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Background with objectives Community acquired pneumonia (CAP) is the leading cause of childhood deaths globally. Poor recognition of the danger signs of CAP, inappropriate care seeking, and community distrust in the primary health system are factors largely responsible for CAP related deaths in rural India. Our objective was to develop and pilot test culturally sensitive communication messages for improving symptom recognition of CAP as a means of encouraging timely health care seeking, and to promote trust in the government primary health system as an effective source of CAP treatment among children. Methods and materials Qualitative research was carried out between February and July 2014 in the states of Uttar Pradesh (U.P.) and Bihar in northern India. Message development entailed a six-step process: (1) theme identification, (2) creative conceptualization of messages, (3) pretesting messages in focus groups (FGs), (4) modification of messages, tagline/logo based on feedback, (5) piloting modified messages in FGs and further refinement and (6) harmonization of final communication products to ensure consistency. Results Messages were piloted in 49 FGs in 7 rural districts. Hindi terms for the signs of respiratory illness and lay use of "pneumonia" as a term encompassing CAP were understandable across all dialects. Five text, five audio and four video based messages were initially developed and pretested. Three text based messages, four audio and three video were deemed acceptable for pilot testing and refinement. Messages selected for use in future communication programs balanced measures of popularity with measures of maximum comprehension and least misunderstanding. Messages selected were harmonized so they would reinforce one another. Common logo and tagline ensured that the messages would be seen as components of a new outreach program associated with the government's efforts to address CAP as a primary healthcare priority. Conclusions Culturally sensitive messages for improving case management of CAP were developed through a multi-stage, evidence-based research process in a rural population. They need to accompany health systems strengthening efforts to increase confidence in government health facilities.

Background Exclusive breastfeeding has been shown to be protective against infants' illnesses. Evidence is sparse about the association of different breastfeeding patterns on neonatal illnesses. Methods The study was conducted at two urban public hospitals at Lucknow. Neonates who did not have any morbidity or congenital malformation and were residents of Lucknow were enrolled within 48h of birth and followed up once at 6 weeks of age, at the outpatients clinic or home to assess neonatal illnesses and established (voluntary) breastfeeding pattern (exclusive, predominant, partial, never breastfed). Association of established breastfeeding patterns with neonatal illnesses was studied using multivariate logistic regression, adjusting for potential confounders. Results A total of 1020 neonates were enrolled. Follow-up information on occurrence of neonatal illnesses (if any) as well as established breastfeeding pattern was available for 937 (91.8%) enrolled neonates. Among these, 46% (431/937) presented with any illness, with 20.2% (189/937) reported with at least one danger sign of severe illnesses as mentioned in Integrated Management of Neonatal and Childhood Illnesses (IMNCI). Partially breastfed neonates were significantly more likely to develop any illness (Adj. OR=6.6; 95% CI: 4.0–10.8, p Conclusions Exclusive breastfeeding during the neonatal period was significantly protective against the occurrence of any illness as well as illnesses mentioned in the IMNCI program, as compared to predominant or partial breastfeeding.

Objectives To describe evidence-based WHO-defined (exclusive, predominant, partial, never breastfed) breastfeeding patterns and the factors associated with them for neonates among urban poor in Lucknow, northern India. Methods This prospective follow-up study was conducted at two urban public hospitals at Lucknow. Neonates who did not have any morbidity or congenital malformation and were residents of Lucknow were enrolled within 48 h of birth and followed-up once at six weeks at the outpatients' clinic or home to assess established (voluntary) breastfeeding pattern. Results A total of 1020 neonates were enrolled from March 2007 to April 2008. Follow-up information on established breastfeeding pattern was available for 937 (91.8%) of the enrolled neonates. Rate of exclusive breastfeeding during the neonatal period was 26.4%, predominant breastfeeding was 28.7%, partial breastfeeding was 40.1%, and no breastfeeding was 4.7%. Potentially harmful weaning materials (animals' milk (35.8%), formula feeds (17.6%), water (48.1%) and other substances (teas/herbal drinks/juices/soups/rice water/mashed banana/etc (9.9%)) were being fed to 74% (95% CI: 70.7%–76.3%) of the neonates. Neonates born to mothers with no formal education, fathers with no formal education, whose mothers had fewer ( p Conclusion The proportion of neonates being exclusively breastfed was low at 26.2% (95% CI: 23.7%–29.4%). There is a need for promotion of exclusive breastfeeding for all newborns in urban Lucknow, northern India.

like UP, that is showing signs of emerging epidemic. These emerging districts and sub-epidemics are related to population migration, and lack of focus on preventive measures. Kanpur is one of the industrial centers of UPwith considerable migrant population. The low awareness regarding HIV transmission noted in the study (0e5.6%) among road-side barbers is of special concern andmay point to lack of focus on IEC and other preventive strategies in this geographical area. It is important to bring this to the notice of the state AIDS Control Organization and NACO. Though the results of the study may not be of major concern with regard to HIV epidemic in India, it has implications on other blood borne infections. There is greater need for effective strategies to control transmission of HBV and HCV in the community. Vaccination and ensuring improved hygienic practices are the best answers to this problem. I am sure that the information generated in the article will help us to refocus our efforts in strengthening the strategies to control blood borne infections in the country.

OBJECTIVE To assess the impact of a behaviour change communication (BCC) intervention on qualified medical care-seeking for sick newborns in urban Lucknow, northern India. METHODS Before and after intervention study conducted at two urban public hospitals at Lucknow. Neonates who did not have any morbidity or congenital malformation and were residents of Lucknow were enrolled within 48 h of birth and followed once between 6 and 8 weeks at the outpatients' clinic or home to assess the primary outcome measure which was qualified medical care-seeking for any neonatal illness. Mothers in the after-intervention phase received BCC intervention at enrolment, targeted at identification of danger signs of neonatal illnesses and promotion of qualified medical care-seeking. Analysis was by intention to treat. RESULTS In the before-intervention phase, 510 neonates were enrolled (from March 2007 to August 2007) and 481 (94.3%) were followed up. In the after-intervention phase, 510 neonates were enrolled (September 2007-April 2008) and 490 (96.1%) were followed up. Neonatal morbidity was 50.3% (242/481) and 44.3% (217/490) in before and after intervention phases, respectively. Qualified medical care-seeking for neonatal illnesses was significantly higher among mothers after-intervention (OR = 2.12; 95% CI = 1.42-3.16; P = 0.0001). CONCLUSION Since the behaviour change intervention package led to significant improvement in qualified medical care-seeking for sick newborns, this may be tested for effectiveness in other settings and considered for scaling up here, with rising proportion of institutional deliveries.

To assess symptom-specific care-seeking practices for newborns and behavioral factors associated with them to inform strategies to enhance newborn care seeking in urban Lucknow, Northern India. This was a prospective follow-up study of consecutive 326 neonates delivered at an urban reproductive and child health (RCH) center. Focused Group Discussions (n=5) were also conducted in urban slums (n=3) at the RCH center (n=1) and at a district hospital (n=1). Overall, 326 neonates were recruited within 48 h of birth and 289 (88.7%) were followed up at 6 weeks (+/-15 days) at home. Parents of 51.2% (148/289) neonates reported at least one symptom of illness. Among these, 27.3% (79/289) neonates had at least one reported Integrated Management of Neonatal and Childhood Illnesses (IMNCI) danger sign, of which 15 (18.9%) did not receive any modern medical care, 5(33.3%) of which were dead by early infancy. Care seeking from unqualified providers (spiritual/traditional) was 33.3% (3/9) for persistent diarrhea and 23.5% (4/17) for pneumonia. Qualitative data from Focused Group Discussions showed that when pictures of some danger signs were shown like sunken eyes, reduced skin turgor, chest in-drawing and bulged fontanel, care seeking for these as well as fast breathing were influenced by 'local beliefs', which considered them to be untreatable by modern medicines alone. Thus, care seeking from multiple providers and use of traditional/home remedies delayed appropriate and timely medical care seeking. Almost half of the neonates had an illness symptom of which half had an IMNCI danger sign, of which one fifth did not receive medical care. Therefore, there is an urgent need to introduce a locally modified community IMNCI program here, for promoting care seeking from qualified providers for sick neonates.

Background WHO-defined pneumonias, treated with antibiotics, are responsible for a significant proportion of childhood morbidity and mortality in the developing countries. Since substantial proportion pneumonias have a viral etiology, where children are more likely to present with wheeze, there is a concern that currently antibiotics are being over-prescribed for it. Hence the current trial was conducted with the objective to show the therapeutic equivalence of two treatments (placebo and amoxycillin) for children presenting with non-severe pneumonia with wheeze, who have persistent fast breathing after nebulisation with salbutamol, and have normal chest radiograph. Methodology This multi-centric, randomised placebo controlled double blind clinical trial intended to investigate equivalent efficacy of placebo and amoxicillin and was conducted in ambulatory care settings in eight government hospitals in India. Participants were children aged 2–59 months of age, who received either oral amoxycillin (31–54 mg/Kg/day, in three divided doses for three days) or placebo, and standard bronchodilator therapy. Primary outcome was clinical failure on or before day- 4. Principal Findings We randomized 836 cases in placebo and 835 in amoxycillin group. Clinical failures occurred in 201 (24.0%) on placebo and 166 (19.9%) on amoxycillin (risk difference 4.2% in favour of antibiotic, 95% CI: 0.2 to 8.1). Adherence for both placebo and amoxycillin was >96% and 98.9% subjects were followed up on day- 4. Clinical failure was associated with (i) placebo treatment (adjusted OR = 1.28, 95% CI: 1.01 to1.62), (ii) excess respiratory rate of >10 breaths per minute (adjusted OR = 1.51, 95% CI: 1.19, 1.92), (iii) vomiting at enrolment (adjusted OR = 1.49, 95% CI: 1.13, 1.96), (iv) history of use of broncho-dilators (adjusted OR = 1.71, 95% CI: 1.30, 2.24) and (v) non-adherence (adjusted OR = 8.06, 95% CI: 4.36, 14.92). Conclusions Treating children with non-severe pneumonia and wheeze with a placebo is not equivalent to treatment with oral amoxycillin. Trial Registration ClinicalTrials.gov NCT00407394

We conducted this study to assess the neonatal morbidity and care-seeking behavior amongst slum and non-slum dwellers at Lucknow. One hundred and fifty neonates were recruited within 48 hours of birth from an urban Reproductive and Child Health center and followed up at 6 weeks +/- 15 days at home. Twenty five (16.6%) were lost to follow-up. Among those followed up, 46.4% (58/125) developed one or more morbidity; 26% (15/58) of these did not receive qualified medical care. Neonatal morbidity was 56.8% (33/58) among slum dwellers and 37.3% (25/67) among non-slum dwellers (absolute difference=19.5%, 95% CI=3.3 to 34.7; P=0.04). Severe neonatal illnesses were also significantly higher among neonates from slums as compared to those from non-slum areas (OR=4.50, 95% CI=1.28 to 16.38, P=0.007). Male gender was associated with any care-seeking (OR=1.24, 95% CI =1.24 to 91.99; P=0.03) and was more likely to be seen by a qualified provider (OR=3.8, 95% CI=1.05 to 13.94; P=0.04). Since nearly half of the neonates had morbidity and more than a quarter of them did not receive qualified medical care, there is a need to introduce Community Integrated Management of Neonatal and Childhood Illnesses (IMNCI) program here, emphasizing on the importance of qualified medical care for ill neonates, including females.

Background Community-acquired pneumonia (CAP) is the leading cause of under-five mortality globally with almost one-quarter of deaths occurring in India. Objectives To identify predisposing, enabling and service-related factors influencing treatment delay for CAP in rural communities of two states in India. Factors investigated included recognition of danger signs of CAP, health care decision making, self-medication, treatment and referral by local practitioners, and perceptions about quality of care. Methods Qualitative research employing case studies (CS) of care-seeking, key informant interviews (KII), semi-structured interviews (SSI) and focus group discussions (FGD) with both video presentations of CAP signs, and case scenarios. Interviews and FGDs were conducted with parents of under-five children who had suffered CAP, community health workers (CHW), and rural medical practitioners (RMP). Results From September 2013 to January 2014, 30 CS, 43 KIIs, 42 SSIs, and 42 FGDs were conducted. Recognition of danger signs of CAP among caregivers was poor. Fast breathing, an early sign of CAP, was not commonly recognized. Chest in-drawing was recognized as a sign of serious illness, but not commonly monitored by removing a child’s clothing. Most cases of mild to moderate CAP were brought to RMP, and more severe cases taken to private clinics in towns. Mothers consulted local RMP directly, but decisions to visit doctors outside the village required consultation with husband or mother-in-law. By the time most cases reached a public tertiary-care hospital, children had been ill for a week and treated by 2-3 providers. Quality of care at government facilities was deemed poor by caregivers. Conclusion To reduce CAP-associated mortality, recognition of its danger signs and the consequences of treatment delay needed to be better recognized by caregivers, and confidence in government facilities increased. The involvement of RMP in community based CAP programs needs to be investigated further given their widespread popularity.

Background The state of Uttar Pradesh, India accounts for one-quarter of India's neonatal deaths and 8 percent of those worldwide. More than half (52%) of these deaths occur due to infections. In order to achieve Millennium Development Goal-4 of reducing child mortality by two-thirds by the year 2015, it is important to study factors which affect neonatal health. In Uttar Pradesh there is meager data for spending on health care in general and neonates in particular. Methods The study was conducted at an urban Reproductive and Child Health (RCH) center and a District hospital. Neonates were enrolled within 48 hours of birth and were followed-up once at 6 weeks ± 15 days at the OPD of the respective hospitals or at home. This study assessed (1) distribution of neonatal illnesses and different health providers sought (2) distribution of out-of-pocket expenditures by type of illness and type of health provider sought (3) socio-economic distribution of neonatal illnesses, care-seeking behavior and out-of-pocket expenditures. Per-protocol analysis was performed. Results Five hundred and ten neonates were enrolled and 481(94.4%) were followed-up. Parents of 50.3% (242/481) neonates reported at least one symptom of illness. Of these 22.3% (107/481) neonates had illnesses with at least one reported Integrated Management of Neonatal and Childhood Illnesses (IMNCI) danger sign. Among IMNCI illnesses, point prevalence of septicemia was 6.2% and pneumonia was 5.2% while among non-IMNCI illnesses point prevalence of upper respiratory infection was 9.5%, and diarrhea was 7%. Community based non-government dispensers (NGDs) were leading health providers (37.6%). Mean monthly income of families was 2804 Indian Rupees (INR) (range: 800 to 14000; n = 510), where US$ 1 = 42 INR. Mean out-of-pocket expenditure on neonatal illness was 547.5 INR (range: 1 to 15000; n = 202) and mean out-of-pocket expenditure for hospitalization was 4993 INR (range: 41 to 15000; n = 17). All hospitalizations were for IMNCI illnesses. Neonates from lower income strata were less likely to receive any medical care (p < 0.0001) and were also less likely to be seen by a Government provider (p = 0.03). Conclusion Since more than half of the neonates have morbidity and out-of-pocket expenditure on neonatal illnesses often exceeds the family income of the lower strata of the low income group in the community, there is a need to either introduce health insurance scheme or subsidize health care for them. Also, since NGDs, half of which could be unqualified are leading health providers, qualified medical care-seeking for sick newborns should be promoted in urban Lucknow.