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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.

Over 70 million women of reproductive age are undernourished in India. Most poverty alleviation programs have not been systematically evaluated to assess impact on women’s empowerment and nutrition outcomes. National Rural Livelihoods Mission’s poverty alleviation and livelihoods generation initiative is an opportune platform to layer women’s nutrition interventions being tapped by project Swabhimaan in three eastern Indian states—Bihar, Chhattisgarh and Odisha. A cross-sectional baseline survey covering 8755 mothers of children under-two years of age, one of the three primary target groups of program are presented. Standardized questionnaire was administered and anthropometric measurements were undertaken from October 2016 to January 2017. 21 indicators on women’s empowerment, Body Mass Index and Mid-upper Arm Circumference for nutrition status, food insecurity indicators as per the Food Insecurity Experience Scale and selected indicators for assessing women’s access to basic health services were included. National Rural Livelihoods Mission operates in contexts with stark social and gender inequalities. Self-help group members exhibited better control on financial resources and participation in community activities than non-members. Using Body Mass Index, at least 45% mothers were undernourished irrespective of their enrolment in self-help groups. Higher proportion of self-help group members (77%-87%) belonged to food insecure households than non-members (66%-83%). Proportion of mothers reporting receipt of various components of antenatal care service package varied from over 90% for tetanus toxoid vaccination to less than 10% for height measurement. Current use of family planning methods was excruciatingly low (8.2%-32.4%) in all states but positively skewed towards self-help group members. Participation in monthly fixed day health camps was a concern in Bihar. Layering women’s nutrition interventions as stipulated under Swabhimaan may yield better results for women’s empowerment and nutrition status under National Rural Livelihoods Mission. While this opportunity exists in all three states, Bihar with a higher proportion of matured self-help groups offers more readiness for Swabhimaan implementation.

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.

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).

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.

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