Sustainability and adherence to behaviour change: a cross-sectional 3-year follow-up survey of an innovative Community Mobilisation and Community Incentivisation strategy (CoMIC trial) for child health in rural Pakistan.

backgroundInfectious diseases remain the leading cause of death among children younger than 5 years due to disparities in access and acceptance of essential interventions. 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 Pakistan. This unplanned follow-up study was designed to assess the health effects, adherence to behaviour change, and sustainability of this strategy 3 years after the completion of the trial.

methodsA cross-sectional follow-up study was conducted 3 years after the completion of the CoMIC trial. CoMIC was a three-group, cluster-randomised, controlled trial in rural areas of the Tando Muhammad Khan district in Pakistan. Clusters were randomly assigned (1:1:1) to either community mobilisation and incentivisation, community mobilisation, or the control group. Community mobilisation included formation of village committees who conducted awareness activities, whereas 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, chosen by the village committees, were conditioned on serial incremental targets for collective improvement in coverage at cluster level of three primary outcomes: proportion of fully immunised children, use of oral rehydration solution, and sanitation index. For this follow-up study 3 years after the cessation of original trial activities, survey data were collected between Sept 4 and Nov 24, 2023 on all outcomes from the mothers or caregivers of children younger than 5 years in selected households. Analyses followed the intention-to-treat approach (ie, all eligible participants were analysed according to the original cluster randomisation irrespective of intervention uptake or participation status). Additional survey and observational data were collected from the village committees to assess the usage and sustainability of the incentive. The trial is registered at ClinicalTrials.gov, NCT03594279, and is completed.

findingsBetween Sept 4 and Nov 24, 2023, a total of 5658 children younger than 5 years from 3906 households in 48 clusters (villages) were included in the follow-up survey. 451 (88%) of the 514 water and sanitation facilities constructed as incentives in the trial and 221 (56%) of the 397 village committees remained functional 3 years after they were created as a part of community mobilisation and incentivisation group. Multivariable analysis indicated a higher proportion of fully immmunised children (adjusted risk ratio [RR] 1·20 [95% CI 1·00-1·43]) and a better sanitation index (mean difference 1·12 [95% CI 0·81-1·43]) in the community mobilisation and incentivisation group compared with the control group. There was no evidence of a difference in oral rehydration solution use (adjusted RR 0·99 [95% CI 0·75-1·31]) in the community mobilisation and incentivisation group compared with the control group. An improved sanitation index and increased use of oral rehydration solution was also observed in the community mobilisation group compared with the control group, despite no such differences being observed in the initial trial.

interpretationFindings from this 3-year follow-up of CoMIC suggest that behaviour changes can be sustained after the intervention if there is an active community engagement strategy with conditional benefits that appeal to the community.

fundingBill & Melinda Gates Foundation.