Effectiveness of a Quality Improvement Program Using Difference-in-Difference Analysis for Home Based Newborn Care – Results of a Community Intervention Trial

  • Akhil Dhanesh GoelEmail author
  • Mudita Gosain
  • Ritvik Amarchand
  • Hanspria Sharma
  • Sanjay Rai
  • Suresh K. Kapoor
  • Anand Krishnan
Original Article



To present evaluation of a quality improvement program for Accredited Social Health Activists (ASHAs).


This community intervention trial was conducted in Ballabgarh, India during 2012–2014 with two Primary Health Center (PHC) areas being the intervention areas and two PHC areas being non-intervention areas receiving standard care. Interventions included two-day training in technical and communication skills of ASHAs followed by supportive supervision in the field. Intervention was evaluated by comparing pre and post training scores, feedback from postnatal mothers and a difference-in-difference (DID) analysis on baseline and endline knowledge-practice survey of recently delivered mothers with 95% confidence intervals.


Only 11.1% ASHAs addressed specific barriers for adopting healthy behaviors. Sixty eight (91.8%) ASHAs attended the training after which knowledge improved by 33.3% (p < 0.001). ASHAs in intervention areas were rated by mothers (n = 69) to have better communication skills (81.2% vs. 59.7%, p = 0.005), make more postnatal visits (52.2% vs. 22.2%; p < 0.001), give advice on newborn care (64% vs. 50.5%; p < 0.001) as compared to standard care area ASHAs. Endline survey (n = 1360) showed a significant improvement in frequency of antenatal visits (0.26;0.19–0.33), knowledge about free transport (0.12;0.05–0.18), better cord-care practices (0.15;0.07–0.22), kangaroo mother care (0.19;0.13–0.25), delayed first bath (0.13;0.06–0.20), restrictive handling (0.11;0.06–0.15) and hand-washing (0.19;0.13–0.25).


Quality improvement program can help improve ASHA’s performance which in turn can address higher neonatal mortality in India.


Accredited social health activists Home-based care Neonatal Communication skills Quality improvement program 



UNICEF, District authorities, ENVISION.

Authors’ Contribution

AK, SKK, SR and RA: Conception and design and interpretation of data. ADG, MG and HS: Data acquisition, analysis and interpretation. All authors have contributed towards drafting the work, revising it critically for important intellectual content and have approved the final version to be published. AK is the guarantor for this paper.

Compliance with Ethical Standards

Conflict of Interest


Source of Funding



  1. 1.
    UNICEF. Levels and trends in child mortality 2017. Child Mortality. 2017. Available at: Accessed 5 Mar 2018.
  2. 2.
    Bang AT, Bang RA, Reddy HM. Home-based neonatal care: summary and applications of the field trial in rural Gadchiroli, India (1993 to 2003). J Perinatol. 2005;25:S108–22.CrossRefGoogle Scholar
  3. 3.
    Das E, Panwar DS, Fischer EA, Bora G, Carlough MC. Performance of accredited social health activists to provide home-based newborn care: a situational analysis. Indian Pediatr. 2014;51:142–4.CrossRefGoogle Scholar
  4. 4.
    Neogi SB, Sharma J, Chauhan M, et al. Care of newborn in the community and at home. J Perinatol. 2016;36:S13–7.CrossRefGoogle Scholar
  5. 5.
    About Accredited Social Health Activists (ASHA) - Ministry of Health and Family Welfare, Governnment of India. Available at: Accessed 3 Apr 2018.
  6. 6.
    MoHFW, GOI. Home based newborn care: operational guidelines (revised 2014). New Delhi; 2014.Google Scholar
  7. 7.
    Shrivastava SR, Shrivastava PS. Evaluation of trained accredited social health activist (ASHA) workers regarding their knowledge, attitude and practices about child health. Rural Remote Health. 2012;12:2099.Google Scholar
  8. 8.
    Bajpai N, Dholakia RH. Improving the performance of accredited social health activists in India (Working Paper No. 1). Working Paper Series, Columbia Global Centers, South Asia, Columbia Unversity. 2011.Google Scholar
  9. 9.
    Mahyavanshi DK, Patel MG, Kartha G, Purani SK, Nagar SS. A cross sectional study on knowledge, attitude and practice regarding spacing methods among married women of the reproductive age group in the field practice area of UHTC in surendranagar district. Healthline (ISSN 2229-337X). 2011;2:50–3. Available at: Accessed 3 Apr 2018.
  10. 10.
    Srivastava DK, Prakash S, Adhish V, Nair KS, Gupta S, Nandan D. A study of interface of ASHA with the community and the service providers in Eastern Uttar Pradesh. Indian J Public Health. 2009;53:133–6.Google Scholar
  11. 11.
    Bansal SC, Nimbalkar SM, Shah NA, Shrivastav RS, Phatak AG. Evaluation of knowledge and skills of home based newborn care among accredited social health activists (ASHA). Indian Pediatr. 2016;53:689–91.CrossRefGoogle Scholar
  12. 12.
    Shrivastava A, Srivastava A. Measuring communication competence and effectiveness of ASHAs (accredited social health activist) in their leadership role at rural settings of Uttar Pradesh (India). Leadersh Health Serv (Bradf Engl). 2016;29:69–81.CrossRefGoogle Scholar
  13. 13.
    Kant S, Misra P, Gupta S, et al. The Ballabgarh health and demographic surveillance system (CRHSP-AIIMS). Int J Epidemiol. 2013;42:758–68.CrossRefGoogle Scholar
  14. 14.
    Sharma H, Goel AD, Gosain M, et al. Community healthcare professionals visits are important determinants of knowledge and practices regarding newborn care among mothers. J Nat Sci Biol Med. 2018;9:159–64.CrossRefGoogle Scholar
  15. 15.
    Gosain M, Goel AD, Kharya P, et al. Reduction of neonatal mortality requires strengthening of the health system: a situational analysis of neonatal care services in Ballabgarh. J Trop Pediatr. 2017;63:365–73.Google Scholar
  16. 16.
    Upadhyay RP, Singh B, Rai SK, Anand K. Role of cultural beliefs in influencing selected newborn care practices in rural Haryana. J Trop Pediatr. 2012;58:406–8.CrossRefGoogle Scholar
  17. 17.
    Dean A, Arner T, Sunki G, et al. Epi InfoTM, a database and statistics program for public health professionals. Atlanta, GA, USA: CDC; 2011.Google Scholar
  18. 18.
    IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk: IBM Corp.Google Scholar
  19. 19.
    Wing C, Simon K, Bello-Gomez RA. Designing difference in difference studies: best practices for public health policy research. Annu Rev Public Health. 2018;39:453–69. Scholar
  20. 20.
    Stalin P, Krishnan A, Rai SK, Agarwal RK. ASHAs involvement in newborn care: a feasibility study. Indian Pediatr. 2011;48:897–9.CrossRefGoogle Scholar
  21. 21.
    MoHFW GOI. Status of Accredited social Health Activist (ASHA) Selection and Shortfall from 2013 to 2015; 2016. Available at: Accessed 3 Aug 2018.
  22. 22.
    Zodpey S, Paul VK (AIIMS). State of India’s Newborns (SOIN) 2014- A Report. New Delhi, India; 2014. Available at: 14-9-2014.pdf. Accessed 28 Nov 2014.
  23. 23.
    Poland ML, Giblin PT, Waller JB, Hankin J. Effects of a home visiting program on prenatal care and birthweight: a case comparison study. J Community Health. 1992;17:221–9.CrossRefGoogle Scholar
  24. 24.
    Bhargavi CN, Sharma A. MCH services in Delhi in terms of beneficiaries’ awareness, coverage and satisfaction. Nurs J India. 2014;105:186–90.Google Scholar
  25. 25.
    Sinha LN, Kaur P, Gupta R, Dalpath S, Goyal V, Murhekar M. Newborn care practices and home-based postnatal newborn care programme - Mewat, Haryana, India, 2013. Western Pac Surveill Response J. 2014;5:22–9.CrossRefGoogle Scholar
  26. 26.
    Satishchandra DM, Naik VA, Wantamutte AS, Mallapur MD. Impact of training of traditional birth attendants on the newborn care. Indian J Pediatr. 2009;76:33–6.CrossRefGoogle Scholar
  27. 27.
    Bashour HN, Kharouf MH, Abdulsalam AA, El Asmar K, Tabbaa MA, Cheikha SA. Effect of postnatal home visits on maternal/infant outcomes in Syria: a randomized controlled trial. Public Health Nurs. 2008;25:115–25.CrossRefGoogle Scholar
  28. 28.
    Das A, Chatterjee R, Karthick M, Mahapatra T, Chaudhuri I. The influence of seasonality and community-based health worker provided counselling on exclusive breastfeeding – findings from a cross-sectional survey in India. PLoS One. 2016;11:e0161186.CrossRefGoogle Scholar
  29. 29.
    Edgar T, Volkman JE. Using communication theory for health promotion: practical guidance on message design and strategy. Health Promot Pract. 2012;13:587–90.CrossRefGoogle Scholar

Copyright information

© Dr. K C Chaudhuri Foundation 2019

Authors and Affiliations

  1. 1.Department of Community Medicine and Family MedicineAll India Institute of Medical SciencesJodhpurIndia
  2. 2.Translational Health Science and Technology InstituteFaridabadIndia
  3. 3.Centre for Community MedicineAll India Institute of Medical SciencesNew DelhiIndia
  4. 4.Department of Development Communication and ExtensionDelhi UniversityNew DelhiIndia
  5. 5.Centre for Chronic Disease ControlGurgaonIndia

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