Community-based bundled interventions for reproductive and child health in informal settlements: evidence, efficiency, and equity.

www.thelancet.com/lancetgh Vol 5 March 2017 e240 Community-based bundled health interventions are complex and challenging to implement, monitor, and assess in informal settlements (slums). Such settlements in urban areas are generally characterised by congestion, squalid conditions, deprivation, violence, crime, and poor sanitation. In Asia and Africa, the numbers of informal settlements have grown exponentially in the large and mega cities of low-income and middleincome countries in the past few decades. Their growth has been driven by rapid urbanisation and economic opportunities, leading to and prompted by ruralto-urban migration of skilled and unskilled workers. Populations in these informal settlements, particularly women, children, and, increasingly, the elderly, are vulnerable to poor and multiple physical and mental health issues that include violence-related and selfinfl icted injuries. In The Lancet Global Health, Neena Shah More and colleagues present evidence from a cluster-randomised, controlled trial in which they assessed the eff ects of community-based integrated interventions on reproductive and child health outcomes in informal settlements in Mumbai. The bundled intervention was implemented systematically by an experienced non-governmental organisation, the Society for Nutrition, Education and Health Action (SNEHA), and was designed primarily to address multiple health needs of women and children (reproductive, maternal, neonatal, and child health, immunisation, nutrition, and prevention of violence). 40 clusters of similar sizes were randomly assigned to have a resource centre providing and arranging help for the community (n=20, 12 614 households) or to have no additional resources (control; n=20, 12 239 households). Data for the indicators used to assess change were obtained through censuses done before and 2 years after the intervention was implemented. Postintervention data were available for 8271 women and 5371 children younger than 5 years in the intervention group, and 7965 women and 5180 children in the control group. Several outcome indicators improved signifi cantly in favour of the intervention group. For example, met need for family planning was greater in the intervention clusters than in the control clusters (odds ratio [OR] 1·31, 95% CI 1·11–1·53). Full immunisation among children aged 12–23 months was similar in the two groups when assessed by intention to treat, but improvement was seen in the per-protocol analysis (ie, children who had been resident in intervention clusters for the entire intervention period; OR 1·73, 95% CI 1·05–2·86). Childhood wasting was improved at the cluster level after 2 years of intervention. These results confi rm the feasibility and eff ectiveness of a communitybased resource model, and the authors have called for replicating the approach in other informal settlements to be considered. The strength of this community intervention was the integrated approach, which mixed health promotion with outreach activities, such as provision of information, communication, supervision, referral and follow-up services, day care, supplementary nutrition for malnourished children, counselling, home visits, liaison with local public systems, and community-based events. SNEHA engaged full-time, paid, and trained community organisers to monitor health and wellbeing and provide these services. They also involved clinicians to provide treatment, medication, and referrals. Although the evidence supporting bundled intervention was statistically robust, I question whether these fi ndings can be generalised to other informal settlements. Generalisability will depend on the causes and degree of association between the intervention components and outcome indicators, eff ect modifi cation, and the variation in reported statistical associations when controlled for potential confounders and external characteristics. To assess the internal validity and causal pathways would require a systematic assessment of adherence to the intervention, health and health-care behaviours, and potential economic, cultural or religious barriers in the intervention clusters. For example, husbands’ or fathers’ involvement and care and economic support from the immediate social Community-based bundled interventions for reproductive and child health in informal settlements: evidence, effi ciency, and equity