Synthesis of Research Evidence
ACCEPTABILITY
High and improving care-seeking rates between 1996 and 2012 suggested high acceptability of FB-IMCI; although for diarrhea, the facility care-seeking rates did not increase markedly (see Effectiveness/Reachcell).
Data on care-seeking for malnutrition were unavailable for the team to review.
FEASIBILITY
Coverage data not available.
By 2001, only 2 departments in Peru had reached “full implementation” per WHO standards.
Early challenges with integration of vertical programs into IMCI as a key informant explained: “IMCI existed at the same time as vertical programs and competed in political priorities and budget with these programs . . . they [vertical programs] were discontinued much more recently and in fact coexisted (with IMCI) for many years.”
Multicountry evaluation found lack of institutionalization and prioritization.
FB-IMCI integration into preservice curriculum for nurses and doctors in 2009.
The MOH institutionalized IMCI as a strategy of the 2003 Comprehensive Childhood Health Care Model.
FIDELITY
By 2001, training coverage remained very low with only 10% of doctors and nurses receiving IMCI training.2,3
The multicountry evaluation found that only 8% of facilities in implementation districts had at least 60% of its health workers trained in IMCI.
The multicountry evaluation found insufficient training and supervision and high staff turnover.3
EFFECTIVENESS/REACH
A study on ARI treatment-seeking found that 75% of children were treated by doctors and the remaining 25% by nurses and nurse auxiliaries.
ORT coverage improved slightly from 22% in 2000 to 31% in 2012 but remained low (see ORT section).
The proportion of children under 5 with ARI symptoms that received antibiotics improved from 29% in 2004–2006 to 38% in 2012 but remained low.
In 1996, when Peru began small-scale testing of FB-IMCI, care-seeking for fever (from health facility or other provider) was 35%, increasing to 56% in 2000 and 68% in 2009, but dropping to 60% by 2012. Similarly, care-seeking for diarrhea (from a health facility) was 32% in 1996 and improved to 45% by 2009, but dropped to 35% in 2012. For ARIs, care-seeking from health facilities continued to improve from 49% in 1996 to 69% in 2009 and 74% in 2012.
By 2015, the proportion of deaths attributable to LRIs had decreased from 163/100,000 to 54/100,000 of U5 population. For diarrhea, this dropped from 44/100,000 to 10/100,000.
These drops in U5 deaths attributable to each condition reflected the effectiveness of FB-IMCI but may also reflect the drop in incidence rates for ARI and diarrhea, improved nutritional status, and additional care from CB-IMCI (see Malnutrition and Other Malaria Interventions section).
IHME DECOMPOSITION RESULTS1
<1% of the reduction in under-five mortality attributed to oral antibiotics, ORS, and zinc treatment.
Synthesis of Research Evidence
ACCEPTABILITY
Enlace program evaluation found care-seeking for children under 2 with suspected pneumonia increased from 37% in 1996 to 71% in 2000.
FEASIBILITY
Not found.
FIDELITY
Not found.
EFFECTIVENESS/REACH
ORT coverage improved slightly from 22% in 2000 to 31% in 2012 but remained low (see ORT section).
An evaluation of CARE’s Enlace program found that the percentage of children under 2 years with suspected pneumonia who were seen at a health facility nearly doubled from 37% in 1996 to 71% in 2000. Twice as many cases received follow-up visits by CHWs, increasing from 40% of sick children at baseline to 81%.4
In 1996, just before implementation of CB-IMCI in Peru began, care-seeking for fever (from health facility or other provider) was 35% and by 2000 increased to 56% and 68% in 2009 although dropped to 60% by 2012. Care-seeking data for ARI and diarrhea were unavailable for the team to review.
DHS reports over the course of the study period showed limited improvement in treatment of ARI and diarrhea in children. Only 31% of children U5 with diarrhea received ORS in 2012, from 26% in 1996.
Remaining inequity by wealth quintile and region in care-seeking rates for pneumonia, diarrhea, and fever.
IHME DECOMPOSITION RESULTS
Synthesis of Research Evidence
ACCEPTABILITY
High acceptability of ORS reported in 2012 study in Lima (though data not found for other areas of the country).
FEASIBILITY
Not found
FIDELITY
New ORS formulas only considered for approval in Peru if following the new WHO-recommended formula.
EFFECTIVENESS/REACH
Treatment of diarrhea with ORS improved but still remained very low – 32% per 2015 DHS.
Regional differences in coverage persisted in 2015 – from 14% in Tacna to 45% in Madre de Dios and Cajamarca (DHS).5
Coverage data for zinc were not available.
IHME DECOMPOSITION RESULTS
Synthesis of Research Evidence
ACCEPTABILITY
Not found.
FEASIBILITY
Committees created at national, regional, and sentinel hospitals to be involved in surveillance implementation.
Regions had varying success with implementing, with some regions struggling to pay for the costs of distribution.
Introduced first in poorest areas of the country.
FIDELITY
EFFECTIVENESS/REACH
National coverage increased to 91% in 2012 from 41% in 2009.
Slight decline in coverage from 91% in 2012 to 87% in 2015.
DECOMPOSITION RESULTS1
13.3% of the reduction in under-five mortality attributed to vaccines including rotavirus, PCV, Hib, Measles, and DTP3.
Synthesis of Research Evidence
ACCEPTABILITY
Acceptance/refusal data not found, but high coverage as described below.
FEASIBILITY
Implementation in all regions.
FIDELITY
EFFECTIVENESS/REACH
High PCV3 coverage (90% in 2015).
DECOMPOSITION RESULTS
Synthesis of Research Evidence
ACCEPTABILITY
Acceptance data not found, but high coverage as described below, suggesting low/no refusal.
FEASIBILITY
Scaled up to entire country in 2007 following phased introduction.
FIDELITY
EFFECTIVENESS/REACH
High coverage achieved, with equivalent coverage in urban and rural areas and narrowing of equity gap.
Remaining differences in regional coverage – ranging from 61% in Madre de Dios to 87% in Tumbes (2014).
Coverage sustained nationally – 90% in 2015.
DECOMPOSITION RESULTS
Synthesis of Research Evidence
ACCEPTABILITY
High coverage achieved by campaigns.
FEASIBILITY
More than 20 million people vaccinated over 4 weeks, surpassing target number.
Ongoing vaccination coverage hovering around 90%.
FIDELITY
Between 2009 and 2014, less than 30% of children in Loreto received the vaccine on time.6
EFFECTIVENESS/REACH
Campaign coverage of 98%, with high coverage across regions.
National coverage of 92% in 2015.
High national presence of antibodies against measles (92%) in 2011-12 study of children 1–4 years.
Coverage dropped from 92% in 2015 to 83% in 2017.
DECOMPOSITION RESULTS
Synthesis of Research Evidence
ACCEPTABILITY
In 2007–2008 study, nearly all respondents (94%) believed traditional nets provided better protection than long-lasting insecticide-treated nets (LLINs).7
FEASIBILITY
Successful distribution and coverage, but some of this was from households purchasing their own ITNs.
FIDELITY
Utilization very high shortly after distribution, but decreased after one year – 77% of children under 5 slept under an ITN one year after distribution.
2007–2008 study found the majority (63%) of households did not use previously distributed LLINs, often preferring to use traditional nets instead.
EFFECTIVENESS/REACH
Distribution of 242,000 LLINs in 194 targeted communities.
By 2007, 85% of households in priority distribution areas owned an ITN, however, many households had actually purchased their own.7
Reduction in malaria cases in Peru during 2005–2010, though not sustained.
IHME DECOMPOSITION RESULTS1
<1% of the reduction in under-five mortality attributed to malaria-related interventions.
Synthesis of Research Evidence
ACCEPTABILITY
Not found
FEASIBILITY
Decline of IRS use following conclusion of the National Malaria Eradication Campaign and shifting of resources and funds for malaria control to the district level.
FIDELITY
High coverage of target areas sprayed in Loreto.
EFFECTIVENESS/REACH
Limited use in Peru during the study period, primarily in 9 districts in Loreto.
High coverage achieved by spraying activities in Loreto.
Twice-yearly spraying in Loreto likely inadequate due to period of effectiveness of deltamethrin.
IHME DECOMPOSITION RESULTS
Synthesis of Research Evidence
ACCEPTABILITY
Community-based RDT use not accepted and supported by some professional health workers.
False negatives resulted in distrust in some communities.
FEASIBILITY
Supply chain issues, including delayed procurement and distribution.
FIDELITY
EFFECTIVENESS/REACH
No large-scale procurement and distribution since 2007.
IHME DECOMPOSITION RESULTS
Synthesis of Research Evidence
ACCEPTABILITY
FEASIBILITY
FIDELITY
Supply chain challenges to timely acquisition and treatment.
EFFECTIVENESS/REACH
IHME DECOMPOSITION RESULTS
Synthesis of Research Evidence
ACCEPTABILITY
Remaining acceptability challenges for some PMTCT interventions like cesarean sections and formula feeding.
FEASIBILITY
Expansion of PMTCT services.
FIDELITY
Stock-outs of rapid tests and PCR reagents affect testing coverage.
EFFECTIVENESS/REACH
Improved coverage of screening and treatment of pregnant women, but low coverage of testing for exposed infants and pediatric ART.
Challenges maintaining coverage of testing.
Estimated MTCT declined from 15% in 2005 to 9.1% in 2009.
IHME DECOMPOSITION RESULTS1
5.9% of the reduction in under-five mortality attributed to PMTCT and ART.
Synthesis of Research Evidence
ACCEPTABILITY
Acceptability issues of chispitas powder due to diarrhea incidence and poor taste affected adherence.
FEASIBILITY
Scaled up to all regions.
Scale-up of Nutriwawa and chispitas prioritized areas with high rates of childhood anemia and chronic malnutrition.
FIDELITY
Challenges in adherence to chispitas.
EFFECTIVENESS/REACH
Low coverage of vitamin A supplementation throughout study period.
IHME DECOMPOSITION RESULTS1
8.8% reduction in child mortality attributed to changes in rates of child growth failure.
Synthesis of Research Evidence
ACCEPTABILITY
FEASIBILITY
Improvements in equity in coverage of ANC.
FIDELITY
Quality issues expressed by key informant despite high coverage.
EFFECTIVENESS/REACH
Per DHS, ANC4+ coverage increased from 69% in 2000 to 94% in 2014.
Lower coverage of ANC in some regions.
High coverage of Juntos program, reaching all municipalities classified by poor by 2015.
IHME DECOMPOSITION RESULTS1
1.3% reduction in U5M attributed to increased use of skilled birth attendants. An additional 8.7% reduction in U5M is attributed to reductions in low birth weight and short gestational age.
Synthesis of Research Evidence
ACCEPTABILITY
Challenges in uptake due adaptation requiring women to seek immunization services outside standard ANC.
FEASIBILITY
Provision to women of childbearing age as well as pregnant women.
FIDELITY
EFFECTIVENESS/REACH
High coverage of protection at birth per DHS (80% in 2014), but lower coverage of TT2+ during pregnancy (54% in 2014) with static rates throughout the study period.
Decline in neonatal mortality due to tetanus over the study period – from 7.14/100,000 newborns to 0.85/100,000 newborns (though this can also be due to clean cord care and better childbirth practices).
IHME DECOMPOSITION RESULTS
Synthesis of Research Evidence
ACCEPTABILITY
FEASIBILITY
FIDELITY
Study of folic acid levels in bread purchased in Peru found all bread had levels higher than legally required.
EFFECTIVENESS/REACH
Decrease in incidence of neural tube defects in Peru by 4.9/10,000 following fortification, though reduction not reported by all studies.
IHME DECOMPOSITION RESULTS
Synthesis of Research Evidence
ACCEPTABILITY
Improved coverage across all regions.
FEASIBILITY
Establishment of 390 maternal waiting homes by 2008.
FIDELITY
EFFECTIVENESS/REACH
Improvement in coverage – 90% coverage of facility-based deliveries in 2014, with sustained progress in coverage improvement (DHS).
Regional differences still reported in 2014, ranging from 67% in Loreto to 100% in Ica and Tumbes (DHS).
Sustainability of maternal waiting homes is variable due to reliance on local prioritization and resources.
IHME DECOMPOSITION RESULTS
Synthesis of Research Evidence
ACCEPTABILITY
Increased uptake of facility-based delivery and skilled birth attendance, though 2013 study found that 50% of Quechua mothers still preferred to be assisted by a traditional birth attendant (TBA).
FEASIBILITY
FIDELITY
EFFECTIVENESS/REACH
2014 DHS reported large differences in skilled birth attendance between regions – from 67% in Loreto to 100% in Ica and Tumbes.
IHME DECOMPOSITION RESULTS
Synthesis of Research Evidence
ACCEPTABILITY
FEASIBILITY
Low facility capacity found in assessments conducted in 2010 and 2015.
FIDELITY
Excessive rates of C-section at national level and in many regions suggests unnecessary C-sections are being performed.
EFFECTIVENESS/REACH
Increased cesarean section rates to reach optimal coverage in many regions.
IHME DECOMPOSITION RESULTS
Synthesis of Research Evidence
ACCEPTABILITY
FEASIBILITY
1,272 health care providers from 54 hospitals trained on neonatal resuscitation techniques as part of the National Resuscitation Initiative.
6 specialists trained 25 people to obtain competency profile. Once the training was decentralized, there lacked specialists to provide and evaluate competency, resulting in poorer quality training.
Additional neonatal incubators and resuscitators were added to hospitals in preparation for H1N1, but routinely used.
National scale-up of HBB training took longer than anticipated.
FIDELITY
1,272 health care providers from 54 hospitals trained on neonatal resuscitation techniques as part of the National Resuscitation Initiative.
EFFECTIVENESS/REACH
Reduction in birth asphyxia mortality demonstrated in hospital participating in the National Resuscitation Initiative.
IHME DECOMPOSITION RESULTS
Synthesis of Research Evidence
ACCEPTABILITY
FEASIBILITY
FIDELITY
EFFECTIVENESS/REACH
Low coverage of NICU services – in 2009, only 59% of neonates with health complications received care in a NICU.
Per a key informant, establishment and strengthening of NICUs.
IHME DECOMPOSITION RESULTS
Synthesis of Research Evidence
ACCEPTABILITY
Per key informant, high acceptability for mothers and families, initially lower but later high acceptability among providers after seeing impact.
FEASIBILITY
KMC scaled up nationally, but still not provided at all facilities in Peru.
FIDELITY
EFFECTIVENESS/REACH
Decrease in neonatal mortality demonstrated by pilot study, but no effect found by 2015 systematic review (possibly a result of the population of newborns enrolled in this review).
Per KI, resulted in reduced mortality.
Per KI, high acceptability aids sustainability.
IHME DECOMPOSITION RESULTS
Synthesis of Research Evidence
ACCEPTABILITY
FEASIBILITY
FIDELITY
In 2015, 76% of women who received postnatal care did so within 4 hours of delivery and 96% of women received postnatal care within the first 2 days after delivery.
EFFECTIVENESS/REACH
High coverage reported by 2015 DHS: 97% of women received a postnatal checkup.
Remaining regional disparities in 2015 – 21% of women in Loreto and 19% in Amazonas did not receive any postnatal care (DHS).
IHME DECOMPOSITION RESULTS
The primary research findings suggest additional contextual factors that contributed to U5M reductions in Peru that were outside of the health system interventions. These include economic growth, improvements in water, sanitation, and hygiene, and women’s empowerment.
IHME DECOMPOSITION RESULTS1
5.0% of the reduction in under-five mortality is attributed to environmental factors, including WASH and air quality.
Abbreviations: ANC, antenatal care; ANC4+, at least 4 ANC visits; ARI, acute respiratory infection; ART, antiretroviral therapy; CB-IMCI, community-based Integrated Management of Childhood Illness; CHW, community health worker; DHS, Demographic and Health Survey; DTP3, diphtheria-tetanus-pertussis; FB-IMCI, facility-based Integrated Management of Childhood Illness; HBB, Helping Babies Breathe; Hib, Haemophilus influenzae type b; IMCI, Integrated Management of Childhood Illness; IRS, indoor residual spraying; ITN, insecticide-treated net; KI, key informant; KMC, kangaroo mother care; LLIN, long-lasting insecticidal net; LRI, lower respiratory infection; MOH, Ministry of Health; MTCT, mother-to-child transmission; NICU, neonatal intensive care unit; ORS, oral rehydration salts; ORT, oral rehydration therapy; PCR, polymerase chain reaction; PCV, pneumococcal conjugate vaccine; PMTCT, prevention of mother-to-child transmission of HIV U5, under-five; RDT, rapid diagnostic testing; TBA, traditional birth attendant; TT, tetanus toxoid; U5M, under-five mortality; WASH, water, sanitation, and hygiene; WHO, World Health Organization.
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1
Institute for Health Metrics and Evaluation (IHME). Global Burden of Disease Study (GBD 2017). Seattle, WA: IHME; 2018. http://www.healthdata.org/gbd. Accessed December 12, 2019.
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2
World Health Organization (WHO). IMCI information. WHO/CHS/CAH/98.1K REV.1. Geneva: WHO; 1999. https://apps.who.int/iris/bitstream/handle/10665/65002/WHO_CHS_CAH_98.1K_eng.pdf?sequence=12. Accessed February 12, 2020.
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3
Huicho L, Dávila M, Gonzales F, Drasbek C, Bryce J, Victora CG. Implementation of the Integrated Management of Childhood Illness strategy in Peru and its association with health indicators: an ecological analysis. Health Policy Plan. 2005;20(1):i32–i41. https://doi.org/10.1093/heapol/czi052. Accessed March 18, 2019.
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4
The United Nations Children’s Fund (UNICEF)/ World Health Organization (WHO). Management of Sick Children by Community Health Workers: Intervention Models and Programme. UNICEF/WHO; 2006. https://www.unicef.org/publications/files/Management_of_Sick_Children_by_Community_Health_Workers.pdf. Accessed February 12, 2020.
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5
Instituto Nacional de Estadistica e Informática (INEI). Encuesta Demográfica y de Salud Familiar (ENDES) 2015 – Peru. Lima, Peru: INEI; 2015. https://www.inei.gob.pe/media/MenuRecursivo/publicaciones_digitales/Est/Lib1356/. Accessed March 18, 2019.
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6
Hoest C, Seidman JC, Lee G, et al. Vaccine coverage and adherence to EPI schedules in eight resource poor settings in the MAL-ED cohort study. Vaccine. 2017;35(3):443–451. https://doi.org/10.1016/j.vaccine.2016.11.075. Accessed February 12, 2020.
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7
Grietens KP, Ribera JM, Soto V, et al. Traditional nets interfere with the uptake of long-lasting insecticidal nets in the Peruvian Amazon: the relevance of net preference for achieving high coverage and use. PLOS One. 2013;8(1):e5029. https://dx.doi.org/10.1371%2Fjournal.pone.0050294. Accessed March 18, 2019.