Elsevier

The Lancet

Volume 372, Issue 9644, 27 September–3 October 2008, Pages 1151-1162
The Lancet

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Effect of community-based behaviour change management on neonatal mortality in Shivgarh, Uttar Pradesh, India: a cluster-randomised controlled trial

https://doi.org/10.1016/S0140-6736(08)61483-XGet rights and content

Summary

Background

In rural India, most births take place in the home, where high-risk care practices are common. We developed an intervention of behaviour change management, with a focus on prevention of hypothermia, aimed at modifying practices and reducing neonatal mortality.

Methods

We did a cluster-randomised controlled efficacy trial in Shivgarh, a rural area in Uttar Pradesh. 39 village administrative units (population 104 123) were allocated to one of three groups: a control group, which received the usual services of governmental and non-governmental organisations in the area; an intervention group, which received a preventive package of interventions for essential newborn care (birth preparedness, clean delivery and cord care, thermal care [including skin-to-skin care], breastfeeding promotion, and danger sign recognition); or another intervention group, which received the package of essential newborn care plus use of a liquid crystal hypothermia indicator (ThermoSpot). In the intervention clusters, community health workers delivered the packages via collective meetings and two antenatal and two postnatal household visitations. Outcome measures included changes in newborn-care practices and neonatal mortality rate compared with the control group. Analysis was by intention to treat. This study is registered as International Standard Randomised Control Trial, number NCT00198653.

Findings

Improvements in birth preparedness, hygienic delivery, thermal care (including skin-to-skin care), umbilical cord care, skin care, and breastfeeding were seen in intervention arms. There was little change in care-seeking. Compared with controls, neonatal mortality rate was reduced by 54% in the essential newborn-care intervention (rate ratio 0·46 [95% CI 0·35–0·60], p<0·0001) and by 52% in the essential newborn care plus ThermoSpot arm (0·48 [95% CI 0·35–0·66], p<0·0001).

Interpretation

A socioculturally contextualised, community-based intervention, targeted at high-risk newborn-care practices, can lead to substantial behavioural modification and reduction in neonatal mortality. This approach can be applied to behaviour change along the continuum of care, harmonise vertical interventions, and build community capacity for sustained development.

Funding

USAID and Save the Children-US through a grant from the Bill & Melinda Gates Foundation.

Introduction

Most neonatal deaths occur at home in low resource settings against a backdrop of poverty, unskilled home deliveries, suboptimum care-seeking, and weak health systems.1, 2, 3 Emerging evidence suggests that a substantial reduction in neonatal mortality can be achieved with simple, low-cost interventions within family and community settings.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11

In a study in Maharashtra, India, Bang and colleagues2, 6 reported a 62–70% reduction in the neonatal mortality rate, and attributed 93% of the reduction to active management of sick newborn babies and 7% to primary prevention. Baqui and colleagues4 reported that an adaptation of this approach in Bangladesh in an effectiveness trial had half the effect (34% reduction) on neonatal mortality. Manandhar and co-workers3 tested a different approach in Nepal with a community-based participatory action-cycle with no prespecified intervention package, in which women's groups identified priorities and implemented local solutions, and reported improvements in care practices, care-seeking, and a 30% reduction in neonatal mortality rate.

Most neonatal deaths in high-mortality regions are attributable to preventable and behaviourally modifiable causes.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 However, the extent to which a preventive package of evidence-based interventions at the community level could reduce neonatal mortality is unknown. Estimates based on modelling of limited empirical data suggest that 18–32% of neonatal mortality could be averted through high (90%) coverage of simple, affordable, methods for preventive family and community newborn care.1

Identification of an effective approach to preventive care that builds on existing capacities and accelerates programme effectiveness is important. The limited success of large-scale studies of behaviour change interventions has been attributed to poor consideration of the social context that shapes behaviours while treating individual health behaviours as stand-alone entities.12, 13, 14, 15, 16, 17, 18

We postulated that an intervention based on a socioculturally contextualised approach of behaviour change management systematically applied to modifiable, high-risk newborn-care practices, with an emphasis on hypothermia, within a community with a high neonatal mortality rate could lead to improved care practices and reduced mortality.

Section snippets

Study area and population

The state of Uttar Pradesh, India, accounts for a quarter of India's neonatal deaths and for 8% of those worldwide, and shares similar sociocultural, demographic, and health system characteristics with other high-mortality Indian states and south Asian countries.3, 4, 5, 19, 20, 21 The study was done in Shivgarh, a rural block in Uttar Pradesh, with a population of 104 123 divided into 39 village administrative units. Socioeconomic indicators are among the lowest in the state.

The formal

Results

The trial profile is shown in figure 2. Pregnancies identified (28·6 per 1000 population) and crude birth rate (26·6 per 1000 population) did not differ statistically across the three arms.

Key baseline characteristics for the three study arms were similar (table 1). The study population was predominantly Hindu with around half from scheduled castes and tribes (ie, the lowest caste designation), roughly a third had low standard of living index, and literacy in the female reproductive age group

Discussion

A behaviour change management appraoch that promoted interventions to prevent high-risk newborn-care practices, targeted at multiple stakeholders within communities, led to substantial behavioural modification and reduced neonatal mortality. The intervention was developed and implemented based on findings from formative research, with active participation of community members throughout the research cycle, thus addressing the fundamental need for people to be involved in decisions affecting

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