Effect of implementation of Integrated Management of Neonatal and Childhood Illness programme on treatment seeking practices for morbidities in infants: cluster randomised trial

The BMJ

Aug 2014

DOI: 10.1136/bmj.g4988

Citations:36

Influential Citations:2

Interventional (Human) Studies

Enhanced Details

Methods

Cluster-randomised trial conducted in Faridabad, Haryana, India, across 18 primary health centre catchment areas (9 intervention clusters and 9 control clusters). 29,667 births in nine intervention clusters and 30,813 births in nine control clusters. Participants were newborns and their primary caregivers (mostly mothers); follow-up interviews at 29 days, 6 months, and 12 months. Not blinded.

Results

Implementation of IMNCI at scale improved treatment-seeking for neonatal and infant illnesses and reduced morbidity. Key findings: (a) among neonates with danger signs, seeking treatment from an appropriate provider increased (46.9% vs 29.5%; RR 1.76), and seeking within 24 hours increased (79.7% vs 68.9%; RR 1.14); (b) seeking for local infections from an appropriate provider rose markedly (RR 4.86); (c) for infants, diarrhoea and pneumonia morbidity declined at 6 months (diarrhoea RR 0.71; pneumonia RR 0.73) and at 12 months (diarrhoea RR 0.63; pneumonia RR 0.60); hospital admissions in infancy declined (RR 0.67 at 12 months). Immunisation coverage by 12 months remained low and did not show consistent improvement. Authors conclude that scaling IMNCI through district health systems can improve treatment-seeking and reduce neonatal/infant morbidity, potentially contributing to reductions in neonatal and infant mortality, though the precise mortality effect could not be quantified in this trial.

Limitations

Not blinded; potential bias due to awareness of allocation. Baseline imbalances between clusters (e.g., distance to highway, urbanisation, socioeconomic indicators) despite adjustments. Limited number of clusters; results may be context-specific to Haryana and may not generalise without adaptation. Immunisation coverage did not improve consistently; reliance on caregiver recall for morbidity data may introduce measurement bias.

Abstract

Objective To determine the effect of implementation of the Integrated Management of Neonatal and Childhood Illness strategy on treatment seeking practices and on neonatal and infant morbidity. Design Cluster randomised trial. Setting Haryana, India. Participants 29 667 births in nine intervention clusters and 30 813 births in nine control clusters. Main outcome measures The pre-specified outcome was the effect on treatment seeking practices. Post hoc exploratory analyses assessed morbidity, hospital admission, post-neonatal infant care, and nutritional status outcomes. Interventions The Integrated Management of Neonatal and Childhood Illness intervention included home visits by community health workers, improved case management of sick children, and strengthening of health systems. Outcomes were ascertained through interviews with randomly selected caregivers: 6204, 3073, and 2045 in intervention clusters and 6163, 3048, and 2017 in control clusters at ages 29 days, 6 months, and 12 months, respectively. Results In the intervention cluster, treatment was sought more often from an appropriate provider for severe neonatal illness (risk ratio 1.76, 95% confidence interval 1.38 to 2.24), for local neonatal infection (4.86, 3.80 to 6.21), and for diarrhoea at 6 months (1.96, 1.38 to 2.79) and 12 months (1.22, 1.06 to 1.42) and pneumonia at 6 months (2.09, 1.31 to 3.33) and 12 months (1.44, 1.00 to 2.08). Intervention mothers reported fewer episodes of severe neonatal illness (risk ratio 0.82, 0.67 to 0.99) and lower prevalence of diarrhoea (0.71, 0.60 to 0.83) and pneumonia (0.73, 0.52 to 1.04) in the two weeks preceding the 6 month interview and of diarrhoea (0.63, 0.49 to 0.80) and pneumonia (0.60, 0.46 to 0.78) in the two weeks preceding the 12 month interview. Infants in the intervention clusters were more likely to still be exclusively breast fed in the sixth month of life (risk ratio 3.19, 2.67 to 3.81). Conclusion Implementation of the Integrated Management of Neonatal and Childhood Illness programme was associated with timely treatment seeking from appropriate providers and reduced morbidity, a likely explanation for the reduction in mortality observed following implementation of the programme in this study. Trial registration Clinical trials NCT00474981; ICMR Clinical Trial Registry CTRI/2009/091/000715. show less