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

The effectiveness of community engagement using M-Mama champions in improving awareness of obstetric danger signs, birth preparedness and complication readiness among pregnant women in Bahi, Dodoma: A cluster randomized pragmatic implementation trial

BACKGROUND

Maternal mortality remains a catastrophic condition for reproductive-age women in Tanzania. Inadequate ANC visits impair the efficiency of education programs for pregnant women on obstetric danger signs, birth preparedness and complication readiness, hence negatively influencing health behaviour and decision-making processes, contributing to maternal mortality. In this case, a complementary health education intervention for pregnant women in the community is necessary. M-MAMA Champions were introduced to determine their effectiveness in creating awareness of obstetric danger signs, birth preparedness complication readiness and their practice to complement the health system.

METHODS

A parallel arms, cluster-randomized pragmatic implementation trial, whereby pregnant women were recruited from four clusters and randomised at a ratio of 1:1. M-MAMA Champions empowered pregnant women with obstetric danger signs, birth preparedness and complication readiness in addition to standard care. Difference-in-difference analysis determined the intervention's effect.

RESULTS

The majority of 124 pregnant women recruited from intervention (N = 60) and control (N = 64) arms, were aged 16 to 19, 31.3% (n = 20) vs 20 to 24, 35.0% (n = 21) and had primary education 48.4% (n = 31) vs 51.7% (n = 31) in the control and intervention arms respectively. Awareness of Obstetric danger signs, birth preparedness complication readiness and their practice improved significantly by 64.2%, (P < 0.0001), 26.3%, (P = 0.00190 and 33.9%, (P = 0.0006) respectively.

CONCLUSION

M-MAMA Champions, the facilitators of women groups in community engagement are effective in improving awareness of obstetric danger signs, birth preparedness and complication readiness among pregnant women. It's, therefore worth an adoption for wider application.

TRIAL REGISTRATION

NCT06325319 (Effect of Community Engagement Using M-Mama Champions), registered on 15th March 2024.

Factors associated with decision-making autonomy in healthcare utilization among married women from the Indonesia demographic health survey 2017

Women's autonomy in healthcare decision-making is crucial not only for improving maternal health but also enhancing their overall health and well-being. However, most studies focused solely on fertility, child health, or maternal healthcare use, often overlooking the broader aspects of women's health. Due to this reason, the magnitudes and factors associated with women's autonomy in other types of healthcare remain unclear. Therefore, this study aimed to estimate the magnitude and identify factors associated with healthcare decision-making autonomy among married women in Indonesia. A national cross-sectional study was conducted among married women using the Indonesia Demographic and Health Surveys 2017. Women's healthcare decision-making autonomy was measured based on responses regarding the individual typically responsible for making healthcare decisions on behalf of the respondent. Potential factors, such as intrapersonal, interpersonal, community, and policy-related were obtained. Multinomial logistic regression was used to determine the associations between potential factors and outcomes. The odds ratio (OR) and 95% confidence intervals (CI) of the analysis were reported. The respondents in this study comprised 16,050 married women across 34 provinces in Indonesia. Most respondents (46.4%) reported making healthcare decisions independently. The result showed that several factors were associated with either women's full autonomy or jointly with the husbands in the healthcare decision-making. These factors included ownership of mobile telephones, urban living, residency in Java, Bali, Sulawesi, Maluku and Papua islands, participation of women in decision-making on how to spend their earnings, on large household purchases, no financial barrier in accessing treatment, and independence in visiting a medical center. Public health interventions should focus on vulnerable women, such as those who live in rural areas, participate less in the decision-making of earnings spending and household purchase, and are incapable of visiting a medical center alone to increase the healthcare decision-making autonomy. Collaborative efforts with health facilities in each region can support the implementation of this intervention.

Building a rights-based approach to nutrition for women and children: harnessing the potential of women's groups and rights-based organizations in South Asia

Women face numerous gender-based barriers that hinder their access to resources, nutritious foods, nutrition services, and maternity entitlements. Evidence shows that certain types of women's groups can improve women's access to resources and social capital and in some approaches also improve health and nutrition outcomes. Women's rights-based organizations in South Asia have a longstanding tradition of collective action toward gender equality. Women's rights-based organizations work in areas such as microfinance, livelihoods, women's rights, health, and combating violence against women. In this perspective article, we explore how women's groups and rights-based organizations can leverage their collective strength to advance nutrition outcomes for women and children. We identify seven pathways implemented through women's groups toward improving nutrition outcomes. These pathways include (i) income generation, (ii) agriculture, (iii) health and nutrition behavior change communication and participatory learning and action, (iv) advocating for rights to better health and social services, (v) food access, (vi) cash transfers, and (vii) strengthening service delivery and fostering convergence with health systems. We also note that women's groups have the potential to implement integrated interventions through combined food-systems-rights pathways. Investing in this area can support transforming nutrition policy from a service delivery model to a rights-based approach.

Changing maternal and child nutrition practices through integrating social and behavior change interventions in community-based self-help and support groups: literature review from Bangladesh, India, and Vietnam

Introduction

Self-help groups (SHGs) and Support Groups (SGs) are increasingly recognized as effective mechanisms for improving maternal and young child nutrition due to their decentralized, community-based structures. While numerous studies have evaluated the outcomes and impact of SHGs and SGs on nutrition practices, there remains a gap in the literature. To address this, we conducted a literature review to examine the role of SHGs and SGs in improving health and nutrition outcomes, focusing on marginalized women, especially pregnant and lactating women (PLW), in India, Bangladesh, and Vietnam, with an emphasis on programs supported by the international non-governmental initiative, Alive & Thrive.

Methods and materials

We conducted a literature review to assess various models, summarizing findings from 34 documents, including research studies, evaluation reports, program materials, strategies, annual reports, work plans, and toolkits. Relevant information from these documents was extracted using predetermined forms.

Results

In India, the models used SHGs with 10-20 women, federated into larger village and district organizations. Bangladesh and Vietnam SGs have similar structures but with local leaders and committees playing key roles. In all three countries, interventions aimed to improve health and nutrition practices through social behavior change (SBC) interventions, including peer-to-peer learning, interpersonal communication, home visits, and community meetings. Outcomes of the interventions showed that SHG members had increased knowledge of breastfeeding, complementary feeding, and improved dietary diversity compared to non-SHG participants. Interventions helped improve infant and young child feeding practices. Common challenges included sustaining the SHGs, ensuring adequate participation, socio-cultural barriers, and logistical difficulties in reaching PLW in remote areas. Limited time for health topics during SHG meetings and the dissolution of older SHGs were also significant issues.

Conclusion

SHG and SG models demonstrate success in improving health and nutrition outcomes but face challenges in scale, sustainability, and participation. Integrating nutrition-focused SBC interventions into SHGs and SGs requires significant capacity building for technical and counseling skills. Ensuring comprehensive coverage and robust quality assessment during community-based rollouts is essential. To sustain these interventions, it is crucial to prevent group dissolution, allow time for maturation, and secure strong stakeholder engagement and political support.

Feasibility and acceptability of a life skills and reproductive health empowerment interventionfor young newly married women in Rajasthan, India: A pre-post convergent mixed methods pilot study

Background

Newly married young women face increased susceptibility to adverse health outcomes, social isolation, and disempowerment, yet interventions targeting this vulnerable group remain limited. We examined the feasibility and acceptability of TARANG, a life skills and reproductive health empowerment intervention, developed for and with young newly married women.

Methods

We recruited 42 newly married women as participants in our study. We conducted a convergent mixed-methods, single-group cluster pilot study to the intervention in which 41 participants (retention rate=97.6%) completed both baseline and endline surveys in July 2023 and January 2024, respectively. We assessed three primary outcomes--feasibility using proportion of participants who completed at least 50% sessions, acceptability using proportion completely satisfied/somewhat satisfied with TARANG and usefulness using proportion who found TARANG useful/somewhat useful. We conducted in-depth interviews with a purposive sample of 12 participants to understand intervention acceptance and usefulness of the intervention and 6 program staff and moderators to understand barriers to implementing the intervention. We analyzed the quantitative data with descriptive statistics and qualitative data using thematic analysis. We triangulated data from monitoring data filled by moderators, quantitative surveys with participants, and qualitative data.

Results

In the pilot study, 35/42 participants had completed at least one session. Overall, 82% participants attended at least 50% of the sessions. Among those who attended at least 1 session,97% were satisfied/somewhat satisfied with the intervention and 100% of participants found the intervention to be useful/somewhat useful. Qualitative findings reveal participants' appreciation for open discussions on sensitive topics, such as family planning, and highlight the intervention's role in filling knowledge gaps and fostering social connections, better sense of agency and improved relationships with mothers-in-law and husbands. While barriers to consistent participation were identified, feedback informed refinements to the intervention for the main trial, including session modifications, increased engagement strategies, and integration of educational videos.

Conclusion

Our community-based participatory approach, developed with input from end users, demonstrated not only high acceptability and feasibility but also had many benefits for newly married women in rural/tribal Rajasthan. Our findings also led to adaptations that may enhance delivery of, and satisfaction with TARANG intervention, which will be tested with a larger sample in a rigorous cluster randomized controlled trial in Rajasthan, India.

ClinicalTrialsgov

The study is registered at ClinicalTrials.gov (NCT06320964). Registered retrospectively on 13 March 2024, https://clinicaltrials.gov/study/NCT06320964.

Women improving nutrition through self-help groups in India: Does nutrition information help?

Women's self-help groups (SHGs) are an important platform for reaching poor women in India. Despite SHGs' women-focused programming, evidence of the impact of SHG-based interventions on nutrition outcomes is limited, and most evaluations of nutrition interventions have not examined intermediate outcomes along the impact pathways or outcomes for women themselves. This paper evaluates the effectiveness of an integrated agriculture-nutrition intervention delivered through women's SHGs in five states in central and eastern India. The interventions involved the delivery of nutrition behavior change communication to groups through participatory approaches, community engagement around key issues, and the strengthening of collective organizations. Our analysis is based on three rounds of rich panel data on close to 2700 rural women and their households from eight districts in these five states and qualitative work from an accompanying process evaluation. Using difference-in-difference models with nearest neighbor matching methods, we present results on women's anthropometry and diet-related outcomes. We do not observe any improvements in women's BMI or overall dietary diversity. Although more women in the nutrition intensification arm consumed animal source foods, nuts and seeds, and fruits, this was not enough to increase overall dietary diversity scores or the proportion of women achieving minimum dietary diversity. We measure intermediate outcomes along the program's impact pathways and find improvements in household incomes, cultivation of home gardens, and utilization of government schemes but not in women's empowerment. The lack of improvement in anthropometry and diets despite changes in some intermediate outcomes can be attributed to several factors such as low implementation intensity, poor facilitator capacity and incentives, the lack of relevance of the BCC topics to the average SHG member, and resource and agency constraints to adoption of recommended practices. Although we do not have data to test the parallel trends assumption and so do not interpret our results as causal, these findings do suggest that optimism about using group-based platforms needs to be tempered in resource-poor contexts.

Individual interventions, collective lessons: Developing mid-range theory on women's groups to improve health

Background

Interventions with women's groups have been widely implemented to improve health outcomes in low- and middle-income settings, particularly India. While there is a large evidence base on the effectiveness of single interventions, it is challenging to predict whether a women's group intervention delivered in one setting can be expected to work in another.

Methods

We applied realist principles to develop and refine a mid-range theory on the effectiveness of women's groups interventions, summarised key lessons for implementation, and reflected on the process. We synthesised primary data from several interventions in India, a systematic review, and an analysis of behaviour change techniques. We developed mid-range theories across three areas: maternal and newborn health, nutrition, and violence against women, as well as an overarching mid-range theory on how women's groups can improve health.

Results

Our overarching mid-range theory suggested that effective interventions should: build group or community capabilities; focus on health outcomes relevant to group members; and approach health issues modifiable through women's individual or collective actions. We identified four key lessons for future interventions with women's groups, including the importance of skilled and remunerated facilitation, sufficient intensity, supply-side strengthening, and the need to adapt delivery during scale up while maintaining fidelity to intervention theory.

Conclusions

Our experience demonstrated the feasibility of developing mid-range theory from a combination of evidence and insights from practice. It also underscored the importance of community engagement and ongoing research to 'thicken' mid-range theories to design effective and scalable women's groups interventions in India and similar settings.

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.

Creating culturally-informed protocols for a stunting intervention using a situated values-based approach (WeValue InSitu): a double case study in Indonesia and Senegal

International development work involves external partners bringing expertise, resources, and management for local interventions in LMICs, but there is often a gap in understandings of relevant local shared values. There is a widespread need to better design interventions which accommodate relevant elements of local culture, as emphasised by recent discussions in global health research regarding neo-colonialism. One recent innovation is the concept of producing 'cultural protocols' to precede and guide community engagement or intervention design, but without suggestions for generating them. This study explores and demonstrates the potential of an approach taken from another field, named WeValue InSitu, to generate local culturally-informed protocols. WeValue InSitu engages stakeholder groups in meaning-making processes which 'crystallize' their envelope of local shared values, making them communicable to outsiders.Our research context is understanding and reducing child stunting, including developing interventions, carried out at the Senegal and Indonesia sites of the UKRI GCRF Action Against Stunting Hub. Each national research team involves eight health disciplines from micro-nutrition to epigenetics, and extensive collection of samples and questionnaires. Local culturally-informed protocols would be generally valuable to pre-inform engagement and intervention designs. Here we explore generating them by immediately following the group WeValue InSitu crystallization process with specialised focus group discussions exploring: what local life practices potentially have significant influence on the environments affecting child stunting, and which cultural elements do they highlight as relevant. The discussions will be framed by the shared values, and reveal linkages to them. In this study, stakeholder groups like fathers, mothers, teachers, market traders, administrators, farmers and health workers were recruited, totalling 83 participants across 20 groups. Themes found relevant for a culturally-informed protocol for locally-acceptable food interventions included: specific gender roles; social hierarchies; health service access challenges; traditional beliefs around malnutrition; and attitudes to accepting outside help. The concept of a grounded culturally-informed protocol, and the use of WeValue InSitu to generate it, has thus been demonstrated here. Future work to scope out the advantages and limitations compared to deductive culture studies, and to using other formative research methods would now be useful.

Effective interventions for improving routine childhood immunisation in low and middle-income countries: a systematic review of systematic reviews

OBJECTIVE

An umbrella review providing a comprehensive synthesis of the interventions that are effective in providing routine immunisation outcomes for children in low and middle-income countries (L&MICs).

DESIGN

A systematic review of systematic reviews, or an umbrella review.

DATA SOURCES

We comprehensively searched 11 academic databases and 23 grey literature sources. The search was adopted from an evidence gap map on routine child immunisation sector in L&MICs, which was done on 5 May 2020. We updated the search in October 2021.

ELIGIBILITY CRITERIA

We included systematic reviews assessing the effectiveness of any intervention on routine childhood immunisation outcomes in L&MICs.

DATA EXTRACTION AND SYNTHESIS

Search results were screened by two reviewers independently applying predefined inclusion and exclusion criteria. Data were extracted by two researchers independently. The Specialist Unit for Review Evidence checklist was used to assess review quality. A mixed-methods synthesis was employed focusing on meta-analytical and narrative elements to accommodate both the quantitative and qualitative information available from the included reviews.

RESULTS

62 systematic reviews are included in this umbrella review. We find caregiver-oriented interventions have large positive and statistically significant effects, especially those focusing on short-term sensitisation and education campaigns as well as written messages to caregivers. For health system-oriented interventions the evidence base is thin and derived from narrative synthesis suggesting positive effects for home visits, mixed effects for pay-for-performance schemes and inconclusive effects for contracting out services to non-governmental providers. For all other interventions under this category, the evidence is either limited or not available. For community-oriented interventions, a recent high-quality mixed-methods review suggests positive but small effects. Overall, the evidence base is highly heterogenous in terms of scope, intervention types and outcomes.

CONCLUSION

Interventions oriented towards caregivers and communities are effective in improving routine child immunisation outcomes. The evidence base on health system-oriented interventions is scant not allowing us to reach firm conclusions, except for home visits. Large evidence gaps exist and need to be addressed. For example, more high-quality evidence is needed for specific caregiver-oriented interventions (eg, monetary incentives) as well as health system-oriented (eg, health workers and data systems) and community-oriented interventions. We also need to better understand complementarity of different intervention types.

What works in engaging communities? Prioritising nutrition interventions in Burkina Faso, Ghana and South Africa

BACKGROUND

"Choosing All Together" (CHAT), is a community engagement tool designed to give the public a voice in how best to allocate limited resources to improve population health. This process evaluation explored the mechanisms through which CHAT generates community engagement.

METHOD

The CHAT tool was adapted and implemented for use in two rural communities (Nanoro, Burkina Faso, and Navrongo, Ghana) and one urban township (Soweto, South Africa) to prioritize maternal and child nutrition interventions. Community discussions were audio-recorded, transcribed, and translated into English. Twenty-two transcripts, including six each from Navrongo and Soweto and 10 from Nanoro, were analysed thematically to generate data driven codes and themes to explain mechanisms underlying the CHAT process. The process evaluation was based on the UK MRC process evaluation guidance.

RESULTS

Seven themes describing the functions and outcomes of CHAT were identified. Themes described participants deliberating trade-offs, working together, agreeing on priorities, having a shared vision, and increasing their knowledge, also the skills of the facilitator, and a process of power sharing between participants and researchers. Participants came to an agreement of priorities when they had a shared vision. Trained facilitators are important to facilitate meaningful discussion between participants and those with lower levels of literacy to participate fully.

CONCLUSION

CHAT has been shown to be adaptable and useful in prioritising maternal and child nutrition interventions in communities in Burkina Faso, Ghana, and South Africa. Conducting CHAT in communities over a longer period and involving policy-makers would increase trust, mutual respect and develop partnerships.

Community perceptions matter: a mixed-methods study using local knowledge to define features of success for a community intervention to improve quality of care for children under-5 in Jigawa, Nigeria

OBJECTIVES

In this study, we used the information generated by community members during an intervention design process to understand the features needed for a successful community participatory intervention to improve child health.

DESIGN

We conducted a concurrent mixed-methods study (November 2019-March 2020) to inform the design and evaluation of a community-facility linkage participatory intervention.

SETTING

Kiyawa Local Government Area (Jigawa State, Nigeria)-population of 230 000 (n=425 villages).

PARTICIPANTS

Qualitative data included 12 community conversations with caregivers of children under-5 (men, older and younger women; n=9 per group), 3 focus group discussions (n=10) with ward development committee members and interviews with facility heads (n=3). Quantitative data comprised household surveys (n=3464) with compound heads (n=1803) and women (n=1661).

RESULTS

We analysed qualitative data with thematic network analysis and the surveys with linear regression-results were triangulated in the interpretation phase. Participants identified the following areas of focus: community health education; facility infrastructure, equipment and staff improvements; raising funds to make these changes. Community involvement, cooperation and empowerment were recognised as a strategy to improve child health, and the presence of intermediate bodies (development committees) was deemed important to improve communication and solve problems between community and facility members. The survey showed functional community relations' dynamics, with high levels of internal cohesion (78%), efficacy in solving problems together (79%) and fairness of the local leaders (82%).

CONCLUSIONS

Combining the results from this study and critical theories on successful participation identified community-informed features for a contextually tailored community-facility link intervention. The need to promote a more inclusive approach to future child health interventions was highlighted. In addition to health education campaigns, the relationship between community and healthcare providers needs strengthening, and development committees were identified as an essential feature for successfully linking communities and facilities for child health.

TRIAL REGISTRATION NUMBER

ISRCTN39213655.

S. R, Saraswat A, Kejrewal N, Shrivastava M, Tripathy L, Murira Z, Vir S. Evaluation of impact of engaging federations of women groups to improve women's nutrition interventions- before, during and after pregnancy in social and economically backward geographies: Evidence from three eastern Indian States

BACKGROUND

Undernutrition-before, during and after pregnancy endangers the health and well-being of the mother and contributes to sub-optimal fetal development and growth. A non-randomized controlled evaluation was undertaken to assess the impact of engaging federations of women's group on coverage of nutrition interventions and on nutrition status of women in the designated poverty pockets of three Indian states-Bihar, Chhattisgarh, and Odisha.

METHOD

The impact evaluation is based on two rounds of cross-sectional data from 5 resource poor blocks across 3 States, assigning 162 villages to the intervention arm and 151 villages to the control arm. The cross-sectional baseline (2016-17) and endline survey (2021-22) covered a total of 10491 adolescent girls (10-19 years), 4271 pregnant women (15-49 years) and 13521 mothers of children under age two years (15-49 years). Exposure was defined based on participation in the participatory learning and action meetings, and fixed monthly health camps (Adolescent Health Days (AHDs) and Village Health Sanitation and Nutrition Days (VHSNDs)). Logistic regression models were applied to establish the association between exposure to programme activities and improvement in coverage of nutrition interventions and outcomes.

RESULTS

In the intervention area at endline, 27-38% of women participated in the participatory learning and action meetings organized by women's groups. Pregnant women participating in programme activities were two times more likely to receive an antenatal care visit in the first trimester of pregnancy (Odds ratio: 2.55 95% CI-1.68-3.88), while mothers of children under 2 were 60% more likely to receive 4 ANC visits (Odds ratio: 1.61, 95% CI- 1.30-2.02). Odds of consuming a diversified diet was higher among both pregnant women (Odds ratio: 2.05, 95% CI- 1.41-2.99) and mother of children under 2 years of age (Odds ratio: 1.38, 95% CI- 1.08-1.77) among those participating in programme activities in the intervention arm. Access to commodities for WASH including safe sanitation services (Odds ratio: 1.80, 95% CI- 1.38-2.36) and sanitary pads (Odds ratio: 1.64, 95% CI- 1.20-2.22) was higher among adolescent girls participating in programme activities.

CONCLUSION

Women's groups led participatory learning and action approaches coupled with strengthening of the supply side delivery mechanisms resulted in higher coverage of health and nutrition services. However, we found that frequency of participation was low and there was limited impact on the nutritional outcomes. Therefore, higher frequency of participation in programme activities is recommended to modify behaviour and achieve quick gains in nutritional outcomes.

Ethnicity, information and cooperation: Evidence from a group-based nutrition intervention

Development programs often rely on locally hired agents for service delivery, especially for interventions promoting agricultural practices, health, and nutrition. These agents are key to reaching underserved communities, especially women, with information and services around recommended practices. However, where societies are socially stratified, differences in ethnic identities between agents and beneficiaries may impact the effectiveness of information and service delivery and the uptake of recommended behaviors. We explore the salience of shared ethnic identity between agents and beneficiaries in promoting collective action using a field experiment with women's self-help groups (SHGs) in India. We cross-randomize an information treatment and a group-agent shared ethnicity treatment at the SHG level. We measure impacts on individual group member information retention and willingness to contribute to a group-owned kitchen garden that could improve access to a diverse and nutritious diet. We find information retention is better when the group is matched with an agent lower in the ethnic hierarchy, but that agents higher in the hierarchy elicit greater individual contributions to the group-owned kitchen garden. We suggest some hypotheses for these seemingly contradictory results. Other characteristics like education, group cohesion and perceived agent ability also matter in changing knowledge and contribution. Our findings have important implications for effective program design and implementation, suggesting that implementers need to consider factors beyond the information content, target group and pedagogical mode of delivery for their strategies to be transformative.

Multicomponent interventions to improve routine childhood vaccine uptake in low and middle-income countries: a scoping review protocol

INTRODUCTION

Vaccine coverage remains inequitable globally. Many systematic reviews have looked at the effectiveness of strategies to improve vaccine uptake; however, these reviews frequently lack data from low and middle-income countries (LMICs), where evidence of cost-effective strategies is most valuable. This is partly because reviews often exclude non-randomised, observational or unpublished evaluations that are common in LMICs. Many reviews also exclude multicomponent interventions due to challenges isolating the effect of each component. A comprehensive mapping of multicomponent interventions implemented in LMICs would increase the visibility of studies excluded from systematic reviews and improve comparability of future evaluations by providing guidance for researchers on evaluation frameworks. This scoping review aims to identify, compare and summarise the properties and evaluation methods of multicomponent interventions to improve uptake of routine childhood vaccines in LMICs, and to assess the strengths and limitations of evaluation frameworks applied.

METHODS AND ANALYSIS

This review will be conducted using the Joanna Briggs Institute methodology for scoping reviews and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews guidelines. We will search the following databases: MEDLINE, Embase, PubMed, Cochrane, Eldis and Global Health (CAB Direct), Global Index Medicus, 3ie Portal, Google Scholar, COnnecting REpositories, and reference lists. One author will screen titles and abstracts and extract data from included articles using a pretested data extraction template. Uncertainties will be resolved through discussion with another author. Only studies published in English will be included for full review. We will assess the practicability, applicability, sensitivity and specificity of the evaluation frameworks used and present results using descriptive statistics, summary tables and charts.

ETHICS AND DISSEMINATION

Ethics approval is not required. The review will be submitted as part of a doctoral thesis, presented at conferences and published in peer-reviewed journals.

STUDY REGISTRATION

https://osf.io/7r84g.

Cash plus programming and intimate partner violence: a qualitative evaluation of the benefits of group-based platforms for delivering activities in support of the Ethiopian government's Productive Safety Net Programme (PSNP)

OBJECTIVES

Intimate partner violence (IPV) is a public health challenge but there is evidence that cash and cash 'plus' interventions reduce IPV. An increasingly popular design feature of these kind of interventions is the group-based modality for delivering plus activities, however, evidence of the mechanisms through which this modality of delivery impacts IPV is limited. We explore how the group-based modality of delivering plus activities that complemented the Government of Ethiopia's Productive Safety Net Programme contributed to modifying intermediate outcomes on the pathway to IPV.

DESIGN

Qualitative study using in-depth interviews and focus group discussions between February and March 2020. Data were analysed using a thematic content and gender lens approach. Findings were interpreted, refined and drafted in collaboration with our local research partners.

SETTING

Amhara and Oromia regions in Ethiopia.

PARTICIPANTS

In total 115 men and women beneficiaries from the Strengthen PSNP4 Institutions and Resilience (SPIR) programme took part in the study. Fifty-eight were interviewed and 57 took part in 7 focus group discussions.

RESULTS

We found that Village Economic and Social Associations-through which SPIR activities were delivered-improved financial security and increased economic resilience against income shocks. The group-based delivery of plus activities to couples appeared to enhance individual agency, collective power and social networks, which in turn strengthened social support, gender relations and joint decision-making. Critical reflective dialogues provided a reference group to support the shift away from social norms that condone IPV. Finally, there appeared to be gender differences, with men highlighting the financial benefits and enhanced social status afforded by the groups, whereas women's accounts focused primarily on strengthened social networks and social capital.

CONCLUSION

Our study offers important insights into the mechanisms by which the group-based delivery of plus activities affects intermediate outcomes on the pathway to IPV. It underscores the importance of the modality of delivery in such programmes, and suggests that policy-makers should consider gender-specific needs as men and women might differentially benefit from interventions that enhance social capital to generate gender transformative impacts.

Intrahousehold power inequalities and cooperation: Unpacking household responses to nutrition-sensitive agriculture interventions in rural India

Nutrition-sensitive agriculture (NSA) interventions offer a means to improve the dietary quality of rural, undernourished populations. Their effectiveness could be further increased by understanding how household dynamics enable or inhibit the uptake of NSA behaviours. We used a convergent parallel mixed-methods design to describe the links between household dynamics-specifically intrahousehold power inequalities and intrahousehold cooperation-and dietary quality and to explore whether household dynamics mediated or modified the effects of NSA interventions tested in a cluster-randomized trial, Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN). We use quantitative data from cross-sectional surveys in 148 village clusters at UPAVAN's baseline and 32 months afterwards (endline), and qualitative data from family case studies and focus group discussions with intervention participants and facilitators. We found that households cooperated to grow and buy nutritious foods, and gendered power inequalities were associated with women's dietary quality, but cooperation and women's use of power was inhibited by several interlinked factors. UPAVAN interventions were more successful in more supportive, cooperative households, and in some cases, the interventions increased women's decision-making power. However, women's decisions to enter into negotiations with family members depended on whether women deemed the practices promoted by UPAVAN interventions to be feasible, as well as women's confidence and previous cultivation success. We conclude that interventions may be more effective if they can elicit cooperation from the whole household. This will require a move towards more family-centric intervention models that empower women while involving other family members and accounting for the varied ways that families cooperate and negotiate.

'Our courage has grown': a grounded theory study of enablers and barriers to community action to address violence against women in urban India

Transforming communities into supportive environments for women facing risks of violence requires community members to play an active role in addressing violence against women (VAW). We did a grounded theory study of enablers and barriers to community response to ongoing violence, sampling from programme areas of a non-governmental organisation (NGO)-led community mobilisation intervention in informal settlements in Mumbai, India. We held 27 focus group discussions and 31 semistructured interviews with 113 community members and 9 NGO staff, along with over 170 hours of field observation. We found that residents responded to violence in diverse ways, ranging from suicide prevention to couple mediation to police and NGO referral. Enabling and constraining factors fit into a social ecological model containing intrapersonal, immediate social network, and wider societal levels. We identified four themes interlinking factors: legitimacy of action, collective power, protection against risk and informal leadership. Legitimacy of action was negotiated in the context of individual disputes, making community members question not only whether VAW was 'wrong', but who was 'wrong' in specific disputes. Collective power through neighbourhood solidarity was key to action but could be curtailed by violent gang crime. Interveners in incidents of VAW turned out to need significant physical, social and legal protection against reprisal. However, repeat interveners could become informal leaders wielding influential prosocial reputations that incentivised and facilitated action. Our model integrates multiple perspectives on community action into one analytical framework, which can be used by implementers to ensure that community members receive encouragement, support and protection to act.

Child Marriage and Problems Accessing Healthcare in Adulthood: Evidence from India

The association between child marriage and the access to or utilization of maternal and antenatal healthcare has been widely studied. However, little is known about child brides' access to healthcare for illnesses later in life. Using data on 496,283 married women aged 18 to 49 years from the India National Family and Health Survey 2015-2016, we developed an 11-point composite score (ranging from 0 to 10) outlining the extent of problems accessing healthcare, as follows: (i) no/little problem (score 0 to 2), (ii) some problems (score 3 to 6), and (iii) big problems (score 7 to 10). The differences between child brides and their peers married as adults were assessed by the relative risk ratios obtained from multinomial logistic regressions. The adjusted risk of having "some problems" and "big problems" accessing healthcare relative to "no/little problem" for child brides was found to be 1.22 (95% CI: 1.20-1.25) and 1.26 (95% CI: 1.22-1.29) times that of those married as adults, respectively. These findings highlight the disproportionate barriers to healthcare access faced by women married as children compared to women married as adults and the need for further research to inform policies regarding effective public health interventions to improve healthcare access.

Facilitators and barriers to participation in health mothers' groups in improving maternal and child health and nutrition in Nepal : A mixed-methods study

Background

In Nepal, Health Mother’s Groups (HMG) are women’s group-based programmes for improving maternal and child health. However, they remain underutilised with only 27% of reproductive-aged women participating in an HMG meeting in 2016. This study aimed to understand the facilitators and barriers to HMG meeting participation.

Methods

We conducted a convergent mixed-methods study using cross-sectional quantitative data from the 2016 Nepal Demographic and Health Survey and primary data collected via 35 in-depth interviews and eight focus group discussions with 1000-day women and their family members, female community health volunteers (FCHVs) and health facility staff in two geographies of Nepal, Kaligandaki and Chapakot. Quantitative data were analysed using logistic regression and qualitative data using deductive coding. The results were triangulated and thematically organised according to the socio-ecological model (SEM).

Results

Facilitators and barriers emerged across individual, interpersonal and community levels of the SEM. In the survey, women with more children under five years of age, living in a male-headed household, or in rural areas had increased odds of HMG participation (p < 0.05) while belonging to the Janajati caste was associated with lower odds of participation (p < 0.05). Qualitative data helped to explain the findings. For instance, the quantitative analysis found women’s education level associated with HMG participation (p < 0.05) while the qualitative analysis showed different ways women’s education level could facilitate or hinder participation. Qualitative interviews further revealed that participation was facilitated by women’s interest in acquiring new knowledge, having advanced awareness of the meeting schedule and venue, and engagement with health workers or non-government organisation staff. Participation was hindered by the lack of meeting structure and work obligations during the agricultural season.

Conclusions

To improve women’s participation in HMGs in Nepal, it is necessary to address factors at the SEM’s individual, interpersonal, and community levels, such as enhancing FCHV literacy, providing advance notice of the meeting schedule, upgrading the meeting venues and reducing women’s workload through family support, particularly during agricultural season. These improvements are essential for strengthening effective implementation of HMG meetings and similar women’s group-based platforms, and for ultimately improving maternal and child health in Nepal.

Matching Intent With Intensity: Implementation Research on the Intensity of Health and Nutrition Programs With Women's Self-Help Groups in India

Adding health interventions to women's groups primarily formed for financial purposes, such as self-help groups, is a widely used strategy to reach low-income women. An analysis of implementation intensity highlights the importance of ensuring that women's groups have sufficient time and population coverage to address health issues.

Introduction:

In India, a large network of self-help groups (SHGs) implements interventions to improve women's and children's health and nutrition. There is growing evidence on the effectiveness of women's group interventions to improve health but limited information on implementation intensity, including how often groups meet, for how long, and with whom, despite this often being cited as a key factor for success. We aimed to assess the implementation intensity of large SHG-based health and nutrition interventions with rural, low-income women, to inform program design, delivery, and measurement.

Methods:

We synthesized process data from surveys, meeting observations, and process evaluations across 8 maternal and child health and nutrition interventions in India. We examined the implementation intensity of 3 common intervention delivery channels: group meetings, home visits, and community-level activities.

Results:

SHG members spent approximately 30 minutes in monthly meetings discussing health or nutrition. SHG dissolution or limited participation in meetings was a common challenge. Beyond group meetings, home visits reached approximately 1 in 3 households with an SHG member. Pregnant and breastfeeding women's participation in community events varied across interventions.

Discussion:

Interventions that aim to capitalize on existing networks of financial women's groups not specifically formed for health and nutrition objectives, such as SHGs, will need to have an implementation intensity that matches the ambition of their health objectives: substantial changes in behavioral or mortality outcomes are unlikely to be achieved with relatively light intensity. Interventions that require sustained interactions with members to achieve health outcomes need to ensure adequate community and individual outreach to supplement group meetings, as well as improved participation through more intensive community mobilization approaches. Evaluations of group-based interventions should report on implementation intensity to support the interpretation of evaluation evidence and to inform further scale-up.

Effects of integrated economic and health interventions with women's groups on health-related knowledge, behaviours and outcomes in low-income and middle-income countries: a systematic review protocol

INTRODUCTION

Economic groups, such as microfinance or self-help groups are widely implemented in low-income and middle-income countries (LMICs). Women's groups are voluntary groups, which aim to improve the well-being of members through activities, such as joint savings, credit, livelihoods development and/or health activities. Health interventions are increasingly added on to existing women's economic groups as a public health intervention for women and their families. Here, we present the protocol for a mixed-methods systematic review we will conduct of the evidence on integrated economic and health interventions on women's groups to assess whether and how they improve health-related knowledge, behaviour and outcomes in LMICs.

METHODS AND ANALYSIS

We will search seven electronic databases for published literature, along with manual searches and consultation. The review will include (1) randomised trials and non-randomised quasiexperimental studies of intervention effects of integrated economic and health interventions delivered through women's groups in LMICs, and (2) sibling studies that examine factors related to intervention content, context, implementation processes and costs. We will appraise risk of bias and study quality using standard tools. High and moderate quality studies will be grouped by health domain and synthesised without meta-analysis. Qualitative evidence will be thematically synthesised and integrated into the quantitative synthesis using a matrix approach.

ETHICS AND DISSEMINATION

This protocol was reviewed and deemed exempt by the institutional review board at the American Institutes for Research. Findings will be shared through peer-reviewed publication and disseminated with programme implementers and policymakers engaged with women's groups.

PROSPERO REGISTRATION NUMBER

CRD42020199998.

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.