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A Cluster Randomized Controlled Trial

Priyanka Pandey, PhD; Ashwini R. Sehgal, MD; Michelle Riboud, PhD; David Levine, MD, ScD; Madhav Goyal, MD, MPH

JAMA. 2007;298:1867-1875.

Context  A lack of awareness about entitled health and social services may contribute to poor delivery of such services in developing countries, especially among individuals of low socioeconomic status.

Objective  To determine the impact of informing resource-poor rural populations about entitled services.

Design, Setting, and Participants  Community-based, cluster randomized controlled trial conducted from May 2004 to May 2005 in 105 randomly selected village clusters in Uttar Pradesh state in India. Households (548 intervention and 497 control) were selected by a systematic sampling design, including both low-caste and mid- to high-caste households.

Intervention  Four to 6 public meetings were held in each intervention village cluster to disseminate information on entitled health services, entitled education services, and village governance requirements. No intervention took place in control village clusters.

Main Outcome Measures  Visits by nurse midwife; prenatal examinations, tetanus vaccinations, and prenatal supplements received by pregnant women; vaccinations received by infants; excess school fees charged; occurrence of village council meetings; and development work in villages.

Results  At baseline, there were no significant differences in self-reported delivery of health and social services. After 1 year, intervention villagers reported better delivery of several services compared with control villagers: in a multivariate analysis, 30% more prenatal examinations (95% confidence interval [CI], 17%-43%; P < .001), 27% more tetanus vaccinations (95% CI, 12%-41%; P < .001), 24% more prenatal supplements (95% CI, 8%-39%; P = .003), 25% more infant vaccinations (95% CI, 8%-42%; P = .004), and decreased excess school fees of 8 rupees (95% CI, 4-13 rupees; P < .001). In a difference-in-differences analysis, 21% more village council meetings were reported (95% CI, 5%-36%; P = .01). There were no improvements in visits by a nurse midwife or in development work in the villages. Both low-caste and mid- to high-caste intervention households reported significant improvements in service delivery.

Conclusions  Informing resource-poor rural populations in India about entitled services enhanced the delivery of health and social services among both low- and mid- to high-caste households. Interventions that emphasize educating resource-poor populations about entitled services may improve the delivery of such services.

Trial Registration  clinicaltrials.gov Identifier: NCT00421291

Author Affiliations: South Asia Human Development, the World Bank, Washington, DC (Drs Pandey and Riboud); Center for Reducing Health Disparities and Division of Nephrology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio (Dr Sehgal); and the Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland (Drs Levine and Goyal).

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