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An estimated 2.4 million newborn infants died in 2020, 80% of them in sub-Saharan Africa and South Asia. To achieve the Sustainable Development Target for neonatal mortality reduction, countries with high mortality need to implement evidence-based, cost-effective interventions at scale. Our study aimed to estimate the cost, cost-effectiveness, and benefit-cost ratio of a participatory women’s groups intervention scaled up by the public health system in Jharkhand, eastern India. The intervention was evaluated through a pragmatic cluster non-randomised controlled trial in six districts. We estimated the cost of the intervention from a provider perspective, with a 42-month time horizon for 20 districts. We estimated costs using a combination of top-down and bottom-up approaches. All costs were adjusted for inflation, discounted at 3% per year, and converted to 2020 International Dollars (INT$). Incremental cost-effectiveness ratios (ICERs) were estimated using extrapolated effect sizes for the impact of the intervention in 20 districts, in terms of cost per neonatal deaths averted and cost per life year saved. We assessed the impact of uncertainty on results through one-way and probabilistic sensitivity analyses. We also estimated benefit-cost ratio using a benefit transfer approach. Total intervention costs for 20 districts were INT$ 15,017,396. The intervention covered an estimated 1.6 million livebirths across 20 districts, translating to INT$ 9.4 per livebirth covered. ICERs were estimated at INT$ 1,272 per neonatal death averted or INT$ 41 per life year saved. Net benefit estimates ranged from INT$ 1,046 million to INT$ 3,254 million, and benefit-cost ratios from 71 to 218. Our study suggests that participatory women’s groups scaled up by the public health system are highly cost-effective in improving neonatal survival and have a very favourable return on investment. The intervention can be scaled up in similar settings within India and other countries.

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.

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 Almost one in three married Indian women have ever experienced physical, sexual, or emotional violence from husbands in their lifetime. We aimed to investigate the preliminary effects of community mobilisation through participatory learning and action groups facilitated by Accredited Social Health Activists (ASHAs), coupled with access to counselling, to prevent violence against women and girls in Jharkhand, eastern India. Methods We piloted a cycle of 16 participatory learning and action meetings with women’s groups facilitated by ASHAs in rural Jharkhand. Participants identified common forms of violence against women and girls, prioritised the ones they wanted to address, developed locally feasible strategies to address them, implemented the strategies, and evaluated the process. We also trained two counsellors and two ASHA supervisors to support survivors, and gave ASHAs information about legal, health, and police services. We did a before-and-after pilot study involving baseline and endline surveys with group members to estimate preliminary effects of these activities on the acceptability of violence, prevalence of past year emotional and physical violence, and help-seeking. Results ASHAs successfully conducted monthly participatory learning and action meetings with 39 women’s groups in 22 villages of West Singhbhum district, Jharkhand, between June 2016 and September 2017. We interviewed 59% (679/1149) of women registered with groups at baseline, and 63% (861/1371) at endline. More women reported that violence was unacceptable in all seven scenarios presented to them at endline compared to baseline (adjusted Odds Ratio [aOR]: 1.87, 95%: 1.39–2.52). Fewer women reported experiencing emotional violence from their husbands in the last 12 months (aOR: 0.55, 95% CI: 0.43–0.71), and more sought help if it occurred (aOR: 2.19, 95% CI: 1.51–3.17). In addition, fewer women reported experiencing emotional or physical violence from family members other than their husbands in the last 12 months (aOR: 0.41, 95% CI: 0.32–0.53, and aOR: 0.36, 95% CI: 0.26–0.50, respectively). Conclusion Combining participatory learning and action meetings facilitated by ASHAs with access to counselling was an acceptable strategy to address violence against women and girls in rural communities of Jharkhand. The approach warrants further implementation and evaluation as part of a comprehensive response to violence.

The prevailing approach to improving population health focuses on shifting population means through a few targeted and universal interventions. The success of this approach for eliminating health disparities depends on an assumption about the distribution of demand for such interventions. We explored whether long tail thinking from business might yield greater progress in eliminating disparities. We examined 2011 to 2013 data from 513 state and local health agency representatives in 47 states who used an online system to create 4351 small media and client reminder products promoting colorectal cancer screening. Products in the long tail were more likely to target minority groups with higher rates of colorectal cancer and lower rates of screening than Whites. Long tail thinking could help improve the public's health and eliminate disparities.

Context Implementing the Affordable Care Act (ACA) in 2014 will require effective enrollment and outreach efforts to previously uninsured individuals now eligible for coverage. Methods From 1996 to 2013, the Health Communication Research Laboratory conducted more than 40 original studies with more than 30,000 participants to learn how to improve the reach to and effectiveness of health information for low-income and racial/ethnic minority populations. We synthesized the findings from this body of research and used them to inform current challenges in implementing the ACA. Findings We found empirical support for 5 recommendations regarding partnerships, outreach, messages and messengers, life priorities of low-income individuals and families, and the information environment. We translated these into 12 action steps. Conclusions Health communication science can inform the development and execution of strategies to increase the public's understanding of the ACA and to support the enrollment of eligible individuals into Medicaid or the Health Insurance Marketplace.

Background Callers to 2-1-1 have greater need for and lesser use of cancer control services than other Americans. Integrating cancer risk assessment and referrals to preventive services into 2-1-1 systems is both feasible and acceptable to callers. Purpose To determine whether callers will act on these referrals. Methods In a randomized trial, 2-1-1 callers ( n =1200) received standard service and those with at least one cancer risk factor or need for screening were assigned to receive verbal referrals only, verbal referrals + a tailored reminder mailed to their home, or verbal referrals + a telephone health coach/navigator. All data were collected from June 2010 to March 2012 and analyzed in March and April 2012. Results At 1-month follow-up, callers in the navigator condition were more likely to report having contacted a cancer control referral than those receiving tailored reminders or verbal referrals only (34% vs 24% vs 18%, respectively; n =772, p Conclusions Given the extensive reach of 2-1-1s and the elevated risk profile of their callers, even modest response rates could have meaningful impact on population health if proactive health referrals were implemented nationally.

Background: In times of crises, 2-1-1 serves as a lifeline in many ways. These crises often cause a spike in call volume that can challenge 2-1-1’s ability to meet its service quality standards. For researchers gathering data through 2-1-1s, a sudden increase in call volume might reduce accrual as 2-1-1 has less time to administer study protocols. Research activities imbedded in 2-1-1 systems may affect directly 2-1-1 service quality indicators. Purpose: Using data from a 2-1-1 research collaboration, this paper examines the impact of crises on call volume to 2-1-1, how call volume affects research participant accrual through 2-1-1, and how research recruitment efforts affect 2-1-1 service quality indicators. Methods: t-tests were used to examine the effect of call volume on research participant accrual. Linear and logistic regressions were used to examine the effect of research participant accrual on 2-1-1 service quality indicators. Data were collected June 2010 –December 2011; data were analyzed in 2012. Results: Findings from this collaboration suggest that crises causing spikes in call volume adversely affect 2-1-1 service quality indicators as well as accrual of research participants. Administering a brief (2–3 minute) health risk assessment did not affect service quality negatively, but administering a longer (15–18 minute) survey had a modest adverse effect on these indicators. Conclusions: In 2-1-1 research collaborations, both partners need to understand the dynamic relationship among call volume, research accrual, and service quality and adjust expectations accord

Background Delivering health information and referrals through 2-1-1 is promising, but these systems need efficient ways of identifying callers at increased risk. Purpose This study explores the utility of using 2-1-1 service request data to predict callers' cancer control needs. Methods Using data from a large sample of callers (N=4101) to United Way 2-1-1 Missouri, logistic regression was used to examine the relationship between caller demographics and type of service request, and cancer control needs. Results Of six types of service requests examined, three were associated with one or more cancer control needs. Two of the service request types were associated also with health insurance status. Conclusions Findings suggest routinely collected 2-1-1 service request data may be useful in helping to efficiently identify callers with specific cancer prevention and control needs. However, to apply this approach in 2-1-1 systems across the country, further research and ongoing surveillance is necessary.

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.

Compare effects of narrative and informational videos on use of mammography, cancer-related beliefs, recall of core content and a range of reactions to the videos.African American women (n=489) ages 40 and older were recruited from low-income neighborhoods in St. Louis, MO and randomly assigned to watch a narrative video comprised of stories from African American breast cancer survivors (Living Proof) or a content-equivalent informational video using a more expository and didactic approach (Facts for Life). Effects were measured immediately post-exposure and at 3- and 6-month follow-up.The narrative video was better liked, enhanced recall, reduced counterarguing, increased breast cancer discussions with family members and was perceived as more novel. Women who watched the narrative video also reported fewer barriers to mammography, more confidence that mammograms work, and were more likely to perceive cancer as an important problem affecting African Americans. Use of mammography at 6-month follow-up did not differ for the narrative vs. informational groups overall (49% vs. 40%, p=.20), but did among women with less than a high school education (65% vs. 32%, p.01), and trended in the same direction for those who had no close friends or family with breast cancer (49% vs. 31%, p=.06) and those who were less trusting of traditional cancer information sources (48% vs. 30%, p=.06).Narrative forms of communication may increase the effectiveness of interventions to reduce cancer health disparities.Narratives appear to have particular value in certain population sub-groups; identifying these groups and matching them to specific communication approaches may increase effectiveness.

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.

Graphic warning labels have been shown to be more effective than text-only labels in increasing attention and perceived health risks, but most U.S. studies have involved single exposures in laboratory or Internet settings.We recruited a convenience sample (N = 202) of U.S. adult smokers from population subgroups with higher rates of smoking and smoking-related deaths who had participated in a larger survey about graphic warning labels. Participants were randomized to get 1 of 9 graphic + text labels or a text-only label. Research staff affixed a warning label sticker to participants' cigarette pack(s) at enrollment. Color graphic labels covered slightly more than the lower half of packs. Black and white labels of current U.S. text-only warnings covered the existing side warning to prompt attention to the label (i.e., attention control). Participants received extra stickers of the same label for subsequent packs, and completed 3 telephone interviews in 1 week.Participants reported low avoidance (34%) and consistent use of the stickers (91%). Smokers consistently paid more attention to graphic than text-only labels. Only 5 of the 9 graphic warning labels were significantly associated with greater thoughts of health risks. Thinking about quitting and stopping smoking did not differ by label. Qualitative data illustrated differences in the "stickiness," self-referencing, and counterarguments of graphic warning labels.U.S. smokers' reactions to graphic warning labels on their own packs were similar to other, more controlled studies. Qualitative findings underscore the need for warning labels that encourage self-referential processing without increasing defensive reactions.

Background/Aims/Objectives: The media are an important source of health information, especially for those with less access to regular health care. Black news outlets such as Black newspapers are a source of health information for African Americans. This study characterized media coverage of genetics-related information in Black weekly newspapers and general audience newspapers from the same communities. Methods: All health stories in a sample of 24 Black weekly newspapers and 12 general audience newspapers from January 2004 to December 2007 were reviewed for genetics-related stories. These stories were further coded for both journalistic and public health variables. Results: Of all health-related stories identified, only 2% (n = 357) were considered genetics related. Genetics-related stories in Black newspapers - compared to those in general audience newspapers - were larger, more locally and racially relevant, and more likely to contain recommendations or action steps to improve health or reduce disease risks and to mention the importance of knowing one's family history. Stories in general audience newspapers were more likely to discuss causes of disease, mention genetic testing or therapy, and suggest a high/moderate degree of genetic determinism. Conclusions: Black newspapers are a viable communication channel to disseminate findings and implications of human genome research to African American audiences.

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.

In times of crises, 2-1-1 serves as a lifeline in many ways. These crises often cause a spike in call volume that can challenge 2-1-1's ability to meet its service quality standards. For researchers gathering data through 2-1-1s, a sudden increase in call volume might reduce accrual as 2-1-1 has less time to administer study protocols. Research activities imbedded in 2-1-1 systems may affect directly 2-1-1 service quality indicators.Using data from a 2-1-1 research collaboration, this paper examines the impact of crises on call volume to 2-1-1, how call volume affects research participant accrual through 2-1-1, and how research recruitment efforts affect 2-1-1 service quality indicators.t-tests were used to examine the effect of call volume on research participant accrual. Linear and logistic regressions were used to examine the effect of research participant accrual on 2-1-1 service quality indicators. Data were collected June 2010-December 2011; data were analyzed in 2012.Findings from this collaboration suggest that crises causing spikes in call volume adversely affect 2-1-1 service quality indicators as well as accrual of research participants. Administering a brief (2-3 minute) health risk assessment did not affect service quality negatively, but administering a longer (15-18 minute) survey had a modest adverse effect on these indicators.In 2-1-1 research collaborations, both partners need to understand the dynamic relationship among call volume, research accrual, and service quality and adjust expectations accordingly. If research goals include administering a longer survey, increased staffing of 2-1-1 call centers may be needed to avoid compromising service quality.

Background Few large and rigorous evaluations of participatory interventions systematically describe their context and implementation, or attempt to explain the mechanisms behind their impact. This study reports process evaluation data from the Ekjut cluster-randomised controlled trial of a participatory learning and action cycle with women's groups to improve maternal and newborn health outcomes in Jharkhand and Orissa, eastern India (2005-2008). The study demonstrated a 45% reduction in neonatal mortality in the last two years of the intervention, largely driven by improvements in safe practices for home deliveries. Methods A participatory learning and action cycle with 244 women's groups was implemented in 18 intervention clusters covering an estimated population of 114 141. We describe the context, content, and implementation of this intervention, identify potential mechanisms behind its impact, and report challenges experienced in the field. Methods included a review of intervention documents, qualitative structured discussions with group members and non-group members, meeting observations, as well as descriptive statistical analysis of data on meeting attendance, activities, and characteristics of group attendees. Results Six broad, interrelated factors influenced the intervention's impact: (1) acceptability; (2) a participatory approach to the development of knowledge, skills and 'critical consciousness'; (3) community involvement beyond the groups; (4) a focus on marginalized communities; (5) the active recruitment of newly pregnant women into groups; (6) high population coverage. We hypothesize that these factors were responsible for the increase in safe delivery and care practices that led to the reduction in neonatal mortality demonstrated in the Ekjut trial. Conclusions Participatory interventions with community groups can influence maternal and child health outcomes if key intervention characteristics are preserved and tailored to local contexts. Scaling-up such interventions requires (1) a detailed understanding of the way in which context affects the acceptability and delivery of the intervention; (2) planned but flexible replication of key content and implementation features; (3) strong support for participatory methods from implementing agencies.

Background In places with poor vital registration, measurement of maternal mortality and monitoring the impact of interventions on maternal mortality is difficult and seldom undertaken. Mortality ratios are often estimated and policy decisions made without robust evidence. This paper presents a prospective key informant system to measure maternal mortality and the initial findings from the system. Methods In a population of 228 186, key informants identified all births and deaths to women of reproductive age, prospectively, over a period of 110 weeks. After birth verification, interviewers visited households six to eight weeks after delivery to collect information on the ante-partum, intra-partum and post-partum periods, as well as birth outcomes. For all deaths to women of reproductive age they ascertained whether they could be classified as maternal, pregnancy related or late maternal and if so, verbal autopsies were conducted. Results 13 602 births were identified, with a crude birth rate of 28.2 per 1000 population (C.I. 27.7–28.6) and a maternal mortality ratio of 722 per 100 000 live births (C.I. 591–882) recorded. Maternal deaths comprised 29% of all deaths to women aged 15–49. Approximately a quarter of maternal deaths occurred ante-partum, a half intra-partum and a quarter post-partum. Haemorrhage was the commonest cause of all maternal deaths (25%), but causation varied between the ante-partum, intra-partum and post-partum periods. The cost of operating the surveillance system was US$386 a month, or US$0.02 per capita per year. Conclusion This low cost key informant surveillance system produced high, but plausible birth and death rates in this remote population in India. This method could be used to monitor trends in maternal mortality and to test the impact of interventions in large populations with poor vital registration and thus assist policy makers in making evidence-based decisions.

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.