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    • br Implementation of a programme called

    2019-06-21


    Implementation of a programme called the , the key component of the UNICEF/WHO Baby-Friendly Hospital Initiative (BFHI) increases exclusive breastfeeding at 3 months, any breastfeeding at 12 months, and reduces diarrhoeal disease. These outcomes were shown in a cluster-randomised study of 31 hospitals and clinics (17 046 mother–infant pairs) in Belarus, in which BFHI was compared with standard care. The study by Marcel Yotebieng and colleagues published in challenges the need for additional support during well-child visits and locally available breastfeeding support materials, and shows that formal accreditation might not be necessary to implement BFHI successfully (and is not readily achievable in many parts of the world). Yotebieng and colleagues assessed a short-cut implementation of the ten steps in a cluster randomised trial of six health-care clinics (957 eligible mother–infant pairs) in DR Congo. They randomly assigned clinics to BFHI steps 1–9 alone (steps 1–9 group), BFHI steps 1–9 plus additional support during well-child visits (steps 1–10 group), or standard care (control). BFHI steps 1–9 focus on the promotion and establishment of breastfeeding within the clinical setting of the birth. Step 10 promotes the establishment of breastfeeding support groups and referral of mothers to these on discharge from hospital or the clinic.
    Community health workers are a vibrant and unique workforce ideally positioned to function as members of interdisciplinary teams needed to address the global burden of non-communicable diseases. The article by Thomas Gaziano and colleagues in provides a compelling scientific argument for incorporating caudatin health workers into the systems of community-based screening and referral to predict cardiovascular disease risk as efficiently and accurately as physicians and nurses do. Gaziano and colleagues showed that, using a simple, non-invasive cardiovascular disease risk prediction indicator, 42 community health workers across four different countries completed 4049 screenings in a short timeframe with a high level of accuracy (96·8% agreement compared with the gold standard of a health professional). Low-income and middle-income countries carry an estimated 80% of the burden of non-communicable diseases and are faced with a shortage of physicians and nurses to address population needs for screening, monitoring, and management. Gaziano and colleagues\' study provides an example of how community health workers can be part of a feasible and low-cost solution to these human and financial shortages. Through a brief structured training protocol (1–2 weeks, 61% of workers met the criteria to do fieldwork), the investigators showed that community health workers can help to detect early disease, which in turn can promote direction of resources to those in highest need and allow physicians and other health-care professionals to spend more time monitoring and treating disease. The article is a very timely contribution in the context of global challenges with the ailing medical model of disease care, and supports a shift towards population-based investments for prevention of non-communicable diseases that are absent at present. A closer look at the results of Gaziano and colleagues\' study reveals several key findings. First, mobilisation of community health workers allowed for an effective way to reach community participants who did not have a previous diagnosis of cardiovascular disease risk factors such as hypertension and diabetes. Community health workers can draw on their in-depth knowledge of the communities\' cultural norms, barriers, and opportunities—a strength that differentiates community health workers from other health-care professionals. Second, community health workers were able to integrate two key functions: screening and referral (non-urgent and urgent). Thus, community health workers showed they were able to assist a continuum of health care (screening and referral), which prevents community members from falling through the cracks in a system that because of human, financial, and organisational constraints is incapable of responding effectively and on time. Finally, Gaziano and colleagues report that community health workers did opportunistic screening for at least 100 community members over 4–6 weeks. Screenings were done in community sites or at the homes of community participants. Thus, community outreach has great potential to bridge prevention, management, and control of non-communicable diseases with empowering community models that incorporate community health workers as a part of the systems of health care and other systems within countries (schools, recreation facilities, churches, neighbourhood dwellings, etc). To communities, this integration would mean that an asset model of prevention within a health-care system can be developed.