Promoting women's and children's health through community groups in low-income and middle-income countries: a mixed-methods systematic review of mechanisms, enablers and barriers

The EMERGE framework to measure empowerment for health and development

RATIONALE

Women's empowerment is a UN Sustainable Development Goal and a focus of global health and development but survey measures and data on gender empowerment remain weak. Existing indicators are often disconnected from theory; stronger operationalization is needed.

OBJECTIVE

We present the EMERGE Framework to Measure Empowerment, a framework to strengthen empowerment measures for global health and development.

METHOD

We initiated development of this framework in 2016 as part of EMERGE - an initiative designed to build the science of survey research and availability of high-quality survey measures and data on gender empowerment. The framework is guided by existing theories of empowerment, evidence, and expert input. We apply this framework to understand women's empowerment in family planning (FP) via review of state of the field measures.

RESULTS

Our framework offers concrete measurable constructs to assess critical consciousness and choice, agency and backlash, and goal achievement as the empowerment process, recognizing its operation at multiple levels-from the individual to the collective. Internal attributes, social norms, and external contexts and resources create facilitators or barriers to the empowerment process. Review of best evidence FP measures assessing empowerment constructs, social norms, and key influencers (e.g., partners and providers) show a strong landscape of measures, including those with women, partners, and providers, but they are limited in assessing translation of choice to agency to achievement of women's self-determined fertility or contraceptive goals, instead relying on assumption of contraceptive use as the goal. We see no measures on collective empowerment toward women's reproductive choice and rights.

CONCLUSION

The EMERGE Framework can guide development and analysis of survey measures on empowerment and is needed as the current state of the field shows limited coverage of empowerment constructs even in areas which have received more study, such as family planning.

Equity and empowerment effects: Multiple styles of 'voluntarism' in community-based health projects

Community health workers (CHW) are individuals with no formal health training who perform various roles to address health disparities. There are long-sustained debates over how different forms of incentives shape CHW programs, which are often staffed with volunteer or minimally remunerated women. These debates are complicated by the diversity of CHW roles and contexts in which they work. Evidence is particularly scant around "change-agent" style CHWs, who shape health knowledge and norms within their community. This paper addresses this gap through an analysis of a change agent-staffed program that provided nutrition participatory education through women's groups in three eastern Indian sites. We examine how contextual factors across sites shaped change-agent management, and analyze the implications of each approach for efficacy, empowerment, and equity. Analyzing 68 interviews and 10 focus groups this study advances a typology of 'varieties' of voluntarism that we name laissez faire, active-cultivation, and honorarium-accountability, and uses comparative analysis to examine the equity and empowerment effects within selection, management, and payment. First, we find tensions in the community-based selection of volunteers because rather than selecting highly motivated women, groups selected women in the most favorable socioeconomic position to volunteer. Second, there is a tension around responsibility and expectations in that greater training and responsibility leads women to see more psychosocial empowerment (e.g., knowledge, confidence), but also may create more 'costs' to participation and leads to wider economic inequities in change-agent ranks. Third, we observe a misplaced focus on payments as central to change-agent motivation. While the two volunteer-only sites see payment as 'the answer' to motivation problems, the honorarium site sees payments as 'the problem' because they attract less intrinsically motivated individuals. We conclude that while payments may not make an unmotivated volunteer into a motivated one, this analysis suggests payments would potentially allow more marginalized women to participate, which may be key to making more equitable and efficacious impacts.

Strengthening theories of change in women's group interventions to improve learning

Background

Supporting women's groups is increasingly seen as an important intervention strategy for advancing women's empowerment, economic outcomes, and family health in low- and middle-income countries. We argue that learning from investments in women's group platforms is often limited by the lack of a well-articulated, evaluable theory of change (ToC) developed by those designing the programmes.

Methods

We first identify a simple set of steps important to specifying a ToC that is evaluable and supports learning (what could be done). We then propose a framework in which we hope social scientists can find a common starting point (reconciling what could be and is being done). The framework emphasises identifying untested assumptions around pathways for introducing and adopting new knowledge, opportunities, technologies, interventions or implementation approaches, and pathways from group participation to behaviour change. Finally, we apply this framework to a portfolio of 46 women's groups investments made by the Bill and Melinda Gates Foundation between 2005 and 2017 to understand the prevalence and clarity of their grantees' theories of change (some of what is done).

Results

The majority of the investment documents reviewed did not make clear the embedded assumptions or hypothesised pathways from decisions to join a group, to women's group participation, to behaviour change and and whether pathways are connected or work independently.

Conclusions

We use an example from an actual investment to illustrate how this framework can support accounting for assumptions in the ToC used to guide the evaluation, the testing and measuring of mechanisms assumed to be driving behaviour change and disentangling the effects of implementationfrom context. A ToC for group-based programmes should specify in what capacities the group-based model is essential to the hypothesised pathways of impact vs. its role as an efficient delivery mechanism for programmes that would potentially generate impacts even if delivered directly to individuals. In addition, without fully specifying the motivation for individuals to change behaviour in terms of their risk/return calculus and testing underlying assumptions, we miss an opportunity to better understand the pathways for how the programme influences or fails to influence individuals' health behaviours. However, fully specifying (and measuring) every link in the programme's ToC is not costless. We present suggestions for developing ToCs with testable hypotheses that foster learning about why a women's group intervention achieved or failed to achieve its intended impact.

How does participatory research work: protocol for a realist synthesis

INTRODUCTION

Participatory research science deals with partnerships underlying research, governance and ownership of research products. It is concerned with relationships behind research objectives and methods. Participatory research has gained significant traction in design of health interventions, contextualising these to local settings and stakeholder groups. Despite a massive increase in participatory research exercises, the field remains undertheorised, and the mechanisms for improving health outcomes remain unclear. This realist review seeks to understand how and under what circumstances participatory research impacts health and social outcomes.

METHODS AND ANALYSIS

The review will follow four steps: (1) searching for and selecting evidence, (2) assessing the quality of evidence, (3) extracting and categorising data and (4) synthesising the data in the form of context-mechanism-outcomes configurations. The review will follow the Realist And Meta Narrative Evidence Syntheses: Evolving Standards (RAMESES) II guidelines for reporting realist evaluations. We categorise and synthesise data in four steps: (1) identifying outcomes, (2) identifying contextual components of outcomes, (3) theoretical redescription (abduction) and (4) identifying mechanisms. A retroductive analysis will identify mechanisms by moving between empirical data and theories, using inductive and deductive reasoning to explain the outcomes-context matches. The output will generate middle-range theories on how participatory research works, for whom and under what circumstances.

ETHICS AND DISSEMINATION

This study is a review of a published literature. It does not involve human participants. We will convene a workshop to share and discuss the preliminary results with partners and key stakeholders involved in participatory health research. We will publish the review results in peer-reviewed journals and academic conferences.

Women's groups, covariate shocks, and resilience: An evidence synthesis of past shocks to inform a response to COVID-19

Background: Interventions with women's groups are increasingly seen as an important strategy for advancing women's empowerment, health, and economic outcomes in low- and middle-income countries, with the potential to increase the resiliency of members and their communities during widespread covariate shocks, such as coronavirus disease 2019 (COVID-19). Methods: This evidence synthesis compiles evidence from past shocks on women's group activities and the extent to which women's groups mitigate the effects of shocks on members and communities. We reviewed 90 documents from academic databases, organizational reports, and additional gray literature, and included literature diverse in geography, type of women's group, and shock. Results: The literature suggests that covariate shocks tend to disrupt group activities and reduce group resources, but linkages to formal institutions can mitigate this impact by extending credit beyond the shock-affected resource pool. Evidence was largely supportive of women's groups providing resilience to members and communities, though findings varied according to shock severity, group purpose and structure, and outcome measures. Further, actions to support individual resilience during a shock, such as increased payment flexibility, may run counter to group resilience. The findings of the evidence synthesis are largely consistent with emerging evidence about women's groups and COVID-19 in South Asia and sub-Saharan Africa. Conclusions: We finalize the paper with a discussion on policy implications, including the importance of sustainable access to financial resources for women's group members; equity considerations surrounding the distribution of group benefits and burdens; and the potential for meaningful partnerships between women's groups and local governments and/or non-governmental organizations (NGOs) to enhance community response amidst crises.

Behaviour change interventions improve maternal and child nutrition in sub-Saharan Africa: A systematic review

Evidence that nutrition-specific and nutrition-sensitive interventions can improve maternal and child nutrition status in sub-Saharan Africa is inconclusive. Using behaviour change theory and techniques in intervention design may increase effectiveness and make outcomes more predictable. This systematic review aimed to determine whether interventions that included behaviour change functions were effective. Six databases were searched systematically, using MeSH and free-text terms, for articles describing nutrition-specific and nutrition-sensitive behaviour change interventions published in English until January 2022. Titles, abstracts and full-text papers were double-screened. Data extraction and quality assessments followed Centre for Reviews and Dissemination guidelines. Behaviour change functions of interventions were mapped onto the COM-B model and Behaviour Change Wheel. PROSPERO registered (135054). The search yielded 1193 articles: 79 articles met inclusion criteria, ranging from low (n = 30) to high (n = 11) risk of bias. Many that applied behaviour change theory, communication or counselling resulted in significant improvements in infant stunting and wasting, household dietary intake and maternal psychosocial measures. Interventions with >2 behaviour change functions (including persuasion, incentivisation, environmental restructuring) were the most effective. We recommend incorporating behaviour change functions in nutrition interventions to improve maternal and child outcomes, specifically drawing on the Behaviour Change Wheel, COM-B model (SORT B recommendation). To enhance the designs of these interventions, and ultimately improve the nutritional and psychosocial outcomes for mothers and infants in sub-Saharan Africa, collaborations are recommended between behaviour change and nutrition experts, intervention designers, policy makers and commissioners to fund and roll-out multicomponent behaviour change interventions.

Implementation characteristics of father-inclusive interventions in low- and middle-income countries: A systematic review

Although prior reviews have documented the effectiveness of engaging male caregivers in early childhood interventions, little is known about how these interventions have been designed and implemented to reach, engage, and support male caregivers in low-resource global settings. We searched five bibliographic databases for intervention studies that engaged male caregivers to improve nurturing care for children under 5 years of age in low- and middle-income countries. Forty-four articles met the inclusion criteria, which represented 33 interventions. Fathers specifically were the most common type of male caregivers targeted in these interventions. The majority of interventions invited fathers to participate alongside their female partners. Community-based peer-groups were the most common delivery model. Most interventions used the same program structure for fathers as applied to mothers, with few considering whether implementation adaptations were needed for men. Intervention curricula were multicomponent and largely targeted child nutrition, health, and couples' relationships. A minority of programs addressed parenting, psychosocial wellbeing, violence prevention, gender attitudes, or economic support. Behavior change techniques were limited to interactive counseling and peer learning. Male caregivers remain missing from caregiving interventions for young children. A greater focus on implementation research can inform better inclusion, engagement, and support for male caregivers in nurturing care interventions.

Identifying the association of women’s empowerment with reproductive and maternal health practices using a cross-sectional study in the context of self-help groups in rural India

Background: Globally, women’s empowerment is captured through different combinations of indicators related to their collective and individual empowerment. In this paper, the association of diverse domains related to women’s collective and individual empowerment on their reproductive and maternal health practices were assessed. Collective empowerment referred to a cluster of indicators measuring mutual support, rights, and access to services women received, as a result of membership in self-help groups (SHGs) focused on micro-finance activities. Women’s individual empowerment was measured through their perception to make decisions on their own, be mobile, financially self-reliant, self-confident in expressing themselves, having self-esteem and being free from spousal violence. Methods: Cross-sectional data were collected in 2017 from 2,197 SHG members across 57 administrative blocks of Uttar Pradesh, India. Using exploratory and confirmatory factor analysis, the sub-domains of individual and collective empowerment were developed. The reproductive and maternal health indicators included antenatal care, delivery preparedness, postnatal care and current contraceptive use. Bivariate and multivariate analyses, using logistic regression, were carried out to measure the association of sub-domains of women’s empowerment with health practices. Results: Collective and individual empowerment were independently and jointly associated with correct health practices. Women with greater empowerment through independent mobility, high self-esteem, access to financial resources, and confidence in interacting with a frontline worker, were more likely to access antenatal care. Similarly, delivery preparedness—which entailed deciding on the place of delivery, arranging for transportation during labor, and managing expenses for the delivery—was positively influenced by collective support from fellow SHG members. Receiving postnatal care was positively associated with self-confidence and financial autonomy, and current family planning method use was positively associated with self-confidence, lower spousal violence and confidence in support from the group. Conclusions: Women’s collective and individual empowerment were independently and jointly positively associated with health outcomes among SHG members.

Popular interventions to enhance sustained attention in children and adolescents: A critical systematic review

There are a myriad of interventions promoting activities designed to help enhance sustained attention in children and adolescents. In this systematic review, we critically evaluate the evidence behind three popular sustained attention training approaches - cognitive attention training, meditation, and physical activity. Seven databases were searched in addition to secondary searches. Cognitive attention training, meditation training or physical activity intervention studies aimed at improving sustained attention (randomised-controlled or non-randomised-controlled designs) in samples of children and adolescents (3-18 years) were included. We screened 3437 unique articles. Thirty-seven studies satisfied inclusion criteria. In general, cognitive attention training (n = 14) did not reliably improve sustained attention. Physical activity (n = 15) and meditation interventions (n = 8) demonstrated somewhat more potential in enhancing sustained attention, but these effects should be considered preliminary and need to be replicated with greater methodological rigour. Cognitive attention training demonstrated very limited transfer to other aspects of attention. Notably, mindfulness training had rather consistent positive effects on selective attention. Across all three intervention types, there was very weak evidence for transfer to other aspects of cognition, behaviour, and academic achievement. The paper concludes with methodological recommendations for future studies to strengthen the evidence base.

Love in the Time of War: Identifying Neighborhood-level Predictors of Intimate Partner Violence from a Longitudinal Study in Refugee-hosting Communities

A high prevalence of intimate partner violence (IPV) has been documented among women living in conflict-affected and refugee-hosting areas, but why this occurs is not well understood. Conflict and displacement deteriorate communities' social cohesion and community connectedness; these neighborhood social environments may influence individual IPV outcomes. We explored neighborhood-level social disorganization and cohesion as predictors of recent IPV in refugee-hosting communities in northern Ecuador by conducting multi-level logistic regression on a longitudinal sample of 1,312 women. Neighborhood social disorganization was marginally positively associated with emotional IPV (AOR: 1.17, 95% CI: .99, 1.38) and physical and/or sexual IPV (AOR: 1.20, 95% CI: .96, 1.51). This was partially mediated by neighborhood-level civic engagement in the case of emotional IPV. At the household level, perceived discrimination and experience of psychosocial stressors were risk factors for both types of IPV, whereas social support was protective. To our knowledge, this is one of the first studies to examine how neighborhood social factors influence IPV outcomes in refugee-hosting communities or in South America. As the world grapples with the largest number of displaced people in history, this research can inform prevention and response programming and reinforces the critical importance of promoting acceptance of refugees and immigrants and positively engaging all community members in civic life in refugee-hosting settings.

Zooming in and out: a holistic framework for research on maternal, late foetal and newborn survival and health

Research is needed to understand why some countries succeed in greater improvements in maternal, late foetal and newborn health (MNH) and reducing mortality than others. Pathways towards these health outcomes operate at many levels, making it difficult to understand which factors contribute most to these health improvements. Conceptual frameworks provide a cognitive means of rendering order to these factors and how they interrelate to positively influence MNH. We developed a conceptual framework by integrating theories and frameworks from different disciplines to encapsulate the range of factors that explain reductions in maternal, late foetal and neonatal mortality and improvements in health. We developed our framework iteratively, combining our interdisciplinary research team's knowledge, experience and review of the literature. We present a framework that includes health policy and system levers (or intentional actions that policy-makers can implement) to improve MNH; service delivery and coverage of interventions across the continuum of care; and epidemiological and behavioural risk factors. The framework also considers the role of context in influencing for whom and where health and non-health efforts have the most impact, to recognize 'the causes of the causes' at play at the individual/household, community, national and transnational levels. Our framework holistically reflects the range of interrelated factors influencing improved MNH and survival. The framework lends itself to studying how different factors work together to influence these outcomes using an array of methods. Such research should inform future efforts to improve MNH and survival in different contexts. By re-orienting research in this way, we hope to equip policy-makers and practitioners alike with the insight necessary to make the world a safer and fairer place for mothers and their babies.

Economies of scale of large-scale international development interventions: Evidence from self-help groups in India

Livelihoods and microfinance programs for women often show reduced impacts after scale-up. Yet, program scale-up may reduce average per capita costs and maintain cost-effectiveness despite lower impact. This paper presents evidence on the association between program scale, costs, and cost-effectiveness by analyzing how the costs of a large-scale Self-Help Group (SHG) program in India changed from its inception in 2007 to its scale-up in 2019. We use expenditure data from program's audit statements of Jeevika - the Bihar Rural Livelihoods Promotion Society - and find that a 1% increase in program membership was associated with a 0.6% increase in annual program expenditures, indicating large economies of scale. Predicted costs from regressions suggest that the annual per capita program expenditures declined from $29 when the program covered 100,000 members to $5 when it reached 10 million members. Previous impact evaluations of Jeevika showed sizeable but smaller substitutions away from high-cost debt after scale-up than during the pilot, but we found that economies of scale led to similar cost-effectiveness ratios for this outcome. We also found that formation of higher-level federations is associated with lower marginal costs than setting up SHGs. However, previous evidence suggests that Jeevika did not generate average impacts on women's agency and asset ownership after scale-up. Building on a rich history of research on Jeevika, we argue that program implementers must identify key success factors in pilot programs to minimize tradeoffs between cost savings and potentially reduced impacts after scale-up. Further, we suggest investments in linking SHGs to federations to improve the cost-effectiveness of SHGs.

Collective efficacy measures for women and girls in low- and middle-income countries: a systematic review

Background

Prior research has shown collective efficacy to be a key determinant of women’s well-being. However, much of the work around measuring this construct has been done in high-income geographies, with very little representation from low- and middle-income countries (LMIC). To fill this gap, and guide future research in low resource settings, we aim to summarize best evidence measures of collective efficacy for women and girls from LMICs.

Methods

Following PRISMA guidelines, we systematically searched five databases for English language peer-reviewed literature on measures of collective efficacy, published between 1 January 2009 and 25 August 2020. In addition, we sought expert input for relevant papers in this area. Research staff screened titles, abstracts, and full-text articles in a double-blind review. Inclusion criteria were: (i) original quantitative analysis, and (ii) sample limited to women/girls only (≥ 100), residing in LMICs.

Results

We identified 786 unique articles, 14 of which met inclusion criteria. Eligible studies captured a diversity of population groups, including pregnant women, recent mothers, adolescent girls, and female sex workers, from across national settings. Two broad constructs of collective efficacy were captured by the measures: (i) group dynamics, and (ii) collective action. All 14 studies included items on group dynamics in their measures, whereas seven studies included items on collective action. Four studies validated new measures of collective efficacy, and seven provided evidence supporting the relationship between collective efficacy and outcomes related to women’s well-being. Overall, measures demonstrated good reliability and validity when tested, and those testing for associations or effects found a positive relationship of collective efficacy with women’s health behaviors.

Conclusion

The past decade has resulted in a number of new collective efficacy measures demonstrating good validity in terms of their associations with key health outcomes among women and girls from across LMIC settings, but there remains no standard measure in the field. Those that exist focus on group dynamics, but less often on collective action. A standard measure of collective efficacy inclusive of group dynamics and collective action can support better understanding of the value of women’s collectives across national settings and populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01688-z.

Self-reliance or social accountability? The raison d'être of community health committees in Nigeria

Social justice requires that communities demand social accountability. We conducted this study to inform ongoing efforts to facilitate social accountability through community health committees in Nigeria. We theorised that committees may see themselves in two ways - as outwardly-facing ('social accountability') and/or as inwardly-facing ('self-reliance'). We analysed the minutes of their meetings, alongside interviews and group discussions with committee members, community members, health workers, and health managers in four states across Nigeria. The committees' raison d'être reflects a bias for self-reliance in three ways. First, seen as a platform for the community to co-finance health services, members tend to be the local elite who can make financial contributions. Second, in a one-sided relationship, they function more to achieve the goals of governments (e.g. to improve the uptake of services), than of the community (e.g. rights-based demands for government support). Third, their activities in the community reflect greater concern to ensure that their community makes the most of what the government has already provided (e.g. helping to drive the uptake of existing services) than asking for more. Optimising the committees for social accountability may require support by actors who do not have conflicts of interests in ensuring that they have the necessary information and strategies to demand social accountability.

Experiences Engaging Family Members in Maternal, Child, and Adolescent Nutrition: A Survey of Global Health Professionals

BACKGROUND

Family members influence maternal, child, and adolescent nutrition and are increasingly engaged in nutrition interventions and research. However, there remain gaps in the literature related to programmatic experiences and lessons learned from engaging these key influencers in nutrition activities.

OBJECTIVES

This research aimed to document global health professionals' experiences engaging family members in nutrition activities, and their perceived barriers, facilitators, and recommendations for nutrition activities that engage family members.

METHODS

Global health and nutrition professionals were invited to complete an online survey about their experiences engaging family members in nutrition activities. The survey included 42 multiple-choice questions tabulated by frequency and 4 open-response questions, which were analyzed thematically.

RESULTS

More than 180 respondents (n = 183) in 49 countries with experience engaging fathers, grandmothers, and other family members in nutrition activities participated in the survey. Participants highlighted the importance of conducting formative research with all members of the family system and using participatory processes in intervention design and implementation. Respondents reported engaging family members increases support for recommended behaviors, improves program sustainability, and facilitates family and community ownership. Some respondents also shared experiences with positive and negative unintended consequences when engaging family members; for example, one-fifth of participants reported that mothers were uncomfortable with involving men in discussions. Common challenges centered on limited resources for program delivery, not involving all influential family members, and traditional gender norms. Recommendations included incorporating family members in the project design phase and ensuring sufficient project resources to engage family members throughout the project lifecycle.

CONCLUSIONS

Surveying global health professionals provides an opportunity to learn from their experiences and fill gaps in the peer-reviewed literature to strengthen intervention design and implementation. Community ownership and sustainability emerged as key benefits of family engagement not previously reported in the literature, but responses also highlighted potential negative unintended consequences.

Exploring the Role of Social Networks in Facilitating Health Service Access Among Low-Income Women in the Philippines: A Qualitative Study

Despite efforts to implement universal health care coverage (UHC) in the Philippines, income poor households continue to face barriers to health care access and use. In light of recent UHC legislation, the aim of this study was to explore how gender and social networks shape health care access and use among women experiencing poverty in Negros Occidental, Philippines. Semi-structured interviews were conducted with women (n = 35) and health care providers (n = 15). Descriptive statistical analyses were performed to report demographic information. Interview data were analyzed thematically using a hybrid deductive-inductive approach and guided by the Patient-Centred Access to Health Care framework. Women’s decisions regarding health care access were influenced by their perceptions of illness severity, their trust in health care facilities, and their available financial resources. Experiences of health care use were shaped by interactions with health professionals, resource availability at facilities, health care costs, and health insurance acquisition. Women drew upon social networks throughout their lifespan for social and financial support to facilitate healthcare access and use. These findings indicate that social networks may be an important complement to formal supports (eg, UHC) in improving access to health care for women experiencing poverty in the Philippines.

The power of the collective empowers women: Evidence from self-help groups in India

Women's groups are important rural social and financial institutions in South Asia. In India, a large majority of women's groups programs are implemented through self-help groups (SHGs). Originally designed as savings and credit groups, the role of SHGs has expanded to include creating health and nutrition awareness, improving governance, and addressing social issues related to gender- and caste-based discrimination. This paper uses panel data from 1470 rural Indian women from five states to study the impact of SHG membership on women's empowerment in agriculture, using the project-level Women's Empowerment in Agriculture Index (pro-WEAI) and the abbreviated Women's Empowerment in Agriculture Index (A-WEAI). Because SHG membership was not randomized and women who self-select to be SHG members may be systematically different from non-members, we employ nearest neighbor matching methods to attribute the impact of SHG membership on women's empowerment in agriculture and intrahousehold inequality. Our findings suggest that SHG membership has a significant positive impact on aggregate measures of women's empowerment and reduces the gap between men's and women's empowerment scores. This improvement in aggregate empowerment is driven by improvements in women's scores, not a deterioration in men's. Greater control over income, greater decisionmaking over credit, and (somewhat mechanistically, given the treatment) greater and more active involvement in groups within the community lead to improvements in women's scores. However, impacts on other areas of empowerment are limited. The insignificant impacts on attitudes towards domestic violence and respect within the household suggest that women's groups alone may be insufficient to change deep-seated gender norms that disempower women. Our results have implications for the design and scale-up of women's group-based programs in South Asia, including the possibility that involving men is needed to change gender norms.

Fathers and grandmothers experiences participating in nutrition peer dialogue groups in Vihiga County, Kenya

Grandmothers and fathers are key influencers of maternal and child nutrition and are increasingly included in interventions. Yet, there is limited research exploring their experiences participating in interventions. This study reports on findings from a qualitative process evaluation of a quasi-experimental study that we conducted with grandmother and father peer dialogue groups to support maternal, infant and young child feeding practices in western Kenya. The aim was to explore grandmother and father experiences participating in interventions and how participation influences care and feeding practices. Grandmother and father peer educators received training to facilitate discussions about maternal and child nutrition, HIV and infant feeding, family communication, and family members' roles. Father peer educators also received training on gender inequities and power dynamics. In the original quasi-experimental study, the intervention was associated with increased social support and improvements in some complementary feeding practices. The process evaluation explored participants' experiences and how participation influenced infant care and feeding practices. We used Atlas.ti to thematically analyse data from 18 focus group discussions. The focus group discussions revealed that grandmothers and fathers valued their groups, the topics discussed and what they learned. Grandmothers reported improved infant feeding and hygiene practices, and fathers reported increased involvement in child care and feeding and helping with household tasks. Both described improved relationships with daughters-in-law or wives. This study highlights the importance of engaging influential family members to support child nutrition and identifies factors to build cohesion among group members, by building on grandmothers' roles as advisors and expanding fathers' roles in nutrition through gender transformative activities.

Classroom, club or collective? Three types of community-based group intervention and why they matter for health

Interventions involving groups of laywomen, men and adolescents to promote health are increasingly popular, but past research has rarely distinguished between different types of intervention with groups. We introduce a simple typology that distinguishes three ideal types: classrooms, clubs and collectives. Classrooms treat groups as a platform for reaching a population with didactic behaviour change strategies. Clubs seek to build, strengthen and leverage relationships between group members to promote health. Collectives engage whole communities in assuming ownership over a health problem and taking action to address it. We argue that this distinction goes a long way towards explaining differences in achievable health outcomes using interventions with groups. First, classrooms and clubs are appropriate when policymakers primarily care about improving the health of group members, but collectives are better placed to achieve population-level impact. Second, classroom interventions implicitly assume bottleneck behaviours preventing a health outcome from being achieved can be reliably identified by experts, whereas collectives make use of local knowledge, skill and creativity to tackle complexity. Third, classroom interventions assume individual participants can address health issues largely on their own, while clubs and collectives are required to engender collective action in support of health. We invite public health researchers and policymakers to use our framework to align their own and communities’ ambitions with appropriate group-based interventions to test and implement for their context. We caution that our typology is meant to apply to groups of laypeople rather than professionalised groups such as whole civil society organisations.

Community interventions with women's groups to improve women's and children's health in India: a mixed-methods systematic review of effects, enablers and barriers

INTRODUCTION

India is home to over 6 million women's groups, including self-help groups. There has been no evidence synthesis on whether and how such groups improve women's and children's health.

METHODS

We did a mixed-methods systematic review of quantitative and qualitative studies on women's groups in India to examine effects on women and children's health and to identify enablers and barriers to achieving outcomes. We searched 10 databases and included studies published in English from 2000 to 2019 measuring health knowledge, behaviours or outcomes. Our study population included adult women and children under 5 years. We appraised studies using standard risk of bias assessments. We compared intervention effects by level of community participation, scope of capability strengthening (individual, group or community), type of women's group and social and behaviour change techniques employed. We synthesised quantitative and qualitative studies to identify barriers and enablers related to context, intervention design and implementation, and outcome characteristics.

FINDINGS

We screened 21 380 studies and included 99: 19 randomised controlled trial reports, 25 quasi-experimental study reports and 55 non-experimental studies (27 quantitative and 28 qualitative). Experimental studies provided moderate-quality evidence that health interventions with women's groups can improve perinatal practices, neonatal survival, immunisation rates and women's and children's dietary diversity, and help control vector-borne diseases. Evidence of positive effects was strongest for community mobilisation interventions that built communities' capabilities and went beyond sharing information. Key enablers were inclusion of vulnerable community members, outcomes that could be reasonably expected to change through community interventions and intensity proportionate to ambition. Barriers included limited time or focus on health, outcomes not relevant to group members and health system constraints.

CONCLUSION

Interventions with women's groups can improve women's and children's health in India. The most effective interventions go beyond using groups to disseminate health information and seek to build communities' capabilities.

TRIAL REGISTRATION NUMBER

The review was registered with PROSPERO: CRD42019130633.

Communities and service providers address access to perinatal care in postconflict Northern Uganda: socialising evidence for participatory action

Objectives

Describe participatory codesign of interventions to improve access to perinatal care services in Northern Uganda.

Study design

Mixed-methods participatory research to codesign increased access to perinatal care. Fuzzy cognitive mapping, focus groups and a household survey identified and documented the extent of obstructions to access. Deliberative dialogue focused stakeholder discussions of this evidence to address the obstacles to access. Most significant change stories explored the participant experience of this process.

Setting

Three parishes in Nwoya district in the Gulu region, Northern Uganda.

Participants

Purposively sampled groups of women, men, female youth, male youth, community health workers, traditional midwives and service providers. Each of seven stakeholder categories included 5–8 participants in each of three parishes.

Results

Stakeholders identified several obstructions to accessing perinatal care: lack of savings in preparation for childbirth in facility costs, lack of male support and poor service provider attitudes. They suggested joining saving groups, practising saving money and income generation to address the short-term financial shortfall.

They recommended increasing spousal awareness of perinatal care and they proposed improving service provider attitudes. Participants described their own improved care-seeking behaviour and patient–provider relationships as short-term gains of the codesign.

Conclusion

Participatory service improvement is feasible and acceptable in postconflict settings like Northern Uganda. Engaging communities in identifying perinatal service delivery issues and reflecting on local evidence about these issues generate workable community-led solutions and increases trust between community members and service providers.

Modelling collective action to change social norms around domestic violence: social dilemmas and the role of altruism

Interventions promoting collective action have been used to prevent domestic violence in a range of settings, but their mechanisms of operation remain unclear. We formalise and combine feminist theoretical approaches to domestic violence into a game-theoretic model of women's collective action to change gendered social norms and outcomes. We show that social norms create a social dilemma in which it is individually rational for women to abstain from action to prevent domestic violence among neighbours, but all women suffer negative consequences if none take action. Promoting altruism among women can overcome the social dilemma. Discouraging women from tolerating domestic violence, imposing additional external punishment on men for perpetrating violence, or lowering costs to women of taking action against violence may not work or even backfire. We invite researchers on community mobilisation to use our framework to frame their understandings of collective action to prevent domestic violence.

Exploring the impact of a community participatory intervention on women's capability: a qualitative study in Gulu Northern Uganda

Background

Community participatory interventions mobilizing women of childbearing age are an effective strategy to promote maternal and child health. In 2017, we implemented this strategy in Gulu Northern Uganda. This study explored the perceived impact of this approach on women's capability.

Methods

We conducted a qualitative study based on three data collection methods: 14 in-depth individual interviews with participating women of childbearing age, five focus group discussions with female facilitators, and document analysis. We used the Sen capability approach as a conceptual framework and undertook a thematic analysis.

Results

Women adopted safe and healthy behaviors for themselves and their children. They were also able to respond to some of their family's financial needs. They reported a reduction in domestic violence and in mistreatment towards their children. The facilitators perceived improved communication skills, networking, self-confidence, and an increase in their social status. Nevertheless, the women still faced unfreedoms that deprived them of living the life they wanted to lead. These unfreedoms are related to their lack of access to economic opportunities and socio-cultural norms underlying gender inequalities.

Conclusion

To expand women's freedoms, we need more collective political actions to tackle gender inequalities and need to question the values underlying women's social status.

Developing stakeholder participation to address lack of safe water as a community health concern in a rural province in South Africa

BACKGROUND

Despite legislative and policy commitments to participatory water governance in South Africa, and some remarkable achievements, there has been limited progress to improve the water infrastructure servicing in marginalized rural communities. Around five million South Africans still do not have access to safe water.

OBJECTIVE

This paper seeks to understand and advance processes to engage multisectoral stakeholders to respond to lack of safe water as a community-nominated health priority in rural South Africa.

METHOD

We engaged representatives from Mpumalanga Department of Health (MDoH), rural communities, other government departments and non-governmental organisations (NGOs) to cooperatively generate, interpret and act on evidence addressing community-nominated priorities. A series of participatory workshops were conducted where stakeholders worked together as co-researchers to develop shared accounts of the problem, and recommendations to address it. Consensus on the problem, mapping existing planning and policy landscapes, and initiating constructive dialogue was facilitated through group discussions in a collective learning process.

RESULTS

Community stakeholders nominated lack of safe water as a local priority public health issue and generated evidence on causes and contributors, and health and social impacts. Together with government and NGO stakeholders, this evidence was corroborated. Stakeholders developed a local action plan through consensus and feasibility appraisal. Actions committed to behavioural change and reorganization of existing services, were relevant to the needs of the local community and were developed with consideration of current policies and strategies. A positive, collective reflection was made on the process. The greatest gain reported was the development of dialogue in 'safe spaces' through which mutual understanding, insights into the functioning of other sectors and learning by doing were achieved.

CONCLUSION

Our process reflected willingness and commitment among stakeholders to work together collectively addressing local water challenges. Location in an established public health observatory helped to create neutral, mediated spaces for participation.

Building cooperative learning to address alcohol and other drug abuse in Mpumalanga, South Africa: a participatory action research process

Background: Alcohol and other drug (AOD) abuse is a major public health challenge disproportionately affecting marginalised communities. Involving communities in the development of responses can contribute to acceptable solutions.

Objectives: To: (1) document forms, processes, and contexts of engaging communities to nominate health concerns and generate new knowledge for action; (2) further build participation in the local health system by reflecting on and adapting the process.

Methods: PAR was progressed with 48 community stakeholders across three rural villages in the MRC/Wits Agincourt Health and Socio Demographic Surveillance System (HDSS) in Mpumalanga, South Africa. A series of workshops explored community-nominated topics, systematised lived experience into shared accounts and considered actions to address problems identified. Photovoice was also used to generate visual evidence. Narrative and visual data were thematically analysed, situated within practice frameworks, and learning and adaption elicited.

Results: AOD abuse was identified as a topic of high priority. It was understood as an entrenched social problem with destructive effects. Biopsychosocial impacts were mapped and related to unemployment, poverty, stress, peer pressure, criminal activity, corruption, and a proliferating number of taverns. Integrated action agendas were developed focussed on demand, supply, and harm reduction underpinned by shared responsibility among community, state, and non-state actors. Community stakeholders appreciated systematising and sharing knowledge, taking active roles, developing new skills in planning and public speaking, and progressing shared accountability processes. Expectations required sensitive management, however.

Conclusion: There is significant willingness and capacity among community stakeholders to work in partnership with authorities to address priority health concerns. As a process, participation can help to raise and frame issues, which may help to better inform action and encourage shared responsibility. Broader understandings of participation require reference to, and ultimately transfer of power towards, those most directly affected, developing community voice as continuous processes within social and political environments.

Measuring the psychological drivers of participation in collective action to address violence against women in Mumbai, India

Background: A growing number of global health interventions involve community members in activism to prevent violence against women (VAW), but the psychological drivers of participation are presently ill-understood. We developed a new scale for measuring three proposed drivers of participation in collective action to address VAW in the context of urban informal settlements in Mumbai, India: perceived legitimacy, perceived efficacy, and collective action norms. Methods: We did a household survey of 1307 men, 1331 women, and 4 trans persons. We checked for 1) social desirability bias by comparing responses to self-administered and face-to-face interviews, 2) acquiescence bias by comparing responses to positive and negatively worded items on the same construct, 3) factor structure using confirmatory factor analysis, and 4) convergent validity by examining associations between construct scores and participation in groups to address VAW and intent to intervene in case of VAW. Results: Of the ten items, seven showed less than five percentage point difference in agreement rates between self-administered and face-to-face conditions. Correlations between opposite worded items on the same construct were negative (p<0.05), while correlations between similarly worded items were positive (p<0.001). A hierarchical factor structure showed adequate fit (Tucker-Lewis index, 0.919; root mean square error of approximation, 0.036; weighted root mean square residual, 1.949). Comparison of multi-group models across gender, education, caste, and marital status showed little evidence against measurement invariance. Perceived legitimacy, efficacy and collective action norms all predicted participation in groups to address VAW and intent to intervene in case of VAW, even after adjusting for social capital (p<0.05). Conclusion: This is the first study to operationalize a measure of the psychological drivers of participation in collective action to address VAW in a low- and middle-income context. Our novel scale may provide insight into modifiable beliefs and attitudes community mobilisation interventions can address to inspire activism in similar low-resource contexts.

Measuring the psychological drivers of participation in collective action to address violence against women in Mumbai, India

Background: A growing number of global health interventions involve community members in activism to prevent violence against women (VAW), but the psychological drivers of participation are presently ill-understood. We developed a new scale for measuring three proposed drivers of participation in collective action to address VAW in the context of urban informal settlements in Mumbai, India: perceived legitimacy, perceived efficacy, and collective action norms. Methods: We did a household survey of 1307 men, 1331 women, and 4 trans persons. We checked for 1) social desirability bias by comparing responses to self-administered and face-to-face interviews, 2) acquiescence bias by comparing responses to positive and negatively worded items on the same construct, 3) factor structure using confirmatory factor analysis, and 4) convergent validity by examining associations between construct scores and participation in groups to address VAW and intent to intervene in case of VAW. Results: Of the ten items, seven showed less than five percentage point difference in agreement rates between self-administered and face-to-face conditions. Correlations between opposite worded items on the same construct were negative (p<0.05), while correlations between similarly worded items were positive (p<0.001). A hierarchical factor structure showed adequate fit (Tucker-Lewis index, 0.920; root mean square error of approximation, 0.035; weighted root mean square residual, 1.952). Perceived legitimacy, efficacy and collective action norms all predicted participation in groups to address VAW and intent to intervene in case of VAW, even after adjusting for social capital (p<0.05). Conclusion: This is the first study to operationalize a measure of the psychological drivers of participation in collective action to address VAW in a low- and middle-income context. Our novel scale may provide insight into modifiable beliefs and attitudes community mobilisation interventions can address to inspire activism in similar low-resource contexts.