Community Medicine, MAHAN Trust, Dharni, Amaravati, Maharashtra, India
Medicine, Mahatma Gandhi Tribal Hospital, Amaravati, Maharashtra, India.
BMJ Glob Health. 2022 Jul;7(7). doi: 10.1136/bmjgh-2022-008909.
Melghat, an impoverished rural area in Maharashtra state, India; has scarce hospital services and low health-seeking behaviour. At baseline (2004) the under-five mortality rate (U5MR) (number of deaths in children aged 0-5 years/1000 live births) was 147.21 and infant mortality rate (IMR) (number of deaths of infants aged under 1 year/1000 live births) was 106.6 per 1000 live births. We aimed at reducing mortality rates through home-based child care (HBCC) using village health workers (VHWs).
A cluster-randomised control trial was conducted in 34 randomly assigned clusters/villages of Melghat, Maharashtra state, between 2004 and 2009. Participants included all under-five children and their parents. Interventions delivered through VHWs were patient-public involvement, newborn care, disease management and behaviour change communications. Primary outcome indicators were U5MR and IMR. Secondary outcome indicators were neonatal mortality rate (NMR) (number of neonatal deaths aged 0-28 days/1000 live births) and perinatal mortality rate (PMR) (number of stillbirths and early neonatal deaths/1000 total births). Analysis was by intention-to-treat at the individual level. This trial was extended to a service phase (2010-2015) in both arms and a government replication phase (2016-2019) only for the intervention clusters/areas (IA).
There were 18 control areas/clusters (CA) allocated and analysed with 4426 individuals, and 16 of 18 allocated IA, analysed with 3230 individuals. The IMR and U5MR in IA were reduced from 106.60 and 147.21 to 32.75 and 50.38 (reduction by 69.28% and 65.78%, respectively) compared with increases in CA from 67.67 and 105.3 to 86.83 and 122.8, respectively, from baseline to end of intervention. NMR and PMR in IA showed reductions from 50.76 to 22.67 (by 55.34%) and from 75.06 to 24.94 (by 66.77%) respectively. These gains extended to villages in the service and replication phases.
This socio-culturally contextualised model for HBCC through VHWs backed up with institutional support is effective for significant reduction of U5MR, IMR and NMR in impoverished rural areas. This reduction was maintained in the study area during the service phase, indicating feasibility of implementation in large-scale public health programmes. Replicability of the model was demonstrated by a linear decline in all the mortality rates in 20 new villages during the government phase.
NCT02473796.
印度马哈拉施特拉邦的梅尔加特是一个贫困的农村地区，医院服务匮乏，人们的健康意识较低。在基线（2004 年）时，五岁以下儿童死亡率（U5MR）（每 1000 例活产中 0-5 岁儿童死亡数）为 147.21，婴儿死亡率（IMR）（每 1000 例活产中 1 岁以下儿童死亡数）为 106.6。我们的目标是通过利用乡村卫生工作者（VHW）实施家庭儿童保健（HBCC）来降低死亡率。
在 2004 年至 2009 年期间，在马哈拉施特拉邦梅尔加特的 34 个随机分配的集群/村庄进行了一项集群随机对照试验。参与者包括所有五岁以下的儿童及其父母。VHW 提供的干预措施包括患者公众参与、新生儿护理、疾病管理和行为改变沟通。主要结局指标是 U5MR 和 IMR。次要结局指标是新生儿死亡率（NMR）（每 1000 例活产中 0-28 天新生儿死亡数）和围产期死亡率（PMR）（每 1000 例总出生数中死产和早期新生儿死亡数）。个体水平上采用意向治疗进行分析。该试验在干预组/地区（IA）延长至服务阶段（2010-2015 年）和政府复制阶段（2016-2019 年），仅针对干预集群/地区（IA）。
分配并分析了 18 个对照区/集群（CA），涉及 4426 人，分配并分析了 18 个区中的 16 个 IA，涉及 3230 人。与 CA 相比，IA 的 IMR 和 U5MR 从 106.60 和 147.21 分别降至 32.75 和 50.38（分别降低了 69.28%和 65.78%），而 CA 的 IMR 和 U5MR 分别从基线的 67.67 和 105.3 增加到 86.83 和 122.8。IA 的 NMR 和 PMR 分别从 50.76 降至 22.67（降低了 55.34%）和从 75.06 降至 24.94（降低了 66.77%）。这些收益扩展到服务和复制阶段的村庄。
通过 VHW 提供的社会文化背景下的 HBCC 模式，辅以机构支持，对于贫困农村地区 U5MR、IMR 和 NMR 的显著降低是有效的。在研究期间，这种降低在服务阶段得以维持，表明在大规模公共卫生计划中实施的可行性。在政府阶段的 20 个新村庄中，所有死亡率呈线性下降，证明了该模型的可复制性。
NCT02473796。
