1
|
Desai S, Kumar N, Gram L, Hazra A, Sanyal KA, Sivaram S, Nair N, Ved R, Prost A. Individual interventions, collective lessons: Developing mid-range theory on women's groups to improve health. J Glob Health 2024; 14:04152. [PMID: 39148485 PMCID: PMC11327848 DOI: 10.7189/jogh.14.04152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Sapna Desai
- Population Council Institute, New Delhi, India
| | - Neha Kumar
- International Food Policy Research Institute, Washington DC, USA
| | - Lu Gram
- UCL Institute for Global Health, London, UK
| | | | | | | | | | - Rajani Ved
- Former ED, National Health Systems Resource Centre, New Delhi, India
| | | |
Collapse
|
2
|
Fivian E, Parida M, Harris-Fry H, Mohanty S, Padhan S, Pradhan R, Das P, Odhiambo G, Prost A, Roopnaraine T, Behera S, James P, Mishra NK, Rath S, Nair N, Rath S, Koniz-Booher P, Danton H, Allen E, Kadiyala S. Feasibility, acceptability and equity of a mobile intervention for Upscaling Participatory Action and Videos for Agriculture and Nutrition (m-UPAVAN) in rural Odisha, India. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003206. [PMID: 38743726 DOI: 10.1371/journal.pgph.0003206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 04/14/2024] [Indexed: 05/16/2024]
Abstract
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.
Collapse
Affiliation(s)
- Emily Fivian
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Helen Harris-Fry
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Shibanath Padhan
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT), Kendrapara, India
| | | | - Pranay Das
- DCOR Consulting Pvt. Ltd., Bhubaneswar, India
| | - Gladys Odhiambo
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Audrey Prost
- Institute for Global Health, University College London, London, United Kingdom
| | | | | | - Philip James
- Emergency Nutrition Network (ENN), Oxford, United Kingdom
| | - Naba Kishor Mishra
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT), Kendrapara, India
| | | | | | | | - Peggy Koniz-Booher
- JSI Research & Training Institute, Inc. Arlington, Virginia, United States of America
| | - Heather Danton
- JSI Research & Training Institute, Inc. Arlington, Virginia, United States of America
| | - Elizabeth Allen
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Suneetha Kadiyala
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| |
Collapse
|
3
|
Manivannan MM, Vaz M, Swaminathan S. Perceptions of healthcare providers and mothers on management and care of severely wasted children: a qualitative study in Karnataka, India. BMJ Open 2023; 13:e067592. [PMID: 37258068 DOI: 10.1136/bmjopen-2022-067592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
OBJECTIVES To explore perceptions of healthcare providers and mothers of children with severe wasting on the perceived reasons for severe wasting, constraints on the management and barriers to caregiving and care-seeking practices. DESIGN In-depth qualitative interviews conducted with healthcare providers and mothers of children with severe wasting. SETTING Urban and rural locations in Karnataka state, India. PARTICIPANTS Healthcare providers (anganwadi workers, accredited social health activists, auxiliary nurse midwives, junior health assistant, medical officers, nutrition counsellors) from public healthcare centres and mothers of children with severe wasting. RESULTS Forty-seven participants (27 healthcare providers, 20 mothers) were interviewed. Poverty of households emerged as the underlying systemic factor across all themes that interfered with sustained uptake of any intervention to address severe wasting. Confusion of 'thinness' and shortness of stature as hereditary factors appeared to normalise the condition of wasting. Management of this severe condition emerged as an interdependent phenomenon starting at the home level coupled with sociocultural factors to community intervention services with its supplemental nutrition programme and clinical monitoring with therapeutic interventions through an institutional stay at specialist referral centres. A single-pronged malnutrition alleviation strategy fails due to the complexity of the ground-level problems, as made apparent through respondents' lived experiences. Social stigma, trust issues between caregivers and care-seekers and varying needs and priorities as well as overburdened frontline workers create challenges in communication and effectiveness of services resulting in perpetuation of severe wasting. CONCLUSIONS To ensure a continuum of care in children with severe wasting, economic and household constraints, coordinated policies across the multidimensional determinants of severe wasting need to be addressed. Context-specific interventions are necessary to bridge communication gaps between healthcare providers and caregivers.
Collapse
Affiliation(s)
- Madhu Mitha Manivannan
- Division of Nutrition, St. John's Research Institute, St John's Medical College, St. John's National Academy of Health Sciences, a recognized research centre of University of Mysore, Bangalore, Karnataka, India
| | - Manjulika Vaz
- Division of Health and Humanities, St John's Research Institute, St John's Medical College, St. John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Sumathi Swaminathan
- Division of Nutrition, St. John's Research Institute, St John's Medical College, St. John's National Academy of Health Sciences, a recognized research centre of University of Mysore, Bangalore, Karnataka, India
| |
Collapse
|
4
|
Mishra A, Singh AK, Parida SP, Pradhan SK, Nair J. Understanding Community Participation in Rural Health Care: A Participatory Learning and Action Approach. Front Public Health 2022; 10:860792. [PMID: 35734758 PMCID: PMC9207712 DOI: 10.3389/fpubh.2022.860792] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 04/27/2022] [Indexed: 11/15/2022] Open
Abstract
Community participation is one of the founding pillars of primary health care. However, due to various reasons, we are yet to achieve complete integration of this component into the health system functioning in India. The objective of our study was to do a formative assessment of community participation in a rural healthcare setting by adopting participatory learning action (PLA). technique. The study participants included frontline health workers and members from local governing institutions of rural areas. The study design is qualitative in nature with a participatory approach. A number of three PLA techniques have been used as a part of this study to recognize available resources for community participation, address its barriers and facilitators, and finally devise a time-line-based action plan. Based on the this, a conceptual framework for community participation pertaining to the rural healthcare system has been developed. This study highlights the importance of understanding the psychosocial aspects of community participation among various stakeholders involved in rural health care. Lessons learned from this PLA study will be helpful in the integration of community-based participatory approach within grassroot level healthcare planning and service delivery.
Collapse
|
5
|
Scott S, Gupta S, Menon P, Raghunathan K, Thai G, Quisumbing A, Prasad V, Hegde A, Choudhury A, Khetan M, Nichols C, Kumar N. A Quasi-Experimental Evaluation of a Nutrition Behavior Change Intervention Delivered Through Women's Self-Help Groups in Rural India: Impacts on Maternal and Young Child Diets, Anthropometry, and Intermediate Outcomes. Curr Dev Nutr 2022; 6:nzac079. [PMID: 35694241 PMCID: PMC9177383 DOI: 10.1093/cdn/nzac079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/21/2022] [Accepted: 04/07/2022] [Indexed: 11/14/2022] Open
Abstract
Background Women's self-help groups (SHGs) have become one of the largest institutional platforms serving the poor. Nutrition behavior change communication (BCC) interventions delivered through SHGs can improve maternal and child nutrition outcomes. Objectives The objective was to understand the effects of a nutrition BCC intervention delivered through SHGs in rural India on intermediate outcomes and nutrition outcomes. Methods We compared 16 matched blocks where communities were supported to form SHGs and improve livelihoods; 8 blocks received a 3-y nutrition intensive (NI) intervention with nutrition BCC, and agriculture- and rights-based information, facilitated by a trained female volunteer; another 8 blocks received standard activities (STD) to support savings/livelihoods. Repeated cross-sectional surveys of mother-child pairs were conducted in 2017-2018 (n = 1609 pairs) and 2019-2020 (n = 1841 pairs). We matched treatment groups over time and applied difference-in-difference regression models to estimate impacts on intermediate outcomes (knowledge, income, agriculture/livelihoods, rights, empowerment) and nutrition outcomes (child feeding, woman's diet, woman and child anthropometry). Analyses were repeated on households with ≥1 SHG member. Results Forty percent of women were SHG members and 50% were from households with ≥1 SHG member. Only 10% of women in NI blocks had heard of intervention content at endline. Knowledge improved in both NI and STD groups. There was a positive NI impact on knowledge of timely introduction of animal-sourced foods to children (P < 0.05) but not on other intermediate outcomes. No impacts were observed for anthropometry or diet indicators except child animal-source food consumption (P < 0.01). In households with ≥1 SHG member, there was a positive NI impact on child unhealthy food consumption (P < 0.05). Conclusions Limited impacts could be due to limited exposure or skills of volunteers, and a concurrent national nutrition campaign. Our findings add to a growing literature on SHG-based BCC interventions and the conditions necessary for their success.
Collapse
Affiliation(s)
- Samuel Scott
- Poverty Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
| | - Shivani Gupta
- Poverty Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
| | - Purnima Menon
- Poverty Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
| | - Kalyani Raghunathan
- Poverty Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
| | - Giang Thai
- Poverty Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Agnes Quisumbing
- Poverty Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | | | - Aditi Hegde
- Public Health Resource Society (PHRS), New Delhi, India
| | - Avijit Choudhury
- Professional Assistance for Development Action (PRADAN), New Delhi, India
| | - Madhu Khetan
- Professional Assistance for Development Action (PRADAN), New Delhi, India
| | - Carly Nichols
- Geographical and Sustainability Studies Department, University of Iowa, Iowa City, IA, USA
| | - Neha Kumar
- Poverty Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| |
Collapse
|
6
|
Hazra A, Das A, Ahmad J, Singh S, Chaudhuri I, Purty A, Prost A, Desai S. Matching Intent With Intensity: Implementation Research on the Intensity of Health and Nutrition Programs With Women's Self-Help Groups in India. GLOBAL HEALTH: SCIENCE AND PRACTICE 2022; 10:GHSP-D-21-00383. [PMID: 35487547 PMCID: PMC9053147 DOI: 10.9745/ghsp-d-21-00383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 02/12/2022] [Indexed: 11/15/2022]
Abstract
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.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Audrey Prost
- UCL Institute of Global Health, London, United Kingdom
| | | |
Collapse
|
7
|
Ahmed S, Chase LE, Wagnild J, Akhter N, Sturridge S, Clarke A, Chowdhary P, Mukami D, Kasim A, Hampshire K. Community health workers and health equity in low- and middle-income countries: systematic review and recommendations for policy and practice. Int J Equity Health 2022; 21:49. [PMID: 35410258 PMCID: PMC8996551 DOI: 10.1186/s12939-021-01615-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 12/27/2021] [Indexed: 01/06/2023] Open
Abstract
Background The deployment of Community Health Workers (CHWs) is widely promoted as a strategy for reducing health inequities in low- and middle-income countries (LMIC). Yet there is limited evidence on whether and how CHW programmes achieve this. This systematic review aimed to synthesise research findings on the following questions: (1) How effective are CHW interventions at reaching the most disadvantaged groups in LMIC contexts? and (2) What evidence exists on whether and how these programmes reduce health inequities in the populations they serve? Methods We searched six academic databases for recent (2014–2020) studies reporting on CHW programme access, utilisation, quality, and effects on health outcomes/behaviours in relation to potential stratifiers of health opportunities and outcomes (e.g., gender, socioeconomic status, place of residence). Quantitative data were extracted, tabulated, and subjected to meta-analysis where appropriate. Qualitative findings were synthesised using thematic analysis. Results One hundred sixty-seven studies met the search criteria, reporting on CHW interventions in 33 LMIC. Quantitative synthesis showed that CHW programmes successfully reach many (although not all) marginalized groups, but that health inequalities often persist in the populations they serve. Qualitative findings suggest that disadvantaged groups experienced barriers to taking up CHW health advice and referrals and point to a range of strategies for improving the reach and impact of CHW programmes in these groups. Ensuring fair working conditions for CHWs and expanding opportunities for advocacy were also revealed as being important for bridging health equity gaps. Conclusion In order to optimise the equity impacts of CHW programmes, we need to move beyond seeing CHWs as a temporary sticking plaster, and instead build meaningful partnerships between CHWs, communities and policy-makers to confront and address the underlying structures of inequity. Trial registration PROSPERO registration number CRD42020177333. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01615-y.
Collapse
|
8
|
Rahmadiyah D, Sahar J, Widyatuti W. Public Health Interventions to Reduce Stunting in Toddlers: A Systematic Review. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Handling stunting in toddlers is not only the responsibility of the government, but the most important thing is family and community responsibility. Public health interventions involving the family and community are important for stunting prevention because the family environment is one of the factors that determine the provision of adequate conditions for the nutritional status and development of children.
AIM: The purpose of this systematic review is to synthesize various public health interventions that are practice-based evidence derived from programs implemented to reduce stunting in toddlers.
METHODS: Initial steps doing this systematic review articles included in this study were retrieved from ProQuest, EBSCOhost, MEDLINE/CINAHL (Academic Search Complete) that were published within 2011–2019 and written in English. Study Quality Assessment was done using keywords and by assessing compatibility of the articles with the study context. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was used to analyze the found articles.
RESULTS: After filtering process, there were 11 articles from 859 articles emphasize on using a combination of two or more Public Health Interventions to reduce stunting in toddlers. The most common public health interventions done to reduce stunting in toddlers are health teaching, counseling, collaboration, and community organizing.
CONCLUSIONS: Here, we show that public health interventions performed by public health nurses to reduce stunting require the involvement of the community itself, especially the family. Public health interventions can be combined with one or more other public health interventions to increase success in preventing stunting in children under five.
Collapse
|
9
|
Scoping Review of Intervention Strategies for Improving Coverage and Uptake of Maternal Nutrition Services in Southeast Asia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182413292. [PMID: 34948904 PMCID: PMC8701361 DOI: 10.3390/ijerph182413292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/21/2021] [Accepted: 12/12/2021] [Indexed: 01/24/2023]
Abstract
Maternal undernutrition can lead to protein-energy malnutrition, micronutrient deficiencies, or anemia during pregnancy or after birth. It remains a major problem, despite evidence-based maternal-nutrition interventions happening on ground. We conducted a scoping review to understand different strategies and delivery mechanisms to improve maternal nutrition, as well as how interventions have improved coverage and uptake of services. An electronic search was conducted in PubMed and Google Scholar for published studies reporting on the effectiveness of maternal-nutrition interventions in terms of access or coverage, health outcomes, compliance, and barriers to intervention utilization. The search was limited to studies published within ten years before the initial search date, 8 November 2019; later, it was updated to 17 February 2021. Of 31 studies identified following screening and data extraction, 22 studies were included for narrative synthesis. Twelve studies were reported from India and eleven from Bangladesh, three from Nepal, two from both Pakistan and Thailand (Myanmar), and one from Indonesia. Nutrition education and counselling, home visits, directly observed supplement intake, community mobilization, food, and conditional cash transfer by community health workers were found to be effective. There is a need to incorporate diverse strategies, including various health education approaches, supplementation, as well as strengthening of community participation and the response of the health system in order to achieve impactful maternal nutrition programs.
Collapse
|
10
|
Ickes SB, Craig C, Heidkamp R. Design Factors for Food Supplementation and Nutrition Education Interventions That Limit Conclusions about Effectiveness for Wasting Prevention: A Scoping Review of Peer-Reviewed Literature. Adv Nutr 2021; 13:328-341. [PMID: 34666351 PMCID: PMC8803494 DOI: 10.1093/advances/nmab107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 05/04/2021] [Accepted: 09/07/2021] [Indexed: 11/13/2022] Open
Abstract
We conducted a scoping review to characterize the evidence base for the effectiveness of food supplementation (FS), nutrition education (NE), or FS/NE interventions to prevent wasting among children aged 6 to 59 mo. We aimed to identify gaps in peer-reviewed literature and to develop recommendations for strengthening study designs. We identified 56 unique studies (FS = 21, NE = 19, FS/NE = 16) for which we assessed intervention design factors, implementation context, evaluation methods, and wasting impact. Compared with studies focused on stunting, fewer wasting-focused studies reported weight-for-height z score (WHZ). Midupper arm circumference (MUAC) was more commonly reported in wasting-focused studies (71.4%) than those focused on stunting (36.8%) or wasting and stunting (30.4%). FS studies measured anthropometry (mean, 95% CI) more frequently at every 11.3 (7.8, 14.8) wk than NE interventions at 36.3 (8.8, 62.1) wk (P = 0.036), but not FS/NE interventions at 25.8 (5.6, 49.1) wk (P = 0.138). NE interventions tended to be of longer duration than FS or FS/NE interventions. Only 6 studies followed and measured children after the intervention period ended. Across all studies, 45% reported a significant effect on wasting; these included FS, NE, and FS/NE interventions. The lack of comparability across studies limits conclusions about the effectiveness of specific types of interventions. To build a more unified evidence base for wasting prevention we recommend that future studies 1) report on a consistent set of metrics, including MUAC; 2) attempt to measure change in wasting incidence using more frequent measures; 3) measure wasting prevalence among the general population; 4) follow children postintervention to assess relapse; 5) measure food insecurity and diet quality; and 6) use harmonized protocols across multiple settings. Such efforts to improve study comparability will strengthen the evidence base, may help unite divergent professional communities, and ultimately accelerate progress toward eliminating child undernutrition.
Collapse
Affiliation(s)
| | | | - Rebecca Heidkamp
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
11
|
Nichols CE. Spaces for women: Rethinking behavior change communication in the context of women's groups and nutrition-sensitive agriculture. Soc Sci Med 2021; 285:114282. [PMID: 34375897 PMCID: PMC8434409 DOI: 10.1016/j.socscimed.2021.114282] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 06/28/2021] [Accepted: 07/27/2021] [Indexed: 11/16/2022]
Abstract
Recently, nutrition-sensitive agriculture programs have taken aim at malnutrition's multi-sectoral roots through re-diversifying agricultural production while integrating women's empowerment and nutrition behavior-change communication components. For these integrated nutrition-sensitive agricultural programs, women-led self-help groups have emerged as promising platforms for program delivery. Yet, while well-designed nutrition behavior-change communication has been successfully used in self-help groups, and is central to nutrition-sensitive agriculture, it can take many forms. These vary widely in their theoretical and ethical underpinnings, communication strategies, and theory of change. As nutrition-sensitive agriculture continues to proliferate, it is critical to better understand how women interact with different behavior-change messages and how to engage individuals in ethical, effective ways. This paper analyzes qualitative data collected from a nutrition-sensitive agricultural project in India that used participatory storytelling to generate knowledge and awareness about malnutrition among women. Drawing from data across two sites, the paper analyzes why certain messages generated more discussion among women then others. We find self-help group women were drawn to topics of early marriage and diet diversity because they emotionally connected to them, and felt they were relevant to their lives with high perceived pay-off and actionability. While other topics on gender and health also provoked emotional, lively discussions, the stories were less effective due to their complexity, which were difficult for volunteer facilitators to communicate. We conclude that there is unmet demand among women in rural India for structured spaces to discuss gendered aspects of health and diet, and nutrition-sensitive agricultural programs could benefit from focusing attention here.
Collapse
Affiliation(s)
- Carly E Nichols
- University of Iowa, 312 Jessup, Hall Iowa City, IA, 52245, United States.
| |
Collapse
|
12
|
Kadiyala S, Harris-Fry H, Pradhan R, Mohanty S, Padhan S, Rath S, James P, Fivian E, Koniz-Booher P, Nair N, Haghparast-Bidgoli H, Mishra NK, Rath S, Beaumont E, Danton H, Krishnan S, Parida M, O'Hearn M, Kumar A, Upadhyay A, Tripathy P, Skordis J, Sturgess J, Elbourne D, Prost A, Allen E. Effect of nutrition-sensitive agriculture interventions with participatory videos and women's group meetings on maternal and child nutritional outcomes in rural Odisha, India (UPAVAN trial): a four-arm, observer-blind, cluster-randomised controlled trial. Lancet Planet Health 2021; 5:e263-e276. [PMID: 33811818 PMCID: PMC8099729 DOI: 10.1016/s2542-5196(21)00001-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 12/20/2020] [Accepted: 12/21/2020] [Indexed: 05/04/2023]
Abstract
BACKGROUND Almost a quarter of the world's undernourished people live in India. We tested the effects of three nutrition-sensitive agriculture (NSA) interventions on maternal and child nutrition in India. METHODS We did a parallel, four-arm, observer-blind, cluster-randomised trial in Keonjhar district, Odisha, India. A cluster was one or more villages with a combined minimum population of 800 residents. The clusters were allocated 1:1:1:1 to a control group or an intervention group of fortnightly women's groups meetings and household visits over 32 months using: NSA videos (AGRI group); NSA and nutrition-specific videos (AGRI-NUT group); or NSA videos and a nutrition-specific participatory learning and action (PLA) cycle meetings and videos (AGRI-NUT+PLA group). Primary outcomes were the proportion of children aged 6-23 months consuming at least four of seven food groups the previous day and mean maternal body-mass index (BMI). Secondary outcomes were proportion of mothers consuming at least five of ten food groups and child wasting (proportion of children with weight-for-height Z score SD <-2). Outcomes were assessed in children and mothers through cross-sectional surveys at baseline and at endline, 36 months later. Analyses were by intention to treat. Participants and intervention facilitators were not blinded to allocation; the research team were. This trial is registered at ISRCTN, ISRCTN65922679. FINDINGS 148 of 162 clusters assessed for eligibility were enrolled and randomly allocated to trial groups (37 clusters per group). Baseline surveys took place from Nov 24, 2016, to Jan 24, 2017; clusters were randomised from December, 2016, to January, 2017; and interventions were implemented from March 20, 2017, to Oct 31, 2019, and endline surveys done from Nov 19, 2019, to Jan 12, 2020, in an average of 32 households per cluster. All clusters were included in the analyses. There was an increase in the proportion of children consuming at least four of seven food groups in the AGRI-NUT (adjusted relative risk [RR] 1·19, 95% CI 1·03 to 1·37, p=0·02) and AGRI-NUT+PLA (1·27, 1·11 to 1·46, p=0·001) groups, but not AGRI (1·06, 0·91 to 1·23, p=0·44), compared with the control group. We found no effects on mean maternal BMI (adjusted mean differences vs control, AGRI -0·05, -0·34 to 0·24; AGRI-NUT 0·04, -0·26 to 0·33; AGRI-NUT+PLA -0·03, -0·3 to 0·23). An increase in the proportion of mothers consuming at least five of ten food groups was seen in the AGRI (adjusted RR 1·21, 1·01 to 1·45) and AGRI-NUT+PLA (1·30, 1·10 to 1·53) groups compared with the control group, but not in AGRI-NUT (1·16, 0·98 to 1·38). We found no effects on child wasting (adjusted RR vs control, AGRI 0·95, 0·73 to 1·24; AGRI-NUT 0·96, 0·72 to 1·29; AGRI-NUT+PLA 0·96, 0·73 to 1·26). INTERPRETATION Women's groups using combinations of NSA videos, nutrition-specific videos, and PLA cycle meetings improved maternal and child diet quality in rural Odisha, India. These components have been implemented separately in several low-income settings; effects could be increased by scaling up together. FUNDING Bill & Melinda Gates Foundation, UK AID from the UK Government, and US Agency for International Development.
Collapse
Affiliation(s)
- Suneetha Kadiyala
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK.
| | - Helen Harris-Fry
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Shibanath Padhan
- Voluntary Association for Rural Reconstruction and Appropriate Technology, Kendrapara, India
| | | | - Philip James
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Emily Fivian
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Naba Kishor Mishra
- Voluntary Association for Rural Reconstruction and Appropriate Technology, Kendrapara, India
| | | | - Emma Beaumont
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Sneha Krishnan
- Environment, Technology and Community Health Consultancy Service, Mumbai, India; Jindal School of Environment and Sustainability, Jindal Global University, Haryana, India
| | | | - Meghan O'Hearn
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | | | | | | | - Jolene Skordis
- Institute for Global Health, University College London, London, UK
| | - Joanna Sturgess
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Diana Elbourne
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Audrey Prost
- Institute for Global Health, University College London, London, UK
| | - Elizabeth Allen
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
13
|
Desai S, Misra M, Das A, Singh RJ, Sehgal M, Gram L, Kumar N, Prost A. 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. BMJ Glob Health 2020; 5:e003304. [PMID: 33328199 PMCID: PMC7745316 DOI: 10.1136/bmjgh-2020-003304] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/08/2020] [Accepted: 10/13/2020] [Indexed: 12/12/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Sapna Desai
- Population Council India, New Delhi, Delhi, India
| | | | | | | | | | - Lu Gram
- Institute for Global Health, University College London, London, UK
| | - Neha Kumar
- International Food Policy Research Institute, Washington, DC, USA
| | - Audrey Prost
- University College London Institute of Child Health, London, UK
| |
Collapse
|
14
|
Chakraborty P, Daruwalla N, Gupta AD, Machchhar U, Kakad B, Adelkar S, Osrin D. Using Participatory Learning and Action in a Community-Based Intervention to Prevent Violence Against Women and Girls in Mumbai's Informal Settlements. INTERNATIONAL JOURNAL OF QUALITATIVE METHODS 2020; 19:1609406920972234. [PMID: 35422681 PMCID: PMC8995557 DOI: 10.1177/1609406920972234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
For over 3 decades, participatory learning and action (PLA) techniques have been prominent in formative and evaluative studies in community-based development programs in the Global South. In this paper, we describe and discuss the use of PLA approaches at the beginning of a community-based program for prevention of violence against women and girls in Mumbai's urban informal settlements. We adapted six PLA techniques as part of a formative community mobilization and rapid needs assessment exercise, addressing perceptions of violence prevalence, sources of household conflict, experiences of safety and mobility, access to services, preferences for service and support, and visualization of an ideal community free from violence. We describe the collaborative process of developing and implementing PLA techniques and discuss its relevance in generating contextual and grounded understandings of violence as well as in identifying factors which can potentially enable and constrain interventions.
Collapse
Affiliation(s)
- Proshant Chakraborty
- Program for Prevention of Violence against Women and
Children (PVWC), Society for Nutrition, Education and Health Action (SNEHA),
Mumbai, Maharashtra, India
- School of Global Studies, University of
Gothenburg, Sweden
| | - Nayreen Daruwalla
- Program for Prevention of Violence against Women and
Children (PVWC), Society for Nutrition, Education and Health Action (SNEHA),
Mumbai, Maharashtra, India
| | - Apoorwa Deepak Gupta
- Program for Prevention of Violence against Women and
Children (PVWC), Society for Nutrition, Education and Health Action (SNEHA),
Mumbai, Maharashtra, India
| | - Unnati Machchhar
- Program for Prevention of Violence against Women and
Children (PVWC), Society for Nutrition, Education and Health Action (SNEHA),
Mumbai, Maharashtra, India
| | - Bhaskar Kakad
- Program for Prevention of Violence against Women and
Children (PVWC), Society for Nutrition, Education and Health Action (SNEHA),
Mumbai, Maharashtra, India
| | - Shilpa Adelkar
- Program for Prevention of Violence against Women and
Children (PVWC), Society for Nutrition, Education and Health Action (SNEHA),
Mumbai, Maharashtra, India
| | - David Osrin
- Institute for Global Health, University College
London, United Kingdom
| |
Collapse
|
15
|
Rath S, Prost A, Samal S, Pradhan H, Copas A, Gagrai S, Rath S, Gope RK, Nair N, Tripathy P, Bhatia K, Rose-Clarke K. Community youth teams facilitating participatory adolescent groups, youth leadership activities and livelihood promotion to improve school attendance, dietary diversity and mental health among adolescent girls in rural eastern India: protocol for a cluster-randomised controlled trial. Trials 2020; 21:52. [PMID: 31915039 PMCID: PMC6950906 DOI: 10.1186/s13063-019-3984-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 12/10/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improving the health and development of adolescents aged 10-19 years is a global health priority. One in five adolescents globally live in India. The Rashtriya Kishor Swasthya Karyakram (RKSK), India's national adolescent health strategy, recommends supporting community-based peer educators to conduct group meetings with boys and girls. Groups aim to give adolescents a space to discuss the social and health issues affecting them and build their capacity to become active community members and leaders. There have been no evaluations of the community component of RKSK to date. In this protocol, we describe the evaluation of the Jharkhand Initiative for Adolescent Health (JIAH), a community intervention aligned with RKSK and designed to improve school attendance, dietary diversity and mental health among adolescent girls aged 10-19 years in rural Jharkhand, eastern India. METHODS The JIAH intervention is delivered by a community youth team consisting of yuva saathis (friends of youth), youth leadership facilitators and livelihood promoters. Teams conduct (a) peer-led Participatory Learning and Action meetings with girls and boys, mobilising adolescents, parents, health workers, teachers and the wider community to make changes for adolescent health and development; (b) group-based youth leadership activities to build adolescents' confidence and resilience; and (c) livelihood promotion with adolescents and their families to provide training and practical skills. We are evaluating the JIAH intervention through a parallel-group, two-arm, superiority, cluster-randomised controlled trial. The unit of randomisation is a geographic cluster of ~1000 people. A total of 38 clusters covering an estimated population of 40,676 have been randomised to control or intervention arms. Nineteen intervention clusters have adolescent groups, youth leadership activities and livelihood promotion. Nineteen control clusters receive livelihood promotion only. Study participants are adolescent girls aged 10-19 years, married or unmarried, in or out of school, living in the study area. Intervention activities are open to all adolescent boys and girls, regardless of their participation in surveys. We will collect data through baseline and endline surveys. Primary trial outcomes are school attendance, dietary diversity and internalising and externalising mental health problems. Secondary outcomes include access to school-related entitlements, emotional or physical violence, self-efficacy and resilience. TRIAL REGISTRATION ISRCTN17206016. Registered on 27 June 2018.
Collapse
Affiliation(s)
| | - Audrey Prost
- Institute for Global Health, University College London, London, UK
| | | | | | - Andrew Copas
- Institute for Global Health, University College London, London, UK
| | | | | | | | | | | | - Komal Bhatia
- Institute for Global Health, University College London, London, UK
| | - Kelly Rose-Clarke
- Department of Global Health and Social Medicine, King's College London, Bush House NE Wing, London, WC2B 4BG, UK.
| |
Collapse
|
16
|
Prost A, Nair N, Copas A, Pradhan H, Saville N, Tripathy P, Gope R, Rath S, Rath S, Skordis J, Bhattacharyya S, Costello A, Sachdev HS. Mortality and recovery following moderate and severe acute malnutrition in children aged 6-18 months in rural Jharkhand and Odisha, eastern India: A cohort study. PLoS Med 2019; 16:e1002934. [PMID: 31613883 PMCID: PMC6793843 DOI: 10.1371/journal.pmed.1002934] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 09/09/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Recent data suggest that case fatality from severe acute malnutrition (SAM) in India may be lower than the 10%-20% estimated by the World Health Organization (WHO). A contemporary quantification of mortality and recovery from acute malnutrition in Indian community settings is essential to inform policy regarding the benefits of scaling up prevention and treatment programmes. METHODS AND FINDINGS We conducted a cohort study using data collected during a recently completed cluster-randomised controlled trial in 120 geographical clusters with a total population of 121,531 in rural Jharkhand and Odisha, eastern India. Children born between October 1, 2013, and February 10, 2015, and alive at 6 months of age were followed up at 9, 12, and 18 months. We measured the children's anthropometry and asked caregivers whether children had been referred to services for malnutrition in the past 3 months. We determined the incidence and prevalence of moderate acute malnutrition (MAM) and SAM, as well as mortality and recovery at each follow-up. We then used Cox-proportional models to estimate mortality hazard ratios (HRs) for MAM and SAM. In total, 2,869 children were eligible for follow-up at 6 months of age. We knew the vital status of 93% of children (2,669/2,869) at 18 months. There were 2,704 children-years of follow-up time. The incidence of MAM by weight-for-length z score (WLZ) and/or mid-upper arm circumference (MUAC) was 406 (1,098/2,704) per 1,000 children-years. The incidence of SAM by WLZ, MUAC, or oedema was 190 (513/2,704) per 1,000 children-years. There were 36 deaths: 12 among children with MAM and six among children with SAM. Case fatality rates were 1.1% (12/1,098) for MAM and 1.2% (6/513) for SAM. In total, 99% of all children with SAM at 6 months of age (227/230) were alive 3 months later, 40% (92/230) were still SAM, and 18% (41/230) had recovered (WLZ ≥ -2 standard deviation [SD]; MUAC ≥ 12.5; no oedema). The adjusted HRs using all anthropometric indicators were 1.43 (95% CI 0.53-3.87, p = 0.480) for MAM and 2.56 (95% CI 0.99-6.70, p = 0.052) for SAM. Both WLZ < -3 and MUAC ≥ 11.5 and < 12.5 were associated with increased mortality risk (HR: 3.33, 95% CI 1.23-8.99, p = 0.018 and HR: 3.87, 95% CI 1.63-9.18, p = 0.002, respectively). A key limitation of our analysis was missing WLZ or MUAC data at all time points for 2.5% of children, including for two of the 36 children who died. CONCLUSIONS In rural eastern India, the incidence of acute malnutrition among children older than 6 months was high, but case fatality following SAM was 1.2%, much lower than the 10%-20% estimated by WHO. Case fatality rates below 6% have now been recorded in three other Indian studies. Community treatment using ready-to-use therapeutic food may not avert a substantial number of SAM-related deaths in children aged over 6 months, as mortality in this group is lower than expected. Our findings strengthen the case for prioritising prevention through known health, nutrition, and multisectoral interventions in the first 1,000 days of life, while ensuring access to treatment when prevention fails.
Collapse
Affiliation(s)
- Audrey Prost
- University College London, Institute for Global Health, London, United Kingdom
- Ekjut, Chakradharpur, Jharkhand, India
| | | | - Andrew Copas
- University College London, Institute for Global Health, London, United Kingdom
| | | | - Naomi Saville
- University College London, Institute for Global Health, London, United Kingdom
| | | | | | | | | | | | | | | | | |
Collapse
|