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Summary: Background: Almost a quarter of the world's undernourished people live in India. We tested the effects of three nutrition-sensitive agriculture (NSA) interventions on maternal and child nutrition in India. Methods: We did a parallel, four-arm, observer-blind, cluster-randomised trial in Keonjhar district, Odisha, India. A cluster was one or more villages with a combined minimum population of 800 residents. The clusters were allocated 1:1:1:1 to a control group or an intervention group of fortnightly women's groups meetings and household visits over 32 months using: NSA videos (AGRI group); NSA and nutrition-specific videos (AGRI-NUT group); or NSA videos and a nutrition-specific participatory learning and action (PLA) cycle meetings and videos (AGRI-NUT+PLA group). Primary outcomes were the proportion of children aged 6–23 months consuming at least four of seven food groups the previous day and mean maternal body-mass index (BMI). Secondary outcomes were proportion of mothers consuming at least five of ten food groups and child wasting (proportion of children with weight-for-height Z score SD

Economic evaluations of nutrition-sensitive agriculture (NSA) interventions are scarce, limiting assessment of their potential affordability and scalability.We conducted cost-consequence analyses of 3 participatory video-based interventions of fortnightly women's group meetings using the following platforms: 1) NSA videos; 2) NSA and nutrition-specific videos; or 3) NSA videos with a nutrition-specific participatory learning and action (PLA) cycle.Interventions were tested in a 32-mo, 4-arm cluster-randomized controlled trial, Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN) in the Keonjhar district, Odisha, India. Impacts were evaluated in children aged 0-23 mo and their mothers. We estimated program costs using data collected prospectively from expenditure records of implementing and technical partners and societal costs using expenditure assessment data collected from households with a child aged 0-23 mo and key informant interviews. Costs were adjusted for inflation, discounted, and converted to 2019 US$.Total program costs of each intervention ranged from US$272,121 to US$386,907. Program costs per pregnant woman or mother of a child aged 0-23 mo were US$62 for NSA videos, US$84 for NSA and nutrition-specific videos, and US$78 for NSA videos with PLA (societal costs: US$125, US$143, and US$122, respectively). Substantial shares of total costs were attributable to development and delivery of the videos and PLA (52-69%) and quality assurance (25-41%). Relative to control, minimum dietary diversity was higher in the children who underwent the interventions incorporating nutrition-specific videos and PLA (adjusted RRs: 1.19 and 1.27; 95% CIs: 1.03-1.37 and 1.11, 1.46, respectively). Relative to control, minimum dietary diversity in mothers was higher in those who underwent NSA video (1.21 [1.01, 1.45]) and NSA with PLA (1.30 [1.10, 1.53]) interventions.NSA videos with PLA can increase both maternal and child dietary diversity and have the lowest cost per unit increase in diet diversity. Building on investments made in developing UPAVAN, cost-efficiency at scale could be increased with less intensive monitoring, reduced startup costs, and integration within existing government programs. This trial was registered at clinicaltrials.gov as ISRCTN65922679.

IntroductionThe WHO recommends community mobilisation with women’s groups practising participatory learning and action (PLA) to improve neonatal survival in high-mortality settings. This intervention has not been evaluated at scale with government frontline workers.MethodsWe did a pragmatic cluster non-randomised controlled trial of women’s groups practising PLA scaled up by government front-line workers in Jharkhand, eastern India. Groups prioritised maternal and newborn health problems, identified strategies to address them, implemented the strategies and evaluated progress. Intervention coverage and quality were tracked state-wide. Births and deaths to women of reproductive age were monitored in six of Jharkhand’s 24 districts: three purposively allocated to an early intervention start (2017) and three to a delayed start (2019). We monitored vital events prospectively in 100 purposively selected units of 10 000 population each, during baseline (1 March 2017–31 August 2017) and evaluation periods (1 September 2017–31 August 2019). The primary outcome was neonatal mortality.ResultsWe identified 51 949 deliveries and conducted interviews for 48 589 (93.5%). At baseline, neonatal mortality rates (NMR) were 36.9 per 1000 livebirths in the early arm and 39.2 in the delayed arm. Over 24 months of intervention, the NMR was 29.1 in the early arm and 39.2 in the delayed arm, corresponding to a 24% reduction in neonatal mortality (adjusted OR (AOR) 0.76, 95% CI 0.59 to 0.98), including 26% among the most deprived (AOR 0.74, 95% CI 0.57 to 0.95). Twenty of Jharkhand’s 24 districts achieved adequate meeting coverage and quality. In these 20 districts, the intervention saved an estimated 11 803 newborn lives (min: 1026–max: 20 527) over 42 months, and cost 41 international dollars per life year saved.ConclusionParticipatory women’s groups scaled up by the Indian public health system reduced neonatal mortality equitably in a largely rural state and were highly cost-effective, warranting scale-up in other high-mortality rural settings.Trial registrationISRCTN99422435.

BackgroundImproving the health and development of adolescents aged 10–19 years is a global health priority. One in five adolescents globally live in India. TheRashtriya Kishor Swasthya Karyakram(RKSK), India’s national adolescent health strategy, recommends supporting community-based peer educators to conduct group meetings with boys and girls. Groups aim to give adolescents a space to discuss the social and health issues affecting them and build their capacity to become active community members and leaders. There have been no evaluations of the community component of RKSK to date. In this protocol, we describe the evaluation of the Jharkhand Initiative for Adolescent Health (JIAH), a community intervention aligned with RKSK and designed to improve school attendance, dietary diversity and mental health among adolescent girls aged 10–19 years in rural Jharkhand, eastern India.MethodsThe JIAH intervention is delivered by a community youth team consisting ofyuva saathis(friends of youth), youth leadership facilitators and livelihood promoters. Teams conduct (a) peer-led Participatory Learning and Action meetings with girls and boys, mobilising adolescents, parents, health workers, teachers and the wider community to make changes for adolescent health and development; (b) group-based youth leadership activities to build adolescents’ confidence and resilience; and (c) livelihood promotion with adolescents and their families to provide training and practical skills. We are evaluating the JIAH intervention through a parallel-group, two-arm, superiority, cluster-randomised controlled trial. The unit of randomisation is a geographic cluster of ~1000 people. A total of 38 clusters covering an estimated population of 40,676 have been randomised to control or intervention arms. Nineteen intervention clusters have adolescent groups, youth leadership activities and livelihood promotion. Nineteen control clusters receive livelihood promotion only. Study participants are adolescent girls aged 10–19 years, married or unmarried, in or out of school, living in the study area. Intervention activities are open to all adolescent boys and girls, regardless of their participation in surveys. We will collect data through baseline and endline surveys. Primary trial outcomes are school attendance, dietary diversity and internalising and externalising mental health problems. Secondary outcomes include access to school-related entitlements, emotional or physical violence, self-efficacy and resilience.Trial registrationISRCTN17206016. Registered on 27 June 2018.

Background Undernutrition causes around 3.1 million child deaths annually, around 45% of all child deaths. India has one of the highest proportions of maternal and child undernutrition globally. To accelerate reductions in undernutrition, nutrition-specific interventions need to be coupled with nutrition-sensitive programmes that tackle the underlying causes of undernutrition. This paper describes the planned economic evaluation of the UPAVAN trial, a four-arm, cluster randomised controlled trial that tests the nutritional and agricultural impacts of an innovative agriculture extension platform of women’s groups viewing videos on nutrition-sensitive agriculture practices, coupled with a nutrition-specific behaviour-change intervention of videos on nutrition, and a participatory learning and action approach. Methods The economic evaluation of the UPAVAN interventions will be conducted from a societal perspective, taking into account all costs incurred by the implementing agency (programme costs), community and health care providers, and participants and their households, and all measurable outcomes associated with the interventions. All direct and indirect costs, including time costs and donated goods, will be estimated. The economic evaluation will take the form of a cost-consequence analysis, comparing incremental costs and incremental changes in the outcomes of the interventions, compared with the status quo. Robustness of the results will be assessed through a series of sensitivity analyses. In addition, an analysis of the equity impact of the interventions will be conducted. Discussion Evidence on the cost and cost-effectiveness of nutrition-sensitive agriculture interventions is scarce. This limits understanding of the costs of rolling out or scaling up programs. The findings of this economic evaluation will provide useful information for different multisectoral stakeholders involved in the planning and implementation of nutrition-sensitive agriculture programmes. Trial registration ISRCTN65922679. Registered on 21 December 2016 Electronic supplementary material The online version of this article (10.1186/s13063-019-3388-2) contains supplementary material, which is available to authorized users.

Many public health interventions aim to promote healthful behaviours, with varying degrees of success. With a lack of existing empirical evidence on the optimal number or combination of behaviours to promote to achieve a given health outcome, a key challenge in intervention design lies in deciding what behaviours to prioritise, and how best to promote them. We describe how key behaviours were selected and promoted within a multisectoral nutrition-sensitive agriculture intervention that aimed to address maternal and child undernutrition in rural India. First, we formulated a Theory of Change, which outlined our hypothesised impact pathways. To do this, we used the following inputs: existing conceptual frameworks, published empirical evidence, a feasibility study, formative research and the intervention team’s local knowledge. Then, we selected specific behaviours to address within each impact pathway, based on our formative research, behaviour change models, local knowledge and community feedback. As the intervention progressed, we mapped each of the behaviours against our impact pathways and the transtheoretical model of behaviour change, to monitor the balance of behaviours across pathways and along stages of behaviour change. By collectively agreeing on definitions of complex concepts and hypothesised impact pathways, implementing partners were able to communicate clearly between each other and with intervention participants. Our intervention was iteratively informed by continuous review, by monitoring implementation against targets and by integrating community feedback. Impact and process evaluations will reveal whether these approaches are effective for improving maternal and child nutrition, and what the effects are on each hypothesised impact pathway.

Background Recent data suggest that case fatality from severe acute malnutrition (SAM) in India may be lower than the 10%–20% estimated by the World Health Organization (WHO). A contemporary quantification of mortality and recovery from acute malnutrition in Indian community settings is essential to inform policy regarding the benefits of scaling up prevention and treatment programmes. Methods and findings We conducted a cohort study using data collected during a recently completed cluster-randomised controlled trial in 120 geographical clusters with a total population of 121,531 in rural Jharkhand and Odisha, eastern India. Children born between October 1, 2013, and February 10, 2015, and alive at 6 months of age were followed up at 9, 12, and 18 months. We measured the children’s anthropometry and asked caregivers whether children had been referred to services for malnutrition in the past 3 months. We determined the incidence and prevalence of moderate acute malnutrition (MAM) and SAM, as well as mortality and recovery at each follow-up. We then used Cox-proportional models to estimate mortality hazard ratios (HRs) for MAM and SAM. In total, 2,869 children were eligible for follow-up at 6 months of age. We knew the vital status of 93% of children (2,669/2,869) at 18 months. There were 2,704 children-years of follow-up time. The incidence of MAM by weight-for-length z score (WLZ) and/or mid-upper arm circumference (MUAC) was 406 (1,098/2,704) per 1,000 children-years. The incidence of SAM by WLZ, MUAC, or oedema was 190 (513/2,704) per 1,000 children-years. There were 36 deaths: 12 among children with MAM and six among children with SAM. Case fatality rates were 1.1% (12/1,098) for MAM and 1.2% (6/513) for SAM. In total, 99% of all children with SAM at 6 months of age (227/230) were alive 3 months later, 40% (92/230) were still SAM, and 18% (41/230) had recovered (WLZ ≥ −2 standard deviation [SD]; MUAC ≥ 12.5; no oedema). The adjusted HRs using all anthropometric indicators were 1.43 (95% CI 0.53–3.87, p = 0.480) for MAM and 2.56 (95% CI 0.99–6.70, p = 0.052) for SAM. Both WLZ < −3 and MUAC ≥ 11.5 and < 12.5 were associated with increased mortality risk (HR: 3.33, 95% CI 1.23–8.99, p = 0.018 and HR: 3.87, 95% CI 1.63–9.18, p = 0.002, respectively). A key limitation of our analysis was missing WLZ or MUAC data at all time points for 2.5% of children, including for two of the 36 children who died. Conclusions In rural eastern India, the incidence of acute malnutrition among children older than 6 months was high, but case fatality following SAM was 1.2%, much lower than the 10%–20% estimated by WHO. Case fatality rates below 6% have now been recorded in three other Indian studies. Community treatment using ready-to-use therapeutic food may not avert a substantial number of SAM-related deaths in children aged over 6 months, as mortality in this group is lower than expected. Our findings strengthen the case for prioritising prevention through known health, nutrition, and multisectoral interventions in the first 1,000 days of life, while ensuring access to treatment when prevention fails., Audrey Prost and colleagues present a survey assessing levels of severe acute malnutrition in young children in 2 regions of rural India; they show levels are below suggested figures from the WHO., Author summary Why was this study done? Moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) increase a child’s risk of dying. The World Health Organization (WHO) estimates that 10%–20% of children die following SAM, but this range comes from studies conducted over 15 years ago, mostly in African nations, and does not discriminate between children with and without medical complications. Recent studies from India have suggested that acute malnutrition may carry a lower risk of mortality than estimated by WHO, with substantial implications for the number of lives that could be saved by treating children as outpatients with ready-to-use therapeutic food. Unfortunately, most Indian studies conducted to date have been cross-sectional, small, or did not examine mortality risk with mid-upper arm circumference (MUAC), a commonly used anthropometric indicator to identify children with MAM or SAM. What did the researchers do and find? We conducted a cohort study as a secondary data analysis nested within a recently completed cluster-randomised controlled trial in 120 geographical clusters of Jharkhand and Odisha, two states of eastern India with a high prevalence of child undernutrition. We determined the incidence and prevalence of MAM and SAM, mortality, and recovery among 2,869 children followed up from 6 to 18 months of age. We found that SAM carried a lower case fatality rate (1.2%) than expected from WHO estimates (10%–20%), echoing results from three other Indian studies, which found case fatality rates ranging from 2.7% to 5.2% among children older than 6 months. We also found that over 40% of children with MAM and SAM remained acutely malnourished for over 3 months. What do these findings mean? Our data add to the accruing evidence that, in India, high rates of acute malnutrition in children over 6 months old are accompanied by lower case fatality rates than those reported in older, largely African studies. Overall, our findings suggest a need to prioritise the prevention of undernutrition by supporting known health, nutrition, and multisectoral interventions in the first 1,000 days of life.

Background India is home to 243 million adolescents. Two million (9%) of them belong to Scheduled Tribes living in underserved, rural areas. Few studies have examined the health of tribal adolescents. We conducted a cross-sectional survey to assess the health, nutrition and wellbeing of adolescent girls in rural Jharkhand, eastern India, a state where 26% of the population is from Scheduled Tribes. We aimed to identify priorities for community interventions to serve adolescents and their families. Methods Between June 2016 and January 2017, interviewers visited all households in 50 purposively sampled villages of West Singhbhum district, Jharkhand. They aimed to interview all girls aged 10–19. Interviewers conducted face-to-face interviews with girls to administer a survey about physical and mental health, disability, nutrition, sexual and reproductive health, gender norms, decision-making, education and violence. Interviewers also measured girls’ height, weight, and Mid-Upper Arm Circumference. Results Interviewers collected data from 3324 (82%) of an estimated 4068 girls residing in the study area. Their mean age was 14.3 (SD 2.9). 82% were from Scheduled Tribes. 89% of younger girls aged 10–14 and 46% of older girls aged 15–19 were in school or college. Girls dropped out of school because they were required for household work (37%) or work on the family farm or business (22%). Over a third reported symptoms of anaemia in the past month, but less than a fifth had a blood test. The prevalence of thinness (

Socioeconomic inequalities in neonatal mortality are substantial in many developing countries. Little is known about how to address this problem. Trials in Asia and Africa have shown strong impacts on neonatal mortality of a participatory learning and action intervention with women's groups. Whether this intervention also reduces mortality inequalities remains unknown. We describe the equity impact of this women's groups intervention on the neonatal mortality rate (NMR) across socioeconomic strata.We conducted a meta-analysis of all four participatory women's group interventions that were shown to be highly effective in cluster randomized trials in India, Nepal, Bangladesh and Malawi. We estimated intervention effects on NMR and health behaviours for lower and higher socioeconomic strata using random effects logistic regression analysis. Differences in effect between strata were tested.Analysis of 69120 live births and 2505 neonatal deaths shows that the intervention strongly reduced the NMR in lower (50-63% reduction depending on the measure of socioeconomic position used) and higher (35-44%) socioeconomic strata. The intervention did not show evidence of 'elite-capture': among the most marginalized populations, the NMR in intervention areas was 63% lower [95% confidence interval (CI) 48-74%] than in control areas, compared with 35% (95% CI: 15-50%) lower among the less marginalized in the last trial year (P-value for difference between most/less marginalized: 0.009). The intervention strongly improved home care practices, with no systematic socioeconomic differences in effect.Participatory women's groups with high population coverage benefit the survival chances of newborns from all socioeconomic strata, and perhaps especially those born into the most deprived households.

BACKGROUND: Maternal common mental disorders are prevalent in low-resource settings and have far-reaching consequences for maternal and child health. We assessed the prevalence and predictors of psychological distress as a proxy for common mental disorders among mothers in rural Jharkhand and Orissa, eastern India, where over 40% of the population live below the poverty line and access to reproductive and mental health services is low. METHOD: We screened 5801 mothers around 6 weeks after delivery using the Kessler-10 item scale, and identified predictors of distress using multiple hierarchical logistic regression. RESULTS: 11.5% (95% CI: 10.7-12.3) of mothers had symptoms of distress (K10 score >15). High maternal age, low asset ownership, health problems in the antepartum, delivery or postpartum periods, caesarean section, an unwanted pregnancy for the mother, small perceived infant size and a stillbirth or neonatal death were all independently associated with an increased risk of distress. The loss of an infant or an unwanted pregnancy increased the risk of distress considerably (AORs: 7.06 95% CI: 5.51-9.04 and 1.49, 95% CI: 1.12-1.97, respectively). LIMITATIONS: We did not collect data on antepartum depression, domestic violence or a mother's past birth history, and were therefore unable to examine the importance of these factors as predictors of psychological distress. CONCLUSIONS: Mothers living in underserved areas of India who experience infant loss, an unwanted pregnancy, health problems in the perinatal and postpartum periods and socio-economic disadvantage are at increased risk of distress and require access to reproductive healthcare with integrated mental health interventions.

The World Health Organisation has called for global action to reduce child stunting by 40% by 2025. One third of the world's stunted children live in India, and children belonging to rural indigenous communities are the worst affected. We sought to identify the strongest determinants of stunting among indigenous children in rural Jharkhand and Odisha, India, to highlight key areas for intervention. We analysed data from 1227 children aged 6–23.99 months and their mothers, collected in 2010 from 18 clusters of villages with a high proportion of people from indigenous groups in three districts. We measured height and weight of mothers and children, and captured data on various basic, underlying and immediate determinants of undernutrition. We used Generalised Estimating Equations to identify individual determinants associated with children's height‐for‐age z‐score (HAZ; p

Background Maternity care in South Asia is available in both public and private sectors. Using data from demographic surveillance sites in Bangladesh, Nepal and rural and urban India, we aimed to compare institutional delivery rates and public-private share. Methods We used records of maternity care collected in socio-economically disadvantaged communities between 2005 and 2011. Institutional delivery was summarized by four potential determinants: household asset index, maternal schooling, maternal age, and parity. We developed logistic regression models for private sector institutional delivery with these as independent covariates. Results The data described 52 750 deliveries. Institutional delivery proportion varied and there were differences in public-private split. In Bangladesh and urban India, the proportion of deliveries in the private sector increased with wealth, maternal education, and age. The opposite was observed in rural India and Nepal. Conclusions The proportion of institutional delivery increased with economic status and education. The choice of sector is more complex and provision and perceived quality of public sector services is likely to play a role. Choices for safe maternity are influenced by accessibility, quantity and perceived quality of care. Along with data linkage between private and public sectors, increased regulation should be part of the development of the pluralistic healthcare systems that characterize south Asia. Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-1069-7) contains supplementary material, which is available to authorized users.

A quarter of the world's neonatal deaths and 15% of maternal deaths happen in India. Few community-based strategies to improve maternal and newborn health have been tested through the country's government-approved Accredited Social Health Activists (ASHAs). We aimed to test the effect of participatory women's groups facilitated by ASHAs on birth outcomes, including neonatal mortality.In this cluster-randomised controlled trial of a community intervention to improve maternal and newborn health, we randomly assigned (1:1) geographical clusters in rural Jharkhand and Odisha, eastern India to intervention (participatory women's groups) or control (no women's groups). Study participants were women of reproductive age (15-49 years) who gave birth between Sept 1, 2009, and Dec 31, 2012. In the intervention group, ASHAs supported women's groups through a participatory learning and action meeting cycle. Groups discussed and prioritised maternal and newborn health problems, identified strategies to address them, implemented the strategies, and assessed their progress. We identified births, stillbirths, and neonatal deaths, and interviewed mothers 6 weeks after delivery. The primary outcome was neonatal mortality over a 2 year follow up. Analyses were by intention to treat. This trial is registered with ISRCTN, number ISRCTN31567106.Between September, 2009, and December, 2012, we randomly assigned 30 clusters (estimated population 156 519) to intervention (15 clusters, estimated population n=82 702) or control (15 clusters, n=73 817). During the follow-up period (Jan 1, 2011, to Dec 31, 2012), we identified 3700 births in the intervention group and 3519 in the control group. One intervention cluster was lost to follow up. The neonatal mortality rate during this period was 30 per 1000 livebirths in the intervention group and 44 per 1000 livebirths in the control group (odds ratio [OR] 0.69, 95% CI 0·53-0·89).ASHAs can successfully reduce neonatal mortality through participatory meetings with women's groups. This is a scalable community-based approach to improving neonatal survival in rural, underserved areas of India.Big Lottery Fund (UK).

Background Child stunting (low height-for-age) is a marker of chronic undernutrition and predicts children’s subsequent physical and cognitive development. Around one third of the world’s stunted children live in India. Our study aims to assess the impact, cost-effectiveness, and scalability of a community intervention with a government-proposed community-based worker to improve growth in children under two in rural India. Methods The study is a cluster randomised controlled trial in two rural districts of Jharkhand and Odisha (eastern India). The intervention tested involves a community-based worker carrying out two activities: (a) one home visit to all pregnant women in the third trimester, followed by subsequent monthly home visits to all infants aged 0–24 months to support appropriate feeding, infection control, and care-giving; (b) a monthly women’s group meeting using participatory learning and action to catalyse individual and community action for maternal and child health and nutrition. Both intervention and control clusters also receive an intervention to strengthen Village Health Sanitation and Nutrition Committees. The unit of randomisation is a purposively selected cluster of approximately 1000 population. A total of 120 geographical clusters covering an estimated population of 121,531 were randomised to two trial arms: 60 clusters in the intervention arm receive home visits, group meetings, and support to Village Health Sanitation and Nutrition Committees; 60 clusters in the control arm receive support to Committees only. The study participants are pregnant women identified in the third trimester of pregnancy and their children (n = 2520). Mothers and their children are followed up at seven time points: during pregnancy, within 72 hours of delivery, and at 3, 6, 9, 12 and 18 months after birth. The trial’s primary outcome is children’s mean length-for-age Z scores at 18 months. Secondary outcomes include wasting and underweight at all time points, birth weight, growth velocity, feeding, infection control, and care-giving practices. Additional qualitative and quantitative data are collected for process and economic evaluations. Discussion This trial will contribute to evidence on effective strategies to improve children's growth in India. Trial registration ISRCTN register 51505201; Clinical Trials Registry of India number 2014/06/004664. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1655-z) contains supplementary material, which is available to authorized users.

To determine whether a women's group intervention involving participatory learning and action has a sustainable and replicable effect on neonatal survival in rural, eastern India.From 2004 to 2011, births and neonatal deaths in 36 geographical clusters in Jharkhand and Odisha were monitored. Between 2005 and 2008, these clusters were part of a randomized controlled trial of how women's group meetings involving participatory learning and action influence maternal and neonatal health. Between 2008 and 2011, groups in the original intervention clusters (zone 1) continued to meet to discuss post-neonatal issues and new groups in the original control clusters (zone 2) met to discuss neonatal health. Logistic regression was used to examine neonatal mortality rates after 2008 in the two zones.Data on 41,191 births were analysed. In zone 1, the intervention's effect was sustained: the cluster-mean neonatal mortality rate was 34.2 per 1000 live births (95% confidence interval, CI: 28.3-40.0) between 2008 and 2011, compared with 41.3 per 1000 live births (95% CI: 35.4-47.1) between 2005 and 2008. The effect of the intervention was replicated in zone 2: the cluster-mean neonatal mortality rate decreased from 61.8 to 40.5 per 1000 live births between two periods: 2006-2008 and 2009-2011 (odds ratio: 0.69, 95% CI: 0.57-0.83). Hygiene during delivery, thermal care of the neonate and exclusive breastfeeding were important factors.The effect of participatory women's groups on neonatal survival in rural India, where neonatal mortality is high, was sustainable and replicable.Déterminer si un groupe féminin menant des activités d’apprentissage et des actions participatives a un effet durable et reproductible sur la survie néonatale dans l’Inde de l’Est rurale.De 2004 à 2011, les naissances et la mortalité néonatale ont été suivies dans 36 zones géographiques des États du Jharkhand et de l'Odisha. Entre 2005 et 2008, ces zones ont été intégrées dans un essai contrôlé randomisé portant sur l’influence sur la santé maternelle et néonatale des réunions de groupes féminins menant des activités d’apprentissage et des actions participatives. Entre 2008 et 2011, les groupes provenant des zones d’intervention d’origine (zone 1) se réunissaient toujours pour débattre des questions post-néonatales, et les nouveaux groupes provenant des zones de contrôle d’origine (zone 2) se sont réunis pour aborder le sujet de la santé néonatale. On a eu recours à la régression logistique pour analyser les taux de mortalité néonatale après 2008 dans ces deux zones.Les données de 41 191 naissances ont été analysées. Dans la zone 1, l’effet de l’intervention s’est révélé durable: le taux de mortalité néonatale moyen de la région a été de 34,2 pour 1 000 naissances vivantes (intervalle de confiance de 95%, IC: 28,3–40) entre 2008 et 2011, par rapport à 41,3 pour 1 000 naissances vivantes (IC de 95%: 35,4–47,1) entre 2005 et 2008. L’effet de l’intervention s’est reproduit dans la zone 2: le taux de mortalité néonatale moyen de la zone a baissé de 61,8 à 40,5 pour 1 000 naissances vivantes entre les deux périodes: 2006–2008 et 2009–2011 (rapport des cotes, RC: 0,69, IC de 95%: 0,57–0,83). L’hygiène pendant l’accouchement, le maintien de la température corporelle du nouveau-né et l’allaitement maternel exclusif ont été des facteurs importants.L’effet des groupes féminins participatifs sur la survie néonatale dans l’Inde rurale, où la mortalité néonatale est élevée, s’est révélé durable et reproductible.Determinar si las intervenciones con aprendizaje y acción participativos con grupos de mujeres tienen un efecto sostenible y reproducible en la supervivencia neonatal en las zonas rurales del este de India.Desde 2004 hasta 2011 se controlaron los nacimientos y muertes neonatales en 36 agrupaciones geográficas en Jharkhand y Odisha. Entre 2005 y 2008, esas agrupaciones formaron parte de un ensayo controlado aleatorio para averiguar cómo las reuniones de grupos de mujeres que incluyen un aprendizaje y acción participativos influyen en la salud materna y neonatal. Entre 2008 y 2011, los grupos en las agrupaciones originales de intervención (zona 1) siguieron reuniéndose para debatir sobre cuestiones posneonatales y otros grupos nuevos en las agrupaciones originales de control (zona 2) se reunieron para debatir sobre la salud neonatal. Se empleó una regresión logística para examinar las tasas de mortalidad neonatal en ambas zonas tras del año 2008.Se analizaron los datos de 41 191 nacimientos. En la zona 1, el efecto de la intervención fue prolongado: la tasa de mortalidad neonatal media en la agrupación fue de 34,2 por cada 1000 nacidos vivos (intervalo de confianza del 95%, IC: 28,3–40,0) entre 2008 y 2011, comparada con el 41,3 por cada 1000 nacidos vivos (IC del 95%: 35,4–47,1) entre los años 2005 y 2008. El efecto de la intervención se repitió en la zona 2: la tasa de mortalidad neonatal media descendió del 61,8 hasta el 40,5 por cada 1000 nacidos vivos entre dos periodos: 2006–2008 y 2009–2011 (cociente de probabilidades: 0,69, IC del 95%: 0,57–0,83). Algunos factores importantes fueron la higiene durante el parto, la atención térmica de los neonatos y la lactancia materna exclusiva.El efecto de los grupos participativos de mujeres sobre la supervivencia neonatal en las zonas rurales de India, donde la mortalidad neonatal es elevada, resultó sostenible y reproducible.تحديد ما إذا كان لتدخل جماعات المرأة الذي يتضمن التعلم والعمل على نحو تشاركي تأثير مستدام قابل للمماثلة على بقاء المواليد على قيد الحياة في المناطق الريفية شرق الهند.في الفترة من 2004 إلى 2011، تم رصد المواليد ووفيات المواليد في 36 مجموعة جغرافية في جاركند وأوديشا. وفي الفترة بين 2005 و2008، كانت هذه المجموعات جزءاً من تجربة عشوائية أجريت في بيئة خاضعة للمراقبة حول مدى تأثير اجتماعات جماعات المرأة التي تتضمن التعلم والعمل على تشاركي على صحة الأمومة والمواليد. وفي الفترة من 2008 إلى 2011، واصلت الجماعات في مجموعات التدخل الأصلية (المنطقة 1) اجتماعاتها لمناقشة القضايا المتعلقة بمرحلة ما بعد المواليد والتقت الجماعات الجديدة في مجموعات المراقبة الأصلية (المنطقة 2) لمناقشة صحة المواليد. وتم استخدام الارتداد اللوجيستي لدراسة معدلات وفيات المواليد بعد عام 2008 في المنطقتين.تم تحليل البيانات المعنية بالمواليد البالغ عددهم 41191 مولوداً. وفي المنطقة 1، تم الحفاظ على تأثير التدخل: بلغ معدل وفيات المواليد لمتوسط المجموعة 34.2 لكل 1000 مولود حي (فاصل الثقة 95 %، فاصل الثقة: من 28.3 إلى 40.0) في الفترة من 2008 إلى 2011، مقارنة بنسبة 41.3 لكل 1000 مولود حي (فاصل الثقة 95 %، فاصل الثقة: من 35.4 إلى 47.1) في الفترة من 2005 إلى 2008. وتم نسخ تأثير التدخل في المنطقة 2: وانخفض معدل وفيات المواليد لمتوسط المجموعة من 61.8 إلى 40.5 لكل 1000 مولود حي بين الفترتين: 2006-2008 و2009-2011 (نسبة الاحتمال: 0.69، فاصل الثقة 95 %، فاصل الثقة: من 0.57 إلى 0.83). وكان التصحيح أثناء الولادة والرعاية الحرارية للمواليد والرضاعة الطبيعية الخالصة عوامل مهمة.كان تأثير جماعات المرأة التشاركية على بقاء المواليد على قيد الحياة في المناطق الهندية الريفية، التي يرتفع بها معدل وفيات المواليد، مستداماً وقابلاً للمماثلة.确定涉及参与式学习和行动的妇女团体干预是否对印度东部的新生儿生存率有可持续和可重复的影响。从2004 年到2011 年，对贾坎德邦和奥里萨邦的36 个地理集群的分娩和新生儿死亡进行监测。在2005 年至2008 年之间，这些集群是随机对照试验的组成部分，这些试验研究涉及参与式学习和行动的妇女团体集会如何影响孕产妇和新生儿健康。在2008 年至2011 年间，原始干预集群的团体（区域1）继续集会，以讨论新生儿后期的问题；原始对照集群的新团体（区域2）集会，以讨论新生儿保健问题。使用逻辑回归查看在2008 年之后两个区域中新生儿的死亡率。分析了41191 例出生的数据。在区域1，干预效果保持：集群平均新生儿死亡率在2008 年至2011 年是每千活产34.2 例（95% 置信区间，CI：28.3–40.0），与之相比的是2005 至2008 年每千活产41.3 例（95% CI：35.4–47.1）。干预效果在区域2 得到重复：在两个期间，2006-2008 和2009-2011 年，集群平均新生儿死亡率从每千活产61.8 例降低至40.5 例（优势比：0.69，95% CI：0.57–0.83）。分娩时的卫生保健、新生儿体温护理和纯母乳喂养是重要因素。在新生儿死亡率高的印度农村地区，与新生儿生存相关的参与性妇女团体的效果是可持续和可重复的。Установить, оказывают ли мероприятия по проведению коллективного обучения и занятий в женской группе продолжительное и воспроизводимое влияние на неонатальную выживаемость в сельских районах восточной Индии.В 2004-2011 гг. проводился мониторинг рождаемости и неонатальной смертности в 36 географических кластерах в штатах Джаркханд и Орисса. В период с 2005 по 2008 гг. данные кластеры участвовали в рандомизированном контролируемом исследовании влияния собраний женских групп, включающих коллективное обучение и занятия, на охрану здоровья матери и ребенка. В период с 2008 по 2011 гг. группы в исходных кластерах проведения мероприятий (зона 1) продолжали проведение встреч для обсуждения постнеонатальных вопросов, а в новых группах исходных контрольных кластеров (зона 2) на встречах обсуждались вопросы неонатального здоровья. В обеих зонах использовалась логистическая регрессия для изучения уровней неонатальной смертности после 2008 года.Проведен анализ данных по 41 191 родам. В зоне 1 влияние проводимых мероприятий было продолжительным: средний уровень неонатальной смертности в кластере составил 34,2 на 1000 живорождений (95% доверительный интервал, ДИ: 28,3–40,0) в период с 2008 по 2011 гг., по сравнению с 41,3 на 1000 живорождений (95% ДИ: 35,4–47,1) в период с 2005 по 2008 гг. Аналогичное влияние проводимых мероприятий отмечено в зоне 2: средний уровень неонатальной смертности в кластере снизился с 61,8 до 40,5 на 1000 живорождений в обоих периодах: 2006-2008 гг. и 2009-2011 гг. (относительный риск: 0,69, 95% ДИ: 0,57-0,83). Важными факторами являлись соблюдение гигиены во время родоразрешения, тепловая защита новорожденных и исключительно грудное вскармливание.Влияние коллективных женских групп на неонатальную выживаемость в сельских районах Индии с высоким уровнем смертности являлось продолжительным и воспроизводимым.

Progress towards the Millennium Development Goals (MDGs) has been uneven. Inequalities in child health are large and effective interventions rarely reach the most in need. Little is known about how to reduce these inequalities. We describe and explain the equity impact of a women's group intervention in India that strongly reduced the neonatal mortality rate (NMR) in a cluster-randomised trial. We conducted secondary analyses of the trial data, obtained through prospective surveillance of a population of 228,186. The intervention effects were estimated separately, through random effects logistic regression, for the most and less socio-economically marginalised groups. Among the most marginalised, the NMR was 59% lower in intervention than in control clusters in years 2 and 3 (70%, year 3); among the less marginalised, the NMR was 36% lower (35%, year 3). The intervention effect was stronger among the most than among the less marginalised (P-value for difference = 0.028, years 2-3; P-value for difference = 0.009, year 3). The stronger effect was concentrated in winter, particularly for early NMR. There was no effect on the use of health-care services in either group, and improvements in home care were comparable. Participatory community interventions can substantially reduce socio-economic inequalities in neonatal mortality and contribute to an equitable achievement of the unfinished MDG agenda.

Background Around a quarter of the world's neonatal and maternal deaths occur in India. Morbidity and mortality are highest in rural areas and among the poorest wealth quintiles. Few interventions to improve maternal and newborn health outcomes with government-mandated community health workers have been rigorously evaluated at scale in this setting. The study aims to assess the impact of a community mobilisation intervention with women's groups facilitated by ASHAs to improve maternal and newborn health outcomes among rural tribal communities of Jharkhand and Orissa. Methods/design The study is a cluster-randomised controlled trial and will be implemented in five districts, three in Jharkhand and two in Orissa. The unit of randomisation is a rural cluster of approximately 5000 population. We identified villages within rural, tribal areas of five districts, approached them for participation in the study and enrolled them into 30 clusters, with approximately 10 ASHAs per cluster. Within each district, 6 clusters were randomly allocated to receive the community intervention or to the control group, resulting in 15 intervention and 15 control clusters. Randomisation was carried out in the presence of local stakeholders who selected the cluster numbers and allocated them to intervention or control using a pre-generated random number sequence. The intervention is a participatory learning and action cycle where ASHAs support community women's groups through a four-phase process in which they identify and prioritise local maternal and newborn health problems, implement strategies to address these and evaluate the result. The cycle is designed to fit with the ASHAs' mandate to mobilise communities for health and to complement their other tasks, including increasing institutional delivery rates and providing home visits to mothers and newborns. The trial's primary endpoint is neonatal mortality during 24 months of intervention. Additional endpoints include home care practices and health care-seeking in the antenatal, delivery and postnatal period. The impact of the intervention will be measured through a prospective surveillance system implemented by the project team, through which mothers will be interviewed around six weeks after delivery. Cost data and qualitative data are collected for cost-effectiveness and process evaluations. Study registration ISRCTN: ISRCTN31567106

Background In India, Village Health Sanitation and Nutrition Committees (VHSNCs) are participatory community health forums, but there is little information about their composition, functioning and effectiveness. Our study examined VHSNCs as enablers of participatory action for community health in two rural districts in two states of eastern India – West Singhbhum in Jharkhand and Kendujhar, in Odisha. Methods We conducted a cross-sectional survey of 169 VHSNCs and ten qualitative focus group discussions with purposively selected better and poorer performing committees, across the two states. We analysed the quantitative data using descriptive statistics and the qualitative data using a Framework approach. Results We found that VHSNCs comprised equitable representation from vulnerable groups when they were formed. More than 75 % members were women. Almost all members belonged to socially disadvantaged classes. Less than 1 % members had received any training. Supervision of committees by district or block officials was rare. Their work focused largely on strengthening village sanitation, conducting health awareness activities, and supporting medical treatment for ill or malnourished children and pregnant mothers. In reality, 62 % committees monitored community health workers, 6.5 % checked sub-centres and 2.4 % monitored drug availability with community health workers. Virtually none monitored data on malnutrition. Community health and nutrition workers acted as conveners and record keepers. Links with the community involved awareness generation and community monitoring of VHSNC activities. Key challenges included irregular meetings, members’ limited understanding of their roles and responsibilities, restrictions on planning and fund utilisation, and weak linkages with the broader health system. Conclusions Our study suggests that VHSNCs perform few of their specified functions for decentralized planning and action. If VHSNCs are to be instrumental in improving community health, sanitation and nutrition, they need education, mobilisation and monitoring for formal links with the wider health system.