title: Programmatic effects of a large-scale multiple-micronutrient supplementation trial in Indonesia: using community facilitators as intermediaries for behavior change.
abstract: BACKGROUND
  Clinical trials can serve as an opportunity gateway for enhanced health benefits to the target population, above and beyond the specific intervention being tested.
  
  
  OBJECTIVE
  The Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT), a randomized, controlled clinical trial in Lombok, Indonesia, found that supplementation during pregnancy with multiple micronutrients reduced 90-day infant mortality by nearly 20% as compared with iron-folic acid. This trial was designed as both a program and research trial and used community facilitators to serve as liaisons between the study and the pregnant women. This analysis documents the programmatic impacts of SUMMIT on health-seeking and early infant mortality resulting from community facilitators' field activities.
  
  
  METHODS
  Data on compliance, human resource practices, health-seeking, and health outcomes from the 31,290 SUMMIT enrollees were analyzed.
  
  
  RESULTS
  Overall compliance with either iron-folic acid or multiple micronutrients was high in the program, at 85.0%. Early prenatal care visits increased significantly. Sixty-three percent of primiparous women used a skilled birth attendant (SBA); among multiparous women, the rate of use of a SBA rose from 35% for the last birth to 53%. Use of a SBA resulted in a 30% reduction in early infant mortality (RR, 0.70; 95% CI, 0.59 to 0.83; p < .0001), independently of any reductions due to multiple micronutrients. The community facilitators played a central role in improving health-seeking; however, the quality of the community facilitators' performance was associated with the impact of the micronutrient supplement on infant health. In a subsample of community facilitators, better-performing facilitators were found to markedly improve the overall impact of the multiple micronutrients on early infant mortality (RR, 0.67; 95% CI, 0.49 to 0.92; p = .0117). In contrast, infants of women with poorly performing community facilitators were found to derive no additional benefit from the multiple micronutrients (RR, 1.04; 95% CI, 0.64 to 1.72; p = .8568).
  
  
  CONCLUSIONS
  Systematic enhancements to the quality of implementation of SUMMIT led to significant increases in use of SBAs at delivery, resulting in a 30% reduction in early infant mortality independent of the impact of micronutrient supplementation. Therefore, if women were to consume multiple micronutrients on a regular basis and were to use a SBA at delivery, the risk of early infant mortality could be reduced by nearly 50%. The impacts of community facilitators in effecting changes in women's health behaviors are notable and are applicable to other health programs. Enhancements to program implementation should be driven by evidence, be accountable to the communities the program serves, and be evaluated on the basis of measurable gains in health for women and children.
authors.affiliation: SUMMIT Institute of Development, Gedung Pusat Penelitian Bahasa dan Kebudayaan (P2BK), University of Mataram, Jalan Pendidikan No. 37, Mataram, NTB, Indonesia. avshanka@jhsph.edu
authors.forename: Anita V
authors.initials: AV
authors.lastname: Shankar
authors.forename: Zaitu
authors.initials: Z
authors.lastname: Asrilla
authors.forename: Josephine K
authors.initials: JK
authors.lastname: Kadha
authors.forename: Susy
authors.initials: S
authors.lastname: Sebayang
authors.forename: Mandri
authors.initials: M
authors.lastname: Apriatni
authors.forename: Ari
authors.initials: A
authors.lastname: Sulastri
authors.forename: Euis
authors.initials: E
authors.lastname: Sunarsih
authors.forename: Anuraj H
authors.initials: AH
authors.lastname: Shankar
mesh_terms: D003150:Community Health Workers / Q000592:standards*; D003677:Deficiency Diseases / Q000178:diet therapy*; D019587:Dietary Supplements; D005260:Female; D005492:Folic Acid / Q000627:therapeutic use; D005494:Folic Acid Deficiency / Q000178:diet therapy; D006293:Health Promotion; D006301:Health Services Needs and Demand; D006801:Humans; D015994:Incidence; D007214:Indonesia / Q000453:epidemiology; D007226:Infant Mortality; D007231:Infant, Newborn; D007501:Iron / Q000627:therapeutic use; D000090463:Iron Deficiencies; D019266:Iron, Dietary / Q000008:administration & dosage; D018977:Micronutrients / Q000172:deficiency / Q000627:therapeutic use*; D010298:Parity; D010349:Patient Compliance; D011247:Pregnancy; D011295:Prenatal Care / Q000379:methods* / Q000706:statistics & numerical data; D011361:Professional Competence
chemical_list: D019266:Iron, Dietary; D018977:Micronutrients; D005492:Folic Acid; D007501:Iron