Does routine home visiting improve the return rate and outcome of DOTS patients who delay treatment? Effect of community-based behaviour change management on neonatal mortality in Shivgarh, Uttar Pradesh, India: a cluster-randomised controlled trial. Paraprofessional women as health care facilitators in mother and child health. The effect of a programme of organised and supervised peer support on the initiation and duration of breastfeeding: a randomised trial. Process and effects of a community intervention on malaria in rural Burkina Faso: randomized controlled trial. Telephone support for pregnant women: outcome in late pregnancy. An experimental evaluation of in-home child abuse prevention services. WIC-based interventions to promote breastfeeding among African-American Women in Baltimore: effects on breastfeeding initiation and continuation. Comparison of the effect of two systems for the promotion of exclusive breastfeeding. A randomized controlled trial of a home-visiting intervention on cognition and behavior in term low birth weight infants. A randomized study of tracking with outreach and provider prompting to improve immunization coverage and primary care. Adherence to isoniazid prophylaxis in the homeless: a randomized controlled trial. Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial. Family support and parenting education in the home: an effective extension of clinic-based preventive health care services for poor children. Differences in program implementation between nurses and paraprofessionals providing home visits during pregnancy and infancy: a randomized trial. Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial. Randomised controlled trial of support from volunteer counsellors for mothers considering breast feeding. Behavioral interventions for the control of tuberculosis among adolescents. Increasing influenza and pneumococcal immunization rates: a randomized controlled study of a senior center-based intervention. Impacts of training of village health volunteers in reduction of morbidity from acute respiratory infections in childhood in southern Thailand. Combining drinking water treatment and hand washing for diarrhoea prevention, a cluster randomised controlled trial. A randomized trial assessing the efficacy of peer counseling on exclusive breastfeeding in a predominantly Latina low-income community. Evaluation of efficacy of community-based vs. institutional-based direct observed short-course treatment for the control of tuberculosis in Kilombero district, Tanzania. Can paraprofessional home visitation enhance early intervention service delivery? Community-based kangaroo mother care to prevent neonatal and infant mortality: a randomized, controlled cluster trial. A clinical trial to reduce the rate of low birth weight in an inner-city black population. A randomized, controlled trial of interventions to improve adherence to isoniazid therapy to prevent tuberculosis in injection drug users. Three-year developmental outcomes in children with prenatal alcohol and drug exposure. Efficacy of the North American guidelines for children's agricultural tasks in reducing childhood agricultural injuries. The effects of peer counseling on smoking cessation and reduction. A randomized, controlled trial of a community-based support program for families of children with chronic illness: pediatric outcomes. A randomized clinical trial of home intervention for children with failure to thrive. Randomized trial of a statewide home visiting program to prevent child abuse: impact in reducing parental risk factors. Acute respiratory infections in children under five years. Control project in Bagamoyo District, Tanzania. Effectiveness of home-based peer counselling to promote breastfeeding in the northeast of Brazil: a randomized clinical trial. Antenatal peer support workers and initiation of breast feeding: cluster randomised controlled trial. Additional therapy for young children with spastic cerebral palsy: a randomised controlled trial. A randomised controlled trial of the efficacy of supervised toothbrushing in high-caries-risk children. Evaluation of Community Action Against Asthma: a community health worker intervention to improve children's asthma-related health by reducing household environmental triggers for asthma. Zinc supplementation reduces the incidence of persistent diarrhea and dysentery among low socioeconomic children in India. Costs and effectiveness of community postnatal support workers: randomised controlled trial. The Resource Mothers Study of Maternal Phenylketonuria: preliminary findings. Does supplementary prenatal nursing and home visitation support improve resource use in a universal health care system? A randomized controlled trial in Canada. Lay health worker intervention with choice of DOT superior to standard TB care for farm dwellers in South Africa: a cluster randomised control trial. Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomised trial. Effects of home-based, informal social support on child health. The effect of peer counselors on breastfeeding rates in the neonatal intensive care unit: results of a randomized controlled trial. Mother-infant interaction: effects of a home intervention and ongoing maternal drug use. Incentives vs outreach workers for latent tuberculosis treatment in drug users. Breastfeeding peer support: maternal and volunteer perceptions from a randomized controlled trial. Paraprofessional home visitation program to prevent childhood unintentional injuries in low-income communities: a cluster randomized controlled trial. A randomized, controlled trial of the effectiveness of community-based case management in insuring uninsured Latino children. Effectiveness of a social support intervention on infant feeding practices: randomised controlled trial. Trends in use of referral hospital services for care of sick newborns in a community-based intervention in Tangail District, Bangladesh. Effect of peer support on prevention of postnatal depression among high risk women: multisite randomised controlled trial. A randomized controlled trial of the provision of a social support service during pregnancy: the South Manchester Family Worker Project. A randomized trial of directly administered antiretroviral therapy and adherence case management intervention. Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Professional and non-professional intervention for highly anxious primiparous mothers. Community mothers' programme: randomised controlled trial of non-professional intervention in parenting. Training in complementary feeding counselling of healthcare workers and its influence on maternal behaviours and child growth: a cluster-randomized controlled trial in Lahore, Pakistan. Hospital and home support during infancy: impact on maternal attachment, child abuse and neglect, and health care utilization. Hepatitis B vaccination of newborn infants in rural China: evaluation of a village-based, out-of-cold-chain delivery strategy. Maternal outcomes of a randomized controlled trial of a community-based support program for families of children with chronic illnesses. Effects of improved access to safety counseling, products, and home visits on parents' safety practices: results of a randomized trial. The impact of reminder-recall interventions on low vaccination coverage in an inner-city population. Postnatal peer counselling on exclusive breastfeeding of low-birthweight infants: a randomized, controlled trial. A cognitive approach to child abuse prevention. A randomised controlled trial of lay health workers as direct observers for treatment of tuberculosis. Impact of massage therapy on health outcomes among orphaned infants in Ecuador: results of a randomized clinical trial. Helping other mothers effectively work at raising young children with type 1 diabetes. Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial [see commments]. Adolescents at risk for mistreating their children. Part II: A home- and clinic-based prevention program. Effect of an integrated nutrition program on child morbidity due to respiratory infection and diarrhea in northern Viet Nam. The effect of outreach workers' educational efforts on disadvantaged preschool children's use of preventive services. Impact of community volunteers on immunization rates of children younger than 2 years.
Over a period of 6 months the effect of home visits on compliance with directly observed therapy, short course (DOTS), was studied on 480 new smear-positive tuberculosis patients who had delayed collecting their drugs on one occasion. Patients registered at 15 tuberculosis treatment centres in Baghdad, Iraq, were randomized to an intervention group (receiving home visits from trained personnel) or a control group. Home visits were highly effective in improving the return to treatment of patients who were late for treatment (231/240, 96.3%). The intervention group showed a higher treatment success rate (94.2% versus 76.7%), lower default rate (0.8% versus 10.0%) and higher smear conversion rate after the end of treatment (92.9% versus 75.0%) than controls. Home visiting by trained personnel significantly improves patient compliance with DOTS. In rural India, most births take place in the home, where high-risk care practices are common. We developed an intervention of behaviour change management, with a focus on prevention of hypothermia, aimed at modifying practices and reducing neonatal mortality.
                We did a cluster-randomised controlled efficacy trial in Shivgarh, a rural area in Uttar Pradesh. 39 village administrative units (population 104,123) were allocated to one of three groups: a control group, which received the usual services of governmental and non-governmental organisations in the area; an intervention group, which received a preventive package of interventions for essential newborn care (birth preparedness, clean delivery and cord care, thermal care [including skin-to-skin care], breastfeeding promotion, and danger sign recognition); or another intervention group, which received the package of essential newborn care plus use of a liquid crystal hypothermia indicator (ThermoSpot). In the intervention clusters, community health workers delivered the packages via collective meetings and two antenatal and two postnatal household visitations. Outcome measures included changes in newborn-care practices and neonatal mortality rate compared with the control group. Analysis was by intention to treat. This study is registered as International Standard Randomised Control Trial, number NCT00198653.
                Improvements in birth preparedness, hygienic delivery, thermal care (including skin-to-skin care), umbilical cord care, skin care, and breastfeeding were seen in intervention arms. There was little change in care-seeking. Compared with controls, neonatal mortality rate was reduced by 54% in the essential newborn-care intervention (rate ratio 0.46 [95% CI 0.35-0.60], p<0.0001) and by 52% in the essential newborn care plus ThermoSpot arm (0.48 [95% CI 0.35-0.66], p<0.0001).
                A socioculturally contextualised, community-based intervention, targeted at high-risk newborn-care practices, can lead to substantial behavioural modification and reduction in neonatal mortality. This approach can be applied to behaviour change along the continuum of care, harmonise vertical interventions, and build community capacity for sustained development.
                USAID and Save the Children-US through a grant from the Bill & Melinda Gates Foundation. The aim of the study was to compare the performance of midwives with that of lady home visitors (LHV; paraprofessionals). The project area was divided into six according to the population map. One midwife or one LHV was assigned to each visiting area. Home visits were carried out to identify and offer guidance on family planning (FP), antenatal care, well-child control, immunizations and other mother and child health related issues to those at high risk. Criteria taken for evaluation were the numbers of pregnant women identified in the last trimester; pregnant women receiving antenatal care; deliveries attended by a health care provider; modern FP users; continuation rate of the new users; pregnancy rate in new users; immunization status of children; well-child visits of the children. No significant differences were found in these health measurements between areas visited by LHV and areas visited by midwives. Response rates to the invitation was also similar in both areas. An important observation was the good performance of the LHV in communicating with the families. Women with limited school attainment from the community can be used effectively and efficiently in community health services. Peer support may improve breastfeeding rates but the evidence is inconclusive. Previous studies and reviews recommend trials in different healthcare settings.
                To test if a specified programme of peer support affects the initiation and/or the duration of breastfeeding.
                A two-group randomised controlled trial of peer support for breastfeeding with evaluation of breastfeeding initiation and duration on an intention-to-treat basis.
                General practice in Ayrshire, Scotland.
                Following informed consent, 225 women at 28 weeks gestation were allocated to control or peer support group by post-recruitment concealed allocation. All peer support and control group mothers received normal professional breastfeeding support. Additionally, those in the peer support group still breastfeeding on return home from hospital had peer support until 16 weeks.
                Thirty-five of the 112 (31%) women in the peer support group were breastfeeding at 6 weeks compared to 33/113 (29%) in the control group, a difference of 2% (95% confidence interval = -10% to 14%). The median breastfeeding duration for all women in the peer support group was 2 days compared to 1 day for the control group and the Kaplan-Meier survival plot shows the peer support group overall breastfeeding slightly longer than the control group, with no statistically significant difference by logrank test (P = 0.5). The median breastfeeding duration among primagravidae in the peer support group was 7 days, compared to 3 days for the control group. Among women who started to breastfeed the medians were 72 days in the peer support group and 56 days in the control group. These differences were not statistically significant.
                Peer support did not increase breastfeeding in this population by a statistically significant amount. In the rural areas of sub-Saharan Africa, the majority of young children affected by malaria have no access to formal health services. Home treatment through mothers of febrile children supported by mother groups and local health workers has the potential to reduce malaria morbidity and mortality.
                A cluster-randomized controlled effectiveness trial was implemented from 2002-2004 in a malaria endemic area of rural Burkina Faso. Six and seven villages were randomly assigned to the intervention and control arms respectively. Febrile children from intervention villages were treated with chloroquine (CQ) by their mothers, supported by local women group leaders. CQ was regularly supplied through a revolving fund from local health centres. The trial was evaluated through two cross-sectional surveys at baseline and after two years of intervention. The primary endpoint of the study was the proportion of moderate to severe anaemia in children aged 6-59 months. For assessment of the development of drug efficacy over time, an in vivo CQ efficacy study was nested into the trial. The study is registered under http://www.controlled-trials.com (ISRCTN 34104704).
                The intervention was shown to be feasible under program conditions and a total of 1.076 children and 999 children were evaluated at baseline and follow-up time points respectively. Self-reported CQ treatment of fever episodes at home as well as referrals to health centres increased over the study period. At follow-up, CQ was detected in the blood of high proportions of intervention and control children. Compared to baseline findings, the prevalence of anaemia (29% vs 16%, p < 0.0001) and malaria parameters such as prevalence of P. falciparum parasitaemia, fever and palpable spleens was lower at follow-up but there were no differences between the intervention and control group. CQ efficacy decreased over the study period but this was not associated with the intervention.
                The decreasing prevalence of malaria morbidity including anaemia over the study period can be explained by an overall increase of malaria prevention and treatment activities in the study area. The lack of effectiveness of the intervention was likely caused by contamination, pre-existing differences in the coverage of malaria treatment in both study groups and an unexpectedly rapid increase of resistance against CQ, the first-line treatment drug at the time of the study. The aim of the study was to test the psychosocial benefits of a telephone support program for pregnant women.
                Randomised controlled trial. The study sample were women recruited from an antenatal clinic and general practice surgeries who were less than 20 weeks gestation and either single or in a relationship where the partner was unemployed. Women in the intervention group received weekly telephone calls throughout their pregnancy. All women were interviewed initially and at 34 weeks gestation. There were 66 women in the control group and 65 women in the intervention group.
                The intervention and control groups did not differ significantly on the psychosocial measures at baseline. Comparisons at 34 weeks were made by analysis of covariance using the baseline scores. The intervention group at 34 weeks had lower stress scores than the control group (means 16.5 vs 18.4, p = 0.02), lower trait anxiety (means 35.2 vs 39.4, p = 0.04) and less depressed mood (means 6.6 vs 8.1, p = 0.02). Self esteem was higher for the intervention group (means 34.9 vs 32.5, p = 0.008). The intervention failed to alter smoking but the intervention women did report more use of community resources (p = 0.02) and were less likely to skip meals (p = 0.03).
                A low cost health promotion program of telephone support during pregnancy can significantly improve a woman's psychosocial status during pregnancy. Perinatal child abuse prevention projects are rarely rigorously evaluated. Women were referred to the Child Parent Enrichment Project (CPEP) project during or just after pregnancy if identified as at-risk of engaging in child abuse by community professionals. Clients were randomly assigned to CPEP services (n = 97) or traditional community services (n = 94). CPEP services are based on ecological theory and involve six months of home visiting by paraprofessional women and linkage to other formal and informal community resources. No advantages on self-report measures for the CPEP group were measured at posttest, and follow-up reports of child abuse were similar for both groups. Consumer satisfaction indicates that clients highly valued the program. Some indication of greater success with families with less serious problems was observed. The results argue for caution regarding the capacities of perinatal child abuse prevention services to serve the high-risk clientele they often receive. We evaluated the single and combined effects of introducing a motivational video and peer counseling into four matched WIC clinics on breastfeeding initiation and continuation at 7-10 days among African-American WIC participants. Of the 242 women with complete data, 48% initiated breastfeeding, but only 31% were still breastfeeding at 7-10 days. Initiation was associated with cesarean delivery, infant feeding instruction, no artificial milk discharge pack, attending the peer counselor only-intervention site, and intention to breastfeed. Continuation was influenced by infant feeding instruction, no artificial milk discharge pack, and intention to breastfeed. Overall, trends toward a positive impact of the breastfeeding promotion activities were evident but weak, and largely gone by 7-10 days postpartum. Promotion of breastfeeding is an important child-survival intervention, yet little is known about which promotional strategies are the most effective. We aimed to compare the effects on rates of breastfeeding of two systems for promotion of breastfeeding in Brazil--a hospital-based system and the same system combined with a programme of home visits.
                In February, 2001, maternity staff from two hospitals in Pernambuco, Brazil, were trained according to the Baby-Friendly Hospital Initiative (BFHI). In a randomised trial between March and August, 2001, 350 mothers giving birth at these hospitals were assigned ten postnatal home visits to promote and support breastfeeding (n=175) or no home visits (n=175). Breastfeeding practices were studied on days 1, 10, 30, 60, 90, 120, 150, and 180 by researchers unaware of group allocation. The primary outcome measure was the rate of exclusive breastfeeding from birth to 6 months. Analyses were by intention to treat.
                The hospital-training intervention achieved a high rate (70%) of exclusive breastfeeding in the hospitals, but this rate was not sustained at home and at 10 days of age only 30% of infants were exclusively breastfed The patterns of exclusive breastfeeding in the two trial groups for days 10-180 differed significantly (p<0.0001), with a mean aggregated prevalence of 45% among the group assigned home visits compared with 13% for the group assigned none.
                The BFHI achieves high rates of exclusive breastfeeding in hospital; however, in Brazil at least, the rates fall rapidly thereafter. Reliance on the BFHI as a strategy for breastfeeding promotion should be reassessed. A combination of promotional systems (hospital-based and in the community) is needed. To determine whether early psychosocial intervention with low birth weight term (LBW-T) infants improved cognition and behavior and to compare LBW-T with normal birth weight (NBW) infants.
                A randomized controlled trial was carried out in Kingston, Jamaica, with 140 LBW-T infants (weight<2500 g). The intervention comprised weekly home visits by paraprofessionals for the first 8 weeks of life aimed at improving maternal-child interaction. LBW-T and 94 matched NBW (weight 2500 to 4000 g) infants were recruited from the main maternity hospital. Main outcome measures were problem solving (2 means-end tests: cover and support) and 4 behavior ratings at 7 months. Analyses used were the t test for intervention effects and multiple regression to compare LBW and NBW infants.
                LBW-T intervened infants had higher scores than LBW-T control infants on the cover test (P<.05) and were more cooperative (P<.01) and happy (P<.05). LBW-T control infants had poorer scores on both the cover (P<.001) and support tests (P<.01), vocalized less (P<.02), and were less cooperative (P<.001), happy (P<.02), and active (P<.02) than NBW infants. LBW-T intervened infants had lower scores than NBW infants only on the support test (P<.05).
                Early low-cost intervention can improve cognition and behavior of LBW-T infants in developing countries. To compare and measure the effects and cost-effectiveness of two interventions designed to raise immunization rates.
                Nine primary care sites serving impoverished and middle-class children.
                Complete birth cohorts (ages 0 to 12 months; n = 3015) from these sites.
                Two 18-month duration interventions: 1) tracking with outreach [tracking/outreach] to bring underimmunized children to their primary care provider office, and 2) a primary care provider office policy change to identify and reduce missed immunization opportunities (prompting).
                Randomized, controlled trial, randomizing within sites using a two-by-two factorial design. Subjects were allocated to one of four study groups: control, prompting only, tracking/outreach only, and combined prompting with tracking/outreach. Outcomes were obtained by blinded chart abstraction.
                Immunization status for age; number of days of delay in immunization; primary care utilization; and rates of screening for occult disease.
                Out of 3015 subjects, 274 subjects (9%) transferred out of the participating sites or had incomplete charts and were excluded. The 2741 (91%) remaining subjects were assessed. At baseline, study groups did not differ in age, gender, insurance type, or immunization status. Of the remaining subjects, 63% received Medicaid. Final series-complete immunization coverage levels were: control, 74%; prompting-only, 76%; tracking/outreach-only 95%; and combined tracking/outreach with prompting, 95%. Analysis of variance showed that: 1) tracking/outreach increased immunization rates 20 percentage points; 2) tracking/outreach decreased mean immunization delay 63 days; 3) tracking/outreach increased mean health supervision visits 0.44 visits per child; 4) tracking/outreach increased mean anemia screening 0.17 screenings per child and mean lead screenings 0.12 screenings per child; 5) impact of tracking/outreach was greatest for uninsured and impoverished patients; and 6) the prompting intervention had no impact on the studied outcomes, and its failure was caused by inconsistent use of prompts and failure to vaccinate ill children when prompted. Using tracking/outreach, the cost per additional child fully immunized was $474. Each $1000 spent on the tracking/outreach intervention resulted in: 2.1 additional fully vaccinated children and 668 fewer child-days of delayed immunization; 4.6 additional health supervision visits and 5.9 additional other visits to the primary care provider; and 1.8 additional anemia screenings and 1.3 additional lead screenings.
                Outreach directed toward children not up-to-date on immunizations improves not only immunization status, but also health supervision visit attendance and screening rates. The cost per additional child immunized was high, but should be interpreted in view of the spillover benefits that accompanied improved immunization. Effective means to improve coverage by reducing missed immunization opportunities still need to be identified. To test 2 interventions to improve adherence to isoniazid preventive therapy for tuberculosis in homeless adults. We compared (1) biweekly directly observed preventive therapy using a $5 monetary incentive and (2) biweekly directly observed preventive therapy using a peer health adviser, with (3) usual care at the tuberculosis clinic.
                Randomized controlled trial in tuberculosis-infected homeless adults. Outcomes were completion of 6 months of isoniazid treatment and number of months of isoniazid dispensed.
                A total of 118 subjects were randomized to the 3 arms of the study. Completion in the monetary incentive arm was significantly better than in the peer health adviser arm (P = .01) and the usual care arm (P = .04), by log-rank test. Overall, 19 subjects (44%) in the monetary incentive arm completed preventive therapy compared with 7 (19%) in the peer health adviser arm (P = .02) and 10 (26%) in the usual care arm (P = .11). The median number of months of isoniazid dispensed was 5 in the monetary incentive arm vs 2 months in the peer health adviser arm (P = .005) and 2 months in the usual care arm (P = .04). In multivariate analysis, independent predictors of completion were being in the monetary incentive arm (odds ratio, 2.57; 95% CI, 1.11-5.94) and residence in a hotel or other stable housing at entry into the study vs residence on the street or in a shelter at entry (odds ratio, 2.33; 95% CI, 1.00-5.47).
                A $5 biweekly cash incentive improved adherence to tuberculosis preventive therapy compared with a peer intervention or usual care. Living in a hotel or apartment at the start of treatment also predicted the completion of therapy. Neonatal mortality accounts for a high proportion of deaths in children under the age of 5 years in Bangladesh. Therefore the project for advancing the health of newborns and mothers (Projahnmo) implemented a community-based intervention package through government and non-government organisation infrastructures to reduce neonatal mortality.
                In Sylhet district, 24 clusters (with a population of about 20 000 each) were randomly assigned in equal numbers to one of two intervention arms or to the comparison arm. Because of the study design, masking was not feasible. All married women of reproductive age (15-49 years) were eligible to participate. In the home-care arm, female community health workers (one per 4000 population) identified pregnant women, made two antenatal home visits to promote birth and newborn-care preparedness, made postnatal home visits to assess newborns on the first, third, and seventh days of birth, and referred or treated sick neonates. In the community-care arm, birth and newborn-care preparedness and careseeking from qualified providers were promoted solely through group sessions held by female and male community mobilisers. The primary outcome was reduction in neonatal mortality. Analysis was by intention to treat. The study is registered with ClinicalTrials.gov, number 00198705.
                The number of clusters per arm was eight. The number of participants was 36059, 40159, and 37598 in the home-care, community-care, and comparison arms, respectively, with 14 769, 16 325, and 15 350 livebirths, respectively. In the last 6 months of the 30-month intervention, neonatal mortality rates were 29.2 per 1000, 45.2 per 1000, and 43.5 per 1000 in the home-care, community-care, and comparison arms, respectively. Neonatal mortality was reduced in the home-care arm by 34% (adjusted relative risk 0.66; 95% CI 0.47-0.93) during the last 6 months versus that in the comparison arm. No mortality reduction was noted in the community-care arm (0.95; 0.69-1.31).
                A home-care strategy to promote an integrated package of preventive and curative newborn care is effective in reducing neonatal mortality in communities with a weak health system, low health-care use, and high neonatal mortality. A study was designed to assess the effect and cost of providing parenting and child care education in the home to inner-city mothers of poor infants receiving comprehensive health care in a large federal Children and Youth Program. Randomly selected, healthy neonates weighing more than 2000 gm and born to black women aged 18 years and older (n = 131) and to comparable control subjects (n = 132) were followed for a mean of 23.4 and 22.9 months, respectively. A community woman, with educational, social service, and medical backup support from the Children and Youth Program, made home visits 7 to 10 days after the birth and between regularly scheduled well-child-care visits. Improved compliance with well-child care, fewer illness visits, and sharp reductions in hospitalization and in neglect or abuse were found in the visited group compared with the control group, and substantial cost was averted. Prerequisite and concomitant to focusing the mother's attention on the infant was the resolution of the numerous crises and survival problems experienced by these poor women. Only then was parenting education accepted by the mother. This study examined differences between nurses and paraprofessionals in implementation of a home visiting program for low-income, first-time parents during pregnancy and the first 2 years of the child's life.
                Mothers were randomly assigned to either a nurse-visited (n = 236) or a paraprofessional-visited (n = 244) condition. Nurse- and paraprofessional-visited families were compared on number and length of visits, topics covered, number of program dropouts, and relationship with home visitor.
                On average, nurses completed more visits than paraprofessionals (28 vs 23; P < .001) and spent a greater proportion of time on physical health issues during pregnancy (38% vs 27%; P < .001) and on parenting issues during infancy (46% vs 32%; P < .001). Paraprofessionals conducted visits that lasted longer and spent a greater proportion of time on environmental health and safety issues (15% vs 7% pregnancy; 15% vs 8% infancy; P < .001). While home visitors were viewed equally positively by mothers, nurses had fewer dropouts than did paraprofessionals (38% vs 48%; P = .04). More paraprofessional-visited families than nurse-visited families experienced staff turnover.
                Nurses and paraprofessionals, even when using the same model, provide home visiting services in different ways. Exclusive breastfeeding is recommended worldwide but not commonly practised. We undertook a randomised controlled study of the efficacy of home-based peer counselling to increase the proportion of exclusive breastfeeding among mothers and infants residing in periurban Mexico City.
                Two intervention groups with different counselling frequencies, six visits (44) and three visits (52), were compared with a control group (34) that had no intervention. From March, 1995, to September, 1996, 170 pregnant women were identified by census and invited to participate in the study. Home visits were made during pregnancy and early post partum by peer counsellors recruited from the same community and trained by La Leche League. Data were collected by independent interview. Exclusive breastfeeding was defined by WHO criteria.
                130 women participated in the study. Only 12 women refused participation. Study groups did not differ in baseline factors. At 3 months post partum, exclusive breastfeeding was practised by 67% of six-visit, 50% of three-visit, and 12% of control mothers (intervention groups vs controls, p<0.001; six-visit vs three-visit, p=0.02). Duration of breastfeeding was significantly (p=0.02) longer in intervention groups than in controls, and fewer intervention than control infants had an episode of diarrhoea (12% vs 26%, p=0.03).
                This is the first reported community-based randomised trial of breastfeeding promotion. Early and repeated contact with peer counsellors was associated with a significant increase in breastfeeding exclusivity and duration. The two-fold decrease in diarrhoea demonstrates the importance of breastfeeding promotion to infant health. To investigate whether offering volunteer support from counsellors in breast feeding would result in more women breast feeding.
                Randomised controlled trial.
                32 general practices in London and south Essex.
                720 women considering breast feeding.
                Primary outcome was prevalence of any breast feeding at six weeks. Secondary outcomes were the proportion of women giving any breast feeds, or bottle feeds at four months, duration of any breast feeding, time to introduction of bottle feeds, and satisfaction with breast feeding.
                Offering support in breast feeding did not significantly increase the prevalence of any breast feeding to six weeks (65% (218/336) in the intervention group and 63% (213/336) in the control group; relative risk 1.02, 95% confidence interval 0.84 to 1.24). Survival analysis up to four months confirmed that neither duration of breast feeding nor time to introduction of formula feeds differed significantly between control and intervention groups. Not all women in the intervention group contacted counsellors postnatally, but 73% (123/179) of those who did rated them as very helpful. More women in the intervention group than in the control group said that their most helpful advice came from counsellors rather than from other sources.
                Women valued the support of a counsellor in breast feeding, but the intervention did not significantly increase breastfeeding rates, perhaps because some women did not ask for help. Activation of latent tuberculosis infection into tuberculosis disease (TB), the primary killer among infectious diseases worldwide, can be prevented with six months of anti-TB medication. A large percentage of adolescents started on medication, however, fail to complete their treatment. The authors developed and tested the effects of innovative educational strategies on infected adolescents at two health centers serving ethnically diverse populations.
                The authors used a randomized experimental four-group design to assess the independent and combined effects of peer counseling and a participant-parent contingency contract intervention.
                A total of 794 adolescents were recruited into the study, for a 79% participation rate. The overall rate of treatment completion was 79.8%. Self-efficacy for medication-taking behavior at post-test correlated strongly with completion of care (R = 0.367, p = 0.002). Participants randomized to the peer counseling groups demonstrated significantly greater improvements in self-efficacy and mastery than the usual care control group. Based on the study results, continuing education seminars and workshops were implemented for TB control staff at the two health clinics and for all TB Control Division staff at the Los Angeles County Health Department. Educational materials and a training manual for enhancing completion of treatment of latent TB infection through tailored educational approaches were developed and disseminated to the clinics.
                Health education and incentives are helpful adjuncts to the completion of treatment for latent tuberculosis infection in adolescents. Immunizations decrease morbidity from influenza and pneumococcal infections. Immunization levels remain below desired levels despite clinic-based and public education efforts. This paper describes a randomized, controlled trial of a senior center-based program, which used peer-to-peer outreach to increase pneumococcal and influenza immunization rates among an urban senior population.
                Seniors were randomized to intervention or control groups. The intervention group received educational brochures mailed with reply cards to report immunization status, telephone calls from senior volunteers to unimmunized participants, and computerized immunization tracking. Immunization rates were obtained before and after the intervention by self-report.
                Among participants without prior pneumococcal immunization, the pneumococcal immunization rate among the intervention group (52.0%; 95% CI = 46.6%-57.4%) was significantly higher than that of the control group (30.9%; 95% CI = 26.6%-35.2%) (rate ratio = 1.68; 95% CI = 1.40-2.03). Among those without influenza immunization in the prior year, significantly more (50.0%; 95% CI = 40.0%-60.0%) were immunized against influenza in the intervention group than in the control group (23.0%; 95% CI = 15.2%-33.3%) (rate ratio = 2.17; 95% CI = 1.42-3.31). Among those with influenza immunization in the prior year, the rate ratio was 1.04 (95% CI = 1.01-1.07).
                The intervention increased both influenza and pneumococcal immunization rates to high levels, suggesting that further progress in increasing adult immunization coverage is possible. In 1990, the Ministry of Public Health of Thailand started a five-year education program on management of cases with acute respiratory infection (ARI). The objective of this-study was to test whether such a program could reduce the average number of sick days of the target children. 30 villages in the study district were randomly allocated into 15 study and 15 control villages. A 2-day training workshop for village health volunteers from the study villages was conducted. The cohort of children age below 5 years in the two areas were followed-up for 19 week in the peak season of the disease. Among the 664 and 649 target children with 67,083 and 67,984 child-days observed in the study and the control villages, 71 and 41 children, respectively, were free from any episode. The preventive odds ratio of treatment adjusted for age and village effects = 0.88, 95% (CI 0.4-1.95). The median of the average sick periods in the individuals were 27 and 34 days, respectively. After adjusting for age, episodes/month and locality, the ratio of average sick days between children in the study and control villages was 0.89 (95% CI 0.76-1.05) or 11% shorter duration without statistical significance. The adjusted odds ratios of visiting the health center, private clinics, the community hospital and provincial hospital were 0.95 (95% CI 0.69-1.25), 1.43 (95% CI 0.98-2.11), 2.01 (95% CI 1.06-3.82) and 4.71 (95% CI 1.50-14.8), respectively. The training program thus had rather little impact on morbidity of the disease but tended to promote utilization of higher level of health services by the affected children. To evaluate the effectiveness of point of use water treatment with flocculent-disinfectant on reducing diarrhoea and the additional benefit of promoting hand washing with soap.
                The study was conducted in squatter settlements of Karachi, Pakistan, where diarrhoea is a leading cause of childhood death. Interventions were randomly assigned to 47 neighbourhoods. Households in 10 neighbourhoods received diluted bleach and a water vessel; nine neighbourhoods received soap and were encouraged to wash hands; nine neighbourhoods received flocculent-disinfectant water treatment and a water vessel; 10 neighbourhoods received disinfectant-disinfectant water treatment and soap and were encouraged to wash hands; and nine neighbourhoods were followed as controls. Field workers visited households at least once a week from April to December 2003 to promote use of the interventions and to collect data on diarrhoea.
                Study participants in control neighbourhoods had diarrhoea on 5.2% of days. Compared to controls, participants living in intervention neighbourhoods had a lower prevalence of diarrhoea: 55% (95% CI 17%, 80%) lower in bleach and water vessel neighbourhoods, 51% (95% CI 12%, 76%) lower in hand washing promotion with soap neighbourhoods, 64% lower (95% CI 29%, 90%) in disinfectant-disinfectant neighbourhoods, and 55% (95% CI 18%, 80%) lower in disinfectant-disinfectant plus hand washing with soap neighbourhoods.
                With an intense community-based intervention and supplies provided free of cost, each of the home-based interventions significantly reduced diarrhoea. There was no benefit by combining hand washing promotion with water treatment. To assess the efficacy of peer counseling to promote exclusive breastfeeding (EBF) among low-income inner-city women in Hartford, Conn.
                Participants recruited prenatally were randomly assigned to either receive support for EBF from a peer counselor plus conventional breastfeeding support (peer counseling group [PC]) or only conventional breastfeeding support (control group [CG]) and followed through 3 months post partum.
                Low-income predominantly Latina community.
                Expectant mothers, less than 32 weeks gestation and considering breastfeeding (N = 162). Intervention Exclusive breastfeeding peer counseling support offering 3 prenatal home visits, daily perinatal visits, 9 postpartum home visits, and telephone counseling as needed.
                Exclusive breastfeeding rates at hospital discharge, 1, 2, and 3 months post partum (n = 135).
                At hospital discharge, 24% in the CG compared with 9% in the PC had not initiated breastfeeding, with 56% and 41%, respectively, nonexclusively breastfeeding. At 3 months, 97% in the CG and 73% in the PC had not exclusively breastfed (relative risk [RR] = 1.33; 95% CI, 1.14-1.56) during the previous 24 hours. The likelihood of nonexclusive breastfeeding throughout the first 3 months was significantly higher for the CG than the PC (99% vs 79%; RR = 1.24; 95% CI, 1.09-1.41). Mothers in the CG were less likely than their PC counterparts to remain amenorrheic at 3 months (33% vs 52%; RR = 0.64; 95% CI, 0.43-0.95). The likelihood of having 1 or more diarrheal episode in infants was cut in half in the PC (18% vs 38%; RR = 2.15; 95% CI, 1.16-3.97).
                Well-structured, intensive breastfeeding support provided by hospital and community-based peer counselors is effective in improving exclusive breastfeeding rates among low-income, inner-city women in the United States. Tuberculosis (TB) has reappeared as a serious public health problem. Non-compliance to antituber-culous drug treatment is cited as one of the major obstacles to the containment of the epidemic. Compliance may be optimized by Directly Observed Treatment (DOT) and short-course treatment regimens. Since 1986, Tanzanian TB patients have received daily DOT at health facilities for the first 2 months of the treatment course. However, adherence and cure rates have been falling as the number of TB cases continues to increase and the burden on already stretched health facilities threatens to become unmanageable. We used an open cluster randomized controlled trial to compare community-based DOT (CBDOT) using a short-course drug regimen with institutional-based DOT (IBDOT). A total of 522 (301 IBDOT and 221 CBDOT) patients with sputum-positive TB were recruited. Overall, there was no significant difference in conversion and cure rates between the two strategies [M-H pooled odds ratio (OR) 0.62; 95% confidence interval (CI) 0.23, 1.71 and OR = 1.58; 95% CI 0.32, 7.88, respectively] suggesting that CBDOT may be a viable alternative to IBDOT. CBDOT may be particularly useful in parts of the country where people live far from health facilities. A 1-year randomized trial compared intensive case management (ICM) versus basic case management (BCM) in facilitating early intervention (EI) service use among children in an urban health system. Of 159 participating families with delayed or at-risk preschool-aged children, 88 received ICM from paraprofessionals versus 71 families who received less comprehensive BCM from a nurse. In the ICM versus BCM group, a shorter interval to assessment (98 vs 140 d, p =.05) but similar assessment rate (86% vs 80%, p =.29) was observed. The ICM group had more services recommended per child (1.64 vs 1.16, p < .004) and initiated (1.20 vs 0.85, p < .04). There was no difference in median time to EI program initiation for ICM versus BCM (228 vs 200 d, p = .88) or initiation and visit compliance rate for EI services. Specific efforts to improve outcomes (e.g., decrease initiation time and increase use of EI services) are still needed. We adapted kangaroo mother care for immediate postnatal community-based application in rural Bangladesh, where the incidence of home delivery, low birth weight, and neonatal and infant mortality is high and neonatal intensive care is unavailable. This trial tested whether community-based kangaroo mother care reduces the overall neonatal mortality rate by 27.5%, infant mortality rate by 25%, and low birth weight neonatal mortality rate by 30%.
                Half of 42 unions in 2 Bangladesh divisions with the highest infant mortality rates were randomly assigned to community-based kangaroo mother care, and half were not. One village per union was randomly selected proportionate to union population size. A baseline survey of 39,888 eligible consenting women collected sociodemographic information. Community-based workers were taught to teach community-based kangaroo mother care to all expectant and postpartum women in the intervention villages. A total of 4165 live births were identified and enrolled. Newborns were followed for 30 to 45 days and infants were followed quarterly through their first birthday to record infant care, feeding, growth, health, and vital status.
                Forty percent overall and approximately 65% of newborns who died were not weighed at birth, and missing birth weight was differential by study group. There was no difference in overall neonatal mortality rate or infant mortality rate. Except for care seeking, community-based kangaroo mother care behaviors were more common in the intervention than control group, but implementation was weak compared with the pilot study.
                The extensive missing birth weight and its potential bias render the evidence insufficient to justify implementing community-based kangaroo mother care. Additional experimental research ensuring baseline comparability of mortality, adequate kangaroo mother care implementation, and birth weight assessment is necessary to clarify the effect of community-based kangaroo mother care on survival. The goal of our study was to measure the effectiveness of a home-based intervention for prevention of low birth weight with 154 high-risk, low-income black women attending a prenatal clinic in Cleveland.
                Based on previous research, risk was defined by clinic registration between the 17th and 28th weeks of gestation, low family functioning score, and experience of at least one stressful life event prior to registration. Optional factors included being a smoker, a low maternal weight-height ratio, being age 27 or older, and a previous premature birth. A 21-item family function screen previously validated in a similar population was the primary determinant of psychosocial risk. Low birth weight was defined as weight less than 2,500 g regardless of gestational age.
                There was no decrease in the rate of low birth weight for women who received four home visits focusing on smoking, drug and nutrition education, support, and links with community services, compared to women who received no visits. The number of prenatal visits was significantly higher in the intervention group, but an increased number of prenatal visits did not correlate with a reduced rate of low birth weight. Despite previous research, the family function screen was not an effective predictor of low birth weight in our study. A revised equation involving a history of previous premature birth, smoking, and a low maternal weight-height ratio did predict low birth weight.
                These findings question the utility of short-term psychosocial interventions for influencing low birth-weight rates in low-income black clinic populations. The family function screen was not cross validated. Integration of any psychosocial intervention with the routine prenatal care occurring in the obstetrical clinic is suggested for future research. To determine the effect of several interventions on adherence to tuberculosis preventive therapy.
                We conducted a randomized trial with a factorial design comparing strategies for improving adherence to isoniazid preventive therapy in 300 injection drug users with reactive tuberculin tests and no evidence of active tuberculosis. Patients were assigned to receive directly observed isoniazid preventive therapy twice weekly (Supervised group, n = 99), daily self-administered isoniazid with peer counseling and education (Peer group, n = 101), or routine care (Routine group, n = 100). Patients within each arm were also randomly assigned to receive an immediate or deferred monthly $10 stipend for maintaining adherence. The endpoints of the trial were completing 6 months of treatment, pill-taking as measured by self-report or observation, isoniazid metabolites present in urine, and bottle opening as determined by electronic monitors in a subset of patients.
                Completion of therapy was 80% for patients in the Supervised group, 78% in the Peer group, and 79% in the Routine group (P = 0.70). Completion was 83% (125 of 150) among patients receiving immediate incentives versus 75% (112 of 150) among patients with deferred incentives (P = 0.09). The proportion of patients who were observed or reported taking at least 80% of their doses was 82% for the Supervised arm of the study, compared with 71% for the Peer arm and 90% for the Routine arm. The proportion of patients who took 100% of doses was 77% for the Supervised arm (by observation), 6% for the Peer arm (by report), and 10% for the Routine arm (by report; P <0.001). Direct observation showed the median proportion of doses taken by the Supervised group was 100%, while electronic monitoring in a subset of patients showed the Peer group (n = 27) took 57% of prescribed doses and the Routine group (n = 32) took 49% (P <0.001). Patients in the Routine arm overreported adherence by twofold when data from electronic monitoring were used as a gold standard. There were no significant differences in electronically monitored adherence by type of incentive.
                Adherence to isoniazid preventive therapy by injection drug users is best with supervised care. Peer counseling improves adherence over routine care, as measured by electronic monitoring of pill caps, and patients receiving peer counseling more accurately reported their adherence. More widespread use of supervised care could contribute to reductions in tuberculosis rates among drug users and possibly other high-risk groups. The purpose of this study was to describe the performance of children whose mothers abused alcohol and drugs heavily during pregnancy, using the Bayley Scales of Infant Development Second Edition (BSID-II) at three years, and to examine the effects of study group, prenatal binge alcohol exposure, and prematurity on developmental outcome.
                Children were born to mothers recruited from two large hospitals or through community referral. Hospital recruits were randomly assigned to either a three-year paraprofessional home visitation intervention program (n = 30) or a control group (n = 31). Community recruits were enrolled in the intervention program (n = 35).
                Among all children the mean BSID-II Mental Developmental Index (MDI) was 84.4 (SD = 14.4) and mean Psychomotor Developmental Index (PDI) was 84.1 (SD = 16.9). Box plots of the MDI and PDI scores by study group, maternal prenatal binge alcohol status, and a binary indicator of prematurity suggested an effect of maternal binge drinking on MDI and PDI scores: children of mothers with a history of binge alcohol consumption have, on average, slightly lower scores. We saw no evidence of a systematic effect of the maternal intervention.
                Developmental performance of preschool children exposed to alcohol and drugs prenatally was, on average, substantially lower than expected for age regardless of study group. Although this home visitation intervention has been shown to be effective in helping mothers address a wide spectrum of needs, it is unlikely sufficient to overcome complex developmental risks of children exposed to alcohol and drugs prenatally. The effect of more comprehensive, multidimensional services specifically designed for the children should be investigated within this context. We assessed whether active dissemination of the North American Guidelines for Children's Agricultural Tasks (NAGCAT) reduced childhood agricultural injuries.
                In this randomized controlled trial, lay educators visited intervention farms to review NAGCAT. New York State farms with resident or working children were randomized. Control farms were visited only to collect baseline data. Data on childhood injuries, tasks, and hours worked were obtained quarterly for 21 months. Injury rates per farm were compared between the treatment and control groups, along with time span to occurrence of an injury and to violation of NAGCAT age guidelines.
                Intervention farms were less likely than control farms to violate NAGCAT age guidelines in the areas of all-terrain-vehicle use and tractor and haying operations. Cox proportional hazards regression models showed a significant protective effect of the intervention on preventable injuries after adjustment for important covariates.
                Our results showed that dissemination of NAGCAT reduced rates of work-related childhood agricultural injuries. A comprehensive public health approach is needed to reduce non-work-related childhood injuries. To evaluate a peer counseling intervention for pregnant smokers.
                One hundred forty-two pregnant, predominantly Hispanic women were assigned to a peer-led smoking cessation program or to usual care.
                Compared with usual care, peer counseling reduced smoking (-9.1 versus -4.5 cigarettes daily, P =.03), but did not affect absolute quit rates (24% versus 21%) at 36 weeks' gestation. Infant birth weight negatively correlated with cigarettes smoked per day (r = -0.29, P <.01) and expired carbon monoxide (r = -0.39, (P <.001) at delivery. Birth weight for infants born to women who quit smoking averaged 7.2 lb versus 6.8 and 6.3 lb for mothers smoking one to six and more than six cigarettes per day at delivery (P <.01).
                Peer counseling reduced the number of cigarettes smoked daily but did not increase cigarette abstinence rates. Infant birth weight increases with both smoking cessation and smoking reduction, suggesting that peer counseling intervention programs may improve newborn health despite their failure to affect smoking cessation. Children with chronic illnesses have a heightened risk for mental health problems.
                To develop, implement, and evaluate child outcomes of a 15-month, community-based, family-support intervention designed to reduce risk for poor adjustment and mental health problems in children with 1 of 4 chronic illnesses (diabetes mellitus, sickle cell anemia, cystic fibrosis, or moderate to severe asthma) and their mothers.
                Randomized, controlled clinical trial design with multiple measures of mental health based on both child and parent reports taken 1 year apart.
                Community-based intervention linked to subspecialty and general pediatric clinics and practices in Baltimore, Md.
                One hundred thirty-six mothers and children aged 7 to 11 years with diabetes mellitus, sickle cell anemia, cystic fibrosis, or moderate to severe asthma.
                The program, provided by "experienced mothers" and child life specialists, included telephone contacts, face-to-face visits, and special family events.
                Outcomes were measured using the following instruments: the Personal Adjustment and Role Skills Scale III, the Children's Depression Inventory, the Revised Children's Manifest Anxiety Scale, and the Self-Perception Profile for Children.
                The experimental group's mean adjustment score increased over the intervention period while the control group's mean adjustment score decreased. Analysis of variance demonstrated that the intervention had a significant main effect on postintervention adjustment controlling for baseline scores (P =.01). Using a cutoff score indicating maladjustment, the percentage of experimental group children in the maladjustment range fell from 19% at baseline to 10% after the intervention; the percentage of control group children in the maladjustment range rose from 15% at baseline to 21% after the intervention. The effect of the intervention was more pronounced for children who had low physical self-esteem than for those who had moderate to high physical self-esteem at the beginning of the program.
                Our results demonstrate modest positive effects of a family support intervention in promoting the adjustment of children with selective chronic health conditions. Including child life specialists in a community-based intervention may be especially salient for children with chronic illnesses who have low physical self-esteem. The intervention had a similar outcome for all diagnostic groups, suggesting that it could be effective for children with any chronic illness and implemented in a variety of pediatric settings. To evaluate the efficacy of a home-based intervention on the growth and development of children with nonorganic failure to thrive (NOFTT).
                Randomized clinical trial.
                The NOFTT sample included 130 children (mean age, 12.7 months; SD, 6.4) recruited from urban pediatric primary care clinics serving low income families. All children were younger than 25 months with weight for age below the fifth percentile. Eligibility criteria included gestational age of at least 36 weeks, birth weight appropriate for gestational age, and no significant history of perinatal complications, congenital disorders, chronic illnesses, or developmental disabilities. Children were randomized into two groups: clinic plus home intervention (HI) (n = 64) or clinic only (n = 66). There were no group differences in children's age, gender, race, or growth parameters, or on any of the family background variables. Most children were raised by single, African-American mothers who received public assistance. Eighty-nine percent of the families (116 of 130) completed the 1-year evaluation.
                All children received services in a multidisciplinary growth and nutrition clinic. A community-based agency provided the home intervention. Families in the HI group were scheduled to receive weekly home visits for 1 year by lay home visitors, supervised by a community health nurse. The intervention provided maternal support and promoted parenting, child development, use of informal and formal resources, and parent advocacy.
                Growth was measured by standard procedures and converted to z scores for weight for height and height for age to assess wasting and stunting. Cognitive and motor development were measured with the Bayley Scales of Infant Development, and language development was measured by the Receptive/Expressive Emergent Language Scale. Both scales were administered at recruitment and at the 12-month follow-up. Parent-child interaction was measured by observing mothers and children during feeding at recruitment and at the 12-month follow-up, and the quality of the home was measured by the Home Observation Measure of the Environment 18 months after recruitment.
                Repeated-measures multivariate analyses of covariance were used to examine changes in children's growth and development and parent-child interaction. Analyses of covariance were used to examine the quality of the home. Independent variables were intervention status and age at recruitment (1.0 to 12.0 vs 12.1 to 24.9 months). Maternal education was a covariate in all analyses. When changes in developmental status and parent-child interaction were examined, weight for height and height for age at recruitment were included as covariates.
                Children's weight for age, weight for height, and height for age improved significantly during the 12-month study period, regardless of intervention status. Children in the HI group had better receptive language over time and more child-oriented home environments than children in the clinic-only group. The impact of intervention status on cognitive development varied as a function of children's ages at recruitment, with younger children showing beneficial effects of home intervention. There were no changes in motor development associated with intervention status. During the study period, children gained skills in interactive competence during feeding, and their parents became more controlling during feeding, but differences were not associated with intervention status.
                Findings support a cautious optimism regarding home intervention during the first year of life provided by trained lay home visitors. Early home intervention can promote a nurturant home environment effectively and can reduce the developmental delays often experienced by low income, urban infants with NOFTT: Subsequent investigations of home intervention should consider alternative options for toddlers with NOFTT: To assess the impact of a home visiting program in reducing malleable parental risk factors for child abuse in families of newborns identified, through population-based screening, as at-risk of child abuse.
                This randomized trial focused on Healthy Start Program (HSP) sites operated by three community-based organizations on Oahu, HI, USA. From 11/94 to 12/95, 643 families were enrolled and randomly assigned to intervention and control groups. Mothers in both groups were interviewed annually for 3 years (88% follow-up each year) to measure mental health, substance use, and partner violence. HSP records were reviewed to measure home visiting services provided. Home visitors were surveyed annually to measure their perceived competence.
                Malleable parental risks for child abuse were common at baseline. There was no significant overall program effect on any risk or on at-risk mothers' desire for and use of community services to address risks. There was a significant reduction in one measure of poor mental health at one agency and a significant reduction in maternal problem alcohol use and repeated incidents of physical partner violence for families receiving > or =75% of visits called for in the model. Home visitors often failed to recognize parental risks and seldom linked families with community resources. HSP training programs were under-developed in preparing staff to address risks and to link families with community resources.
                Overall, the home visiting program did not reduce major risk factors for child abuse that made families eligible for service. Research is needed to develop and test strategies to improve home visiting effectiveness in reducing parental risks for child abuse. Control of acute respiratory infections (ARI) in children under five years of age has been implemented as an integrated part of Primary Health Care in rural Bagamoyo District in Tanzania. Community supported Village Health Workers visited each family at their homes every six to eight weeks, giving health education on recognition and prevention of ARI, treating children with pneumonia on the spot with oral Cotrimoxazole or referring them to the next higher level of care. Within a two-year period the total under five mortality has been reduced by 27.2% from 40.1 to 29.2/1000 children aged under five per year. The disease-specific mortality rate for pneumonia has been reduced by 30.1% from 14.3 to 10.0/1000 under-five per year, contributing 40% to the overall mortality reduction. It is concluded that an active health service outreach programme, within Primary Health Care, can efficiently reduce high child mortality rates from ARI and other diseases. A similar approach will be used to tackle other problems such as diarrhoeal diseases, malnutrition, malaria and child spacing. To evaluate the effectiveness of home-based peer counselling to increase breastfeeding rates for unfavourably low birthweight babies.
                Randomized clinical trial carried out in maternity hospitals and households in Fortaleza, one of the regions in Brazil with very low income; 1003 mothers and their newborns were selected in eight maternity hospitals. Newborns needed were healthy and weighed less than 3000 g.
                Breastfeeding counselling, conducted by lay counsellors from the community, during home visits carried out on days 5, 15, 30, 60, 90 and 120 after birth.
                Feeding methods in the fourth month of life.
                The intervention increased exclusive breastfeeding (24.7% vs 19.4%; p=0.044), delayed the introduction of formula and increased the time infants substituted breastfeeding to bottle milk (bottle milk 33.4% in the control group and 20.1% in the intervention group; p=0.00002). When comparing the frequency of artificial breastfeeding versus all other forms of breastfeeding (exclusive+predominant+partial), the intervention increased breastfeeding rates in 39% (RR=0.61; CI 95%: 0.50-0.75); 15% of children were free from artificial feeding (absolute risk reduction). The number of families to be visited to avoid one child receiving artificial feeding (NNT) was 7 (CI 95%: 5-13).
                Breastfeeding counselling, promoted by lay counsellors, can impact favourably on exclusive breastfeeding rates and contribute to delaying the utilization of milk formula and weaning. The intervention has great application potential because most cities in the northeast of Brazil count on community health workers that could do the counselling. To assess the effectiveness of an antenatal service using community based breastfeeding peer support workers on initiation of breast feeding.
                Cluster randomised controlled trial.
                Community antenatal clinics in one primary care trust in a multiethnic, deprived population.
                66 antenatal clinics with 2511 pregnant women: 33 clinics including 1140 women were randomised to receive the peer support worker service and 33 clinics including 1371 women were randomised to receive standard care.
                An antenatal peer support worker service planned to comprise a minimum of two contacts with women to provide advice, information, and support from approximately 24 weeks' gestation within the antenatal clinic or at home. The trained peer support workers were of similar ethnic and sociodemographic backgrounds to their clinic population.
                Initiation of breast feeding obtained from computerised maternity records of the hospitals where women from the primary care trust delivered.
                The sample was multiethnic, with only 9.4% of women being white British, and 70% were in the lowest 10th for deprivation. Most of the contacts with peer support workers took place in the antenatal clinics. Data on initiation of breast feeding were obtained for 2398 of 2511 (95.5%) women (1083/1140 intervention and 1315/1371 controls). The groups did not differ for initiation of breast feeding: 69.0% (747/1083) in the intervention group and 68.1% (896/1315) in the control groups; cluster adjusted odds ratio 1.11 (95% confidence interval 0.87 to 1.43). Ethnicity, parity, and mode of delivery independently predicted initiation of breast feeding, but randomisation to the peer support worker service did not.
                A universal service for initiation of breast feeding using peer support workers provided within antenatal clinics serving a multiethnic, deprived population was ineffective in increasing initiation rates.
                Current Controlled Trials ISRCTN16126175. To investigate whether, in the short and medium term, additional support by (a) a physiotherapy assistant improved physical function in young children with spastic cerebral palsy and (b) a family support worker improved family functioning.
                This was a multi-centre randomised controlled trial (RCT) with blinded assessments and a cost-effectiveness analysis. The children studied had spastic cerebral palsy that was the consequence of perinatal adversity. All were less than 4 years old on entry to the study.
                In the child development centre and in the home.
                Seventy-six families completed the intervention period. Forty-three families were reassessed 6 months after the end of the intervention and 34 of these after a further 6-month period.
                Randomisation was to: (a) a group who received extra physiotherapy from a physiotherapy assistant; (b) a group who received standard physiotherapy; and (c) a group where the child received standard physiotherapy and the family was also visited by a family support worker. Children in all groups continued to receive standard physiotherapy in addition to the study interventions.
                The child outcome measures were motor functioning, developmental status and adaptive functioning. The family outcome measures were self-reported maternal stress, level of family needs and parental satisfaction.
                There was no evidence that additional physical therapy for 1 hour per week for 6 months by a physiotherapy assistant improved any child outcome measure in the short or medium term. Intervention by a family support worker did not have a clinically significant effect on parental stress or family needs. Over the 6-month period the total cost of services for each child ranged from 250 pounds to 6750 pounds, with higher costs associated with children with more severe impairments. No significant relationship was found between measures of intensity of services received by the children and families and the main outcome measures. Low-functioning children, in terms of both motor and cognitive function, were more likely to receive more services in terms of range and frequency. Parents generally reported high satisfaction ratings after all interventions and some stated that the interventions had benefited the child and/or the family. There was therefore a discrepancy between the perceptions of these parents and the objective, quantitative measurements. The family support workers identified a small number of families who were experiencing considerable family problems, but who had not been referred for appropriate support by any other agency.
                The findings of this study provide support for the current literature that there was no evidence that additional intervention (in this case by a physiotherapy assistant or family support worker) helped the motor or general development of young children with spastic cerebral palsy. Nor was there any quantitative evidence that providing extra family support helped levels of parental stress and family needs. The implication was that the provision of extra physical therapy does not necessarily improve the motor function of a young child with cerebral palsy and additional family support should not automatically be assumed to be beneficial. In addition, no significant association was found between the intensity of the local services provided and any outcome measure, other than a slight association with lowered family needs. The provision of local services was related to the severity of the child's impairments and not to family difficulties. A small group of families with complex family problems needed more service input. There was a wide range in the costs of services. Research is needed to examine what 'sufficient' levels of provision or therapy might be for which children and which families. A time series of different levels of input and outcomes would provide valuable information for practitioners. It is also recommended that future assessments of therapies of this type adopt a similar multifaceted approach, which is likely to be more suitable than a simple RCT for the evaluation of clinical interventions where the effects are complex. The most appropriate measures of outcome should be used, including assessment of provision of information and emotional support for families. Scottish children have one of the highest levels of caries experience in Europe. Only 33% of 5-year-old children in Dundee who developed caries in their first permanent molars by 7 brushed their teeth twice a day. High-caries-risk children should benefit if they brush more often with fluoridated toothpaste. The aim of this clinical trial was to determine the reduction in 2-year caries increment that can be achieved by daily supervised toothbrushing on school-days with a toothpaste containing 1,000 ppm fluoride (as sodium monofluorophosphate) and 0.13% calcium glycerophosphate, combined with recommended daily home use, compared to a control group involving no intervention other than 6-monthly clinical examinations. Five hundred and thirty-four children, mean age 5.3, in schools in deprived areas of Tayside were recruited. Each school had two parallel classes, one randomly selected to be the brushing class and the other, the control. Local mothers were trained as toothbrushing supervisors. Children brushed on school-days and received home supplies. A single examiner undertook 6-monthly examinations recording plaque, caries (D(1) level), and used FOTI to supplement the visual caries examination. For children in the brushing classes, the 2-year mean caries increment on first permanent molars was 0.81 at D(1) and 0.21 at D(3) compared to 1.19 and 0.48 for children in the control classes (significant reductions of 32% at D(1) and 56% at D(3)). In conclusion, high-caries-risk children have been shown to have significantly less caries after participating in a supervised toothbrushing programme with a fluoridated toothpaste.
                Copyright 2002 S. Karger AG, Basel This article describes the evaluation of a community-based participatory research (CBPR) community health worker (CHW) intervention to improve children's asthma-related health by reducing household environmental triggers for asthma. After randomization to an intervention or control group, 298 households in Detroit, Michigan, with a child, aged 7 to 11, with persistent asthma symptoms participated. The intervention was effective in increasing some of the measures of lung function (daily nadir Forced Expiratory Volume at one second [p = .03] and daily nadir Peak Flow [p = .02]), reducing the frequency of two symptoms ("cough that won't go away," "coughing with exercise"), reducing the proportion of children requiring unscheduled medical visits and reporting inadequate use of asthma controller medication, reducing caregiver report of depressive symptoms, reducing concentrations of dog allergen in the dust, and increasing some behaviors related to reducing indoor environmental triggers. The results suggest a CHW environmental intervention can improve children's asthma-related health, although the pathway for improvement is complex. Persistent diarrhea (PD) and dysentery (DD) account for most diarrhea-associated deaths among children in developing countries. Zinc deficiency can cause stunting and impaired immune function, both of which are risk factors for these diarrheal illnesses. We investigated the effect of zinc supplementation on the incidence of PD and DD in a community-based, double-blind randomized trial in children 6-35 mo of age. Increase over baseline in plasma zinc concentrations in the supplemented group compared with a control group (3.61 vs. 0.009 mumol.L-1), indicated successful supplementation. The overall reductions in the zinc supplemented group of 21% in the incidence of PD (95% CI -6 to 42%) and 14% in the incidence of dysentery (95% CI -15 to 36%) were not significant. There was a significant interaction of treatment effect with baseline plasma zinc concentration and age for PD and with gender for DD. In the zinc-supplemented group compared with the control group, the incidence of PD was reduced by 73% (P < 0.05; 95% CI 34 to 91%) in children with a baseline zinc < 7.65 mumol.L-1 and by 49% (P < 0.05; 95%CI 24 to 66%) in children > 11 mo of age. Zinc supplementation resulted in a 38% (P < 0.05 95%CI 8 to 59%) reduction in the incidence of DD in boys. There was no effect on PD among children 6-11 mo old or on DD in girls. In conclusion, zinc supplementation had a significant impact on the incidence of persistent diarrhea in children > 1 y old and in children with low plasma zinc, as well as on dysentery in boys. These findings may have important implications for reducing diarrhea-related morbidity and mortality. To establish the relative cost effectiveness of postnatal support in the community in addition to the usual care provided by community midwives.
                Randomised controlled trial with six month follow up.
                Recruitment in a university teaching hospital and care provided in women's homes.
                623 postnatal women allocated at random to intervention (311) or control (312) group. Intervention: Up to 10 home visits in the first postnatal month of up to three hours duration by a community postnatal support worker. Main outcome measure: General health status as measured by the SF-36 and risk of postnatal depression. Breast feeding rates, satisfaction with care, use of services, and personal costs.
                At six weeks there was no significant improvement in health status among the women in the intervention group. At six weeks the mean total NHS costs were pound 635 for the intervention group and pound 456 for the control group (P=0.001). At six months figures were pound 815 and pound 639 (P=0.001). There were no differences between the groups in use of social services or personal costs. The women in the intervention group were very satisfied with the support worker visits.
                There was no health benefit of additional home visits by community postnatal support workers compared with traditional community midwifery visiting as measured by the SF-36. There were no savings to the NHS over six months after the introduction of the community postnatal support worker service. Women with phenylketonuria (PKU) must follow a strict low-phenylalanine diet during pregnancy in order to protect the fetus from the deleterious effects of high maternal blood phenylalanine. The Resource Mothers Study of Maternal PKU was undertaken to determine whether a home visitation programme was effective in helping women with PKU attain blood phenylalanine control earlier during pregnancy. Resource Mothers were trained to provide social support and practical assistance to women with PKU during pregnancy. Eight metabolic clinics in the United States participated in the study. Women with PKU who were planning pregnancy or already pregnant were enrolled in the study and were treated with a low-phenylalanine diet aimed at controlling blood phenylalanine to 120-360 micromol/L. They were randomly assigned to receive the services of a Resource Mother (RM group) or to a control group. Fifty women were enrolled, and accounted for 44 pregnancies which resulted in 28 live births, and 6 spontaneous abortions. Ten women are currently pregnant and another 6 have not become pregnant. Fifty-six percent of enrolled women began the diet prior to becoming pregnant. Fifty-three percent of women in the Resource Mother group were in metabolic control by 10 weeks gestation as compared to 39% in the control group. In addition, women who began diet after pregnancy and had a Resource Mother attained metabolic control earlier (mean gestational age of 22.4 weeks in the RM group vs 29.8 weeks in the control group). There was no difference in birth measurement z -scores of offspring born to women in the RM group compared to controls. All but 4 women rated themselves as feeling worse about the diet at the end of pregnancy than at the beginning, and few women in either group remained on diet after delivery. The addition of supplementary prenatal support may improve the health and well-being of high-risk women and families. The objective of this randomized controlled trial was to examine the impact of supplementary prenatal care on resource use among a community-based population of pregnant women.
                Pregnant women from three urban maternity clinics were randomized (a) to current standard of physician care, (b) to current standard of care plus consultation with a nurse, or (c) to (b) plus consultation with a home visitor. Participants were 1,352 women who received 3 telephone interviews. The primary outcome was resource use (e.g., attended prenatal classes, used nutritional counseling).
                Overall, those in the nurse intervention group were more likely to attend an "Early Bird" prenatal class and parenting classes, and to use nutrition counseling and agencies that assist with child care. Women provided with extra nursing and home visitation supports were more likely to use a written resource guide, nutrition counseling, and agencies that assist with child care. Among women at higher risk (e.g., language barriers, young maternal age, low income), the nurse intervention significantly increased use of early prenatal classes, whereas the nurse and home visitor intervention significantly increased use of the written resource guide and nutrition counseling. The intervention substantially increased the amount of information received on numerous pregnancy-related topics but had little impact on resource use for mental health and poverty-related needs. Among those with added support, resource use among low-risk women was generally greater than among high-risk women.
                Additional support provided by nurses, or nurses and home visitors, can successfully address informational needs and increase the likelihood that women will use existing community-based resources. This finding was true even for high-risk women, although this intervention did not reduce the difference in resource use between high- and low-risk women. Farms in the Boland health district, Western Cape Province, South Africa.
                To evaluate the effect of lay health workers (LHWs) on tuberculosis (TB) control among permanent farm workers and farm dwellers in an area with particularly high TB prevalence.
                Pragmatic, unblinded cluster randomised control trial.
                This trial measured successful treatment completion rates among new smear-positive (NSP) adult TB patients on 106 intervention farms, and compared them with outcomes in patients on 105 control farms. Farms were the unit of randomisation, and analysis was by intention to treat.
                A total of 164 adult TB patients were recruited into the study, 89 of whom were NSP. The successful treatment completion rate in NSP adult TB patients was 18.7% higher (P = 0.042, 95%CI 0.9-36.4) on farms in the intervention group than on farms in the control group. Case finding for adult NSP TB cases was 8% higher (P = 0.2671) on farms in the intervention group compared to the control group.
                Trained LHWs were able to improve the successful TB treatment rate among adult NSP TB patients in a well-established health service, despite reduction of services. No satisfactory strategy for reducing high child mortality from malaria has yet been established in tropical Africa. We compared the effect on under-5 mortality of teaching mothers to promptly provide antimalarials to their sick children at home, with the present community health worker approach.
                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 70,506) 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 the intervention tabias, mother coordinators were trained to teach other local mothers to recognise symptoms of malaria in their children and to promptly give chloroquine. In both intervention and control tabias, all births and deaths of under-5s were recorded monthly.
                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). 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. 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.
                A major reduction in under-5 mortality can be achieved in holoendemic malaria areas through training local mother coordinators to teach mothers to give under-5 children antimalarial drugs. To enhance mother-infant interaction, paraprofessional home visitors provided parents with emotional support, information, and help in using community resources during pregnancy and throughout the infants' first 14 months. This study reports effects on child health. Both home-visited women and controls made good use of well-child care. Home-visited women made greater use of sick-child care (p = 0.002), most of which was appropriate. The greater use of sick-child care was concentrated among mothers with moderate or high family stress, with whom home visitors had closer relationships. Case histories showed a variety of individual effects on parents. To determine whether peer counselors impacted breastfeeding duration among premature infants in an urban population.
                This was a randomized controlled clinical trial.
                The trial was conducted in the Newborn Intensive Care Unit at Boston Medical Center, an inner-city teaching hospital with approximately 2000 births per year.
                One hundred eight mother-infant pairs were enrolled between 2001 and 2004. Pairs were eligible if the mother intended and was eligible to breastfeed per the 1997 guidelines from the American Academy of Pediatrics and if the infant was 26 to 37 weeks' gestational age and otherwise healthy.
                Subjects were randomized to either a peer counselor who saw the mother weekly for 6 weeks or to standard of care.
                The main outcome measure was any breast-milk feeding at 12 weeks postpartum.
                Intervention and control groups were similar on all measured sociodemographic factors. The average gestational age of infants was 32 weeks (range, 26.3-37 weeks) with a mean birth weight of 1875 g (range, 682-3005 g). At 12 weeks postpartum, women with a peer counselor had odds of providing any amount of breast milk 181% greater than women without a peer counselor (odds ratio, 2.81 [95% confidence interval, 1.11-7.14]; P = .01).
                Peer counselors increased breastfeeding duration among premature infants born in an inner-city hospital and admitted to the neonatal intensive care unit. Peer counseling programs can help to increase breastfeeding in this vulnerable population. Examined the effects of a home-based intervention on mother-infant interaction among drug-using women and their infants. At 2 weeks postpartum, mothers and infants were randomly assigned to either an intervention (n = 84) or a control (n = 87) group. Control families received brief monthly tracking visits, and intervention families received weekly visits by trained lay visitors. Mother-infant interaction was evaluated at 6 months through observation of feeding. Although there were no direct effects of the intervention, in the control group, mothers who continued to use drugs were less responsive to their babies than mothers who were drug free. In the intervention group, drug use was not associated with maternal responsiveness. Weekly home-based intervention may be a protective strategy for children of drug-using women because it disrupts the relation between ongoing maternal drug use and low maternal responsiveness. Drug users are at increased risk for latent tuberculosis infection (LTBI) and also at increased risk for noncompletion of medication regimens for treatment of LTBI or tuberculosis disease. Directly observed therapy (DOT) provided by outreach workers, the use of incentives, or both have been suggested as a means to increase adherence.
                To compare the independent and combined effects of monetary incentives and outreach worker provision of DOT for LTBI treatment in a sample of active drug users.
                The research design was a randomized controlled trial in a community outreach program setting. Participants consisted of a volunteer sample of 163 active injection drug and crack cocaine users placed on twice weekly DOT. Condition 1 of the interventions consisted of provision of DOT by an outreach worker at a location chosen by the participant (active outreach) and a $5 per visit incentive. Condition 2 was comprised of active outreach with no monetary incentive, and Condition 3, provision of DOT at the study community site and a $5 per visit incentive. The main outcome measures were percentage of medication taken as prescribed and completion of medication regimen.
                The percentage of prescribed medication taken was higher for those who received incentives, either with (71%) or without (68%) active outreach, compared to those who received active outreach alone (13%). Only 4% of participants assigned to Condition 2 completed treatment, compared to 53% of Condition 1 participants, and 60% of Condition 3 participants.
                Monetary incentives were clearly superior to active outreach. Active outreach in combination with monetary incentives did not increase adherence over incentives alone. Several studies have demonstrated the positive effects of peer support on various breastfeeding outcomes, but no study has assessed women's and peer volunteers' views on, or the nature and intensity of, the supportive intervention. The objective of this study was to describe maternal and peer volunteer perceptions of their experience while participating in a breastfeeding peer support trial.
                A randomized controlled trial was conducted to evaluate the effect of telephone-based peer (mother-to-mother) support on breastfeeding duration. Two hundred and fifty-six primiparous breastfeeding women were randomly allocated to receive either conventional care or conventional care plus peer support. Three primary outcome measures were peer volunteer activity logs, maternal perceptions of peer support, and evaluations of the peer volunteer experience.
                Questionnaires were completed by 98.5 percent (n=130) of the mothers in the peer support group. Mothers reported their peer volunteers were available when difficulties were experienced, increased their confidence, decreased their concerns, and assisted them in reaching their breastfeeding goals. These supportive interactions resulted in 81.5 percent of mothers (n=106) being satisfied with their peer support experience and suggesting that every new mother should be offered this intervention. Similarly, all the peer volunteers interviewed (n=30) viewed their experience positively. They suggested some intervention modifications as follows: ensure that mothers enrolled in the program want peer support; provide peer volunteers with ongoing educational sessions and opportunities to "socialize" with other volunteers; and disseminate the results of peer support efforts.
                Both mothers and peer volunteers perceived their intervention experiences positively. Whereas maternal satisfaction was related to the number and duration of peer volunteer contacts, peer volunteers enjoyed their training session and the opportunity to assist mothers for a variety of reasons. Specific intervention modifications should be implemented to enhance peer volunteer satisfaction and retention. To investigate the effectiveness of a paraprofessional home visitation program (HVP) to improve home safety and prevent injuries among children living in low-income settings.
                The HVP was implemented in two low-income communities in South Africa. In each community, approximately 200 households were randomly selected for the trial. Eligible households were those with children aged < or = 10 years. Intervention households received four visits, one every two weeks, by trained paraprofessionals that focused on a specific injury topic and consisted of: information dissemination about specific injury prevention practices; home inspection accompanied by information about home hazards; and the supply of safety devices. The key outcomes to measure the presence of home hazards were scores for burns (safety practices, paraffin, and electrical), poisoning, and falls.
                Significant reductions were found for injury risks related to burn safety practices. For injury risks related to electrical burns, paraffin burns, and poisoning, a decline was also noted although this was not statistically significant. No decline was noted for fall-related risks.
                Subject to further replication and evaluation, home visits by paraprofessionals providing safety education, home inspection, and safety devices be considered for integration into a comprehensive child injury prevention strategy in low-income communities. Lack of health insurance adversely affects children's health. Eight million US children are uninsured, with Latinos being the racial/ethnic group at greatest risk for being uninsured. A randomized, controlled trial comparing the effectiveness of various public insurance strategies for insuring uninsured children has never been conducted.
                To evaluate whether case managers are more effective than traditional methods in insuring uninsured Latino children.
                Randomized, controlled trial conducted from May 2002 to August 2004.
                A total of 275 uninsured Latino children and their parents were recruited from urban community sites in Boston.
                Uninsured children were assigned randomly to an intervention group with trained case managers or a control group that received traditional Medicaid and State Children's Health Insurance Program (SCHIP) outreach and enrollment. Case managers provided information on program eligibility, helped families complete insurance applications, acted as a family liaison with Medicaid/SCHIP, and assisted in maintaining coverage.
                Obtaining health insurance, coverage continuity, the time to obtain coverage, and parental satisfaction with the process of obtaining insurance for children were assessed. Subjects were contacted monthly for 1 year to monitor outcomes by a researcher blinded with respect to group assignment.
                One hundred thirty-nine subjects were assigned randomly to the intervention group and 136 to the control group. Intervention group children were significantly more likely to obtain health insurance (96% vs 57%) and had approximately 8 times the adjusted odds (odds ratio: 7.78; 95% confidence interval: 5.20-11.64) of obtaining insurance. Seventy-eight percent of intervention group children were insured continuously, compared with 30% of control group children. Intervention group children obtained insurance significantly faster (mean: 87.5 vs 134.8 days), and their parents were significantly more satisfied with the process of obtaining insurance.
                Community-based case managers are more effective than traditional Medicaid/SCHIP outreach and enrollment in insuring uninsured Latino children. Case management may be a useful mechanism to reduce the number of uninsured children, especially among high-risk populations. To assess whether monthly home visits from trained volunteers could improve infant feeding practices at age 12 months, a randomised controlled trial was carried out in two disadvantaged inner city London boroughs.
                Women attending baby clinics with their infants (312) were randomised to receive monthly home visits from trained volunteers over a 9-month period (intervention group) or standard professional care only (control group). The primary outcome was vitamin C intakes from fruit. Secondary outcomes included selected macro and micro-nutrients, infant feeding habits, supine length and weight. Data were collected at baseline when infants were aged approximately 10 weeks, and subsequently when the child was 12 and 18 months old.
                Two-hundred and twelve women (68%) completed the trial. At both follow-up points no significant differences were found between the groups for vitamin C intakes from fruit or other nutrients. At first follow-up, however, infants in the intervention group were significantly less likely to be given goats' or soya milks, and were more likely to have three solid meals per day. At the second follow-up, intervention group children were significantly less likely to be still using a bottle. At both follow-up points, intervention group children also consumed significantly more specific fruit and vegetables.
                Home visits from trained volunteers had no significant effect on nutrient intakes but did promote some other recommended infant feeding practices.
                Current Controlled Trials ISRCTN55500035. The Projahnmo-II Project in Mirzapur upazila (sub-district), Tangail district, Bangladesh, is promoting care-seeking for sick newborns through health education of families, identification and referral of sick newborns in the community by community health workers (CHWs), and strengthening of neonatal care in Kumudini Hospital, Mirzapur. Data were drawn from records maintained by the CHWs, referral hospital registers, a baseline household survey of recently-delivered women conducted from March to June 2003, and two interim household surveys in January and September 2005. Increases were observed in self-referral of sick newborns for care, compliance after referral by the CHWs, and care-seeking from qualified providers and from the Kumudini Hospital, and decreases were observed in care-seeking from unqualified providers in the intervention arm. An active surveillance for illness by the CHWs in the home, education of families by them on recognition of danger signs and counselling to seek immediate care for serious illness, and improved linkages between the community and the hospital can produce substantial increases in care-seeking for sick newborns. To evaluate the effectiveness of telephone based peer support in the prevention of postnatal depression.
                Multisite randomised controlled trial.
                Seven health regions across Ontario, Canada.
                701 women in the first two weeks postpartum identified as high risk for postnatal depression with the Edinburgh postnatal depression scale and randomised with an internet based randomisation service.
                Proactive individualised telephone based peer (mother to mother) support, initiated within 48-72 hours of randomisation, provided by a volunteer recruited from the community who had previously experienced and recovered from self reported postnatal depression and attended a four hour training session.
                Edinburgh postnatal depression scale, structured clinical interview-depression, state-trait anxiety inventory, UCLA loneliness scale, and use of health services.
                After web based screening of 21 470 women, 701 (72%) eligible mothers were recruited. A blinded research nurse followed up more than 85% by telephone, including 613 at 12 weeks and 600 at 24 weeks postpartum. At 12 weeks, 14% (40/297) of women in the intervention group and 25% (78/315) in the control group had an Edinburgh postnatal depression scale score >12 (chi(2)=12.5, P<0.001; number need to treat 8.8, 95% confidence interval 5.9 to 19.6; relative risk reduction 0.46, 95% confidence interval 0.24 to 0.62). There was a positive trend in favour of the intervention group for maternal anxiety but not loneliness or use of health services. For ethical reasons, participants identified with clinical depression at 12 weeks were referred for treatment, resulting in no differences between groups at 24 weeks. Of the 221 women in the intervention group who received and evaluated their experience of peer support, over 80% were satisfied and would recommend this support to a friend.
                Telephone based peer support can be effective in preventing postnatal depression among women at high risk.
                ISRCTN 68337727. A pilot scheme was introduced in Manchester to provide additional social support to pregnant women at above average risk of giving birth to a low-birthweight baby. The help of lay workers, known as family workers, was made available to eligible women. The effect on infant birthweight of offering the help of a family worker was assessed by a randomized controlled trial. No significant differences were observed between the experimental and control group, but on a number of grounds the interpretation of this finding is not straightforward, and further research is recommended. A randomized, controlled trial was conducted to evaluate the impact of a directly administered antiretroviral therapy program (DAART) and intensive adherence case management (IACM) intervention on virologic and immunologic response to highly active antiretroviral therapy (HAART) among patients at 3 public human immunodeficiency virus clinics in Los Angeles County, California.
                Participants included 250 treatment-naive and treatment-experienced persons for whom no more than 1 prior HAART regimen had failed. Five days per week for 6 months, a community worker delivered 1 HAART dose to DAART participants and observed the participant take it. IACM participants met weekly with a case manager to overcome barriers to HAART adherence. A control group (the standard of care [SOC] group) received the usual care.
                The majority of patients were Latino (64%) or African American (24%); 57% were monolingual Spanish speakers. Seventy-five percent of the patients were male, and 64% reported an annual income of <10,000 dollars. In an intent-to-treat analysis, no statistical differences were observed in the percentage of patients with an undetectable viral load (i.e., <400 copies/mL) at 6 months between the DAART group (54%), IACM group (60%), and SOC group (54%; P>.05). An on-treatment analysis determined that there were no statistical differences in the percentage of patients with an undetectable viral load at 6 months between the DAART group (71%), IACM group (80%), and SOC group (74%; P>.05). Additionally, there were no statistical differences in 6-month changes in the CD4+ cell count or in self-reported adherence to therapy.
                Among patients with limited prior HAART experience and adherence barriers that had not been assessed before randomization, no differences were found in virologic or immunologic response for DAART or IACM, compared with SOC, at 6 months. DAART and IACM did not improve short-term outcomes when SOC included other means of adherence support that were not controlled for by the study design. Neonatal deaths in developing countries make the largest contribution to global mortality in children younger than 5 years. 90% of deliveries in the poorest quintile of households happen at home. We postulated that a community-based participatory intervention could significantly reduce neonatal mortality rates.
                We pair-matched 42 geopolitical clusters in Makwanpur district, Nepal, selected 12 pairs randomly, and randomly assigned one of each pair to intervention or control. In each intervention cluster (average population 7000), a female facilitator convened nine women's group meetings every month. The facilitator supported groups through an action-learning cycle in which they identified local perinatal problems and formulated strategies to address them. We monitored birth outcomes in a cohort of 28?931 women, of whom 8% joined the groups. The primary outcome was neonatal mortality rate. Other outcomes included stillbirths and maternal deaths, uptake of antenatal and delivery services, home care practices, infant morbidity, and health-care seeking. Analysis was by intention to treat. The study is registered as an International Standard Randomised Controlled Trial, number ISRCTN31137309.
                From 2001 to 2003, the neonatal mortality rate was 26.2 per 1000 (76 deaths per 2899 livebirths) in intervention clusters compared with 36.9 per 1000 (119 deaths per 3226 livebirths) in controls (adjusted odds ratio 0.70 [95% CI 0.53-0.94]). Stillbirth rates were similar in both groups. The maternal mortality ratio was 69 per 100000 (two deaths per 2899 livebirths) in intervention clusters compared with 341 per 100000 (11 deaths per 3226 livebirths) in control clusters (0.22 [0.05-0.90]). Women in intervention clusters were more likely to have antenatal care, institutional delivery, trained birth attendance, and hygienic care than were controls.
                Birth outcomes in a poor rural population improved greatly through a low cost, potentially sustainable and scalable, participatory intervention with women's groups. Primiparous women (n = 627) were screened on state and trait anxiety measures in the post-partum period; sub-groups of highly anxious (n = 89), moderately anxious (n = 29), and minimally anxious (n = 29) mothers were derived and subsequently interviewed. The high-anxiety mothers were randomly assigned to a professional intervention, to a non-professional intervention, and to a control group, and their progress was reviewed over the following 12 months. Compliance, both in responding to progressive assessments and in accepting therapeutic intervention, was extremely high. Changes in anxiety levels for mothers not receiving an intervention were minimal over the study. In the high-anxiety sub-groups, there was a 19% reduction in state anxiety levels for those receiving a professional intervention, a 12% reduction for those receiving a non-professional intervention, and a 3% reduction in the controls. A planned contrast analysis determined that only professional intervention had a significant effect, intervention successfully lowering state anxiety levels to a value comparable with the moderately anxious mothers. To see whether non-professional volunteer community mothers could deliver a child development programme to disadvantaged first time mothers for children aged up to 1 year.
                Randomised controlled trial.
                A regional health authority in Dublin.
                262 first time mothers who were delivered during six months in 1989 and who lived in a deprived area of Dublin; 30 experienced mothers from the same community recruited as community mothers.
                All the first time mothers received standard support from the public health nurse. In addition, those in the intervention group received the services of a community mother, who was scheduled to visit monthly during the first year of the child's life.
                232 (89%) first time mothers completed the study--127 in the intervention group, 105 controls. At the end of the study children in the intervention group were more likely to have received all of their primary immunisations, to be read to, and to be read to daily, played more cognitive games; and were exposed to more nursery rhymes. They were less likely to begin cows' milk before 26 weeks and to receive an inappropriate energy intake and inappropriate amounts of animal protein, non-animal protein, wholefoods, vegetables, fruit, and milk. Mothers in the intervention group also had a better diet than controls. At the end of the study they were less likely to be tired, feel miserable, and want to stay indoors; had more positive feelings; and were less likely to display negative feelings.
                Non-professionals can deliver a health promotion programme on child development effectively. Whether they can do so as effectively as professionals requires further study. Malnutrition is common among children aged 6-24 months in developing countries. It increases the risk of mortality. Interventions to improve infant-feeding hold the promise of reducing malnutrition among these children. A study in Brazil has shown the success of training in communication and counselling skills among health workers in improving the nutritional status of young children. Questions were raised whether the method used in the study in Brazil would also be effective when applied in other countries. The aim of the present study was to reduce growth faltering in young children through proper nutrition-promotion techniques. The objective of the study was to determine the efficacy of training health workers in nutrition counselling in enhancing their communication skills and performance, improving feeding practices, and reducing growth faltering in children aged 6-24 months. A cluster-randomized controlled trial was carried out. The method used in this study was a replica of the method in a similar study in Pelotas, Brazil. Forty health centres were paired, and one centre of each pair was randomly allocated to the intervention group, and the other to the control group. The Integrated Management of Childhood Illness (IMCI) module-'Counsel the mother'-was used for training health workers in the health centres in the intervention group. Data from 36 paired health centres and 375 mothers and their children aged 6-24 months recruited from these health centres following consultation with health workers were included in analysis. Independent observers, masked to the intervention status, examined the performance of health workers within the first month after training. Mother-child pairs were visited at home within two weeks, 45 days, and 180 days after recruitment. Information was recorded on the feeding practices, recall of the recommendations of health workers, and sociodemographic variables at these home-visits. Weight and length of the child were measured at each contact. The communication skills and consultation performance of health workers were significantly better in the intervention group than in the control group. The mothers' recall of the recommendation of health workers and reported infant-feeding practices were also significantly better in the intervention group than in the control group, even 180 days after the recruitment consultation. Growth faltering was less in the intervention group, with the largest effect observed among children in the age-group of 12 + months. These results indicate that training in IMCI feeding counselling can enhance the communication skills and performance of health workers. Improved feeding practices of counselled mothers can, in turn, reduce growth faltering in their children. Effects of early and extended postpartum contact and paraprofessional home visits on maternal attachment, reports of child abuse and neglect, and health care utilization were determined by random assignment of 321 low-income women to intervention or control groups immediately after delivery. Observations of maternal attachment were made at four months and 12 months. Hospital, health and welfare agency records, and interviews were used to determine reports of child abuse and neglect and health care utilization. After establishing a control for maternal background variables, early and extended contact explained statistically significant but small amounts of variance in several of the attachment measures. There were no statistically significant effects of the home visit interventions on maternal attachment, and neither intervention was related to reports of child abuse and neglect and health care utilization. Although the study supported earlier findings that early and extended contact has a significant effect, additional interventions are needed to support mother-infant attachment. To prevent perinatal transmission of hepatitis B virus (HBV), WHO recommends that the first dose of hepatitis B (HepB) vaccine be given within 24 hours after birth. This presents a challenge in remote areas with limited cold-chain infrastructure and where many children are born at home.
                Rural townships in three counties in China's Hunan Province were randomized into three groups with different strategies for delivery of the first dose of HepB vaccine. In group 1, vaccine was stored within the cold chain and administered in township hospitals. In group 2, vaccine was stored out of the cold chain in villages and administered by village-based health workers to infants at home. Group 3 used the same strategy as group 2, but vaccine was packaged in a prefilled injection device. Training of immunization providers and public communication conveying the importance of the birth dose was performed for all groups.
                Among children born at home, timely administration (within 24 hours after birth) of the first dose of HepB vaccine increased in all groups after the study: group 1, from 2.4% to 25.2%; group 2, from 2.6% to 51.8%; and group 3, from 0.6% to 66.7%; P < 0.001 in each case. No significant difference in antibody response to vaccine was observed between the groups.
                Timely administration of the first dose of HepB vaccine was improved by communication and training activities, and by out-of-cold-chain storage of vaccine and administration at the village level, especially among children born at home. Parents of children with chronic illnesses are at high risk for secondary mental health problems, such as anxiety and depression.
                To evaluate maternal outcomes of a support intervention for families of children with selected chronic illnesses.
                A randomized controlled clinical trial design with repeated measures 1 year apart.
                A community-based family support intervention linked to subspecialty and general pediatric clinics and practices in a metropolitan area.
                A population-based sample of 193 mothers of children aged 7 to 11 years; the children were diagnosed as having diabetes, sickle cell anemia, cystic fibrosis, or moderate to severe asthma. About 15% of the persons contacted refused to participate in the research, and 14% of the families were lost to follow-up.
                The 15-month intervention, the Family-to-Family Network, was designed to enhance mothers' mental health by linking mothers of school-aged children with selected chronic illnesses with mothers of older children with the same condition. The program included telephone contacts, face-to-face visits, and special family events.
                Beck Depression Inventory score and the Psychiatric Symptom Index.
                Maternal anxiety scores for participants in the experimental group decreased during the intervention period for all diagnostic groups and for the total group; scores for the control group increased (F = 5.07, P =.03). In multiple regression analyses, the intervention group was a significant predictor of posttest anxiety scores (P =.03). Effects were greater for mothers with high baseline anxiety (P<.001) and for those who were themselves in poor health (P<.01).
                A family support intervention can have beneficial effects on the mental health status of mothers of children with chronic illnesses. This type of intervention can be implemented in diverse pediatric settings. To present the results of an intervention trial to enhance parents' home-safety practices through pediatric safety counseling, home visits, and an on-site children's safety center where parents receive personalized education and can purchase reduced-cost products.
                Pediatricians were randomized to a standard- or an enhanced-intervention group. Parents of their patients were enrolled when the patient was 6 months or younger and observed until 12 to 18 months of age.
                A hospital-based pediatric resident continuity clinic that serves families living in low-income, inner-city neighborhoods.
                First- and second-year pediatric residents and their patient-parent dyads.
                Parents in the standard-intervention group received safety counseling and referral to the children's safety center from their pediatrician. Parents in the enhanced-intervention group received the standard services plus a home-safety visit by a community health worker.
                Home observers assessed the following safety practices: reduction of hot-water temperature, poison storage, and presence of smoke alarms, safety gates for stairs, and ipecac syrup.
                The prevalence of safety practices ranged from 11% of parents who stored poisons safely to 82% who had a working smoke alarm. No significant differences in safety practices were found between study groups. However, families who visited the children's safety center compared with those who did not had a significantly greater number of safety practices (34% vs 17% had > or 3).
                Home visiting was not effective in improving parents' safety practices. Counseling coupled with convenient access to reduced-cost products appears to be an effective strategy for promoting children's home safety. Reminder-recall interventions have improved immunization rates in numerous studies.
                To evaluate the impact of large-scale, registry-based reminder-recall interventions on low immunization rates in an inner-city population.
                Randomized, controlled, effectiveness trial.
                Fulton County, Georgia.
                A total of 3050 children (76% black, 14% Hispanic, 7% white, and 3% other or unknown; median age, 9 months; range, 1-14 months) identified in an immunization registry as receiving health care in the public sector.
                Each child was randomly assigned to 1 of 4 groups: control (usual care), autodialer (automated telephone or mail reminder recall), outreach (in-person telephone, mail, or home visit recall), and combination (autodialer with outreach backup). Interventions continued until the child reached 24 months of age.
                Completion by the age of 24 months of the 4-3-1-3 vaccination series based on intention-to-treat analysis.
                A total of 260 (34%) of the 763 patients in the control group, 306 (40%) of the 763 in the autodialer group, 284 (37%) of the 760 in the outreach group, and 293 (38%) of 764 in the combination group completed the vaccination series.
                Large-scale, registry-based reminder-recall interventions produced only small improvements in low immunization rates of an inner-city population. Exclusive breastfeeding increases survival and optimizes growth of low-birthweight (LBW) infants. If supported, mothers can overcome the unique difficulties associated with breastfeeding from birth to 6 mo. We tested the efficacy of postnatal peer counselling among first-time mothers that aimed to increase exclusive breastfeeding of term LBW infants.
                In a Manila hospital, 204 mothers were randomized into three groups. Two intervention groups receiving home-based counselling visits, one by counsellors trained in breastfeeding counselling (n=68), the other by counsellors trained in general childcare (n=67), were compared with a control group of mothers (n=69) who did not receive counselling.
                Eighty-eight per cent of the participating pairs completed the trial. At 6 mo, 44% of the breastfeeding counselled mothers, 7% childcare-counselled mothers and none of the mothers in the control group were exclusively breastfeeding. More mothers in the breastfeeding counselled group than in the other groups were still breastfeeding at 6 mo. Twenty-four infants who were exclusively breastfed for 6 mo did not have any diarrhoea. All groups had improved mean weight-for-age Z-scores at 6 mo.
                This study has provided fundamental evidence of successful intervention to achieve 6 mo of exclusive breastfeeding among term LBW infants. By improving health outcomes, enhanced breastfeeding offers a distinct possibility of disrupting the intergenerational cycle of undernourished women giving birth to LBW infants. This investigation tested the incremental utility of cognitive retraining as a component within a program designed to prevent child maltreatment. High-risk families (N = 96) were randomly assigned to a control condition, home visitation modeled after the Healthy Start program (unenhanced home visitation), or home visitation that included a cognitive component (enhanced home visitation). Mothers were identified late during pregnancy or soon after birth, and their participation continued for 1 year. Lower levels of harsh parenting were found among mothers in the enhanced home visitation condition than among those in the unenhanced home visitation or control conditions. Prevalence of physical abuse (percentage of mothers who were abusive) during the first year was 26% in the control condition, 23% in the unenhanced home visitation condition, and 4% in the enhanced home visitation condition. Benefits were greatest in families that included a medically at-risk child. A linear pattern of benefits was found for child health; as program features were added, benefits for child health increased. Study conducted in a suburb of Cape Town, South Africa.
                Comparison of successful tuberculosis treatment outcome rates between self supervision, supervision by lay health worker (LHW), and supervision by clinic nurse.
                Open, randomised, controlled trial with intention-to-treat analysis.
                All groups (n = 156) achieved similar outcomes (LHW vs. clinic nurse: risk difference 17.2%, 95% confidence interval [CI] -0.1-34.5; LHW vs. self supervision 15%, 95%CI -3.7-33.6). New patients benefit from LHW supervision (LHW vs clinic nurse: risk difference 24.2%, 95%CI 6-42.5, LHW vs. self supervision 39.1%, 95%CI 17.8-60.3) as do female patients (LHW vs. clinic nurse 48.3%, 95%CI 22.8-73.8, LHW vs. self supervision 32.6%, 95%CI 6.4-58.7).
                LHW supervision approaches statistically significant superiority, but fails to reach it most likely due to the study's limitation, the small sample size. It is possible that subgroups (new and female patients) do well under LHW supervision. LHW supervision could be offered as one of several supervision options within TB control programmes. Diarrhea is the second leading cause of death among infants and young children in the developing world. This project investigated whether therapeutic infant massage could reduce diarrheal episodes and decrease overall illness of infants. Infants living in 2 orphanages in Quito, Ecuador, were matched by age and randomly assigned to an experimental or a control condition. The experimental group received an intervention, daily infant massage therapy by orphanage staff or volunteers, which lasted an average of 53 days, and symptoms of illness data were documented daily by volunteers in the orphanages. Results indicated that control group infants had a 50% greater risk of having diarrhea than experimental infants (rate ratio [RR] = 1.54, 95% confidence interval [CI] = 1.18, 2.03, P < 0.001). Control group infants were also 11% more likely than experimental infants to experience illness of any kind (RR = 1.11, 95% CI = 0.96, 1.28, P = 0.17). The implications for the use of therapeutic infant massage, a remarkably inexpensive intervention, are discussed, and the need for further research is highlighted. This study examined the feasibility of a postdiagnosis parent mentoring intervention for mothers of young children (1-10 years old) newly diagnosed with type 1 diabetes.
                A mixed-method, prospective, randomized, controlled clinical trial design was used. Parent mentors (experienced mothers who have successfully raised young children with type 1 diabetes) and mother participants with young children newly diagnosed with type 1 diabetes were recruited from 2 regional pediatric diabetes centers. The mentors were trained to provide informational, affirmational, and emotional support using Ireys' modified parent mentor curriculum. During a 6-month trial, mentors provided home visits and phone call support to the mothers who were randomized to the experimental group. The control group had the option of receiving the intervention after the 6-month trial.
                Mothers in the experimental group had fewer concerns, more confidence, identified more resources, and perceived diabetes having less of a negative impact on their family compared with mothers in the control group. Parent mentors provided important, practical day-to-day management information, reassurance, and emotional support during times of crises.
                A postdiagnosis parent mentoring intervention for mothers of children with diabetes appears to be feasible and potentially effective. Most mothers breastfeed in Bangladesh, but they rarely practise exclusive breastfeeding. Hospital-based strategies for breastfeeding promotion cannot reach them because about 95% have home deliveries. We postulated that with the intervention of trained peer counsellors, mothers could be enabled to breastfeed exclusively for the recommended duration of 5 months.
                40 adjacent zones in Dhaka were randomised to intervention or control groups. Women were enrolled during the last trimester of pregnancy between February and December, 1996. In the intervention group, 15 home-based counselling visits were scheduled, with two visits in the last trimester, three early postpartum (within 48 h, on day 5, between days 10 and 14), and fortnightly thereafter until the infant was 5 months old. Peer counsellors were local mothers who received 10 days' training.
                363 women were enrolled in each group. Peer counselling significantly improved breastfeeding practices. For the primary outcome, the prevalence of exclusive breastfeeding at 5 months was 202/228 (70%) for the intervention group and 17/285 (6%) for the control group (difference=64%; 95% CI 57%-71%, p>0.0001). For the secondary outcomes, mothers in the intervention group initiated breastfeeding earlier than control mothers and were less likely to give prelacteal and postlacteal foods. At day 4, significantly more mothers in the intervention group breastfed exclusively than controls.
                Peer counsellors can effectively increase the initiation and duration of exclusive breastfeeding. We recommend incorporation of peer counsellors in mother and child health programmes in developing countries. To determine if adding an intensive home visitation component to a comprehensive adolescent-oriented maternity program prevents child abuse and neglect.
                We studied 171 participants in a comprehensive, adolescent-oriented maternity program who were deemed to be at high risk for child abuse and neglect. Half were randomly assigned to receive in-home parenting instruction. Major disruptions of primary care-giving by the adolescent mother were classified hierarchically as abuse, neglect, and abandonment.
                Compliance with home visits varied in relation to the support the teenage mothers received from their families and the fathers of their babies (p < .0001). There were no significant treatment group differences in the pattern of health care utilization, the rate of postpartum school return, repeat pregnancies, or child abuse and neglect. The incidence of maltreatment rose in tandem with the predicted risk status of the mother. Ultimately, 19% of the children were removed from their mother's custody.
                Prediction efforts were effective in identifying at-risk infants, but this intensive home- and clinic-based intervention did not alter the incidence of child maltreatment or maternal life course development. A parenting program that was more inclusive of the support network might be more popular with teenagers and therefore more effective. Our findings also emphasize the importance of including counseling specifically designed to prevent teenagers from abandoning their children. Infectious disease and poor diet are the two proximal causes of malnutrition in children. During the 1990s, integrated nutrition programs implemented by Save the Children (SC) in Viet Nam reduced severe child malnutrition, but it has not been clear if this impact was due primarily to improved diet or reduced disease. The aim of this study was to determine whether a community-based, integrated nutrition program in Viet Nam reduced child morbidity due to diarrhea or acute respiratory infections. Children 5 to 25 months old were randomly selected from randomly assigned intervention and comparison communes. Caregivers of children from the intervention and comparison groups (n = 119 per group) were interviewed about their child's morbidity at program baseline and at study months 2, 4, 6, and 12. Multiple logistic regression and general estimating equations (GEE) were used to evaluate the effect of the intervention on the occurrence of any diarrhea and respiratory illness in the preceding two weeks. Respiratory illness, mainly upper respiratory illness, was more common than diarrheal disease at baseline (54% vs. 6%, respectively). During follow-up, children in the intervention communes had approximately half the respiratory illness experienced by those in comparison communes (AOR = 0.5; p = .001). Diarrheal disease was also lower in the intervention group, although differences were not statistically significant. We conclude that SC's integrated nutrition program was associated with reduced upper respiratory illness, perhaps due to improved hygiene practices and/or improved micronutrient intakes. A special program of outreach services was implemented to assist a poverty population to appropriately use health services in the Kaiser-Permanente Medical Care Program. A study was conducted to determine the effect of outreach workers' intervention on the use of preventive services by this population. Intially, families were divided into two groups, one with and one without outreach workers. Outreach workers (neighborhood health coordinators) were trained in prevention and health education. They were then assigned to specific subgroups of the poverty population to teach the importance of preventive services and to motivate persons to use these services. This paper focuses on the effect of outreach workers' services on the use of selected preventive care services (immunizations and tine test) by preschool children from poverty families. Preschool children in families with coordinator services had higher use rates for preventive care. The sub-group for which outreach workers were specially trained to focus on preventive procedures for the pre-school group had markedly higher use rates for preventive care. The findings suggest that special intervention programs, using indigenous and nonprofessional outreach workers, can increase preventive service utilization by poverty groups. To assess the effectiveness of a volunteer-driven outreach program on immunization rates in children younger than 2 years.
                Randomized controlled trial.
                Pediatric ambulatory clinics in New York, NY.
                A total of 163 children were randomly assigned to receive services from the volunteer-driven outreach program or to serve as control subjects. All children were (1) younger than 2 years, (2) no-shows for a scheduled appointment in the pediatric clinic, and (3) due or overdue for a vaccine.
                Immunization outreach, tracking, and follow-up were provided by community volunteers throughout follow-up (mean, 6.5 months). Control children were notified of immunization status at enrollment but received no further contact until the conclusion of follow-up (mean, 6.4 months).
                Immunization status 6 months after enrollment.
                Significantly more intervention children were up-to-date with their vaccination series than controls (75% vs. 54%; P = .03). Children in the control group were 2.8 times more likely to be late for a vaccine than intervention children (odds ratio = 2.8; P = .02). In addition, an immunization delay of longer than 30 days at enrollment was a significant predictor of final immunization delay (odds ratio = 2.6; P = .02).
                This volunteer-driven program significantly improved immunization rates among intervention children compared with controls. Results confirm previous findings that indicate an increased risk of an incomplete immunization series by 2 years of age among children who fall behind early in their primary vaccination series. However, control children were almost 3 times more likely to be late (for > or =1 vaccines) than intervention children, regardless of whether an earlier immunization delay was present.
LHWs provide promising benefits in promoting immunisation uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared to usual care. For other health issues, evidence is insufficient to draw conclusions about the effects of LHWs.