Team-Based Goals and Incentives for Community-Based Health Workers to Promote Maternal and Child Health in Bihar, India

Use of Team-Based Goals and Incentives to Improve the Performance of Community-Based Health Workers in Promoting Reproductive, Maternal, Newborn and Child Health and Nutrition Behaviors in Bihar, India: A Cluster Randomized Trial

This study is designed to evaluate the impact of team-based goals and performance-based incentives for community-based health workers on health-promoting behaviors among women related to reproductive, maternal, newborn and child health and nutrition in Bihar, India.

The intervention was funded by the Bill and Melinda Gates Foundation (BMGF) and implemented from 2012 to 2014. Health sub-centers in the catchment areas of five blocks (sub-districts) of the district of Bengusarai were randomly assigned to treatment or control arms (38 sub-centers were assigned to each). Data were collected in the Intervention and Control areas from mothers of infants 0-12 months at baseline and at 2.5-year follow-up, to assess the intervention's effects on quality and quantity of FLW home visits, postnatal health behaviors, and among older infants/toddlers, complementary feeding and vaccination. Difference in difference analyses were used to assess outcome effects in this quasi experimental study.

The TBGI intervention was implemented in areas where the BMGF-funded Ananya program (official title: Bihar Family Health Initiative) was also being implemented. Thus, the impact is of the [TBGI intervention + Ananya] versus [Ananya alone]. The Ananya program was developed and implemented via a partnership of BMGF and the Government of Bihar. The ultimate purpose of Ananya was to reduce maternal, newborn, and child mortality; fertility; and child undernutrition in Bihar, India. Ananya involved multi-level interventions designed to build front line health worker (FLW) capacities and reach to communities and households, as well as to strengthen public health facilities and quality of care to improve maternal and neonatal care and health behaviors, and thus survival. It was implemented from 2012 to 2014. Eight focal districts in western and central Bihar received Ananya, while 30 districts did not.

Study Overview

• Status: Completed
• Conditions: Healthy
• Intervention / Treatment: Behavioral: Team-Based Goals and Incentives; Other: Control Condition

• Study Type: Interventional
• Enrollment (Actual): 3581
• Phase: Not Applicable

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 15 years and older (Child, Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Mothers of infants 0-12 months residing in the catchment area of the subcenters (public health facilities)

Exclusion Criteria:

-

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Non-Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Control Arm	Other: Control Condition; Standard of care
Experimental: Intervention arm	Behavioral: Team-Based Goals and Incentives; The intervention included 3 main components. 1) The intervention fostered a sense of team collective responsibility and solidarity (TEAM) by emphasizing the value of teamwork and front-line community health workers (FLWs) reciting a pledge at meetings to serve beneficiaries. 2) To establish goals and coverage targets related to maternal and child health outcomes (GOALs), 7 targets were identified related to delivery preparations, newborn care, exclusive breastfeeding, and family planning. 3) Small non-cash incentives were awarded to FLWs each quarter if their team met greater than 70% of the collective subcenter goals; incentives were most common cookware products (e.g., dish, cooking vessel, steamer). Non-cash incentives also included a certificate of recognition for teams that met their targets in all quarters (INCENTIVES). In the areas of the intervention and control arms, the Ananya program was also underway (see Brief Summary of the project).

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
At least 2 antenatal home visits in final trimester	Assessed via self-report from representative sample of mothers of children aged 0-11 months.	Up to 2.5 years
At least one home visit within 24 hours of delivery, among women who had a home delivery	Assessed via self-report from representative sample of mothers of children aged 0-11 months.	2.5 year follow-up
At least one home visit within 1 week of delivery	Assessed via self-report from representative sample of mothers of children aged 0-11 months.	2.5 year follow-up
Complementary feeding home visit for women with infant 6-11 months old	Assessed via self-report from representative sample of mothers of children aged 0-11 months.	2.5 year follow-up
Postpartum family planning home visits	Assessed via self-report from representative sample of mothers of children aged 0-11 months.	2.5 year follow-up
Obtained phone number for delivery (Frontline worker's (FLW) number, number for private vehicle, number for ambulance, any of the above)	Assessed via self-report from representative sample of mothers of children aged 0-11 months.	2.5 year follow-up
Received 90 IFA tablets	Assessed via self-report from representative sample of mothers of children aged 0-11 months.	2.5 year follow-up
Immediate breastfeeding (within 1 hour of delivery)	Assessed via self-report from representative sample of mothers of children aged 0-11 months.	2.5 year follow-up
Nothing applied to the cord after cutting	Assessed via self-report from representative sample of mothers of children aged 0-11 months.	2.5 year follow-up
Infant age 6-11 months old ate cereal-based meal in previous day	Assessed via self-report from representative sample of mothers of children aged 6-11 months.	2.5 year follow-up
Current use of any modern method of contraception:	Assessed via self-report from representative sample of mothers of children aged 0-11 months.	2.5 year follow-up
Child age 6-11 months old received DPT3 vaccination	Assessed via self-report from representative sample of mothers of children aged 6-11 months.	2.5 year follow-up

Collaborators and Investigators

• Sponsor: Stanford University
• Collaborators: Bill and Melinda Gates Foundation

Study record dates

Study Major Dates

• Study Start (Actual): January 1, 2012
• Primary Completion (Actual): November 30, 2014
• Study Completion (Actual): November 30, 2014

Study Registration Dates

• First Submitted: June 6, 2018
• First Submitted That Met QC Criteria: June 6, 2018
• First Posted (Actual): June 19, 2018

Study Record Updates

• Last Update Posted (Actual): April 19, 2023
• Last Update Submitted That Met QC Criteria: April 17, 2023
• Last Verified: April 1, 2023

More Information

Terms related to this study

• Keywords: health; nutrition; pregnancy; child; infant
• Other Study ID Numbers: TBGI

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No