the intervention the percentage of women who continued breastfeeding remained similar (50% pre intervention and 50.1% post intervention). The program resulted in possible behavioural change ie. increase in initiation of breastfeeding but not in maintenance of breastfeeding. Authors point to the "infinite number of other variables" that could have affected breastfeeding rates

Jingheng,H., Yindi,X., Yongxin,J. and Jie,X. (1994)  Evaluation of a health education programme in China to increase breast-feeding rates.  Health Promotion International  9, 95-98. Ref ID: 3561 (Borderline for inclusion in database)


Abstract: Target group/Country Women at maternal and child health centre in Luwan District, China

Intervention methodology Health education program, "A Friend of Pregnant Women," to provide information and skills in breast feeding (BF) at the Maternal and Child Health Center. The health education messages included the importance of massaging breasts and washing breasts with warm water

Evaluation Method The program involved follow-up visits at the 3rd and 42nd day after delivery and at 4 and 6 mo after delivery. 131 women were initially registered for the study, 24 had miscarriages and subsequently 106 formed the treatment group. 30% of these did not take part in the health education programme. Breast feeding was defined as babies receiving no more than 120 ml of formula milk/day, but the paper does not specify how this was measured.

Impact Achieved The program was effective in increasing knowledge about BF among attenders, with 44% of women correctly responding to knowledge items at pretest compared with 60% at posttest. In addition, the rate of BF at 4 mo was significantly greater in the group receiving the program compared to a control group who did not receive the program (44% vs 21%). Insufficient milk was  claimed to be the most important factor contributing to a failure to do BF. 76% of mothers did not was breasts and 88% did not massage breasts. Note that given the lack of control, lack of information on measurement of breast feeding, and unnecessary nature of the advice given, this would not seem a particularly relevant study and is likely to be eliminated from the database.

Lutter, C.K., Perez-Escamilla, R., Segall, A., Sanghvi, T., Teruya, K. and Wickham, C. (1997) The effectiveness of a hospital-based program to promote exclusive breast-feeding among low-income women in Brazil. American Journal of Public Health 87, 659-663. Ref ID : 6733

Target Group/Country Women at a maternity hospital in Santos, Brazil

Intervention Methodology For 20 years the programme hospital has had a comprehensive breastfeeding promotion programme characterized by rooming-in, early initiation of breastfeeding and breastfeeding assistance and talks during hospitalisation. These talks include information on the importance of exclusive breastfeeding for the first six months of infancy, how to solve common breast-feeding problems and where to find postpartum breastfeeding help. The control hospital was of similar size but had no breastfeeding programme although it had recently instituted several reforms mandated by Brazilian law which included rooming-in and prohibition of free gifts of infant formula.

Evaluation Method In a prospective design, women who delivered at a hospital with an active breast-feeding promotion program (n = 236) were compared with women who delivered at a nearby control hospital (n = 206). Data were collected from hospital records and by interviewing the women just prior to hospital discharge and at home at 30 and 90 days post-partum. Prior to discharge exposure to hospital breastfeeding practices and activities was assessed by maternal recall. Information was also collected on breastfeeding history and plans and exposure to breastfeeding information. Exclusive breastfeeding was assessed at each follow-up visit by 24 hr maternal recall in response to a list of liquids (including water) and foods. There was about 20% of both sample lost to follow-up (with no major differences in characteristics of those lost)

Impact Achieved The two groups had similar demographic characteristics and previous breast-feeding histories. Exposure to breast-feeding activities, assessed by maternal recall prior to discharge, was higher for the intervention group both during the ante-natal period (p<0.05), during the period in hospital (p<0.01) and in the period up to the first follow-up visit (p<0.001) but the difference in exposure to breast feeding information was not significant between the 1st and 2nd follow-up visit. The differences in extent of advice/demonstrations received during the stay in hospital on management of expressing, engorgement, sore nipples, knowing whether infant received enough breast milk  and increasing breast milk supply, time to introduce liquids and solids were particularly striking with % recall by the mothers in programme hospital varying between 31-76% and in the control hospital between 1.5-5.4% (P<0.01). Multivariate survival analysis showed that exclusive breast-feeding lasted 53 days longer among women who delivered at the program hospital (p<0.0001).

Savina,G. and Kennedy,K. (1989)  The effect of a breastfeeding education program on lactational amenorrhea in the Philippines.  Stud. Fam. Plann.  20, 203-215. Ref ID: 5924

Nakao, R.M., Kennedy, K.I. and Savina, G. (1992) Breastfeeding education and infant health in the rural Philippines. Ecology of Food and Nutrition 27, 115-126. Ref ID : 6677

Target Group/Country Women in two communities of population 15,000 each in eastern Negros oriental, central Phillippines.

Intervention Methodology Two health educators hired by the study worked with local midwives to establish small classes of 5 to 10 women, usually neighbours. The classes were conducted in the women's homes or in local health centres, The health educators used lectures, pictorials, games and activities and maintained to social and informal atmosphere. Midwives and others were often present and health topics other than breastfeeding were discussed. The health educators also visited the study participants in their homes once or more each month th answer questions about breastfeeding and other concerns. Referrals between midwives and health educators took place frequently. Education in the experimental group began two to three months before birth and continued up to 12 months post-partum. Each mother attended a two-hour class and one individual counselling session per month. The mothers in the control group received no special education about infant feeding.

Evaluation Method   There were 68 mothers in the experimental group and 67 in the controls. Each month a 24 hr self-report form was completed, recording each breastfeeding episode an any supplemental feeds. Each mother was also interviewed monthly about feeding practices, health status/illness episodes of the children. The respondents were given watches to time their feeding episodes and monthly photographs of their children which are socially valued items. The accuracy and reliability of data were monitored by random rechecks of respondents by a supervisor. Data collectors were trained to inspect the respondents' homes visually for evidence of feeding bottles and to ensure that observations matched interview data.

Impact Achieved 97% of the experimental mothers reported feeding colostrums to their infants compared to 72% of controls (p<0.001). Significantly more experimental mothers (p<0.001) reported feeding colostrums to the study infant compared to their previous child with no significant difference in the controls. The mean age for giving a first taste of any food and for introducing regular supplements (either liquid of solids) was significantly younger for the control infants (p<0.01) but there was no difference between the two groups in the mean age when regular solids were started). The authors state that significantly more control mothers (56%) ever used bottles compared with mothers in the experimental group (35%) but raw data and p values are not provided. A greater percentage of infants had fewer self-reported illness episodes in the education community from month 2-7 ( values each moth varied between <0.01 and <0.1), even after results were controlled for maternal age and education (data from clinic attendance confirmed the difference).There was no significant difference between the two groups in the mean duration of postpartum amenorrhea. Note that while demonstrating an impressive impact on breastfeeding and health, the resources deployed in this intervention were considerable and issues of sustainability are not addressed.

Prasad, B. and Costello, A.M. Impact and sustainability of a "baby friendly" health education intervention at a district hospital in Bihar, India. BMJ 310:621-623, 1995. Ref ID : 4279

Target Group/Country Mothers at a district hospital in a small town in Bihar, India

Intervention Methodology  A baby friendly training intervention for staff at an Indian district hospital 10 day training programme for doctors, nurses, and midwives, explaining the benefits and feasibility of early breast feeding and dangers of prelacteal feeds together with instruction on explaining this information to mothers. Messages: "initiate breast feeding within the first hours after birth", benefits of colostrum, that breast milk is all the child needs for the first 4 months of life and advice on some common breast feeding problems

Evaluation Method   Intervention study with assessment by interviewing mothers. 172 mothers were recruited before the intervention, 195 recruited immediately after the intervention, and 101 recruited six months later.  The interview recorded : Age of infant when breastfeeding started, use of prelacteal feeds and colostrum feeding.

Impact Achieved  Breast feeding was started within 24 hours of birth by 53 (29%) of control mothers, 164 (84%) in the early follow up group, and 60 (59%) in the late follow up group. Prelacteal feeds were used by 165 (96%), 84 (43%), and 78 (77%) respectively. Only 36 mothers in the late follow up group reported receiving education on feeding. Mothers in this group who had received the education were significantly more likely than mothers who received no education to breast feed early (28 (78%) v 11 (17%), P < 0.001) and not use prelacteal feeds (21 (58%) v 2 (3%), P < 0.001). Training doctors and midwives greatly improves the feeding practices of mothers. However, the impact of the training fell off quickly and authors concluded that refresher training is needed to sustain the improvement.  . In addition, approval needed of guardian, mother in law or religious advisor indicating a need to  target these groups for health education intervention.

Pugin, E., Valdes, V., Labbok, M.H., Perez, A., and Aravena, R. Does prenatal breastfeeding skills group education increase the effectiveness of a comprehensive breastfeeding promotion program? Journal of Human Lactatation 12(1):15-19, 1996. Ref ID : 7573

Valdes, V., Perez, A., Labbok, M., Pugin, E., Zambrano, I., and Catalan, S. The impact of a hospital and clinic-based breastfeeding promotion programme in a middle class urban environment. J.Trop.Pediatr. 39(3):142-151, 1993. Ref ID : 6326

Target Group/Country Middle class urban women at the maternity unit of the  Catholic Hospital of Chile in Santiago, Chile

Intervention Methodology All mothers received a breast-feeding intervention of five activities: training of health workers, activities at pre-natal clinic and hospital, outpatient lactation clinic and offering the lactation ammenorrhoea method as a form of birth control. A subgroup group received a further breastfeeding skills group education at pre-natal consisting of three 20 minute small group sessions where women were encouraged o discuss various aspects of breastfeeding and share their own personal experiences. Prior to the above experimental programme mothers received a normal breastfeeding support programme details of which are not provided.

Evaluation Method A prospective intervention study with a control group. The control group of 313 urban middleclass mother-child pairs were recruited in the hospital in the postpartum period and were followed for 6 months. A group of 422 mother-child pairs of the same socio-economic status were recruited for the intervention. The selection criteria for the participation of the mothers in the control and intervention group included age between 18 and 39 years, parity of 5 or less, healthy mother, stable union with partner, term vaginal delivery weighing over 2500 g at delivery and a work situation compatible with 6 months of exclusive breastfeeding.313 control infants received the normal breastfeeding support, 422 received the breastfeeding intervention of whom 59 also received the pre-natal education intervention. Women were recruited if they intended to breastfeed.

Impact Achieved In the control group 32% were still fully breastfeeding at six months compared to 67% of the complete intervention group (p<0.0001). 80% of the women who had received prenatal education were fully breastfeeding after six months compared with 65% of those who did not receive this intervention (p<0.026). It is not clear from the report why this 65% differs from the 67% also cited. Note that the definition of fully breastfeeding allowed for only two supplemental feeds per week. Both were higher than the control group 32% who received the standard package (p<0.0001). Note also that a goal of fully breastfeeding at six months appears rather strict given that by then many infants might require the commencement of weaning.  Also the selection criteria of middle class background, an intention to breastfeed and also lack of restrictions from employment make this a clearly very special sample and the results cannot be generalised to other groups.

Ross, S.M., Loening, W.E. and Van Middelkoop, A. (1983) Breastfeeding-evaluation of a health education programme. S. Afr. Med. J. 64, 361-363. Ref ID : 1081

Target Group/Country Women in South Africa

Intervention Methodology Over an 8 month period health education was given by an experienced midwife to women during the antenatal period. Teaching was presented to groups of 3-6 primigravidas/ multigravidas in two half hour sessions 1) advantages of breastfeeding 2) technique. Materials: photographs and "motivational literature", discussion encouraged

Evaluation Method   Intervention study with treatment group and controls. Mothers at the clinic interviewed after delivery: Group A received health education (n=59); Group B controls (n= 66). Long term: Mothers from the clinic interviewed 24 weeks after delivery: Group C had received health education (n=74); Group D controls (n=48). There was no baseline.

Impact Achieved  Significant increase in knowledge post delivery of nutritional advantages of breast milk and value of colostrums (p=0.02). Higher but reduced knowledge level 24 weeks later. 72% of the infants had commenced formula feeding at between 1 and 5 weeks. The commonest reason for supplementary feeding "not enough milk", "baby not satisfied". The authors draw attention to marketing of baby milks, their use by higher socio economic groups and their sale by health personnel as contributing towards difficulties in achieving behaviour change. This study is limited by the lack of a base line or measures to prevent contamination of control group by intervention.

Seema, Patwari, A.K. and Satyanarayana, L. (1997) Relactation: an effective intervention to promote exclusive breastfeeding. Journal of Tropical Paediatrics 43, 213-216. Ref ID : 7244 (Borderline for inclusion in database)

Target Group/Country Nursing mothers in India

Intervention Methodology  Relactation was attempted in both the groups with motivation, support, and repeated suckling. Group II mothers, in addition, were given metoclopramide

Evaluation Method  ifty mothers of hospitalized infants less than 4 months old with partial or complete lactation failure (LF) from a hospital in India (name unspecified) were randomly assigned to two groups of 25 each for relactation. The primary outcome variables measured included the time of appearance of first breast milk secretion (in complete LF), time for partial and complete relactation.

Impact Achieved  Relactation attempt was successful in 49 mothers (98 per cent), wlth complete relactation in 46 (92 per cent) and only partial relactation in three mothers (6 per cent). All the outcome variables of the two groups were comparable (P > 0.05). The pattern of weight gain, the rate of reduction in the amount of top milk and subsequent weight gain in the follow-up was also comparable in both the groups (P > 0.05). Maternal factors like breast conditions, nutrition, parity, feeding practices in previous babies, lactation gap, and infants' initial refusal to suck at the breast did not influence the outcome variables as long as repeated suckling was ensured. The authors conclude that that relactation is possible in most of the mothers without the help of lactagogues. Apart from educating and motivating the mother for exclusive breastfeeding during the first 4-6 months, strong proressional support by a skilled health worker is needed to overcome the initial problems during relactation

Valdes,V., Pugin,E., Schooley,J., Catalan,S. and Aravena,R. (2011) Clinical support can make the difference in exclusive breastfeeding success among working women. Journal of Tropical Paediatrics 46, 149-154. Ref ID: 8914

Target Group/Country Working mothers from Chile

Intervention Methodology Following a hospital based breastfeeding support programme mothers attended a clinic at 30 days, were explained the benefits of exclusive breastfeeding for 6 months. Hand expression was demonstrated to groups of mothers. Mothers and infants were seen at the clinic by a paediatrician and nurse-midwife monthly for first six months and again at 12 months. During the vist they were invited to share concerns about health issues and other anxieties. If the infant was in good health they were encouraged to continue exclusive breastfeeding. Detailed information on the educational methods are not provided.

Evaluation Method All women entered to study at 30 days post-partum and had received the similar hospital breastfeeding support programme and were exclusively breastfeeding at time of enrolment. 146 women were in the intervention group. 116 women were in the control group who received the standard care during monthly attendance at the Well baby clinics. Information on feeding practices were collected at the monthly and final clinic.

Impact Achieved Only 6 per cent of women in the control group were able to complete 6 months of exclusive breastmilk feeding compared to 53 per cent of those in the intervention group (p value not given). The most important difference between the strategies used by both groups of mothers for maintaining exclusive breastmilk feeding after returning to work was that only 23 per cent of the control group practiced milk expression compared to 66 per cent in the intervention group (pvalues not given). 39 infants were weaned at 6 months in the control group (34%) and 12 in intervention group (8.2%, p<0.0005). The authors comment that even with "relatively supportive" legislation on maternity leave and delivery in a hospital committed to the baby-friendly initiative the numbers in the control group practicing exclusive breastfeeding at 6 months were low and achievement of the levels of the intervention group required an additional educational input. It is disappointing that the additional input is not described in more detail and costed. Also given that the control group were regular attenders at their well baby clinic - it would have been of interest to know whether levels might have been increased with a minor changes to these existing services without recourse to the programme of intensive support that was provided. It is worth noting that both the controls and intervention samples were drawn from women already exclusively breastfeeding at 30 days which represents a highly motivated self-selected sample.

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6.  Oral rehydration therapy

Bandyopadhyay, S., Banerjee, K., and Sharma, R.S. Practices of preparation of oral rehydration solution among mothers reporting to the drug distribution centres in Delhi, India, 1992. Journal of Diarrhoeal Diseases Research 11(4):249-251, 1993. Ref ID : 6367 (Borderline for inclusion in database)

Target Group/Country  Urban communities in Delhi, North India

Intervention Methodology  Routine function of Government service outlets including giving out of ORS packets.

Evaluation Design One centre from each of the municipal zones of Delhi was selected randomly.  Four hundred mothers who had taken a child having diarrhoea the nearest centre and had received ORS packets were studied using a standardized questionnaire adopted from the WHO household survey schedule. 85% of the interviews were competed within 7 days of the receipt of ORS from the drug distribution centre. Two paramedical personnel from each of the centres who were responsible for distribution of ORS were also interviewed regarding their knowledge of preparation of ORS. There were no controls and no baseline.

Impact Achieved  Results indicate that only 10.8% of mothers utilised the recommended full packet for the preparation of ORS and the rest used part of the packet only. Of the mothers who used a full packet 91.5% used the recommended one litre of water and the rest used less than one litre. prepared the ORS correctly. This showed the inadequacy of the accompanying health education on diarrhoea provided at these clinics (though the interviews showed that the majority (83%) of the paramedicals involved in ORS distribution that were interviewed had correct knowledge about its preparation.  Despite lack of controls and baseline, this is a useful practical evaluation. It is unfortunate that there is no data on whether health education/explanation was actually provided.  Given that the health workers displayed a satisfactory level of knowledge of diarrhoea, it would have been of value to have included some data gathering to explore why there was no impact on correct preparation. From the data it looks as if all the mothers actually tried to make up the ORS - however it is not clear. If that was the case, it would appear that the problem was not the mother's motivation to give ORS, but her understanding of the correct way of making it up. This is a good example of the kind or follow-up that can be carried out within routine services to find out the impact of educational activities. However, lack of controls, lack of baseline and insufficient data on the amount of health education provided limit the value of this study,

Brieger, W.R., Ramakrishna, J., Chirwa, B.U., and Arday-Kotei, M. Developing health education for oral rehydration therapy at a rural Nigerian clinic: part I. Patient Education and Counselling 11(3):189-202, 1988. Ref ID : 3273

Chirwa, B., Brieger, W.R., and Ramakrishna, J. Evaluating health education for oral rehydration therapy at a rural Nigerian clinic: part II. Patient Education and Counselling 11:203-213, 1988. Ref ID : 6410

Target Group/Country  Patients at rural community hospital in Nigeria

Intervention Methodology  Educational activities at the Oral Rehydration Therapy (ORT) Unit consisted of an interactive session between groups of 5-10 mothers who brought their children to the general preschool clinic because of diarrhoea and the health aides who manage the Unit.  A series of 8 posters about diarrhoea and its management served as prompts for the health aides who engaged mothers in discussion around what they perceived in the posters. Mothers beliefs were sought and attempts were made to guide discussion so that a synthesis or common ground between community ideas and medical knowledge was achieved. The session culminated in a participatory demonstration on the preparation of salt-sugar solution (SSS). Each mother had a chance to practice levelling the 10 3ml teaspoons of sugar and one teaspoon of salt that go into the 600ml (one beer bottle) of water required in the formula being promoted at that time.

Evaluation Design Pre- and post-test evaluation record forms were completed on a total of 524 attenders of the Diarrhoea Treatment Unit between late September 1985 and June 1986. Their ideas on diarrhoea prevention and treatment and SSS preparation were recorded. Each of the 524 homes were visited at least 3 times during the two months from September 1986. A total of 124 women could be traced. The were asked the same questions as at pre and post-test and in addition mothers were asked to mix the drink. And their performance was observed. Mothers were also asked for details of recent episodes of diarrhoea. 110 mothers from the same neighbourhood as clinic attenders were selected as controls.

Impact Achieved  Konowledge of mothers about diarrhoea rose from 49.2% at pre-test to 100% at post-test and remained high at follow-up (91.1%) which was significantly better (p<0.0005) better than the 53% of control mothers. 36.4% of controls listed SSS as part of treatment in contrast to 87.1% of women at follow-up (p<0.0001). All of the124  clinic attenders followed up knew about the beer bottle method and 74.7 (n=111) could correctly describe it. Only 27 out of 110  control mothers knew about the beer bottle method and of these only 14.8 could correctly describe it (p<0.0005).6.3% of Unit attenders added more salt than recommended compared to 25.9% of controls who attempted the method. There were 26 bouts of diarrhoea reported among the clinic attenders and 17 in the controls. More than double the number of attenders (80.8%) reported using SSS  during those episodes compared to 35.3% of controls (p<0.005).

el-Mougi,M., El-Akkad,N., El-Hadi Emam,M. and Talkhan,A.M. (1986)  Evaluation of a programme of teaching mothers the management of acute diarrhoea.  J. Trop. Pediatr.  32, 24-25. Ref. ID: 7855

Target Group/Country  Mothers whose children attended the Diarrhoeal Disease Research and Rehydration Centre, Bab El Sharreya  University Hospital, Egypt.

Intervention Methodology Mothers were taught after the treatment of their children at the clinic. Teaching was done by a doctor and nurse in groups of 10. Each session lasted 1-2 hours. Educational objectives: 1) to recognise two dehydration signs, 2)to correctly prepare and administer ORS as long as baby accepts it, 3) prepare two suitable foods ( breast/ formula) given during diarrhoea.  Method: Practical sessions used household utensils and the locally produced ORS packet. Skills were broken down into steps. Mothers practiced and were given plenty of praise. The doctor then prepared the ORS solution making mistakes for mothers to point out. Mothers then repeated the preparation of ORS. Lessons on feeding, diagnosis of dehydration were demonstrated followed by feedback from mothers. Signs and symptoms of dehydration were shown from children on the ward, photos or by pinching the back of the hand.

Evaluation Method Of a pool of 600 mothers who had attended the educational programme 100 were selected at random. Each mother was asked to identify a good friend and 100 of these formed the sample of 'neighbours'. 100 mothers from a distant neighbourhood formed the controls. Post intervention interviews were carried out with mothers in all three groups 3-7 months after the intervention. Mothers were asked to prepare ORS for the interviewers. There was no baseline.

Impact Achieved  There were significant differences between the three study groups (p<0.01) in the use of ORS (98% cf. 41% cf 8% for intervention, neighbours, controls) , the knowledge of correct preparation of ORS 100%, 82% and 73), continued feeding (84%, 24%, 3%). The intervention mothers scored highest, neighbours second and controls lowest.  Knowledge of the major signs of dehydration and continuing feeding ( breast / formula) showed no significant difference between neighbours and controls but significant differences between these groups and intervention mothers. Authors suggest (but present no evidence) that the controls scores are due to the promotion of ORS via the television and that the higher scores of neighbours scores are due to intervention mothers passing on information.

Jacoby,E.R., Benavides,B.M., Bartlett,J.C. and Figueroa,D. (1994)  Effectiveness of two methods of advising mothers on infant feeding and dietetic management of diarrhoea Peru.  Journal of Diarrhoeal Diseases Research  12, 59-64. Ref ID: 6372

Target Group/Country  Mothers of small children attending a hospital's Oral Rehydration Unit in Peru

Intervention Methodology The intervention was carried out in a room adjacent to an oral rehydration unit. The first intervention group received oral counselling and a recipe pamphlet. The nutritionist gave each mother a 5 min. explanation of infant feeding practices making three general recommendations: 1) a puree is the best food for infants instead of customary soups and broths; 2) additional oil/;butter is necessary to "strengthen" weaning foods; 3) the recipe should be used regularly and also when the infant has diarrhoea The nutritionist described how to prepare one of the recipes and used two posters as a visual aid and gave a pamphlet of recipes that had been designed and pre-tested for that specific community. The second intervention group received the same counselling and recipe book but also observed a cooking demonstration which lasted about 20 minutes.

Evaluation Design The sample was drawn from mothers of infants aged 5-15 months who had initiated weaning, were fully rehydrated and resided in one of 11 poor districts of Lima. Once the mother child pair was recruited, the educational intervention was randomly assigned and the nutritionist in charge of it was selected by lottery. There were 74 mothers in the group receiving oral counselling plus pamphlet and 70 in the group receiving the additional cooking demonstration. Each mother was interviewed prior to the intervention, 48 hr post intervention and 30 days post intervention during home visits. Mothers were asked to recall all the food preparations and main ingredients given to the child during the previous day. Mother's recall as also used to determine the consistency of the food which was used as a proxy for energy density. To avoid bias from the interviewers preferences for particular educational methods, they were kept blind to the study objectives, Also the interviewer presented her visits as part of a comprehensive infant health evaluation and not as an evaluation of the infant feeding education. There were no controls.

Impact Achieved Both interventions had a statistically significant (p < 0.05) impact on maternal knowledge and practices; differences between the impact of the two practices were negligible. After merging both groups into a single sample, it was observed that changes over time were significantly large (p < 0.05). Knowledge rates were 27.6% before the intervention, 73.7% 2 days later and 75% 30 days later. The corresponding figures for practices were 2.6%, 58.3% and 37.5% respectively. They  conclude that when place, time and message are adequately chosen, a simple method may be an effective way of good communication. There were no controls, however given that the practices being introduced were new, this is not a major shortcoming. The demonstration that a simple educational method is as effective as a more complex one has useful practical implications.

Jinadu, M.K., Olusi, S.O., Alade, O.M., and Ominiyi, C.L. Effectiveness of primary health-care nurses in the promotion of oral rehydration therapy in a rural area of Nigeria. International Journal of Nursing Studies 25(3):185-190, 1988. Ref ID : 103

Target Group/Country  Mothers in a rural area of Nigeria

Intervention Methodology  Verbal instructions and demonstration by public health nurses on preparation of ORT.

Evaluation Design 255 mothers were interviewed prior to the educational programme. 184 mothers were followed up 309 months after the session and interviewed and observed in the practice of ORT and preferred way of managing the disease. There were no controls.

Impact Achieved  Although the proportion of mothers that knew how to prepare and give oral rehydration therapy (ORT) increased significantly from 6.2 to 47.0% (p<0.01), few (9.5%) were practising it during subsequent episodes of diarrhoea. The use of starvation by the mothers also decreased significantly from 43.0 to 8.2% however the use of traditional medicines and medicines from chemists did not show any significant change. The beliefs that sugar worsens diarrhoea, that home-made ORT was not a medicine, and continued reliance of the mothers on traditional healers and medicine dealers for advice were factors constraining adoption of the ORT by the mothers. Given the largely negative outcome of the educational programme, lack of controls should not be seen as a constraint to its validity [JH]

Mushtaque, A., Chowdhury, A.M., Karim, F., and Ahmed, J. Teaching ORT to women: individually or in groups? Journal of Tropical Medicine & Hygiene 91(6):283-287, 1988.  Ref ID : 1444

Target Group/Country  Rural women in Bangladesh

Intervention Methodology  The Bangladesh Rural Advancement Committee (BRAC) sent its health workers to individual households, and mothers were trained through a one-to-one approach. The cost of training a mother was 72 US cents. Recently, an alternative approach was tried. Instead of individually, mothers were trained in groups which halved the cost. :Female health workers taught groups of five women in the intervention villages.  Messages: "Seven points to remember": 1) Definition of diarrhoea, 2) When loose motion turns to diarrhoea, 3) Treatment, 4) When to give LSG and why, 5) How much to give, 6) Prevention, 7) Nutrition (*Abed 1983). Mothers were asked to prepare the lobon-gur solution (LGS) under the supervision of the female health worker. Note: same content for intervention (group) and control (individual) groups

Evaluation Design Intervention study with intervention (n=2498) and control (n=3851) groups from differing districts Comparison of individual and group instruction one year later using 1) Structured interviews conducted by female interviewers to evaluate mothers knowledge (2500 households in each area selected by multi stage random sampling). 2) Usage of LGSA determined. 3) A random 5% of mothers asked to make LGS and sample analyzed for chloride to evaluate safety

Impact Achieved  69% (intervention) and 75% (controls) of mothers scored >70%. The control group had a slightly higher mean score but this was not significant ( 8.0 v 7.7, P>0.05). Overall usage rate for LGS was very low, intervention 4.1% and controls 4.5%, difference not significant (P>0.05). There was an increased in the use of LGS for severe diarrhoea in both groups. There was little difference in the preparation of LGS between intervention and control groups. The cost of teaching groups was less than that of individuals without apparent compromise to the quality of education. Authors suggest that a change from individual to group teaching is reasonable. However they do caution that differences in group/ individual sessions might be dependant on group size and differences might become apparent in group numbering >5.

Nagarajan,L., Majumdar,S., Natarajan,U., Ganguly,N.K. and Walia,B.N. (1989)  A comparative study of different methods of training of rural subjects for reconstitution of oral rehydration solutions.  Indian Pediatr.  26, 323-329. Ref ID: 7447

Target Group/Country  Women from three rural villages in Ropar District of Punjab State, North India

Intervention Methodology  The women in Group I were verbally instructed in the regional language regarding how to reconstitute the entire contents of a sachet containing oral rehydration salts in half a litre of water. Women from Group II, were given the same verbal instructions and in addition, were demonstrated the correct method of doing the same. Subjects from Group III were provided with plastic bags containing oral rehydration salts, which when filled with water up to the printed line, was expected to accommodate half a litre of water, when the bag was hung from a hook or held by another person from its upper ends

Evaluation Design Group I (n=21), Group II (n=20) and Group II (n=20) after receiving the intervention were given a sachet of ORS at told that they should reconstitute the solution 2-3 hours later in the presence of the community health worker and the doctor. A sample was taken so that the sodium, potassium, and glucose contents of the ORS reconstituted by the three groups of rural women could be determined. Details of the sampling are not provided although data is presented to show that there was no significant difference in age, monthly income and literacy status between the women in the three groups.

Impact Achieved  The contents of ORS reconstituted by Group II, who were demonstrated the actual procedure following verbal instructions, were near ideal followed by the ORS reconstituted by Group III and by Group I which both differed significantly from the ideal (p<0.001). The conclusions drawn by the authors is that the mothers were better able to prepare the solution when they are exposed to an actual demonstration. Note that this evaluation is a measure of comprehension of instructions and not an evaluation of actual use of ORS.

Nwoye, L.O., Uwagboe, P.E. and Madubuko, G.U. (1988) Evaluation of home-made salt-sugar oral rehydration solution in a rural Nigerian population. Journal of Tropical Medicine & Hygiene 91, 23-27. Ref ID : 1457

Target Group/Country  Mothers attending the outpatient Clinic at Obukpa Health Center, Nsukka, Anambra State of Nigeria

Intervention Methodology  45 illiterate mothers were taught through repeated demonstrations of how to prepare sugar-salt solutions (SSS). The formula being promoted is one level (3ml) spoonful of salt and 10 of granulated sugar (or 5 cubes) dissolved in one standard beer bottle or two soft drink bottles (650ml) of clean water. The levelling is done with either the edge of a knife or the little finger so that the edge of the spoon is visible and free from the ingredient.

Evaluation Design The mothers were asked to prepare the solution at home and to bring samples on the same day to the clinic. 40 mothers responded and the home made solutions were analysed. There were no controls and no baseline.

Impact Achieved  Analysis showed that 60% (924 mothers)of them made accurately composed solutions. All the rest made hypertonic solutions with too much salt (more than 80mmol/l) which might give rise to hypernatremia. Salt type, spoon size and levelling technique are all possible causes of their error. The tendency to err only on the side of greater rather than lower salt concentration may be culture based or simply due to natural maternal instinct to give a little extra. This simple evaluation is typical of the many that were carried out at that time in the history of ORT and provided the evidence that led to the abandonment of the promotion of home made sugar salt solution in favour of ORS sachets.

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6. Immunization

Berhane, Y. and Pickering, J. Are reminder stickers effective in reducing immunization dropout rates in Addis Ababa, Ethiopia? Journal of Tropical Medicine & Hygiene 96(3):139-145, 1993. Ref ID : 601

Target Group/Country Communities in two urban settings in of Addis Ababa, Ethiopia

Intervention Methodology Use of a reminder sticker in reducing immunization dropout rates. The sticker was circular with a picture of a child receiving vaccination and an appointment date on it with the name of the month written in Amharic. The mothers were instructed to apply the sticker to the inside of their home front door. Both groups received health education individually. The health education took approximately 10 minutes for both intervention and control groups. Explanation of the sticker took and additional 1 minute for the intervention group only.

Evaluation method A total of 703 children were entered into the study. The intervention days and non-intervention days were randomly selected and caretakers were recruited on arrival at the vaccination centres  for their first DPT dose  between 6weeks and 23 months. The intervention group received a reminder sticker and the control group did not. All other services were identical. A baseline interview using a closed ended questionnaire was given which documented the socio-demographic and maternal characteristics potentially related to immunization services. Children who did not return for the second injection after 8 weeks (4 weeks was the recommended time period) were classified as dropouts and reasons for not attending were determined through a questionnaire.

Impact Achieved The dropout rates were 7.3 and 13.3% in the intervention and control groups respectively. This difference is clinically and statistically (P < 0.01) significant. On supplying reasons for not bringing children for immunization 11of the control mothers gave unawareness of the need for a follow-up dose as the main reason while none of the intervention mothers did so(p<0.01). Therefore, it is concluded that the reminder sticker is effective in reducing immunization dropout rates. However the authors draw attention to the urban setting and relatively better off nature of the community which may affect the success of the method in other communities.

Zeitlyn, S., Rahman, A.K., Nielsen, B.H., Gomes, M., Kofoed, P.L. and Mahalanabis, D. (1992) Compliance with diphtheria, tetanus, and pertussis immunisation in Bangladesh: factors identifying high risk groups. B. M. J. 304, 606-609. Ref ID : 2776 (Borderline for inclusion in database)

Target Group/Country Urban mothers in Dhaka, Bangladesh

Intervention Methodology All children received their 1st dose of the vaccine against diphtheria, tetanus, and pertussis and health workers gave education to mothers using small group discussions, individual counselling and visual aids. Messages included the nature of the diseases that  vaccinations protect against were explained and the need for a second dose four weeks later and 3rd and 4th visits to complete the vaccination course were emphasised.

Target Group/Country This cohort study of infants included 136 unimmunized children ages 6 weeks-23 months who lived within reach of the treatment center. 1st doses of the vaccination were given immediately followed by an interview to measure knowledge about immunization. This was followed up with a second interview 6 weeks later to ascertain compliance with having the 2nd dose. At the 6-week follow-up, 16 of the children could not be traced and 7 had died.. Interviews were carried out Rate of non-compliance with advice to return the child for 2nd vaccination was the main outcome measure. There were no controls.

Target Group/Country 46 of 113 children (41%) received the 2nd vaccine dose. Factors most closely associated with maternal failure to comply with 2nd dose were lack of education and low income. Children whose mothers know most about immunization at 1st interview were more likely to have their 2nd dose. The authors suggest that further research needs to be aimed at ways of making health education more effective among uneducated parents and that such health education programs need to be targeted at those who are non literate and do not own television or radios. In the absence of controls it is difficult to attribute any impact to the implementation of the educational programme. It is also unfortunate that so little information is provided on the nature of the health education input - it would have been useful to have had some observational study on the quality of the health education to suggest ways in which it might be improved.

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8. Acute Respirtory Infections

Ellerbeck, E., Khallaf, N., el Ansary, K.S., Moursi, S. and Black, R. (1995) Caretaker compliance with different antibiotic formulations for treatment of childhood pneumonia. J. Trop. Pediatr. 41, 103-108. Ref ID : 4104

Target Group/Country Care-givers to children at outpatient clinics at the Ismailiya governorate of Egypt

Intervention Methodology Treatment involved one of the following formulations of cotrimoxazole: 1. syrup accompanied by a 10-ml measuring cup; 2. syrup accompanied by a 5-ml measuring spoon; 3. tablets; 4. single-dose sachets of antibiotic powder. All care givers were given standardised verbal instructions on giving the antibiotics

Evaluation Method 400 children, aged 2 months to 5 years, with a presumptive diagnosis of pneumonia, were randomly assigned to receive each formulation. A research assistant visited the child's home on the fourth day of therapy, asked the care-giver about compliance, and observed the care-giver prepare a dose of the medication. The remaining amount of medicine was measured, and when possible (n = 151), a urine specimen was tested for the presence of sulphamethoxazole.

Impact Achieved All of the care-givers reported giving at least one dose on the first day of therapy. By the fourth day, 82 per cent of those receiving syrup were still taking their medication compared to 71 and 55 per cent of those receiving sachets or tablets, respectively (P < 0.01). Of those who received syrup accompanied by a spoon, 38 per cent under-dosed the medicine by at least 30 per cent. Overall, compliance was highly correlated with the care-giver's report of difficulty in administering the medication.

Gunay, O., Ozturk, A., and Ozturk, Y. The impact of mothers' health education on the prevalence of acute respiratory infections in children. Turk.J.Pediatr. 36:1-5, 1994.  Ref ID : 4431

Target Group/Country Mothers in Hacilar district of Kayseri, a province in Central Anatolia

Intervention Methodology The intervention consisted of 30 minutes of face-to-face education in the home by the health centre doctor of mothers regarding ARI prevention and treatment. This was supported by a booklet that was given to the mothers.

Evaluation Method The intervention group included 69 children and the control group 57 children between the ages of 0 and 4 years. The children in both groups were checked for symptoms of acute respiratory infections (ARI) in January 1990 and 1991, before and after intervention. In addition, the numbers of clinic visits by children for acute infections before and after intervention were compared.

Impact Achieved The prevalence of acute respiratory infections decreased from 49.3% to 27.5% in the intervention group and from 43.9% to 38.6% in the control group. The decrease in the prevalence of acute respiratory infections in the intervention group differed significantly (p<0.05), from that of the control group. On the other hand, clinic visits by the intervention group for acute respiratory infections increased significantly (p<0.05)

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9. Growth Monitroing

Fagbule, D.O., Olaosebikan, A. and Parakoyi, D.B. (1990) Community awareness and utilization of growth chart in a semi-urban Nigerian community. East. Afr. Med. J. 67, 69-74. Ref ID : 8397 (Borderline for inclusion in database)

Target Group/Country Mothers resident in Adeta, Sawmill and Baboko Communities of Ilorin Local Government Area of Kwara State, Nigeria

Intervention Methodology Mothers had attended a health facility in the previous six months either for preventive or curative child health purposes. The service provided had included use of growth monitoring and there was no special programme effort over and above that of routine growth monitoring service.

Evaluation Method 518 mothers were interviewed to assess their knowledge, utilization, and understanding of the growth chart. Five health facilities in the communities studied were visited to assess the availability, utilization and understanding of growth. There were no controls.

Impact Achieved Over half (53.7%) of the mothers interviewed had heard about growth charts. The level of awareness was significantly influenced by maternal age, educational status and parity (p<0.05) Of those who have heard about growth chart, only 155 (55.8%) had it, and 150 of these (96.8%) used it regularly. One hundred and seventy four (33.6%) of all mothers, but 62.6% of those who have heard about the chart demonstrated an understanding of the markings on it. One hundred and sixteen mothers found the growth chart useful for immunization record, nutrition advice, clinic appointment dates, and assessment of developmental milestones. This study provides a useful evaluation of the educational impact of routine child health services. A limitation is that the study did not record the reasons for attendance of health facilities by mothers with children and the degree of exposure to health education. Also the study did not collect data that might help to explain whether the reasons for the non-understanding of the growth charts could be attributed to the deficiencies in the health education content of the growth monitoring process or other factors. There were no controls.

Forsyth, S.J. (1984) Nutrition education: lack of success in teaching Papua New Guinea mothers to distinguish "good" from "not good" weight development charts. Food and Nutrition Bulletin 6, 22-26. Ref ID : 6665

Target Group/Country Mothers attending child health clinics in Papua New Guinea

Intervention Methodology Some of these mothers received individual training to identify examples of weight charts.

Evaluation Method A survey of 142 women, attending maternal and child health clinics A follow-up was done 4 months later to measure the effects of nutrition education in mothers' accuracy in identifying test charts and the children's nutritional development.

Impact Achieved Results indicate that weight charts achieve little in the way of motivating urban Papua New Guinea mothers to provide nourishment for their children. Despite the wide popularity of weight charts in nutrition education, their role in involving mothers in assisting child development was not demonstrated

George, S.M., Latham, M.C., Abel, R., Ethirajan, N., and Frongillo, E.A.,Jr. Evaluation of effectiveness of good growth monitoring in south Indian villages . Lancet 342(8867):348-352, 1993. Ref ID : 207

Target Group/Country Mothers of under fives in rural Tamil Nadu, India.

Intervention Methodology A functioning primary health care system was in place in all 12 villages implemented a set of interventions including health and nutritional education. The interventions were identical in the two sets of villages except for the use of growth charts in education in the 6 Growth Monitoring Programme (GMP) villages The nutrition worker in the non-Growth Monitoring Programme (NGM) villages had the same contact time as in the GMP villages but advised mothers without the benefit of growth charts

Evaluation Method A community intervention trial in 12 villages. The villages were divided into 6 "growth-monitoring package" of intervention villages (GMP) and 6 "non-growth-monitoring package" of intervention villages (NGM). About 550 children under the age of 60 months were studied over 4 years in GMP villages and a similar number of children in NGM villages. The research team, independently of the nutrition worker, did anthropometric studies on children in all villages every 4 to 5 months. Comparisons were done by calculating monthly gains in stature, and weight, and the significance of differences observed was adjusted for age and sex.

Impact Achieved After 30 months of interventions, similar improvements in growth were seen in GMP and NGM children. The interventions seemed to have improved the nutritional status of young children in both groups of villages. In view of the lack of additional benefit from growth monitoring over other educational interventions, the authors question its use as part of child survival programmes in India.

Martinez,H., Chavez,M.M., Guarneros,A.R., Rios,A. and Chavez,A. (1996)  Mothers' knowledge, understanding, and use of the bubble chart in a rural area of central Mexico.  Food and Nutrition Bulletin  17, 241-247.Ref ID: 6653

Target Group/Country Mothers living in a rural area of central Mexico

Intervention Methodology The bubble chart is a growth chart that has a vertical layout rather than the more common horizontal one, and bubbles instead of criss-crossing lines. All mothers of children<2yrs were visited and invited to participate. Mothers who accepted were visited by field auxiliaries at home once a month when the child was weighed, the weight plotted and the mother was instructed on how to interpret the chart. When growth faltered the mothers were instructed on appropriate actions.

Evaluation Method Of 100 eligible mothers, 85 agreed to participate. The evaluation was done with a pre-intervention-post intervention design - the first test took place after the field auxiliaries had been visiting the mothers for four months. The second took place 12 months after the monthly visits had begun. At each evaluation a field psychologist carried out a home interview with the mother using a questionnaire containing 14 questions based on Bloom's taxonomy of the learning process, which defines a sequence that goes from knowledge to understanding (comprising translation, interpretation and extrapolation) and finally to application. There were no controls.

Impact Achieved All areas evaluated showed an increase between pre-intervention and post-intervention, with a statistically significant (p<0.5) increase in knowledge, interpretation, and application; the mothers ranked highest in knowledge. The children's nutritional status increased significantly (p<.0001) between pre-intervention and post-intervention. Except for one child, they had at least one period of weight loss during the study period. However, 81% of them gained weight most of the time (i.e. at least two-thirds of weight records showed neither gain nor loss), and 12% lost weight most of the time (at least two-thirds of records showed weight loss). Mothers of children who mostly gained weight had higher knowledge, understanding, and application scores (p<.01). Similarly, these mothers were most likely to perform all the activities promoted as part of the growth programme (p<001). Whilst demonstrating an impact, this study is limited by lack of controls and the intensive nature of the intervention which raises issues of sustainability. Whilst not having a control, the demonstration of the effect of improved knowledge on nutritional status does at least provide some supporting evidence for the impact of the programme.

Ruel, M.T., Habicht, J.P., and Olson, C. Impact of a clinic-based growth monitoring programme on maternal nutrition knowledge in Lesotho. International Journal of Epidemiology 21(1):59-65, 1992. Ref ID : 2516 (Borderline for inclusion in database)

Target Group/Country Mothers with children < 2 years attending health clinics in Lesotho

Intervention Methodology At the clinics, the mothers did not undergo individual counseling or receive training in growth charts. Group nutrition education efforts did take place however, but separately from the growth monitoring program. Details of this nutrition education are not provided but according to the authors it was "of variable duration and quality depending on the skills, interest and enthusiasm of the clinic nurse in charge".

Evaluation Method Data from 907 mothers of <2-year-old children in 8 clinics were analyzed to determine if attendance at a typical nationwide clinic-based growth monitoring program improved maternal knowledge of weaning practices and diarrhhoea management. All mothers with a child younger than 2 years and who had attended the clinic for less than 2 years were included in the study. There were no controls and no baseline.

Impact Achieved Mothers who attended a clinic had a significantly higher increased knowledge of the appropriate timing for introducing animal protein rich foods and about the use of oral rehydration salts than those who did not attend (p<.05). This association was especially significant for mothers with only primary education and those with infants <6 months old. The mothers reported breast feeding a mean of 2 years. 85% knew to introduce cereals and liquids between 4-6 months old. Yet few mothers knew how to appropriately stop breast feeding. For example, 50% believed it should stop in 1 day. A problem with this report is that clinic attendance is not defined and data is not presented of the distribution of clinic attendance among the sample, especially since the sample members were recruited from the clinic itself.

Sohal, H., Wilkinson, D., and Morley, D. The 'growth monitoring teaching aid' rapidly improves mothers' understanding of growth curves. Trop.Doct. 28(3):160-162, 1998. Ref ID : 7898

Target Group/Country Mothers attending various clinics at hospital in rural Hlabisa District, Kwa Zulu

Intervention Methodology The 'Growth Monitoring Teaching Aid' (GMTA) is an educational game which attempts to expedite the process of understanding growth curves by simulating the growth curve of a child using water added to a bucket suspended below the direct recording scales

Evaluation Method Thirty mothers were divided into an experimental group who used the GMTA for 2-4 h and a control group who did not use it. Six questions were used to test each subject's understanding of growth curves.

Impact Achieved Paired t tests revealed that the experimental group significantly increased their understanding of growth, whereas the control group did not. The mean score for the experimental group prior to playing the game was 1.43; this increased to 5.27 after playing the game (P < 0.0001). The GMTA by rapidly improving the present poor level of understanding of growth curves, may allow greater maternal participation in growth monitoring. Note that this is an evaluation of a methodology under ideal conditions and that a field test might produce different results according to the skill and motivation of health workers using it as an educational tool.

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10 Nutrition programmes

Jacoby, E.R., Benavides, B.M., Bartlett, J.C., and Figueroa, D. Effectiveness of two methods of advising mothers on infant feeding and dietetic management of diarrhoea Peru. Journal of Diarrhoeal Diseases Research 12(1):59-64, 1994. Ref ID : 6372

Target Group/Country Mothers of small children attending a hospital's Oral Rehydration Unit in Peru

Intervention Methodology The intervention was carried out in a room adjacent to an oral rehydration unit. The first intervention group received oral counselling and a recipe pamphlet. The nutritionist gave each mother a 5 min. explanation of infant feeding practices making three general recommendations: 1) a puree is the best food for infants instead of customary soups and broths; 2) additional oil/;butter is necessary to "strengthen" weaning foods; 3) the recipe should be used regularly and also when the infant has diarrhoea The nutritionist described how to prepare one of the recipes and used two posters as a visual aid and gave a pamphlet of recipes that had been designed and pre-tested for that specific community. The second intervention group received the same counselling and recipe book but also observed a cooking demonstration which lasted about 20 minutes.

Evaluation Method 74 mothers were in the oral Mothers of infants aged 5-15 months who had initiated weaning, were fully rehydrated and resided in one of 11 poor districts of Lima. Once the mother child pair was recruited the educational intervention was random assigned and the nutritionist in charge of it was selected by lottery. There were 74 mothers in the group receiving oral counselling plus pamphlet and 70 in the group receiving the additional cooking demonstration. Each mother was interviewed prior to the intervention, 48 hr post intervention and 30 days post intervention during home visits. Mothers were asked to recall all the food preparations and main ingredients given to the child during the previous day. Mother's recall as also used to determine the consistency of the food which was used as a proxy for energy density. To avoid bias from the interviewers preferences for particular educational methods, they were kept blind to the study objectives, Also the interviewer presented her visits as part of a comprehensive infant health evaluation and not as an evaluation of the infant feeding education. There were no controls.

Impact Achieved Both interventions had a statistically significant (p < 0.05) impact on maternal knowledge and practices; differences between the impact of the two practices were negligible. After merging both groups into a single sample, it was observed that changes over time were significantly large (p < 0.05). Knowledge rates were 27.6% before the intervention, 73.7% 2 days later and 75% 30 days later. The corresponding figures for practices were 2.6%, 58.3% and 37.5% respectively. We conclude that when place, time and message are adequately chosen, a simple method may be an effective way of good communication. There were no controls, however given that the practices being introduced were new, this is not a major shortcoming. The demonstration that a simple educational method is as effective as a more complex one has useful practical implications.

Paramjit, Chawla,K. and Puri,R. (1996)  Impact of nutrition education on food and nutrient intake of pregnant women.  Indian Journal of Maternal and Child Health  7, 11-15. Ref ID 8681

Target Group/Country Low socio-economic pregnant women were selected from two hospitals and two urban family welfare centers in Ludhiana city, India.

Intervention Methodology Nutrition education was carried out through 10 group contacts and three individual contacts over 13 weeks. The woman came to an urban family welfare center once a week from 9.30 to 12 noon during which period were taught about nutrition for 45 minutes in groups of 7 to 10 women. Teaching was carried out through in local language Punjabi using lectures, discussions and demonstrations. Charts, posters and actual foods were used as visual aids. Content of the nutrition education included: functions of food, balanced diet during ping pregnancy, anaemia and its eradication, methods of improving nutritive value of diets, breast feeding and weaning.

Evaluation Method Researchers compared data on 33 pregnant women attending nutrition education classes regularly over a 13-week period (nutrition education group) with data on 33 other pregnant women who did not receive such education (controls). A dietary survey was conducted at 20 weeks gestation and again at 36 weeks gestation.

Impact Achieved At 20 weeks, the two groups were not statistically different. In both the nutrition education group and the control group, nutrient intake was higher at 36 weeks than at 20 weeks due to the increased food requirements of pregnancy. Women in the nutrition education group were more likely than the control group to consume more protein, vitamin A, thiamine, folic acid, and vitamin C (p<0.01). This likely reflects a higher consumption of pulses, milk and milk products, fruits, and vegetables as well as adopting favorable nutritional practices (e.g., use of sprouted grains). Nevertheless, intake was below RDIs for many nutrients, even for women in the nutrition education group. These findings suggest that nutrition education for pregnant women does improve nutrient intake but also that more needs to be done to bring intake levels up even higher

India Sachdeva, R. and Mann, S.K. (1993) Impact of nutrition education and medical supervision on pregnancy outcome. Indian Pediatr. 30, 1309-1314. Ref ID : 6572

Target Group/Country Punjabi women from low and lower middle income groups from  villages of the Ludhiana district, Indiz

Intervention Methodology Supplements of iron, folic acid and calcium (Folifer and Calcium Sandoz tablets) were supplied regularly to the experimental (E) group (n=30) from the second trimester onwards. A pamphlet about diet during pregnancy was distributed to E. Moreover, 4 individual and 3 group contacts were made during the second half of pregnancy to reinforce the nutrition education provided by the pamphlet. The control (C) group (n=30) received iron and folate supplements

Evaluation Method 30 in experimental group and 30 in control.  Body height, weight, mid-upper arm circumference (MUA) and skinfold thickness were recorded. Weight gained during pregnancy and post-partum weight were also recorded and body mass index was calculated. Crown heel length (CHL), birth weight (BW), skinfold thickness, MUA, head circumference, chest circumference and ponderal index (PI) of neonates were recorded within 8 h of birth. control.

Impact Achieved Weight gain during pregnancy was 6.30 and 5.7 kg in E and C groups, respectively (p<0.01). Body weight, crownheel length, skinfold thickness and ponderal index of the neonates were greater in E than C (P<0.01). Mean body weight of neonates in E and C groups was 2700 and 2300 g, respectively. Weight gain during pregnancy was correlated with MUA, BW and skinfold thickness of the neonate (P<0.05). It would have been helpful to have had some supporting information on any change in dietary practices/total food intake to support the information provided.

Vijayaraghavan, K., Hanumantha Rao, D., and Swaminathan, M.C. India Population Project, Karnataka. Evaluation of nutrition education activities. Hygie 1(3-4):9-14, 1982.Ref ID : 541

Target Group/Country Rural mothers in Kanataka State, India

Intervention Methodology Educational activities were carried out in 2 primary health care centers where supplementary feeding for pregnant women (last trimester), nursing mothers during the 1st 6 months of lactation, and children between 6 and 24 months had been introduced.  They consisted of group talks, cooking demonstrations, mobile nutrition exhibitions, and films on nutrition and other health matters. Topics included: Importance of supplementary food for women during pregnancy and lactation, prevention of vitamin A deficiency and nutritional anaemias and the need for childhood immunisations. Intervention villages had participated in the educational activities at least six or more times during the five year period of IPP programme.

Evaluation Method 12 villages where group talks or cooking demonstrations had taken place 6 or more times over the 5-year period were surveyed, generally through interviews with mothers; personnel involved in educational activities were also interviewed. Pre tested questionnaires of intervention households (n=120) and controls households (n=145).

Impact Achieved Intervention householders were more likely than controls to know that greater amounts of food should be consumed by pregnant women (P<0.001). More intervention households could recall the major ingredients demonstrated in recipes than controls (P<0.01). More intervention women prepared the demonstrated recipes at home compared to controls (P<0.001). Significantly more intervention women were aware of and received iron and folate tablets (P<0.01). There was also increased awareness of immunisation (P<0.001) and the need for prophylactic Vit. A among the intervention households (P<0.001). Where food supplementation was recognized as a need (p<0.01), lack of resources made it difficult for villagers to provide it

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11 Infections and tropical diseases

Onchocerciasis

Oladepo, O., Okunade, A., Brieger, W.R., Oshiname, F.O. and Ajuwon, A.J. (1996) Outcome of two patient education methods on recruitment and compliance with ivermectin in the treatment of onchocerciasis. Patient Education and Counseling 29, 237-245. Ref ID:7278

Target Group/country Rural communities in South West Nigeria

Intervention Methodology The programme explored the use of two educational approaches in supporting passive ivermectin distribution from primary health care clinics. Information Media (IM) approach used posters, hand megaphones at markets, meeting places and mosques/churches and town criers and Social Network (SN) approach worked through existing organisations including churches, farmers associations and cooperatives.

Evaluation Method Two communities each were randomly assigned to the IM intervention group (n=679), 2 to the SN group (n=505) , and 2 served as controls (n=81). Data was collected on persons presenting themselves to the clinics for ivermectin after the interventions and for follow-up six months later.

Impact Achieved The percentages of eligible persons presenting for ivermectin after initial education were SN group 30.3% (n=679), IM group 29.9% (n=679) and control 7.3%(n=88) but the differences between intervention groups were not significant. The drop-off in attendance at the 2nd round of ivermectin distribution. From the original attenders was 43.3% n=219 for SN and 47.4% n=322 for IM), while few control patients came back for their 2nd dose (12.3%).. Ref ID : 7278

Tuberculosis

Demissiea,M., Getahun,H. and Lindtjrn,B. (2013) Community tuberculosis care through ''TB clubs'' in rural North Ethiopia. Social Science and Medicine 56, 2009-2018. Reference ID: 9114

Target Group/Country TB patients in rural areas of Northern Ethiopia

Intervention Methodology TB patients living in rural kebeles (villages) of Este were organised according to their residential area into clubs by the TB health worker. Members of a TB club had the same clinic dates for follow up. A TB club had 3-10 TB patients and members of the club chose their leader and whenever possible a literate (able to read and write) club member led the club. The club leader communicated the activities and schedule of the club to the health worker at the clinic. The TB club leader ensured that all members of the club attended the TB clinic at the date of appointment, and informed the clinic staff about absent members. Each club had a regular weekly meeting on Sundays and the leader also co-ordinated other ad hoc meetings usually on holidays and market days. The duration of the regular weekly meetings was 1-2 h. The meetings were often conducted in places such as churches, mosques, market places or other venues for social events. The purpose of the regular meetings was for members of the TB club to support each other in adhering to treatment, and to share information about the course of the disease and possible drug side effects. Patients failing to make satisfactory progress or suffering from side effects were reported to the health centre. All the club members in the different kebeles had a monthly meeting organised by the health centre. The regular monthly meetings of the health workers with TB clubs were to maintain active participation of members and to provide technical advice. The TB club leaders also sought the help of other influential community members such as priests and Moslem religious leaders and community elders in encouraging and supporting patients to complete the full course of the treatment. The TB club leaders were provided with educational material on TB prepared by the Ministry of Health and the Regional Health Bureau, written in Amharic, the local and national language. Members of the TB clubs exchanged information on TB with other community members, through public reading (most of the time at church) and disseminated educational materials. The TB club leaders also help in identifyingand referring new TB suspects to the health centre, in which case individuals referred were exempted from the long waiting line in the health centre. There was no payment or other incentive given to members of the TB clubs or to the leaders. Nevertheless, the TB patients had easy access to the health units and were allowed to refer TB suspects. Local health workers and community health agents supervised the TB clubs by attending their weekly meetings on a regular basis.

Evaluation Method The study utilised both quantitative (cohort study) and qualitative (focus group discussion and an in-depth interview) methods. The cohort study was conducted in two rural districts of Northern Ethiopia. A total of 128 sputum positive pulmonary patients were enrolled and followed, 64 in the TB club and 64 in the comparison groups, to determine treatment outcome of anti-TB therapy. The impact of the TB clubs in changing societal attitudes and behaviour associated with TB was assessed using qualitative methods (focus group studies and in-depth interviews -11 of the 47 TB clubs were selected for fgds). Details are not provided of the analysis of the qualitative data.

Impact Achieved The treatment completion rate was signicantly better (Chi squared = 5:41; P<0:02) in the TB club group, 44 out of 64 patients (68.7%) completed treatment in TB club while only 30 of the 64 (46.8%) completed treatment in the comparison group. The defaulter rate was also signi.cantly lower (Chi squared = 11:57; P<0:001) in the TB club group 8/64 (12.5%) compared to 26/64 (40.6%) in the comparison group. The qualitative part of the study also demonstrated remarkable changes in patients' understanding of TB, patients' initial reaction to a TB diagnosis, misconceptions as to the cause and treatment of TB, the social isolation and compliance and belief in the modern health care in the TB club area.The complementary results obtained from the quantitative and qualitative components of the study indicate that the TB club approach has a significant impact in improving patients' compliance to anti-TB treatment and in building positive attitudes and practice in the community regarding TB. This study, thus, provides convincing evidences that the TB club approach is useful in delivering TB treatment successfully in rural populations. This study provides a good example of the way that a community-based activities can support clinic-based DOTS approach. It would have been good to have had some data on staffing and time inputs into the clubs to assess the feasibility of replication in other areas.

Dick, J. and Lombard, C. Shared vision--a health education project designed to enhance adherence to anti-tuberculosis treatment. Int.J.Tuberc.Lung Dis. 1(2):181-186, 1997.  Ref ID : 7320

Target Group/Country Tuberculosis patients at two adjacent Cape Town Local Authority health clinics, South Africa

Intervention Methodology The combined strategy of a patient-centred interview plus the issuing of a patient education booklet to increase the adherence of notified pulmonary tuberculosis (TB) patients to prescribed treatment. The intervention was based on social learning theory.  The five nurses at the clinic received training in patient-centred communication (cost 250R per nurse ($70) . A photonovel costing R1 ($0.30) was produced in Afrikaans called "Where there is a will   " based on research that also incorporated a calendar to enable patients to monitor their progress through treatment. A role model was created by the heroine of the story whose experience shoed the obstacles to adherence e.g. stigma of the disease, depression and side-effects. The message of the booklet was reinforced by the counselling provided by the nurses while the self-monitoring process of completing the calendar  was designed to give the patient a sense of cognitive control.

Evaluation Method A controlled intervention study was implemented using a cohort of the first 60 consecutive patients notified with pulmonary TB at both Clinic A (intervention clinic) and Clinic B (control clinic)

Impact Achieved The patients exposed to the educational input in Clinic A achieved a mean adherence rate to treatment of 95% with only one patient defaulting. This was a significant (p<0.0001) improvement. The mean adherence of Clinic B was 83% with 13 patients dropping out. The risk of non adherence was significantly (p=0.014 reduced at the experimental clinic versus the control. It was not possible to indicated which part of the health education approach contributed to the difference as it was delivered as a package. Another possible contributing factor was the increased motivation of the staff in Clinic A as a result of their training. Note there is some ambiguity in the data presneted for adherance as it refers to a subset of each clinic which presumably means the sample drawn for the study..

Malaria

Denis, M.B. (1998) Improving compliance with quinine plus tetracycline for treatment of malaria: evaluation of health education interventions in Cambodian villages. Bull. World Health Organ. 76 Suppl 1:43-9. 43-49..Ref ID : 8466

Target Group/Country General community and malaria patients in villages in a malaria-endemic area of Cambodia

Intervention Methodology To improve compliance with a 7-day quinine and tetracycline regimen against malaria, 2 health education interventions were tested upon populations in 2 groups of  for 10 weeks during July-September 1996. Drug vendors and health care workers received training on the importance of giving advice on compliance. During the intervention period posters were displayed in the villages of both groups. Approximately 150 posters were distributed in each village for display in schools, temples, clinics, pharmacies, village chief's offices, army camps, plantation units and video parlours. The videos were shown approximately 25-30 times each week in the second group of villages in video parlours, restaurants and at ceremonial gatherings.

Evaluation Method Two groups of three villages of population about 15,000 each were selected. 103 patients were interviewed at the start and at the end of the intervention to determine recall of advice provided, purchase of anti-malarials and compliance

Impact Achieved In one group, the use of posters and video improved compliance rates from 0.5% to 20% (20% effectiveness, 95%CI, 0-12% p<0.0004), while in the other group, where only posters were used, full compliance rose from 6% to 11% (6% effectiveness; 95%CI, 0-12% p<0.09 NS). Among private health care practitioners, the effectiveness of posters plus video in reducing poor compliance was approximately 40%, compared with only 2% among drug vendors. This difference did not seem to be the result of more private practitioners giving advice to use full doses. Rather, patients were less likely to take the advice of a pharmacist/drug vendor to take full medication. Another explanation could be that the group was prone to poor compliance regardless of any advice received.

Helitzer-Allen, D.L., Macheso, A., Wirima, J., and Kendall, C. Testing strategies to increase use of chloroquine chemoprophylaxis during pregnancy in Malawi. Acta Tropica 58(3-4):255-266, 1994. . Ref ID : 4952

Helitzer-Allen, D.L., McFarland, D.A., Wirima, J.J., and Macheso, A.P. Malaria chemoprophylaxis compliance in pregnant women: a cost-effectiveness analysis of alternative interventions. Social Science & Medicine 36(4):403-407, 1993. . Ref ID : 1856

Target Group/Country Pregnant women at ante-natal clinics in Malawi

Intervention Methodology Following an ethnographic study the traditional health education messages were revised to take into account local terminology and stress the seriousness of malaria for pregnant women. To overcome opposition to the bitter taste of chloroquine, a sugar-coated version was used.

Evaluation Method 3 interventions were tested on 1035 women in 4 ante-natal clinics: (A) the revised health education (n=116) (B) distribution of a sugar-coated chloroquine tablet with traditional health education (n=67) and (C) sugar-coated chloroquine and revised health education. (n=73) Data collection included reported chloroquine use and measurement of chloroquine in urine at the initial antenatal visit and on first return visit

Impact Achieved For those women who were not taking chloroquine at outset, the % taking chloroquine on return visit were: A -57% (revised health education message)  B 84% (coated chloroquine p<0.00007) and C 91% (coated chloroquine and revised health education p<0.04). The study shows that improving the product was the most important factor in increasing the use of the programme, and that changing the health education message can also make an impact on use. Cost-effectiveness analysis showed that the cost per compliant women using coated chloroquine or improved health education separately or combined was lower than the existing method.

Kidane,G. and Morrow,R.H. (2011)  Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomised trial.  Lancet  356, 550-555. Ref ID 8735

Target Group/Country Mothers of under-fives in Tigray, Ethiopia

Intervention Methodology Mother coordinators were trained to teach other local mothers to recognise symptoms of malaria in their children and to promptly give chloroquine. Pictorial charts were designed and produced for use and reference by mother coordinators giving standard chloroquine doses by age.

Evaluation Method Of 37 tabias (cluster of villages) in two districts with hyperendemic to holoendemic malaria, tabias reported to have the highest malaria morbidity were selected. A census was done which included a maternity history to determine under-5 mortality. Tabias (population 70506) were paired according to under-5 mortality rates. One tabia from each pair was allocated by random number to an intervention group and the other was allocated to the control group.  In both intervention and control tabias, all births and deaths of under-5s were recorded monthly. For every third child who died, a structured verbal autopsy was undertaken to ascribe cause of mortality as consistent with malaria or possible malaria, or not consistent with malaria

Impact Achieved From January to December 1997, 190 of 6383 (29.8 per 1000) children under-5 died in the intervention  tabias compared with 366 of 7294 (50.2 per 1000) in the control tabias. Under-5 mortality was reduced by 40% in the intervention localities (95% CI from 29.2-50.6; paired t test, p<0.003). Of the 190 verbal autopsies, 13 (19%) of 70 in the intervention  tabias were consistent with possible malaria compared with 68 (57%) of 120 in the control tabias. While the study does demonstrate that a major reduction in under-5 mortality can be achieved in holoendemic malaria areas data is not provided to attribute that reduction to improved case management by mothers. Very little detail is provided on the educational intervention and training methods used.

Marsh,V.M., Mutemi,W.M., Muturi,J., Haaland,A., Watkins,W.M., Otieno,G. and Marsh,K. (1999)  Changing home treatment of childhood fevers by training shop keepers in rural Kenya.  Trop. Med. Int. Health   4, 383-389 Ref. ID: 8604

Target Group/Country Community in a rural area of coastal Kenya

Intervention Methodology The programme involved formative research followed by a training programme for 43 shopkeepers from 23 shops serving a population of approximately 3500. Shopkeepers were trained  in a series of three workshops each lasting three days. They were trained to use two types of materials to give information to purchasers; dosage charts for chloroquine and aspirin/paracetamol-based drugs and sets of rubber stamps depicting the correct way of using chloroquine in children of different ages. These stamps printed a visual reminder of the verbal advice given and were retained by the drug purchaser

Evaluation Method At baseline April 1996 structured observations were made at shops (n=289) and interviews with purchasers outside the shop and a follow-up interview of parents of children three days afterwards (n=109). This was repeated for similar sample sizes during peak malaria seasons in June-July 1996 and December 1996/January 1997. Training was evaluated by measuring changes in the proportions of drug sales where an adequate amount of chloroquine was purchased and in the percentage of home-treated childhood fevers given an adequate amount of chloroquine. The programme was assessed qualitatively in the community following the shop keeper training.

Impact Achieved The percentage of drug sales for children with fever which included an antimalarial drug rose from 34.3% (95% CI 28.9%-40.1%) before the training to a minimum of 79.3% (95% CI 71.8%-85.3%) after the training. The percentage of antimalarial drug sales where an adequate amount of drug was purchased rose from 31.8% (95% CI 26.6%- 37.6%) to a minimum of 82.9% (95% CI 76.3%-87.3%). The percentage of childhood fevers where an adequate dose of chloroquine was given to the child rose from 3.7% (95% CI 1.2%-9.7%) before the training to a minimum of 65.2% (95% CI 57.7%-72.0%) afterwards, which represents an increase in the appropriate use of over-the-counter chloroquine by at least 62% (95% CI 53.7%-69.3%). Shop keepers and community members were strongly supportive of the aims and outcome of the programme. Whilst some of the impact seen may be attributable to research effects in a relatively small scale pilot study, he large shifts in behaviour observed indicate that the approach of training shop keepers as a channel for information to the community is both feasible and likely to have a significant impact.

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12 Eye Health

Rahman, M.M., Islam, M.A., Mahalanabis, D., Chowdhury, S., and Biswas, E. Impact of health education on the feeding of green leafy vegetables at home to children of the urban poor mothers of Bangladesh. Public Health 108(3):211-218, 1994. Ref ID : 2119

Target Group/Country Urban poor mothers in Bangladesh

Intervention Methodology Health education within hospital setting and on home visit and a feeding demonstration and sample of cooked green leafy vegetables (GLV) given to their children. The mothers of the first intervention group (n = 44) were given health education including a feeding demonstration, by offering a single meal of cooked GLV to their children.

Evaluation Method The mothers in the second intervention group (n = 36) received health education.160 mothers of children  6-35 months. 1st group (n=44) received health education and feeding demonstration, 2nd group (n=36) received health education only. Controls (n=80) were mothers from immediate neighbourhood with child of same age range. A baseline interview was carried out (details not provided) and mothers were visited at home after 8 weeks of intervention without prior notice and observation/interviews used to explore perceptions of GLV and find out if children had been fed GLV that day.

Impact Achieved The percentages of mothers who fed their children GLV were 57%, 64%, and 26% in groups 1, 2, and comparison group respectively (p < 0.001) but no baseline data provided. The influence of health education on GLV feeding persisted after controlling for the effect of maternal literacy (Mantel Haenszel chi-square = 16.99; P<0.0001).

Cintra,F.A., Costa,V.P., Tonussi,J.A.G. and Jos,N.K. (1998)  Avaliao de programa educativo para portadores de glaucoma [Evaluation of an educational program for patients with glaucoma].  Revista Sade Pblica  32, 495-501. Reference ID: 8688

Target Group/Country: Patients at the Glaucoma service of the University of Campinas, Brazil: Educational methods:

Intervention Methodology Fifty glaucoma patients were given information about the disease and its treatment by an experienced nurse

Evaluation Method: They were given the same questionnaire before and 2.7 months after the initial explanation. The technique of eyedrop instillation was compared before and after the educational program. There were no controls.

Impact There was no significant improvement concerning the knowledge of the identification of the ocular disease, the side effects, the meaning of glaucoma, the importance of treatment, the purpose of medications and the normal value of intraocular pressure. There was a significant improvement in all steps of eyedrop instillation (p<0.01) and in knowledge regarding the importance of heredity (p <0.001) and the purpose of perimetry (p=0. 033). Although a significant improvement was observed in the technique of eyedrop instillation, the authors conclude that this plan was not complete enough for its contents fully to be understood. It also highlighted the difficult nature of the information to be communicated and the complexity of control/treatment of glaucoma.

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15 Chronic infections including diabetes, epilepsy

Fernando, D.J. Knowledge about diabetes and metabolic control in diabetic patients. Ceylon.Med.J. 38(1):18-21, 1993.. Ref ID : 7348

Target Group/Country Diabetic patients Sri Jayawardenepura General Hospital, Talapathpitiya, Nugegoda, Sri Lanka

Intervention Methodology The educational session consisted of didactic lectures by trained nurses, individual instruction, information leaflets and group discussions. This was reinforced at 23 month intervals by repeat attendance at nurse education sessions.

Evaluation Method A randomised controlled clinical trial in patient education was conducted at a diabetic and general medical clinic in Sri Jayawardenepura General Hospital. Two groups of diabetic patients matched for age, gender and duration of diabetes were allocated randomly to conventional care at general medical clinics or to a diabetes clinic where specific educational objectives were defined and patients trained to achieve these objectives. The doctors treating these patients were not 'blinded' to treatment groups. Diabetes knowledge was assessed using a diabetes knowledge scale and metabolic control assessed by mean fasting blood glucose. 80 patients were initially enrolled and final number was reduced to 61 with drop-outs due to death, going away, difficulty of tracing and exclusion due to development of acute myocardial infarcation.

Impact Achieved The patients attending the diabetic clinic showed significant improvement in both knowledge scores (67% vs 34%, p < 0.01) and mean fasting blood glucose 6.38 +/- 0.85 mmol/l vs 9.7 +/- 1.7 mmol/l, p < 0.01) at 6 months.

Goldhaber-Fiebert, J. D., Goldhaber-Fiebert, S. N., Tristan, M. L. and Nathan, D. M. (2013) Randomized controlled community-based nutrition and exercise intervention improves glycemia and cardiovascular risk factors in type 2 diabetic patients in rural Costa Rica. Diabetes Care, 26, 24-29. Ref ID: 9294

Target Group/Country Type 2 Diabetic patients in Costa Rica

Intervention Methodology A community-based, group-centered public health intervention addressing nutrition and exercise delivered through 11 weekly nutrition classes (90 min each session). Subjects for whom exercise was deemed safe also participated in triweekly walking groups (60 min each session).
Before random assignment to the treatment groups, all volunteers received standard diabetes education in the form of a lecture that reviewed type 2 diabetes and its symptoms, treatment, and associated complications. After randomization, the subjects in the intervention group began the 12-week lifestyle intervention, and the subjects in the control group were informed that they would be offered a similar program at the end of the study. The lifestyle intervention included 11 weekly nutrition classes (90 min each session) in centrally located community centers. The classes were taught by three nutritionists who were enrolled in a nutrition Master's degree program at the University of San Jose. They received instruction in the specific dietary curriculum that was used in the study and helped to refine it to conform to local customs. Each class was offered twice per week in each community to enhance attendance. The classes were limited to 15 individuals per class; subjects were encouraged to bring family members. The course focused on portion control for weight reduction and use of healthier food substitutes (electronic copies of the Spanish- language curriculum are available upon request from the corresponding author). Because the concept of counting calories is less common in Costa Rica, specific suggestions were made for portion the saturated fat content in foods such as chicharrones (fried pork sausages). To harness the benefits of peer support, subjects set weekly goals for specific changes in their eating behaviors to decrease portion sizes and make healthier food choices. These goals were shared with the group at the end of class, and progress was reported at the beginning of the next class. Emphasis was placed on the importance of nutritional health for all family members, regardless of diabetes status. Each participant was given written handouts and a notebook to take notes and record food diaries. Those who were not able to read or write were assisted during the class and were encouraged to ask a family member for assistance at home. Each participant was also given a measuring cup and taught how to use it for portion control. The subjects in the intervention group were invited to participate in 60- min walking group sessions three times per week for 12 weeks.

Evaluation Method A total of 75 adults with type 2 diabetes, mean age 59 years, were randomly assigned to the intervention group or the control group. All participants received basic diabetes education. Glycosylated hemoglobin, fasting plasma glucose, total cholesterol, triglycerides, HDL and LDL cholesterol, height, weight, BMI, and blood pressure were measured at baseline and the end of the study (after 12 weeks).

Impact Achieved The intervention group lost 1.0 +/- 2.2 kg compared with a weight gain in the control group of 0.4 +/- 2.3 kg (P = 0.028). Fasting plasma glucose decreased 19 +/- 55 mg/dl in the intervention group and increased 16 +/- 78 mg/dl in the control group (P = 0.048). Glycosylated hemoglobin decreased 1.8 +/- 2.3% in the intervention group and 0.4 +/- 2.3% in the control group (P = 0.028). Authors concluded that glycemic control of type 2 diabetic patients can be improved through community-based, group-centered public health interventions addressing nutrition and exercise

Adamolekun, B., Mielke, J.K. and Ball, D.E. (1999) An evaluation of the impact of health worker and patient education on the care and compliance of patients with epilepsy in Zimbabwe. Epilepsia 40, 507-511.Ref ID : 8458

Target Group/Country Community in Zvimba district in Zimbabwe

Intervention Methodology The use of primary health care nurses in the diagnosis and management of epilepsy patient-information pamphlets to promote drug compliance and clinic attendance. Primary health care workers from 24 clinics  attended a workshop to improving their knowledge in the diagnosis and management of generalized tonic-clonic seizures. An illustrated leaflet was produced containing information on the nature of epilepsy, the importance of drug therapy and good drug compliance and the emergency management of seizures.

Evaluation Method Half of the clinics (experimental group) subsequently received patient-information pamphlets for distribution to patients and relatives, whereas the other half (control group) did not. Frequency of clinic attendance, mean seizure frequencies, and mean serum levels of phenobarbitone were compared at baseline and at 6 months after intervention in patients within each group, and at 6 months after intervention between both groups.  Patients who missed two consecutive clinic appointments were regarded as defaulters

Impact Achieved 296 patients with epilepsy were on the epilepsy registers of the 245 clinics at the beginning of the study and 400 at the end - an increase of 74% (204270 cases in the clinic receiving the pamphlet and 92 130 in the group not receiving a pamphlet). There was an overall marked improvement in patient drug compliance over the 6-month study period. The group receiving patient patient-information pamphlets showed a marked reduction in patient default from clinic follow-up (p<0.01) but there was no increase in drug compliance or seizure frequency for the group receiving the leaflet. The authors concluded that oral communication by health workers might have a greater impact than printed materials in a community with a low level of literacy.  Note that the investigation did not attempt to ascertain whether the pamphlets, once received by the patients in the experimental group, were actually read and understood by them. Their reasons were that they were keeping their intervention simple and capable of replication elsewhere so such a study would have added to the complexity of the intervention. However, this argument confuses the generalisable intervention from the separate research component which is needed to evaluate the intervention but would not form part of the model of change being investigated.  

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16 Miscellaneous patient education

Chalker,J. (1998)  Improving quality of care in Hai Phong Province.  Essential Drugs Monitor 15-17. Ref ID 8691 Ref ID8691

Target Group/Country
1.6 million people in twelve districts of Vietnam

Intervention methodology Following workshops with community members and health workers an IEC programme was developed which included the following messages: 1) Never use injections if tablets will do. Injections can be dangerous and are usually not necessary.2) If you need antibiotics, you must use a full dose. Not finishing the dose means that the next time you need them they may be less effective.3) When you are ill do not self-prescribe, ask your local expert. Use your commune health station. 4)The media used included: two posters - --five distributed to every Community Health Stations (CHS); four radio programmemes (short, five-minute p plays of five minutes) and four 30 -second radio spots broadcast on district and regional radio and also distributed as cassettes to be broadcast through commune loudspeaker systems; four 5-minuteTV programmesmes each 5 minutes long and one -minute TV spots were broadcast on provincial TV; newspaper advertisements; a leaflet was given to every householder in five communes. The content of the educational programmemes was closely matched to the messages above.

Evaluation Method Two hundred 200 households were randomly selected from each of five 5 communes and interviewed. Forty 40 CHSs were randomly chosen and data obtained from the outpatients book, the drug cabinet, the accounting books and some interviews were carried out. The last thirty 30 treatments in the outpatient books of for each CHS wereas examined.

Impact Achieved  89% of households could repeat some IEC message, 75% claimed to have had a change in knowledge or practice. Respondents claimed to have heard messages from the following sources: commune public address system (67%); TV (52%, note TV ownership is 51%), CHS staff (53%), newspapers (7.5%), posters (15%), leaflet (37%). The following improvements were noted between August 1994 and December 1995: patients given vitamins (75% 8%); percentage% of patients given injections (33%7%); patients given antibiotics (69%46%); patients given correct doses of antibiotics (29%91%). Follow-up data in September 1`996 showed that improvements were sustained. By using local resources the additional costs came to a total of $2,200.   This case study was included because it is one of the rare examples showing from developing countries of use of mass media for public education on drugs in a developing country. Its evaluation data have limitations in In showing an impact for the educational component, their evaluation data has limitations. While they demonstrated that their campaign was received, their impact data highlighted was health worker practices. From the data, iIt is difficult to establish from the data whether or not the improvements are a result of the training of of health workers iin improved prescribing or the educational component. However, even if the change is mainly due to improved prescribing, it is important that this is acceptable to patients. It is possible, but not proven by their data, that the educational campaign also contributed although there is but no evidence is available to support this.. While cost data is welcome, it should be noted that this is the additional costs but routine operational costs, research and supervision do not seem have been factored into the costing.

Edem, C.U., Brieger, W. and Jegede, R.O. (1985) A Nigerian experiment in presurgical patient counseling: a pilot study. Patient Education and Counseling 7, 167-179. Ref ID : 6646

Target Group/Country Patients in hospital in Nigeria

Intervention Methodology Preoperative counselling and relation training was provided to patients over 18 yrs undergoing between December 1982 and January 1983 the following operations: laparotomy, colporrhaphy, herniorrhaphy and hemorrhoidectomy. A total of 42 male and female patients were assigned to experimental and control groups.

Evaluation Method Measurement were made at five points in time for each patient - the evening before surgery, the evening after surge and the mornings of the next 3 days following surgery. Zung's anxiery Status Inventory Scale was adapted to the Nigerian context for diagnosis of situational anxiety. Note this was not a blind study.

Impact Achieved An experimental group showed reduced analgesic intake (p<0.01) and reduction in anxiety levels. This simple study would be worth repeating with a larger sample and with further development of the anxiety scale.

Hadiyono, J.E., Suryawati, S., Danu, S.S., Sunartono, and Santoso, B. Interactional group discussion: results of a controlled trial using a behavioral intervention to reduce the use of injections in public health facilities. Social Science & Medicine 42(8):1177-1183, 1996. , Ref ID : 6058

Target Group/Country Patients attending health facilities in a hilly area 45 km from Yogyakarta, Indonesia

Intervention Methodology Interactional Group Discussion (IGD), for reducing the overuse of injections. The groups, , were facilitated by a behavioural scientist and a clinician.. Each group consisted of 6 prescribers (both physicians and paramedics) and 6 patients (who were from a different health centre catchment). The single session lasted 90-120 minutes and was held in a relaxed informal setting of a restaurant with a free meal provided. The session included an exploration of feelings of members about being included in the group, discussions of the discrepancies between the prescribers’ and patient’s beliefs and motivations for injection use, the presentation of scientific materials and a conclusion

Evaluation Method 24 of 29 public health in a single district  were chosen because records showed that at least 20% of presecriptions were injections. These were randomized to 12 intervention and 12 control groups. 24 IGDs were held in a 4-week period, and all invited prescribers participated. Outcomes were measured by a retrospective prescribing survey covering the periods 3 months before and 3 months after the intervention, with samples of 100 prescriptions per center per month. 6900 cases were collected before intervention and 7200 afterwards. Rates of injection and average number of drugs per prescription were computed separately for each centre, and t-tests were used to compare pre-post changes in outcomes in both groups.

Impact Achieved Results showed a significant decrease in injection use from 69.5 to 42.3% in the intervention group, compared to a decrease from 75.6 to 67.1% among controls [-18.7.0% intervention vs control, 95% CI = (-31.1%, -6.4%), P < 0.025]. The largest proportional decline in injection use occurred for analgesics and vitamins with baseline rates nearly halved in the experimental groups. There was also a significant reduction in average number of drugs per prescription [-0.37 drugs prescribed per patient, 95% CI = (-0.04, -0.52), P < 0.05], indicating that injections were not substituted with other drugs. The authors concluded that the IGD significantly reduces the overuse of injections. Note the decline in the control health centres was probably a result of cross communication and also illustrates that the reduction in injections in the intervention health centres could not be explained by patients going elsewhere. This study is also of interest because it revealed considerable misperceptions by health workers of the wishes of their patients.

Kara, M. and Asti, T. Effect of education on self-efficacy of Turkish patients with chronic obstructive pulmonary disease. Patient Educ Coun 55, 114-120. 2013. Ref ID: 9296

Target Group/Country Patients with chronic obstructive pulmonary disease (COPD in Turkey


Intervention Methodology The patients were asked to visit the outpatient pulmonary clinic with family member or caregiver three or four times per week. The researcher met the referred patients. Initially, for one patient, the structured education program consisted of 60-70 min by enabling the patient and his or her family to take part. Then, the classes were designed by the researcher, lasting 35-40 min and three or four times per week. In addition, education was tailored to the needs and environment of the patient, interactive, directed at improving quality of life, simple to follow, practical and appropriate to the intellectual and social skills of the patient and caregiver.. The classes of were consisted of a didactic component that focused on pathphysiology and management of COPD, self-care instruction, and social support. The education component was also followed by training and workout sessions that focused on respiratory muscle training, breathing retraining, aerobic and anaerobic exercises, and relaxations training. The class size for each program ranged from three to five participants. A small class size helped to ensure that there would be time to meet individual needs. Four components were incorporated to influence efficacy mastery experiences, modelling, verbal persuasive, and decreasing emotional/physical. Mastery experiences were integrated into the structured education program by having the participants indicate in writing what their goals were for attending the program. Vicarious experiences involved allowing observation of other siwith comparable degrees of physical impairment successfully performing tasks. Verbal persuasion was achieved through praising participant's efforts . A patient education brochure was prepared to accompany the educational session. Note - details of the total number of classes is not provided.

Evaluation Method There were 30 patients in control and experimental group measurements were obtained on the COPD Self-Efficacy Scale (CSES). Self-efficacy, as it affects managing or avoiding breathing difficulty, was measured before and after the structured education program and the nursing care.

Impact Achieved There was a significant difference between control group and experimental group scores on the efficacy scores. Patients' self-efficacy scores significantly improved after the structured education and remained significantly improved 1-month later (p<0.001). Standard nursing care alone was also effective in significantly improving self-efficacy scores, but patients' scores 1-month later were not significantly better than pre-program (p> 0.05). Note that details of the total number of classes is not provided so it is not possible to estimate the total effort required to achieve the results. Also information is not provided on the specific contribution or the booklet compared to the counselling sessions. Given that there was some improvement in the control group it would be interesting to know if that improvement might have been sustained with the leaflet alone.

Krause, G., Benzler, J., Heinmller, R., Borchert, M., Koob, E., Oattara, K., and Diesfeld, H.J. Performance of village pharmacies and patient compliance after implementation of an essential drug programme in rural Burkina Faso. Health Policy and Planning 13(2):159-166, 1998. Ref ID : 7378

Target Group/Country Patients using village pharmacies in Burkina Faso

Intervention Methodology A nation-wide essential drug programme. Village pharmacies were been installed in all villages with health centres, an essential drug list and treatment guidelines have been published, nurses received refresher courses on essential drugs and drug vendors have been trained on selling the drugs within the new village pharmacies. A village committee is in charge of the new village pharmacy. Details are not provided of the training and it is not stated whether it included patient communication skills.

Evaluation Method Structured non-participant observation for two week periods was carried simultaneously from June 25 to July 26, 1995 in 9 health centres in 3 districts and in the 8 corresponding village pharmacies and was combined with household interviews of the corresponding patients in 2 of the districts. All general consultations (except wound treatment) were observed (313 patients) and 498 client-vendor contacts (12 vendors distributing a total of 908 drugs). 170 out of 190 patients from the two districts were located and interviewed in the middle of their treatment period. The number of remaining pills were counted and the patient asked how he/she was supposed to take it.

Impact Achieved For only 32.9% of the prescribed drugs did the prescriber specify to the patient how long the drug had to be taken. Patients could recall the correct dosage for 68.3 % of the drugs. From the pills remaining in the household it was shown that children under 5 yrs received correct dosage in only 40.3% of cases while patients of 5 years or more were compliant for 64.7 of the drugs (chi2 =11.91, p<0.001). 11.5% of the drugs had obviously been taken incorrectly to such an extent that the occurrence of undesired drug effects was likely. The evaluation indicates that essential drugs programme had been successful as far as performance of the pharmacies and drug purchasing behaviour, but not as far as utilization of medicines.

Ngoh, L.N. and Shepherd, M.D. (1997) Design, development, and evaluation of visual aids for communicating prescription drug instructions to non-literate patients in rural Cameroon. Patient Education and Counseling 30, 257-270.. Ref ID : 6884

Target Group/Country Illiterate, female patients using health facilities in Cameroon

Intervention Methodology Culturally-sensitive, visual aids were designed to convey instructions for use of prescription antibiotics(ampicillin, sulfamethoxazole, trimethoprim, metronidazole, and tetracycline) to illiterate women. The education involved use of visual aids and an "advanced organiser." The advanced organiser (introductory information used to explain why the drug is needed) used the example of farming to explain antibiotic use - a body as a crop field, disease as weeds, and antibiotics as a farmer. Visual aids were subjected to a rigorous process of development and pre-testing. Drawings were based on photographs selected by the community as depicting local relevant scenes.

Evaluation Method The study, conducted in three health centres, gave initial and follow-up tests to three randomly selected groups of 26 illiterate female patients. After their consultation and purchase of medicines patients were given a test to measure comprehension of the medicines in their treatment regime. One group was treated as control, a second group received the visual aids and some explanation and the third group the control and advance organizer. A second comprehension test was given after these two educational sessions. The comprehension test consisted of 7 questions on name and purpose of the medication, amount of each single dose and route, timing, total number of daily doses, number of days. The follow-up repeated the comprehension test in the home and compliance was assessed with a pill count

Impact Achieved It was found that the experimental groups (1 with only visual aids, 1 with visual aids and the advanced organizer) scored significantly higher (p<0.05) than the controls in measures of comprehension and compliance and that use of the advanced organizer improved scores significantly (p<0.05%) over that of just visual aids. It is concluded that, to be effective, visual aids must be population-specific but that their preparation and use contributes significantly to achieving desired results in patients

Ponnusankar, S., Surulivelrajan, M., Anandamoorthy, N. and Suresh, B. (2013) Assessment of impact of medication counseling on patients' medication knowledge and compliance in an outpatient clinic in South India. Patient Educ Couns., 54, 55-60. Ref ID: 9293


Target Group/Country
Patients with chronic conditions attending an outpatient clinic in a private hospital in South India

Intervention Methodology At the out patient clinic, counseling sessions were performed at a separate corner of the clinic to ensure privacy. One patient was counseled at a time. Counseling sessions were designed so that all patients were counseled according to their individual understanding and attitude of their medication. Pharmacist explained about their disease, the name of the medications, identification of the medications, dose, time of administration, purpose, duration of therapy of their medication, food and other medications that have to be avoided during their therapy, etc. Counseling sessions lasted 15-20 minutes.

Evaluation Method Ninety patients were randomized in the ratio of 1:2 into either counseled or usual care group. Their medication knowledge was assessed by a questionnaire and adherence was assessed by pill count method and self-assessment by the patients. Their medication knowledge was assessed at baseline and during their subsequent appointments. . Statistical analysis of medication knowledge was carried out and all the demographic characters and number of medication were individually correlated with medication knowledge score

Impact achieved The average medication knowledge score of the counseled group versus usual care group was 13.82+/-1.8064 and 11.78+/-3.5037 (p<0.001). Compliance score of the patients during their follow-up period was 92.29+/-4.5 and 84.71+/-11.80 for the counseled and control group, respectively and the difference observed was statistically significant (p values not provided)

See also studies in the malaria section on compliance with malaria prophylaxis, diabetes counselling in Chronic section and counselling in AIDS and Family Planning sections.

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