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The COVID-19 pandemic provided lessons for health policies across the globe. We assessed the knowledge, attitudes and practices of vulnerable populations in an informal settlement in Mumbai, India, during the pandemic. We discuss the viability and effectiveness of communication strategies based on these results and offer suggestions for policy modifications regarding awareness generation and behavioral change during health emergencies. The study was conducted through a telephone survey among 460 respondents (233 men and 226 women) from April to May 2021. Television (94%) and family (70%) were the most common sources of information, but they were not the most trusted. Most respondents were aware of the causes and preventive measures of COVID-19, including vaccination. However, this awareness did not always result in changes in attitudes and behavior- 66% perceived low or no risk to COVID-19, while 93% did not consider it essential to wear masks in workspaces and 78% did not sanitize their hands before entering workspaces. More respondents were concerned about loss of employment (53%) than about their physical (10%) or mental (4%) health. The study highlights the need for context-specific communication strategies for vulnerable populations. This includes providing reliable and accessible sources of information, emphasizing accuracy and detail, and adopting a holistic and multidimensional approach to awareness and information sharing. [ABSTRACT FROM AUTHOR]

Introduction 'I am because we are and because we are I am. A person is not a separated and isolated individual but a community of related individuals. Despite all this, [...], Public health interventions usually operate at the level of groups rather than individuals, and cluster randomized controlled trials (RCTs) are one means of evaluating their effectiveness. Using examples from six such trials in Bangladesh, India, Malawi and Nepal, we discuss our experience of the ethical issues that arise in their conduct. We set cluster RCTs in the broader context of public health research, highlighting debates about the need to reconcile individual autonomy with the common good and about the ethics of public health research in low-income settings in general. After a brief introduction to cluster RCTs, we discuss particular challenges we have faced. These include the nature of--and responsibility for--group consent, and the need for consent by individuals within groups to intervention and data collection. We discuss the timing of consent in relation to the implementation of public health strategies, and the problem of securing ethical review and approval in a complex domain. Finally, we consider the debate about benefits to control groups and the standard of care that they should receive, and the issue of post-trial adoption of the intervention under test. Les interventions de sante publique s'operent habituellement au niveau des groupes plutot qu'a celui des individus et les essais controles randomises (RCT) en grappes constituent un moyen d'evaluer leur efficacite. En utilisant celui exemples six de ces essais menes au Bangladesh, en Inde, au Malawi et au Nepal, nous evoquons notre experience des problemes ethiques intervenant dans la realisation de ces essais. Nous replacons les RCT en grappes dans le contexte plus large de la recherche en sante publique, en mettant en avant les debats sur la necessite de concilier autonomie individuelle et bien commun et sur les aspects ethiques de la recherche en sante publique dans les pays a faible revenu en general. Apres avoir brievement introduit les RCT en grappes, nous avons evoque les difficultes particulieres que nous avons rencontrees. Ces difficultes portaient notamment sur la nature--et sur la responsabilite--du consentement collectif et sur la necessite que les individus au sein des groupes consentent egalement a l'intervention et au recueil des donnees. Nous avons examine le moment ou devait intervenir le consentement dans la mise en oeuvre des strategies de sante publique et les difficultes pour garantir un examen et une approbation ethiques dans un domaine complexe. Enfin, nous avons debattu des benefices pour les groupes temoins et de la norme de soins a leur appliquer, ansi que du probleme de l'adoption de l'intervention testee apres l'essai. Las intervenciones de salud publica inciden por lo general en grupos mas que en individuos, y los ensayos controlados aleatorizados (ECA) por conglomerados son un instrumento para evaluar su eficacia. A partir de ejemplos de seis ensayos de ese tipo Ilevados a cabo en Bangladesh, la India, Malawi y Nepal, analizamos nuestra experiencia en cuanto a los dilemas eticos que plantea la realizacion de esos ensayos. Situamos los ECA por conglomerados en el contexto general de las investigaciones de salud publica, resaltando los debates sobre la necesidad de compaginar la autonomia individual y el bien comun, y sobre la etica de las investigaciones de salud publica en los entornos de ingresos bajos en general. Tras una breve introduccion a los ECA por conglomerados, examinamos los problemas particulares que hemos encontrado, entre los que cabe citar la naturaleza del consentimiento colectivo -y la responsabilidad de obtenerlo- y la necesidad de consentimiento de los individuos, dentro de los grupos, respecto a la realizacion de la intervencion y la recogida de datos. Analizamos el momento del consentimiento en relacion con la aplicacion de las estrategias de salud publica, asi como los problemas que surgen para garantizar el examen etico y la aprobacion en un dominio complejo. Por ultimo, se considera el debate sobre los beneficios para los grupos de control y el nivel de atencion que deberian recibir, asi como el tema de la adopcion de la intervencion sometida a ensayo una vez concluido este.

This article describes the critical first steps taken to revitalize the vast public health system of Mumbai City through the active participation of personnel from within the system. It focuses [...]

Context: The National Nutrition Mission (POSHAN Abhiyaan) intends to "converge" nutrition-related program components across sectors (nutrition, health, water, and sanitation). In this study, we have examined the perspectives of Anganwadi workers (AWWs), the frontline workers of the Integrated Child Development Services, on working in convergence with the public health sector. Methods: This exploratory qualitative study was done between June 2018 and June 2019 in two urban informal settlements in Mumbai. We conducted in-depth interviews with 26 AWWs and their supervisors, purposively sampled and diversified in terms of age, education, and years of experience. We used the software NVivo version 12 to aid analysis. Results: Most AWWs acknowledged that a convergent framework of action between "nutrition" and "health" was likely to be beneficial to the community. However, they also shared that cross-sector convergence was currently limited due to technical unfamiliarity with "health-sector" issues in the frontline, discomfort with data sharing, and lack of meaningful incentives for joint work. Broader organizational challenges such as poor infrastructure and lack of supervision, as well as challenges in the urban context (migration and cultural barriers) further hindered joint activities. Conclusions: The findings indicate that critical structural gaps in the urban setup of ICDS need to be addressed and AWWs need to be better familiarized with the changing roles expected from them under POSHAN Abhiyaan. To work better with the health sector, the work timings of AWWs need to be aligned with those of the health sector and meaningful financial incentives need to be put in place for cross-sector activities. [ABSTRACT FROM AUTHOR]

Abstract Background Chronic childhood malnutrition remains common in India. As part of an initiative to improve maternal and child health in urban slums, we collected anthropometric data from a sample of children followed up from birth. We described the proportions of underweight, stunting, and wasting in young children, and examined their relationships with age. Methods We used two linked datasets: one based on institutional birth weight records for 17 318 infants, collected prospectively, and one based on follow-up of a subsample of 1941 children under five, collected in early 2010. Results Mean birth weight was 2736 g (SD 530 g), with a low birth weight ( Discussion Our data support the idea that much of growth faltering was explained by faltering in height for age, rather than by wasting. Stunting appeared to be established early and the subsequent decline in height for age was limited. Our findings suggest a focus on a younger age-group than the children over the age of three who are prioritized by existing support systems. Funding The trial during which the birth weight data were collected was funded by the ICICI Foundation for Inclusive Growth (Centre for Child Health and Nutrition), and The Wellcome Trust (081052/Z/06/Z). Subsequent collection, analysis and development of the manuscript was funded by a Wellcome Trust Strategic Award: Population Science of Maternal and Child Survival (085417ma/Z/08/Z). D Osrin is funded by The Wellcome Trust (091561/Z/10/Z).

Abstract Background Aggregate urban health statistics mask inequalities. We described maternity care in vulnerable slum communities in Mumbai, and examined differences in care and outcomes between more and less deprived groups. Methods We collected information through a birth surveillance system covering a population of over 280 000 in 48 vulnerable slum localities. Resident women identified births in their own localities and mothers and families were interviewed at 6 weeks after delivery. We analysed data on 5687 births over one year to September 2006. Socioeconomic status was classified using quartiles of standardized asset scores. Results Women in higher socioeconomic quartile groups were less likely to have married and conceived in their teens (Odds ratio 0.74, 95% confidence interval 0.69–0.79, and 0.82, 0.78–0.87, respectively). There was a socioeconomic gradient away from public sector maternity care with increasing socioeconomic status (0.75, 0.70–0.79 for antenatal care and 0.66, 0.61–0.71 for institutional delivery). Women in the least poor group were five times less likely to deliver at home (0.17, 0.10–0.27) as women in the poorest group and about four times less likely to deliver in the public sector (0.27, 0.21–0.35). Rising socioeconomic status was associated with a lower prevalence of low birth weight (0.91, 0.85–0.97). Stillbirth rates did not vary, but neonatal mortality rates fell non-significantly as socioeconomic status increased (0.88, 0.71–1.08). Conclusion Analyses of this type have usually been applied across the population spectrum from richest to poorest, and we were struck by the regularly stepped picture of inequalities within the urban poor, a group that might inadvertently be considered relatively homogeneous. The poorest slum residents are more dependent upon public sector health care, but the regular progression towards the private sector raises questions about its quality and regulation. It also underlines the need for healthcare provision strategies to take account of both sectors.

Abstract Background The United Nations Millennium Development Goals look to substantial improvements in child and maternal survival. Morbidity and mortality during pregnancy, delivery and the postnatal period are prime obstacles to achieving these goals. Given the increasing importance of urban health to global prospects, Mumbai's City Initiative for Newborn Health aims to improve maternal and neonatal health in vulnerable urban slum communities, through a combination of health service quality improvement and community participation. The protocol describes a trial of community intervention aimed at improving prevention, care seeking and outcomes. Objective To test an intervention that supports local women as facilitators in mobilising communities for better health care. Community women's groups will build an understanding of their potential to improve maternal and infant health, and develop and implement strategies to do so. Design Cluster-randomized controlled trial. Methods The intervention will employ local community-based female facilitators to convene groups and help them to explore maternal and neonatal health issues. Groups will meet fortnightly through a seven-phase process of sharing experiences, discussion of the issues raised, discovery of potential community strengths, building of a vision for action, design and implementation of community strategies, and evaluation. The unit of allocation will be an urban slum cluster of 1000–1500 households. 48 clusters have been randomly selected after stratification by ward. 24 clusters have been randomly allocated to receive the community intervention. 24 clusters will act as control groups, but will benefit from health service quality improvement. Indicators of effect will be measured through a surveillance system implemented by the project. Key distal outcome indicators will be neonatal mortality and maternal and neonatal morbidity. Key proximate outcome indicators will be home care practices, uptake of antenatal, delivery and postnatal care, and care for maternal and neonatal illness. Data will be collected through a vital registration system for births and deaths in the 48 study clusters. Structured interviews with families will be conducted at about 6 weeks after index deliveries. We will also collect both quantitative and qualitative data to support a process evaluation. Trial registration Current controlled trials ISRCTN96256793

Introduction The current consensus on improving maternal and newborn survival [1-3], particularly in low-income countries, is that perinatal care needs to involve both health service strengthening and community activities [4-6]. [...], Introduction: Improving maternal and newborn health in low-income settings requires both health service and community action. Previous community initiatives have been predominantly rural, but India is urbanizing. While working to improve health service quality, we tested an intervention in which urban slum-dweller women's groups worked to improve local perinatal health. Methods and Findings: A cluster randomized controlled trial in 24 intervention and 24 control settlements covered a population of 283,000. In each intervention cluster, a facilitator supported women's groups through an action learning cycle in which they discussed perinatal experiences, improved their knowledge, and took local action. We monitored births, stillbirths, and neonatal deaths, and interviewed mothers at 6 weeks postpartum. The primary outcomes described perinatal care, maternal morbidity, and extended perinatal mortality. The analysis included 18,197 births over 3 years from 2006 to 2009. We found no differences between trial arms in uptake of antenatal care, reported work, rest, and diet in later pregnancy, institutional delivery, early and exclusive breastfeeding, or care-seeking. The stillbirth rate was non- significantly lower in the intervention arm (odds ratio 0.86, 95% CI 0.60-1.22), and the neonatal mortality rate higher (1.48, 1.06- 2.08). The extended perinatal mortality rate did not differ between arms (1.19, 0.90-1.57). We have no evidence that these differences could be explained by the intervention. Conclusions: Facilitating urban community groups was feasible, and there was evidence of behaviour change, but we did not see population-level effects on health care or mortality. In cities with multiple sources of health care, but inequitable access to services, community mobilization should be integrated with attempts to deliver services for the poorest and most vulnerable, and with initiatives to improve quality of care in both public and private sectors. Trial registration: Current Controlled Trials ISRCTN96256793 Please see later in the article for the Editors' Summary.

Urbanization is rapidly spreading throughout the developing world. An urban slum poses special health problems due to poverty, overcrowding, unhygienic surroundings and lack of an organized health Infrastructure. The primary causes of neonatal mortality are sepsis, perinatal asphyxia and prematurity. Home deliveries, late recognition of neonatal illness, delay in seeking medical help and inappropriate treatment contribute to neonatal mortality. Measures to reduce neonatal mortality in urban slums should focus on health education, improvement of antenatal practices, institutional deliveries, and ensuring quality perinatal care. Success of a comprehensive health strategy would require planned health infrastructure, strengthening and unification of existing health care program and facilities; forming a system of referral and developing a program with active participation of the community.