An Innovative Community Mobilisation and Community Incentivisation for Child Health in Rural Pakistan (CoMIC): A Cluster-randomised, Controlled Trial

"Community mobilisation and incentivisation led to enhanced acceptance evidenced by improved community behaviours and increased coverage of essential interventions for child health."

The Community Mobilisation and Community Incentivisation (CoMIC) trial was designed to evaluate a customised community mobilisation and incentivisation strategy for improving coverage of evidence-based interventions for child health in polio-endemic Pakistan. It is based on the recognition that behaviour change interventions should ensure active engagement and adapt context-specific strategies to facilitate change (bottom-up approach) for sustainable improvement. Such an approach could be especially useful to aid with multifaceted issues related to child health, including vaccine hesitancy and healthcare seeking.

CoMIC was a three-arm cluster-randomised, controlled trial conducted in the rural areas of Tando Muhammad Khan district in the province of Sindh, Pakistan. Clusters were formed by grouping villages based on geographical proximity and ethnic consistency. Clusters, which had 1,500-3,000 people each, were randomly assigned (1:1:1) to either community mobilisation, community mobilisation and incentivisation, or the control arm.

The first intervention arm of community mobilisation involved awareness and mobilisation activities, and findings from the formative phase (see Related Summaries, below) guided the development of educational materials and video messages. The villagers, through consensus, formed separate male and female village committees of 6-8 members in each cluster. The study team conducted a 6-day training for these village committee members on specific messages in line with the study objectives of improving uptake of interventions (e.g., immunisation, breastfeeding, nutrition, and care-seeking practices for childhood diarrhoea and pneumonia). Village committees were then responsible for carrying out community mobilisation activities in every village and school in their catchment area; every month for the first 6 months, every 2 months for the next 6 months, and quarterly in the second year. Community mobilisation activities included distribution of educational materials (posters, pictorial brochures, flip charts, and promotional videos in local language), community meetings, and health and awareness sessions in communities and schools.

Clusters in the community mobilisation and incentivisation group were provided with a novel conditional, collective, community-based incentive (C3I) in addition to community mobilisation. C3I was conditioned on serial incremental targets for collective improvement in coverage at cluster level of three key indicators (primary outcomes): proportion of fully immunised children, use of oral rehydration solution, and sanitation index, assessed at 6 months, 15 months, and 24 months. Village committees decided on non-cash incentives (e.g., water and sanitation facilities) for people in the villages.

Clusters in the standard care control arm continued to receive routine child health care and sanitation management through existing structures and facilities.

Data were analysed as intention-to-treat by an independent team masked to study groups.

Between October 1 2018 and October 31 2020, 21,638 children younger than 5 years from 24,846 households, with a total population of 139,005 in 48 clusters, were included in the study. 16 clusters comprising of 152 villages and 7,361 children younger than 5 years were randomly assigned to the community mobilisation and incentivisation group; 16 clusters comprising of 166 villages and 7,546 children younger than 5 years were randomly assigned to the community mobilisation group; and 16 clusters comprising of 139 villages and ,6731 children younger than 5 years were randomly assigned to the control group. Endline analyses were conducted on 3,812 children (1,284 in the community mobilisation and incentivisation group, 1,276 in the community mobilisation group, and 1,252 in the control group).

Multivariable analysis indicates improvements in all primary outcomes including a higher proportion of fully immunised children (risk ratio [RR] 1.3 [95% confidence interval (CI) 1.0-1.5]), higher total sanitation index (mean difference 1.3 [95% CI 0.6-1.9]), and increased oral rehydration solution use (RR 1.5 [1.0-2.2]) in the community mobilisation and incentivisation group compared with the control group at 24 months. In fact, the difference-in-differences analysis found evidence for an intervention effect in the community mobilisation and incentivisation group when compared with the control group for all primary and most secondary outcomes. However, there was no evidence for differences between the community mobilisation group and the control group except for exclusive breastfeeding, which was higher in the community mobilisation group.

Thus, "C3I could potentially act as an impetus for bringing change in community behaviours when these benefits are community driven, offered on serial incremental targets and conditioned on behaviour change...Results from the CoMIC trial suggest that the community is ready to invest if they decided on the incentives, as was evident in the 36% of cost sharing against the target of 25% through providing labour, land, and supplies. These community-driven incentives delivered in the CoMIC trial...not only promoted ownership and sustainability but can have multifold benefits by improving the general sanitation and health status and wellbeing of the communities."

Per the researchers, the "CoMIC trial had some built-in features to ensure sustainability in the design phase: for example, incorporating formative research to understand community motives and emotions that led to community itself being a driver and supporter of behaviour change, and the community further contributing towards labour and land provision for the incentives that translated into community ownership of the incentive and potential future sustainability. However, further studies will be needed to assess the cost-effectiveness and long-term sustainability of such strategies..."

In conclusion: "The CoMIC trial provides important insights for designing context-specific, community-directed interventions for child health at a larger scale and has the potential to inform policy and future implementation of programmes targeting behaviour change....The findings...have the potential to inform future programmes targeting behaviour change guidelines not only in Pakistan but also in similar low-income and middle-income countries with a high burden of childhood morbidity and mortality."

Editor's note: The following protocol studies may be consulted for further reading:

• "Community Mobilization and Community Incentivization (CoMIC) Strategy for Child Health in a Rural Setting of Pakistan: Study Protocol for a Randomized Controlled Trial", by Jai K. Das, Rehana A. Salam, Arjumand Rizvi, Sajid B. Soofi, and Zulfiqar A. Bhutta. Methods and Protocols 2023, 6(2), 30; https://doi.org/10.3390/mps6020030.
• "The Last Mile - Community Engagement and Conditional Incentives to Accelerate Polio Eradication in Pakistan: Study Protocol for a Quasi-Experimental Trial", by Jai K. Das, Amira Khan, Farhana Tabassum, Zahra Ali Padhani, Atif Habib, Mushtaq Mirani, Abdu R. Rahman, Zahid Ali Khan, Arjumand Rizvi, Imran Ahmed, and Zulfiqar Bhutta. Methods and Protocols 2023, 6(5), 83; https://doi.org/10.3390/mps6050083.
   

Full list of authors, with institutional affiliations: Jai K Das; Aga Khan University; Rehana A Salam, The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW; Zahra Ali Padhani, University of Adelaide; Arjumand Rizvi, Aga Khan University; Mushtaq Mirani, Aga Khan University; Muhammad Khan Jamali, Aga Khan University; Imran Ahmed Chauhadry, Aga Khan University; Imtiaz Sheikh, Aga Khan University; Sana Khatoon, Aga Khan University; Khan Muhammad, Aga Khan University; Rasool Bux, Aga Khan University; Anjum Naqvi, Aga Khan University; Fariha Shaheen, Aga Khan University; Rafey Ali, Aga Khan University; Sajid Muhammad, Aga Khan University; Prof Simon Cousens,London School of Hygiene & Tropical Medicine; Prof Zulfiqar A Bhutta, Aga Khan University and The Hospital for Sick Children