Effectiveness of participatory women's groups scaled up by the public health system to improve birth outcomes in Jharkhand, eastern India: a pragmatic cluster non-randomised controlled trial

Feasibility, acceptability and equity of a mobile intervention for Upscaling Participatory Action and Videos for Agriculture and Nutrition (m-UPAVAN) in rural Odisha, India

Addressing undernutrition requires strategies that remove barriers to health for all. We adapted an intervention from the 'UPAVAN' trial to a mobile intervention (m-UPAVAN) during the COVID-19 pandemic in rural Odisha, India. In UPAVAN, women's groups viewed and discussed participatory videos on nutrition-specific and nutrition-sensitive agricultural (NSA) topics. In m-UPAVAN, weekly videos and audios on the same topics were disseminated via WhatsApp and an interactive voice response system. We assessed feasibility, acceptability, and equity of m-UPAVAN using a convergent parallel mixed-methods design. m-UPAVAN ran from Mar-Sept 2021 in 133 UPAVAN villages. In Feb-Mar 2021, we invited 1000 mothers of children aged 0-23 months to participate in a sociodemographic phone survey. Of those, we randomly sampled 200 mothers each month for five months for phone surveys to monitor progress against targets. Feasibility targets were met if >70% received videos/audios and >50% watched/listened at least once. Acceptability targets were met if >75% of those watching/listening liked the videos/audios and <20% opted out of the intervention. We investigated mothers' experiences of the intervention, including preferences for m-UPAVAN versus UPAVAN, using in-person, semi-structured interviews (n = 38). Of the 810 mothers we reached, 666 provided monitoring data at least once. Among these mothers, feasibility and acceptability targets were achieved. m-UPAVAN engaged whole families, which facilitated family-level discussions around promoted practices. Women valued the ability to access m-UPAVAN content on demand. This advantage did not apply to many mothers with limited phone access. Mothers highlighted that the UPAVAN interventions' in-person participatory approaches and longer videos were more conducive to learning and inclusive, and that mobile approaches provide important complementarity. We conclude that mobile NSA interventions are feasible and acceptable, can engage families, and reinforce learning. However, in-person participatory approaches remain essential for improving equity of NSA interventions. Investments are needed in developing and testing hybrid NSA interventions.

Knowledge and practice of family planning among pregnant tribal women in Southern India: an observational study

BACKGROUND

There are over 700 Scheduled Tribes (ST) living in 30 Indian states. As with other indigenous groups across the world, Indian ST have some of the poorest infant and child health outcomes of any communities in India. A child born to an ST family is 19% more likely to die in the first month of life and has a 45 percent risk of dying in their first year compared with other Indian populations. Research suggests that early conception, high fertility, and low use of family planning methods are large contributors to these disparities.

METHODS

A cross sectional survey in Kannada was conducted among 303 pregnant tribal women in Mysore, India after obtaining informed consent. Univariate and multivariable analyses were carried out to determine the demographic and psychosocial factors associated with knowledge of contraceptive methods using Stata 14.0.

RESULTS

There was widespread knowledge about female sterilization, while only 39.3% of women reported hearing about one or more forms of temporary contraception, and 36.3% knew where to get them. The largest proportion of women had heard about copper-T (33.0%), followed by oral contraceptive pills (23.8%), condoms (11.9%), and injectables (4.6%). Only 2.7% of women reported ever using any form of temporary contraception. Results from the multivariable logistic regression indicated that knowledge of at least one form of temporary contraception was linked to higher age (adjusted odds ratio[AOR]: 1.09; 95% CI: 1.02, 1.17), greater number of years of marriage (AOR: 0.90; 95% CI: 0.85, 0.96), and last birth in a government facility (AOR: 3.67; 95% CI: 1.99, 6.82).

CONCLUSIONS

The study revealed poor knowledge and utilization of temporary contraceptive methods among a tribal population in rural Mysore, India. Interventions aiming to increase knowledge of contraceptive options are important for birth spacing in this population and should target younger women and those without contact with government health facilities.

Is it feasible to implement a community-based participatory group programme to address issues of access to healthcare for people with disabilities in Luuka district Uganda? A study protocol for a mixed-methods pilot study

INTRODUCTION

On average, people with disabilities face many difficulties in accessing healthcare and experience worse health outcomes. Yet, evidence on how to overcome these barriers is lacking. Participatory approaches are gaining prominence as they can generate low-cost, appropriate and scalable solutions. This study protocol is for the pilot testing of the co-created Participatory Learning and Action for Disability (PLA-D) groups to assess feasibility.

METHODS AND ANALYSIS

We will pilot test PLA-D in five groups in Luuka district, Uganda during 2023. Each group will include approximately 20 members (people with disabilities, family members, carers) who will meet every 2-3 weeks over a 9-11 month period. The groups, guided by a trained facilitator, will identify issues about health and healthcare access and plan and implement locally generated solutions (eg, raising awareness of rights, advocacy and lobbying, establishing health savings and financing schemes). We will collect diverse sources of data to assess feasibility: (1) in-depth interviews and focus group discussions with group participants, non-participants and group facilitators; (2) monitoring of group activities; (3) direct observation of groups and (4) quantitative survey of group participants at baseline and endline. Data analyses will be undertaken to assess feasibility in terms of: acceptability, demand, implementation and practicality. We will develop and refine evaluation tools in preparation for a future trial.

ETHICS AND DISSEMINATION

Ethical approval for the study has been received by the London School of Hygiene & Tropical Medicine and the Uganda Virus Research Institute ethics committees. Informed consent will be obtained from all study participants, making adaptations for people with disabilities as necessary. We will reach different groups for our dissemination activities, including (1) people with disabilities (eg, community meetings); (2) policy and programme stakeholders in Uganda and international (eg, individual meetings, evidence briefs) and (3) academics (journal articles, conference/seminar presentations).

Economic evaluation of participatory women's groups scaled up by the public health system to improve birth outcomes in Jharkhand, eastern India

An estimated 2.4 million newborn infants died in 2020, 80% of them in sub-Saharan Africa and South Asia. To achieve the Sustainable Development Target for neonatal mortality reduction, countries with high mortality need to implement evidence-based, cost-effective interventions at scale. Our study aimed to estimate the cost, cost-effectiveness, and benefit-cost ratio of a participatory women's groups intervention scaled up by the public health system in Jharkhand, eastern India. The intervention was evaluated through a pragmatic cluster non-randomised controlled trial in six districts. We estimated the cost of the intervention at scale from a provider perspective, with a 42-month time horizon for 20 districts. We estimated costs using a combination of top-down and bottom-up approaches. All costs were adjusted for inflation, discounted at 3% per year, and converted to 2020 International Dollars (INT$). Incremental cost-effectiveness ratios (ICERs) were estimated using extrapolated effect sizes for the impact of the intervention in 20 districts, in terms of cost per neonatal deaths averted and cost per life year saved. We assessed the impact of uncertainty on results through one-way and probabilistic sensitivity analyses. We also estimated benefit-cost ratio using a benefit transfer approach. Total intervention costs for 20 districts were INT$ 15,017,396. The intervention covered an estimated 1.6 million livebirths across 20 districts, translating to INT$ 9.4 per livebirth covered. ICERs were estimated at INT$ 1,272 per neonatal death averted or INT$ 41 per life year saved. Net benefit estimates ranged from INT$ 1,046 million to INT$ 3,254 million, and benefit-cost ratios from 71 to 218. Our study suggests that participatory women's groups scaled up by the Indian public health system were highly cost-effective in improving neonatal survival and had a very favourable return on investment. The intervention can be scaled up in similar settings within India and other countries.

Stakeholder perceptions on scaling-up community-led interventions for prevention and control of non-communicable diseases in Bangladesh: a qualitative study

BACKGROUND

Engaging communities is an important component of multisectoral action to address the growing burden of non-communicable diseases (NCDs) in low- and middle-income countries. We conducted research with non-communicable disease stakeholders in Bangladesh to understand how a community-led intervention which was shown to reduce the incidence of type 2 diabetes in rural Bangladesh could be scaled-up.

METHODS

We purposively sampled any actor who could have an interest in the intervention, or that could affect or be affected by the intervention. We interviewed central level stakeholders from donor agencies, national health policy levels, public, non-governmental, and research sectors to identify scale-up mechanisms. We interviewed community health workers, policy makers, and non-governmental stakeholders, to explore the feasibility and acceptability of implementing the suggested mechanisms. We discussed scale-up options in focus groups with community members who had attended a community-led intervention. We iteratively developed our data collection tools based on our analysis and re-interviewed some participants. We analysed the data deductively using a stakeholder analysis framework, and inductively from codes identified in the data.

RESULTS

Despite interest in addressing NCDs, there was a lack of a clear community engagement strategy at the government level, and most interventions have been implemented by non-governmental organisations. Many felt the Ministry of Health and Family Welfare should lead on community engagement, and NCD screening and referral has been added to the responsibilities of community health workers and health volunteers. Yet there remains a focus on reproductive health and NCD diagnosis and referral instead of prevention at the community level. There is potential to engage health volunteers in community-led interventions, but their present focus on engaging women for reproductive health does not fit with community needs for NCD prevention.

CONCLUSIONS

Research highlighted the need for a preventative community engagement strategy to address NCDs, and the potential to utilise existing cadres to scale-up community-led interventions. It will be important to work with key stakeholders to address gender issues and ensure flexibility and responsiveness to community concerns. We indicate areas for further implementation research to develop scaled-up models of community-led interventions to address NCDs.

‘We are the bridge’: an implementation research study of SEWA Shakti Kendras to improve community engagement in publicly funded health insurance in Gujarat, India

Introduction

India’s efforts towards universal health coverage include a national health insurance scheme that aims to protect the most vulnerable from catastrophic health expenditure. However, emerging evidence on publicly funded health insurance, as well as experience from community-based schemes, indicates that women face specific barriers to access and utilisation. Community engagement interventions have been shown to improve equitable utilisation of public health services, but there is limited research specific to health insurance. We examined how existing community-based resource centres implemented by a women’s organisation could improve women’s access to, and utilisation of, health insurance.

Methods

We conducted an implementation research study in Gujarat, India to examine how SEWA Shakti Kendras, established by the Self-Employed Women’s Association, worked to improve community engagement in health insurance. SEWA organises women in the informal sector and provides social protection through health, insurance and childcare services. We examined administrative data, programme reports and conducted 30 in-depth qualitative interviews with users and staff. Data were analysed thematically to examine intervention content, context, and implementation processes and to identify enablers and barriers to improving women’s access to health insurance through SEWA’s community engagement approach.

Results

The centres worked through multiple channels—doorstep services, centre-based support and health system navigation—to strengthen women’s capability to access health insurance. Each centre’s approach varied by contextual factors, such as women’s digital literacy levels and rural–urban settings. Effective community engagement required local leadership, strong government partnerships and the flexibility to address a range of public services, with implementation by trusted local health workers.

Conclusion

SEWA Shakti Kendras demonstrate how a local, flexible and community-based model can serve as a bridge to improve utilisation of health insurance, by engaging women and their households through multiple channels. Scaling up this approach will require investing in partnerships with community-based organisations as part of strategies towards universal health coverage.

Economic Evaluation of Nutrition-Sensitive Agricultural Interventions to Increase Maternal and Child Dietary Diversity and Nutritional Status in Rural Odisha, India

BACKGROUND

Economic evaluations of nutrition-sensitive agriculture (NSA) interventions are scarce, limiting assessment of their potential affordability and scalability.

OBJECTIVES

We conducted cost-consequence analyses of 3 participatory video-based interventions of fortnightly women's group meetings using the following platforms: 1) NSA videos; 2) NSA and nutrition-specific videos; or 3) NSA videos with a nutrition-specific participatory learning and action (PLA) cycle.

METHODS

Interventions were tested in a 32-mo, 4-arm cluster-randomized controlled trial, Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN) in the Keonjhar district, Odisha, India. Impacts were evaluated in children aged 0-23 mo and their mothers. We estimated program costs using data collected prospectively from expenditure records of implementing and technical partners and societal costs using expenditure assessment data collected from households with a child aged 0-23 mo and key informant interviews. Costs were adjusted for inflation, discounted, and converted to 2019 US$.

RESULTS

Total program costs of each intervention ranged from US$272,121 to US$386,907. Program costs per pregnant woman or mother of a child aged 0-23 mo were US$62 for NSA videos, US$84 for NSA and nutrition-specific videos, and US$78 for NSA videos with PLA (societal costs: US$125, US$143, and US$122, respectively). Substantial shares of total costs were attributable to development and delivery of the videos and PLA (52-69%) and quality assurance (25-41%). Relative to control, minimum dietary diversity was higher in the children who underwent the interventions incorporating nutrition-specific videos and PLA (adjusted RRs: 1.19 and 1.27; 95% CIs: 1.03-1.37 and 1.11, 1.46, respectively). Relative to control, minimum dietary diversity in mothers was higher in those who underwent NSA video (1.21 [1.01, 1.45]) and NSA with PLA (1.30 [1.10, 1.53]) interventions.

CONCLUSION

NSA videos with PLA can increase both maternal and child dietary diversity and have the lowest cost per unit increase in diet diversity. Building on investments made in developing UPAVAN, cost-efficiency at scale could be increased with less intensive monitoring, reduced startup costs, and integration within existing government programs. This trial was registered at clinicaltrials.gov as ISRCTN65922679.

Socioeconomic inequalities in stillbirth and neonatal mortality rates: evidence on Particularly Vulnerable Tribal Groups in eastern India

Background

Tribal peoples are among the most marginalised groups worldwide. Evidence on birth outcomes in these groups is scant. We describe inequalities in Stillbirth Rate (SBR), Neonatal Mortality Rate (NMR), and uptake of maternal and newborn health services between tribal and less disadvantaged groups in eastern India, and examine the contribution of poverty and education to these inequalities.

Methods

We used data from a demographic surveillance system covering a 1 million population in Jharkhand State (March 2017 – August 2019) to describe SBR, NMR, and service uptake. We used logistic regression analysis combined with Stata’s adjrr-command to estimate absolute and relative inequalities by caste/tribe (comparing Particularly Vulnerable Tribal Groups (PVTG) and other Scheduled Tribes (ST) with the less marginalised Other Backward Class (OBC)/none, using the Indian government classification), and by maternal education and household wealth.

Results

PVTGs had a higher NMR (59/1000) than OBC/none (31/1000) (rate ratio (RR): 1.92, 95%CI: 1.55–2.38). This was partly explained by wealth and education, but inequalities remained large after adjustment (adjusted RR: 1.59, 95%CI: 1.28–1.98). NMR was also higher among other STs (44/1000), but disparities were smaller (RR: 1.47, 95%CI: 1.23–1.75). There was a systematic gradient in NMR by maternal education and household wealth. SBRs were only higher in poorer groups (RR_{poorest vs. least poor}:1.56, 95%CI: 1.14–2.13). Uptake of facility-based services was low among PVTGs (e.g. institutional birth: 25% vs. 69% in OBC/none) and among poorer and less educated women. However, 65% of PVTG women with an institutional birth used a maternity vehicle vs. 34% among OBC/none. Visits from frontline workers (Accredited Social Health Activists [ASHAs]) were similar across groups, and ASHA accompaniment of institutional births was similar across caste/tribe groups, and higher among poorer and less educated women. Attendance in participatory women’s groups was similar across caste/tribe groups, and somewhat higher among richer and better educated women.

Conclusions

PVTGs are highly disadvantaged in terms of birth outcomes. Targeted interventions that reduce geographical barriers to facility-based care and address root causes of high poverty and low education in PVTGs are a priority. For population-level impact, they are to be combined with broader policies to reduce socio-economic mortality inequalities. Community-based interventions reach disadvantaged groups and have potential to reduce the mortality gap.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01655-y.

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.