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Indian Journal of Community Medicine

Social Audits for Community Action: A tool to Initiate Community Action for Reducing Child Mortality

Author(s): D. Nandan, S.K. Misra, M. Jain, D. Singh, M.Verma, V. Sethi

Vol. 30, No. 3 (2005-07 - 2005-09)


Research question: (i) What is the community's perception (assessment & analysis) of causes underlying neonatal, infant and under five deaths? (ii) What action does the community take thereafter?

Objectives: To stimulate the community to assess and analyze the causes and underlying social delays responsible for neonatal, infant and under five deaths in their villages and subsequently take collective action to prevent these deaths in future using Social Audits for Community Action (SACA).

Design: Retrospective Participatory study.

Setting: Rural community development blocks, district Agra, Uttar Pradesh.

Material and Methods: SACA were conducted in a total of 152 villages of Fathehpur Sikri and Bichpuri blocks of district Agra, U.P. One SACA was conducted in each of the 211 anganwadi catchment areas, wherein 10-15 women from different socioclusters of the community participated in a participatory discussion on issues pertaining to number of births and deaths of children less than five years of age in the last one-year.

Results: 7,656 live births and 749 under-five deaths were reported during the year 2002.The neonatal, infant and under-five mortality rate was 39.4, 73.5 and 85 per 1,000 live births respectively. Hypothermia, pneumonia, birth asphyxia, prematurity and low birth weight emerged as major causes of neonatal deaths. Majority of deaths of infants and children 1-5 years of age were found to have occurred due to severe malnutrition and diarrhoea. The community realized that majority of deaths occurred because of the delay in recognition of the seriousness of problem, delay in taking decision to seek appropriate care and delay in arranging transport/money. Subsequently, behaviour change communication strategies were re-defined to help community assess signs of illness and take preparedness measures to prevent child deaths in future.

Conclusion: Strategies like dialoguing with the community using social audits for community action is a more useful and cost effective approach for initiating behaviour change at community level.

Key words: Social Audits, Social Delays, and Child Mortality


The neonatal, infant and under five mortality rates in Uttar Pradesh (rural) are as high as 56.6, 91.7 and 129.5 per 1,000 live births1. Although studies have reported medical causes underlying deaths of children less than five years of age, growing body of evidence suggests that social causes/delays influence the multi-causality under-five death spectrum2. These social delays include: (i) delay in recognition of seriousness of the problem; (ii) delay in taking decision to seek appropriate care; (iii) delay in arranging transport/money to reach the nearest health facility and (iv) delay in receiving appropriate care at health facility. Hence, for effectively addressing child mortality through appropriate Behaviour Change Communication strategies, medical and social causes need to be viewed and addressed together.

It has been repeatedly demonstrated that communities can make deep and lasting contributions to their own health and well-being and, through example and imitation, to the health and well being of other communities. Thus, if the community is stimulated to participate in group dialogue and action to assess the social and medical causes of deaths they would possibly by group effort, think to devise simpler strategies to prevent them and take action as well to increase control over and to improve their health3. Social Audits for Community action can enable the community to achieve the foresaid objective.

Methodology Study Area: The study was conducted in all the 152 villages of two selected community development blocks viz. Bichpuri and Fatehpur Sikri of district Agra, Uttar Pradesh.

Data Collection: Initially of all the anganwadi centers of 152 villages in two selected blocks were listed and one SACA was conducted in each of the anganwadi catchment area. In each anganwadi area SACA were conducted as participatory discussions with community members. The process encompassed Triple 'A' approach (Assessment, Analysis & Action) with the following steps:

In the first step, for Assessment, the group was asked to recall the total number of childbirths in their respective sociocultural clusters in the last one year.

The second step, involved Analysis of the causes of deaths by the community members.The community group reported in 'local terminology' the causes of death and the symptoms & signs of illness during the illness and at the time of child death, whcih were recorded in 'verbatim'. This was followed by interpretations of the social delays (i.e. recognition of the problem, taking decision to seek advice, arranging transport/ money, or receiving appropriate care at a health facility) by community members lying behind each of these deaths.

In the third step during each SACA (in all anganwadi areas) discussions related to action that needs to be taken for preventing these deaths were also done. Herein participants were asked regarding the preventive measures that could have been taken at family and community level for preventing child.s death.

Data Analysis: Verbatim responses of the community members noted down at the time of SACA were free and analyzed by the investigators. On the bsais of signs and symptoms revealed by the community, medical causes were interpreted by medical staff of Department of S.P.M., S.N. Medical College, Agra.

Results and Discussion

One Social Audit for Community Action was conducted in all 211 anganwadi centers of 152 villages (including hamlets) of the two selected community development blocks. In all a total of 7,656 live births and 749 under-five deaths were revealed in the period between April, 2001 to March, 2002. Of the total deaths, 40.2%, 34.8% and 24.8% deaths were found to be neonatal, infant (1-<12 months) and childhood (1-5 years of age), respectively. NFHS-II data also suggests that neonatal deaths contribute to 46% of all infant deaths1. Community- based studies also report conjectural findings3,4. In the present study, neonatal, infant and under-five mortality rates were revealed as 39.4, 73.5 and 85 per 1,000 live births respectively.

The cause of neonatal, infant and under five deaths as revealed through verbatim responses are delineated in table I-III. These are discussed below:

Table I: Causes of Neonatal Deaths

Medical cause of death and verbatim responses
by the community
N (%)
Low Birth Weight -bahut kamzoor paida hua tha 53 (17.6)
Prematurity -samay se pehlae paida hua 48 (16.0)
Birth Asphyxia -saas nahi li aur paida hotae hi mar gaya 40 (13.5)
Hypothermia -Baccha bahut thanda tha 38 (12.6)
Pneumonia -Pasli chal rahi thi aur tez bukhar tha 38 (12.6)
Congenital abnormality -Absence of limbs at birth/IUGR/ bachae kae pait mein pani bhar gaya 29 (9.7)
Acute Diarrhoea -dasth 10 (3.4)
Neonatal Tetanus -Jara Ulli 17 (5.7)
Birth Injury -delivery kae dauraan bachhae ko chot lagi 8 (2.7)
Neonatal -Peelia 9 (3.1)
Jaundice Neonatal sepsis -naal pak gayi/khal par phora 9 (3.1)
  Total 302 (100.0)

Figure in parentheses indicates percentages

I. Medical Causes:

a) Neonatal Mortality: In the peresent study, low birth weight (17.6%), prematurity (16%), birth asphyxia (13.5%), hypothermia (12.6%) and pneumonia (12.6%) emerged as chief medical causes of neonatal deaths (Table I). Earlier community based studies have reported sepsis (52%), birth asphyxia (20%) and prematurity (15%) as primary causes of neonatal mortality in rural Indian homes4,5. In the present study, hypothermia contributed to 12.6% of neonatal deaths.These findings are conjectural to the community-based studies by Bang et al (Maharashtra) and Kumar et al (Ambala) who reported significant hypothermia (<95OF) in 17% and 19% of rural homes respectively4,7.

b) Infant and under-five mortality: Malnutrition was assessed as a contributing factor in nearly 60% of deaths in children for which infectious diseases is an underlying cause. The incidence of severe malnutrition amongst young children has though declined over the past decade in Uttar Pradesh however still remains a problem of public health significance1,8. In the present study, the chief causes of deaths of infants and children under-five years of age as revealed by social audits were severe malnutriton and diarrhoea respectively

Table II : Causes of Deaths of Infants (1-<12 Months)

Medical cause of death and verbatim responses by the community N (%)
Diarrhoea dasth 64 (24.6)
Pneumonia nak bahna, pasli chalna aur bahut tez bukhar 59 (22.7)
Severe malnutrition sukh gaya tha 57 (21.9)
Measles khasra 11 (4.3)
Jaundice peelia 7 (2.7)
Diptheria gala gothu 2 (0.8)
Cholera haiza/ulti dasth 19 (7.3)
Typhoid meyadi bukhar 7 (2.7)
Others (accident/unknown/congenital abnormality) 26 (10.0)
  Total 261 (100.0)

Figure in parentheses indicates percentages

Table III: Causes of Deaths of Children (1-5 Years of Age)

Medical Causes of Deaths and Responses by the Community N (%)
Diarrhoea dasth 34 (18.3)
Pneumonia nak bahna, pasli chalna aur bahut tez bukhar 15 (13.4)
Severe malnutrition sukh gaya tha 34 (18.3)
Measles khasra 24 (12.9)
Jaundice peelia 2 (1.08)
Diptheria gala gothu 1 (0.5)
Cholera haiza/ulti dasth 16 (8.6)
Typhoid meyadi bukhar 14 (7.6)
High grade fever bahut tez bukhar 19 (10.2)
Others (accident/unknown/congenital abnormality) 24 (12.9)
Total   186 (100.0)

Figure in parentheses indicates percentages

Table IV: Social Delays of Under-Five Mortality

Social Causes of Deaths Number of Deaths
Neonatal Children
(1-11 months)
(1-5 years)
Delay in recognition of seriousness of problem 136 (45.0) 177 (67.8) 104 (55.9)
Delay in taking decision to seek appropriate care 9 (2.9) 6 (2.3) 9 (4.8)
Delay in arranging for transport and money 110 (36.4) 155 (59.4) 89 (47.8)
Delay in receiving care at health facility 4 (1.3) 4 (1.5) 1 (1.0)

Figure in parentheses indicates percentages (Table II-III).

II. Community's Analysis of the Social Causes of under five deaths

In the present study, the social causes/delays for under-five mortality as emerged following discussions with the community during the SACA's. are presented in table IV. It can be evinced that majority of neonatal, infant and under five deaths occurred because of the delay in recognition of the seriousness of problem and arranging for timely transportation. Verbatim responses in this context of a mother of a sick infant with diarrhoea, which is self-explanatory of current practices was: 'kuch din tak to bacchae ko ghar par hi dekhtae rahae, jab baccha sust para hua tha aur khaal sikur gayi to doctor kae paas lae kar gaye.'

III: Action taken by the community after social audits:

Social Audits for Community Action cycle is complete only when the community after their self-assessment and analysis of child deaths takes 'collective action' for prevention of these deaths and in this regard. SACA differs from a verbal autopsy of under-five deaths. In the present study following the social audits for community aciton the community realized and demanded for the need to be aware to identify danger signs of child illnesses.


Participatory Strategies like Social Audits for Community Action that use dialoguing with the community to assess and analysis their present situation, to trigger need for change and take collective action to improve their situation is more useful and cost effective approach. First, it is less time consuming than other methods and focuses on behaviour change at community level. If carried out on ongoing basis, it can also be used as a monitoring tool for child and maternal mortality and secondly, it can be a tool for assessing the training needs and IEC needs of community mobilizers to guide behaviour change promotion in appropriate maternal and child health behaviours. It can also increase the accountability of health services and strengthen local action to promote the involvement of health and other sectors for health development. However, more research needs to be carried out to compare the reliability of data collection using tool as compared to other methods.


We would like to acknowledge UNICEF, Lucknow for providing financial support to community based Maternal Child Health and Nutrition (MCHN) Project at Agra. The study could not have been completed without the generous and willing cooperation of the communities in the project villages, and untiring commitment of project staff and postgraduate students of Department of Social and Preventive Medicine, S.N. Medical College, Agra.


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Deptt. of Social & Preventive Medicine,
S.N. Medical College, Agra-282 002.
E-mail: [email protected]

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